T85.613A — Breakdown (mechanical) of artificial skin graft and decellularized allodermis, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.
- The documentation must clearly support the ICD-10-CM code(s) reported on the claim.
- An attending or treating physician's order, properly signed and dated, is required for each lumbar MRI test.
- Radiologists and ordering physicians must include sufficient clinical information in the MRI report to justify necessity; the MRI report or clinical record must document clinical findings and relevant prior treatment.
Key Coverage Criteria
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
- T82.535S | Leakage of umbrella device, sequela
- M84.38XP | Stress fracture, other site, subsequent encounter for fracture with malunion
- M84.38XS | Stress fracture, other site, sequela
5 Active Policies
A57207 — Billing and Coding: Lumbar MRI
AETNA-CPB-0175 — Pulsed Electromagnetic Stimulation
A57206 — Billing and Coding: Lumbar MRI
L34220 — Lumbar MRI
L37281 — Lumbar MRI
Related Codes
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