Does S12.091S require prior authorization?

No, S12.091S does not require prior authorization (high confidence). Covered without prior authorization.

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`S12.091S`, Other nondisplaced fracture of first cervical vertebra, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

An updated and completed OASIS M2200 for the billing period must be in the patient's medical record and made available to the Medicare Administrative Contractor upon request to support medical necessity for therapy services.
Medical records must document which modalities and specific procedures were performed for each therapy visit and be available to the MAC upon request.
When multiple heating modalities are provided the same date of service, documentation of the medical necessity for multiple modalities must be present in the medical record.

Key Coverage Criteria

Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.
Therapeutic exercise (CPT 97110) is covered when used to address impairments of exercise tolerance due to cardiopulmonary impairments.
Range of motion testing (CPT 95851) may be used for extremity ROM when every joint of the extremity is tested and documentation explains why such comprehensive assessment was warranted.
Occupational therapists may recertify home health patients under a plan of care if services meet CMS occupational therapy definitions and the patient's home health eligibility is established by prior need for skilled nursing (not solely venipuncture), speech-language pathology, or physical therapy in the current or prior certification period.

20 Active Policies

CGS-J15-L39741, Cervical Fusion

J15

CGS-J18-L39741, Cervical Fusion

J18

WPS-J5-L39788, Cervical Fusion

A59664, Billing and Coding: Cervical Fusion

NGS-J6-L39770, Cervical Fusion

A59632, Billing and Coding: Cervical Fusion

WPS-J8-L39788, Cervical Fusion

A59674, Billing and Coding: Cervical Fusion

FIRST_COAST-L39799, Cervical Fusion

NOVITAS-JH-L39793, Cervical Fusion

NGS-JK-L39770, Cervical Fusion

NOVITAS-JL-L39793, Cervical Fusion

A59668, Billing and Coding: Cervical Fusion

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

A57311, Billing and Coding: Physical Therapy - Home Health

A53057, Billing and Coding: Home Health Occupational Therapy

A59624, Billing and Coding: Cervical Fusion

A59634, Billing and Coding: Cervical Fusion

A59608, Billing and Coding: Cervical Fusion

A53058, Billing and Coding: Home Health Physical Therapy

`S12.091S`, Other nondisplaced fracture of first cervical vertebra, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

S12.091S, Other nondisplaced fracture of first cervical vertebra, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`S12.091S`, Other nondisplaced fracture of first cervical vertebra, sequela