S32.613B — Displaced avulsion fracture of unspecified ischium, initial encounter for open fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- For advanced joint disease, document arthritis supported by X-ray or MRI that demonstrates at least one specified radiographic finding (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis).
- Document pain or functional disability (e.g., interference with ADLs, pain on initiation of activity, pain with weight bearing) when pain is the indication for the procedure.
Key Coverage Criteria
- Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.
- Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.
- THA or TKA is covered when the patient has pain or functional disability at the hip or knee, e.g., pain interfering with activities of daily living (ADLs), pain increased with initiation of activity, or pain increased with weight bearing.
- THA or TKA is covered when there is documentation of unsuccessful conservative therapy appropriate to the episode of care, generally a reasonable attempt of usually 3 months or more (e.g., trial of NSAIDs or supervised physical therapy, or documented contraindication to such therapy).
- THA or TKA is covered for other LCD-indicated causes when appropriate supporting evidence is documented, e.g., malignancy of the joint supported by pathology and oncology referral, or fracture supported by X-ray.
- Revision TKA or THA for infection is covered when laboratory and/or pathology reports documenting infection, documentation of infection treatment, and a physician note indicating it is appropriate to proceed with surgery are present in the medical record.
2 Active Policies
A57765 — Billing and Coding: Major Joint Replacement (Hip and Knee)
J09
L33618 — Major Joint Replacement (Hip and Knee)
J09
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.