S63.638A — Sprain of interphalangeal joint of other finger, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each claim must be submitted with ICD-10-CM codes that reflect the patient's condition and the reason for the service; claims without ICD-10-CM codes will be returned.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- A permanent record of the ultrasound and its interpretation must be kept in the patient's record, including images labeled with exam date, patient identification, and image orientation; documentation of variations from normal with measurements; and a formal interpretation.
Key Coverage Criteria
- Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
- Extremity ultrasound is indicated to detect and evaluate cysts, abscesses, tumors (including assessment of tumor size), and joint or soft-tissue effusions in the arms and legs.
- Extremity ultrasound is indicated to distinguish solid masses from fluid-filled cysts and evaluate soft-tissue masses, ganglion cysts, intermetatarsal neuromas, and stress fractures of the metatarsals.
- Extremity ultrasound is indicated to evaluate tendons (including tears, tendonitis, tenosynovitis), joints, plantar fascia, and ligaments in the arms and legs.
- Extremity ultrasound is indicated to aid in the diagnosis and to assist surgical removal/localization of foreign bodies in the extremities.
2 Active Policies
A56787 — Billing and Coding: Nonvascular Extremity Ultrasound
J06
L33619 — Nonvascular Extremity Ultrasound
J06
Related Codes
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