T87.30 — Neuroma of amputation stump, unspecified extremity
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Maintain all documentation in the patient's medical record and make it available to the contractor upon request; every page must be legible and include patient identifiers (complete name, dates of service).
- Medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the 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.
- Documentation should state whether the block was performed for diagnostic or therapeutic purposes.
Key Coverage Criteria
- Peripheral nerve blocks are covered when they meet the reasonable and necessary requirements specified in LCD L33933.
- Peripheral nerve block is reasonable when the patient's pain appears due to a classic mononeuritis but neuro-diagnostic studies fail to provide a structural explanation.
- Peripheral nerve blocks are reasonable for peripheral nerve injuries/entrapment or extremity trauma that lead to complex regional pain syndrome (CRPS).
- Selective peripheral nerve blockade is reasonable diagnostically when the clinical picture is unclear to isolate the specific pain source.
- Occipital nerve block is reasonable to confirm suspected occipital neuralgia (used diagnostically and therapeutically).
- Suprascapular nerve block is reasonable to confirm suspected suprascapular nerve entrapment producing shoulder pain and weakness.
5 Active Policies
AETNA-CPB-0100 — Cryoablation
AETNA-CPB-0630 — Prosthetic Limb Vacuum Systems
AETNA-CPB-0639 — Autotransfusers
A57788 — Billing and Coding: Peripheral Nerve Blocks
L33933 — Peripheral Nerve Blocks
Related Codes
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