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ICD-10-CM S02.11ES, Type III occipital condyle fracture, right side, sequela | No Prior Auth

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`S02.11ES`, Type III occipital condyle fracture, right side, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.

Key Coverage Criteria

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.

2 Active Policies

A56612, Billing and Coding: CT of the Head

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

Related Codes

A17.0(2 policies)A17.81(2 policies)A06.6(2 policies)70450(2 policies)70460(2 policies)A17.1(2 policies)70470(2 policies)A17.82(2 policies)

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Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.