T84.060A — Wear of articular bearing surface of internal prosthetic right hip joint, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
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.
- 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.
14 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
L36007 — Lower Extremity Major Joint Replacement (Hip and Knee)
Related Codes
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