S72.026B — Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open fracture type I or II
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, legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient's care.
- 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.
- The ordering/referring physician/nonphysician practitioner must state the reason for the duplex scan in the order and provide relevant diagnostic information to the performing provider.
Key Coverage Criteria
- Duplex scan of lower extremity arteries is covered when medically necessary per LCD L33667, with the ordering/referring provider documenting signs and symptoms, relevant history (including known diagnoses and/or prior imaging) supporting evaluation of lower extremity arterial disease.
- 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.
4 Active Policies
A57064 — Billing and Coding: Duplex Scan of Lower Extremity Arteries
J09
A57765 — Billing and Coding: Major Joint Replacement (Hip and Knee)
J09
L33618 — Major Joint Replacement (Hip and Knee)
J09
L33667 — Duplex Scan Of Lower Extremity Arteries
J09
Related Codes
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