Does S72.426S require prior authorization?

No, S72.426S does not require prior authorization (high confidence). Covered without prior authorization.

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`S72.426S`, Nondisplaced fracture of lateral condyle of unspecified femur, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For wound-related modalities (G0281, G0329) document wound etiology and duration and prior treatments by physician, non-physician practitioner, nurse, and/or therapist (additional required wound documentation text truncated in source).
For 97032, document the type of electrical stimulation (specify 'manual' and 'attended'), area(s) treated, and when used for muscle weakness include objective strength ratings and functional deficits; when used for pain include pain rating, pain location, and effect of pain on function.
For non-implantable pelvic floor stimulation, document that the patient is cognitively intact and motivated, that a documented PME training trial was completed (4 weeks) with no clinically significant improvement, and that the nerve supply to the muscle is intact.

For G0283, document the type of electrical stimulation (e.g., TENS, IFC), area(s) treated, and objective/subjective measures of impact on pain intensity, pain location, function, and/or swelling.

Electrodes used with unattended electrical stimulation (G0283) are included in the practice expense and should not be billed separately to Medicare or the patient.

All documentation must be maintained in the patient's medical record, legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.

Key Coverage Criteria

CPT 97032 (attended/manual electrical stimulation) is covered when delivered with direct 1-on-1 contact by qualified personnel (examples: direct motor point stimulation; FES/NMES when performed with therapeutic exercise, neuromuscular reeducation, or functional activities).
CPT 97032 may be billed for the application, instruction, and adjustment of a TENS unit or other probe-based stimulation (including determining trigger points) when provided as an attended/manual modality.
Non-implantable pelvic floor electrical stimulation (97032 for probes; G0283 for electrode-based delivery) is covered for treatment of 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.
HCPCS G0283 (unattended/supervised electrical stimulation) is covered for non-wound-care indications as part of a therapy plan of care when delivered without constant direct contact after skilled application (examples: TENS, IFC, cyclical muscle stimulation).
HCPCS G0329 (electromagnetic therapy) is covered for chronic stage III/IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that show no measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
HCPCS G0281 (unattended electrical stimulation for wounds) is covered for chronic stage III/IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that are not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.

2 Active Policies

A57064, Billing and Coding: Duplex Scan of Lower Extremity Arteries

A53064, Billing and Coding: Outpatient Occupational Therapy

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S72.426S, Nondisplaced fracture of lateral condyle of unspecified femur, sequela