Does M84.68XA require prior authorization?

No, M84.68XA 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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`M84.68XA`, Pathological fracture in other disease, other site, initial encounter for fracture

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

All services ordered or rendered to Medicare beneficiaries must be signed; providers/suppliers must notify beneficiaries in writing prior to rendering the service if aware the test/item/procedure may not be covered.
A valid ICD-10-CM diagnosis code that best describes the patient's condition must be reported on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Key Coverage Criteria

Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
A DXA confirmatory test may be performed and covered as a baseline for future monitoring (exception to the 'one type only' rule).
CPT code 77082 (vertebral fracture assessment) is covered when medically necessary, with symptoms documented and when results are anticipated to be used in patient management.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.

15 Active Policies

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

WPS-J5-L34623, Intraoperative Neurophysiological Testing

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

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

WPS-J8-L34623, Intraoperative Neurophysiological Testing

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

A57132, Billing and Coding: Bone Mass Measurement

A57206, Billing and Coding: Lumbar MRI

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59040, Billing and Coding: Bone Mass Measurement

`M84.68XA`, Pathological fracture in other disease, other site, initial encounter for fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

15 Active Policies

Related Codes

Have a follow-up question?

M84.68XA, Pathological fracture in other disease, other site, initial encounter for fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

15 Active Policies

Related Codes

Have a follow-up question?

`M84.68XA`, Pathological fracture in other disease, other site, initial encounter for fracture