Does S42.434A require prior authorization?

No, S42.434A does not require prior authorization (high confidence). Covered without prior authorization.

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`S42.434A`, Nondisplaced fracture (avulsion) of lateral epicondyle of right humerus, initial encounter for closed fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

A valid, written, physician-signed and dated plan of treatment must be established prior to provision of physical therapy and must outline type, amount, frequency, duration, functional diagnosis deficits, and anticipated short- and long-term goals.
Services must be ordered by a physician and the order must be documented in the medical record.
Treatment notes must be completed per visit, be legible, objectively document findings (e.g., numeric pain scores), relate to established goals, reflect all services billed, and use consistent symbols/acronyms or provide a legend.

Signature requirements: documentation must bear a legible identity (handwritten or electronic per state law) and the individual whose name appears is responsible for authenticity.

Refer to Medicare Benefit Policy Manual (Pub 100-02), Chapter 7, Section 40.2 and applicable CPT/HCPCS code documentation guidance on CMS website; review Federal Register update CMSA 1510-F for recent documentation changes.

Key Coverage Criteria

Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
Beneficiary is under the care of a physician.
Beneficiary is receiving services under a plan of care that is established and periodically reviewed by a physician.
Beneficiary needs skilled nursing care on an intermittent basis, or physical therapy, or speech-language pathology, or has a continued need for occupational therapy.
Physical therapy services ordered by a physician and provided by a qualified physical therapist or under the general supervision of a qualified physical therapist are covered when reasonable and necessary to treat illness/injury or to restore or maintain function.
Physical therapy services provided as a result of a valid written, physician-signed and dated plan of treatment established prior to provision that specifies type, amount, frequency, duration, functional diagnosis deficits, and short- and long-term goals are covered.

1 Active Policy

A57311, Billing and Coding: Physical Therapy - Home Health

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S42.434A, Nondisplaced fracture (avulsion) of lateral epicondyle of right humerus, initial encounter for closed fracture