S32.474S — Nondisplaced fracture of medial wall of right acetabulum, sequela
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.
- Claims and coding must follow and reference the Local Coverage Determination L33456; consult L33456 for specific clinical coverage criteria and required documentation.
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
Key Coverage Criteria
- Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
- Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
- Beneficiary is under the care of a physician.
20 Active Policies
A59811 — Billing and Coding: Total Joint Arthroplasty
J05
L39911 — Total Joint Arthroplasty
J05
A57765 — Billing and Coding: Major Joint Replacement (Hip and Knee)
J09
L33618 — Major Joint Replacement (Hip and Knee)
J09
A56796 — Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)
Related Codes
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