Does S22.038B require prior authorization?

No, S22.038B does not require prior authorization (high confidence). Covered without prior authorization.

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`S22.038B`, Other fracture of third thoracic vertebra, initial encounter for open fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
Billing and coding for immunizations must follow the coverage indications, limitations, and medical necessity criteria set forth in the associated Local Coverage Determination LCD L34596 (Immunizations).
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.

The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.

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.
Tetanus immunization is covered when given for a wound or documented direct exposure to Clostridium tetani (injury-related or exposure-related prophylaxis).
Tetanus immunization is covered when given for an injury or direct exposure to tetanus (i.e., wound management or exposure prophylaxis).

13 Active Policies

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

WPS-J5-L34596, Immunizations

A56900, Billing and Coding: Immunizations

WPS-J8-L34596, Immunizations

A58873, Billing and Coding: Tetanus Immunization

NOVITAS-JH-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

NOVITAS-JL-L35434, Oximetry Services

A58872, Billing and Coding: Tetanus Immunization

A59040, Billing and Coding: Bone Mass Measurement

A56580, Billing and Coding: Computerized Axial Tomography (CT), Thorax

A57132, Billing and Coding: Bone Mass Measurement

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S22.038B, Other fracture of third thoracic vertebra, initial encounter for open fracture