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ICD-10-CM T84.018A, Broken internal joint prosthesis, other site, initial encounter | No Prior Auth

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`T84.018A`, Broken internal joint prosthesis, other site, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.
The documentation must clearly support the ICD-10-CM code(s) reported on the claim.
An attending or treating physician's order, properly signed and dated, is required for each lumbar MRI test.

Radiologists and ordering physicians must include sufficient clinical information in the MRI report to justify necessity; the MRI report or clinical record must document clinical findings and relevant prior treatment.

The referring physician's medical record must support any contemplated diagnosis or treatment change derived from MRI findings and must be made available to the contractor upon request.

The contractor may request medical records from the referring physician if the radiologist's documentation does not validate that the service is reasonable and necessary.

Key Coverage Criteria

Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
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.

2 Active Policies

A57206, Billing and Coding: Lumbar MRI

A57311, Billing and Coding: Physical Therapy - Home Health

Related Codes

G54.1(2 policies)G57.01(2 policies)G04.1(2 policies)G14(2 policies)G54.4(2 policies)G54.5(2 policies)B91(2 policies)G57.02(2 policies)

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