S42.294A — Other nondisplaced fracture of upper end of right humerus, initial encounter for closed fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A valid, written, physician-signed and dated plan of treatment must be established prior to provision of physical therapy and must outline type, amount, frequency, duration, functional diagnosis deficits, and anticipated short- and long-term goals.
- Services must be ordered by a physician and the order must be documented in the medical record.
- Treatment notes must be completed per visit, be legible, objectively document findings (e.g., numeric pain scores), relate to established goals, reflect all services billed, and use consistent symbols/acronyms or provide a legend.
- Signature requirements: documentation must bear a legible identity (handwritten or electronic per state law) and the individual whose name appears is responsible for authenticity.
Key Coverage Criteria
- Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
- Beneficiary is under the care of a physician.
- Beneficiary is receiving services under a plan of care that is established and periodically reviewed by a physician.
- Beneficiary needs skilled nursing care on an intermittent basis, or physical therapy, or speech-language pathology, or has a continued need for occupational therapy.
- Physical therapy services ordered by a physician and provided by a qualified physical therapist or under the general supervision of a qualified physical therapist are covered when reasonable and necessary to treat illness/injury or to restore or maintain function.
- Physical therapy services provided as a result of a valid written, physician-signed and dated plan of treatment established prior to provision that specifies type, amount, frequency, duration, functional diagnosis deficits, and short- and long-term goals are covered.
5 Active Policies
A59877 — Billing and Coding: Total Shoulder Arthroplasty
A57311 — Billing and Coding: Physical Therapy - Home Health
A59878 — Billing and Coding: Total Shoulder Arthroplasty
L39956 — Total Shoulder Arthroplasty
L33942 — Physical Therapy - Home Health
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.