Does S32.616D require prior authorization?

No, S32.616D does not require prior authorization (high confidence). Covered without prior authorization.

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`S32.616D`, Nondisplaced avulsion fracture of unspecified ischium, subsequent encounter for fracture with routine healing

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For CPT 97032, document the type of electrical stimulation (including 'manual'/'attended'), area(s) treated, and if used for muscle weakness provide objective strength ratings and functional deficits; if used for pain provide pain rating, pain location, and effect on function.
For HCPCS G0283, document the type of electrical stimulation (e.g., TENS, IFC), area(s) treated, and objective/subjective measures showing impact on pain intensity/location/functional impact and/or swelling.
For non-implantable pelvic floor stimulation, document cognitive intactness, patient motivation, and a failed documented trial of PME training (defined as no clinically significant improvement after 4 weeks of an ordered PME plan).

For wound-related modalities (HCPCS G0281, G0329), document that the ulcer (stage III/IV pressure, arterial, diabetic, venous stasis) has not demonstrated measurable signs of healing after 30 days of conventional care and include wound measurements and treatment history.

If electrical stimulation is used beyond 12 visits as adjunctive therapy or for muscle retraining, documentation must clearly support medical necessity for continued use and improvement in function.

All documentation must be maintained in the patient's medical record, be legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner.

Key Coverage Criteria

Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.
Electromagnetic therapy (HCPCS G0329) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
Unattended electrical stimulation for wound management (HCPCS G0281) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that have not shown measurable healing after 30 days of conventional care.
Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.

3 Active Policies

FIRST_COAST-L33618, Major Joint Replacement (Hip and Knee)

A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

A53065, Billing and Coding: Outpatient Physical Therapy

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S32.616D, Nondisplaced avulsion fracture of unspecified ischium, subsequent encounter for fracture with routine healing