Does Z96.659 require prior authorization?

No, Z96.659 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z96.659`, Presence of unspecified artificial knee joint

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium 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.

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.

10 Active Policies

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

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

NOVITAS-JH-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

NOVITAS-JL-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

A56796, Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)

AETNA-CPB-0204, Manipulation Under General Anesthesia

AETNA-CPB-0100, Cryoablation

ANTHEM-SURG.00142, Genicular Procedures for Treatment of Knee Pain

AETNA-CPB-0676, Electrical Stimulation for Nausea, Vomiting, Motion Sickness and Other Selected Indications

A53064, Billing and Coding: Outpatient Occupational Therapy

`Z96.659`, Presence of unspecified artificial knee joint

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

Z96.659, Presence of unspecified artificial knee joint

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

`Z96.659`, Presence of unspecified artificial knee joint