S32.301B — Unspecified fracture of right ilium, initial encounter for open fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- Documentation must describe pain and functional disability in context (e.g., interference with ADLs, pain with initiation or weight bearing).
- The medical record must include a history and physical, discharge summary, physician progress notes, and an operative report for the THA episode of care and must be made available to Noridian upon request.
- Imaging (X-ray, MRI, or CT) results must be in the record and should demonstrate the specific arthritic findings listed (e.g., subchondral cysts, sclerosis, osteophytes, subluxation, joint-space narrowing, avascular necrosis, bone-on-bone).
Key Coverage Criteria
- Total hip arthroplasty (THA) is covered for advanced hip joint disease when hip arthritis is documented by X-ray, MRI, or CT demonstrating one or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, degree of joint space narrowing, avascular necrosis, or bone-on-bone articulation.
- THA is covered when the patient has hip pain or functional disability documented in context (e.g., pain interfering with ADLs, pain increased with initiation of activity, or pain increased with weight bearing).
- THA is covered when documentation shows unsuccessful conservative (non-surgical) therapy as appropriate for the current episode (e.g., documented trial of NSAIDs or supervised physical therapy, or documented contraindication to such therapy).
- THA is covered for joint malignancy when supporting evidence is in the record (e.g., pathology report and oncologist referral) demonstrating malignancy of the joint.
- THA or revision/replacement is covered for acute or chronic fracture when imaging (e.g., X-ray) documents the fracture and justifies the procedure.
- Revision or replacement THA is covered when pain at the hip is documented as a reason for the procedure (e.g., pain interfering with ADLs, pain increased with initiation of activity or weight bearing).
10 Active Policies
A59811 — Billing and Coding: Total Joint Arthroplasty
J05
L39911 — Total Joint Arthroplasty
J05
L33618 — Major Joint Replacement (Hip and Knee)
J09
A57765 — Billing and Coding: Major Joint Replacement (Hip and Knee)
J09
A57684 — Billing and Coding: Total Hip Arthroplasty
Related Codes
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