Does M25.59 require prior authorization?

No, M25.59 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M25.59`, Pain in other specified joint

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Claims and documentation requirements for CPNB are governed by and must follow the Local Coverage Determination L37641 referenced by this guideline.
When billing CPT 95905 for carpal tunnel, the diagnosis code must be G56.01 or G56.02.
Data gathered during NCS should be available to support the claim, although it is not necessary to include documentation with every claim submission.
Providers are expected to use CPT 95870 for sampling muscles other than paraspinals associated with tested extremities; CPT 95870 should not be billed for paraspinal sampling when extremity EMG codes 95860, 95861, 95863, or 95864 are also billed.

Key Coverage Criteria

No specific coverage indications are stated in this billing/coding guideline; refer to Local Coverage Determination L37641 for covered indications for continuous peripheral nerve blocks (CPNB).
Automated nerve conduction testing using the NC-stat (CPT 95905) is allowed only when there is a high pre-test or prior probability of carpal tunnel syndrome and the claim uses diagnosis code G56.01 or G56.02; allowed one service per arm.
If authorized by state law, physical therapists (PTs) are allowed to perform the technical and professional components of nerve conduction studies represented by CPT codes 95907-95913 consistent with a 7A supervision designation (effective 01/01/2013).
If authorized by state law, the technical component of neuromuscular junction testing CPT 95937 (TC) with supervision designation 7A is allowable for PTs consistent with the 7A description (effective 01/01/2013).
Needle electromyography CPT codes 95860-95872 and 95885-95887 have a 6A designation for the technical portion; PTs who are ABPTS-certified as qualified electrophysiologic clinical specialists and are authorized by state law may perform the technical and professional components according to the 6A description.
Electrodiagnostic nerve conduction studies and electromyography that provide real-time response parameters (amplitude, latency, configuration, conduction velocity) are acceptable for Medicare payment and should be used for provider interpretation.

20 Active Policies

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L36029, Urine Drug Testing

J18

WPS-J5-L34645, Urine Drug Testing

A56915, Billing and Coding: Urine Drug Testing

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

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M25.59, Pain in other specified joint