Documentation requirements
medical_necessity_and_claims
medical_record_content
physical_exam_requirements_PART
claim_content_requirements
signatures_and_ABN
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 98940 | HCPCS | Covered |
| 98941 | HCPCS | Covered |
| 98942 | HCPCS | Covered |
| 98943 | HCPCS | Covered |
| G43.009 | ICD10CM | Covered |
| G43.019 | ICD10CM | Covered |
| G43.109 | ICD10CM | Covered |
| G43.119 | ICD10CM | Covered |
| G43.909 | ICD10CM | Covered |
| G43.919 | ICD10CM | Covered |
| G43.A0 | ICD10CM | Covered |
| G43.A1 | ICD10CM | Covered |
| G43.B0 | ICD10CM | Covered |
| G43.B1 | ICD10CM | Covered |
| G43.C0 | ICD10CM | Covered |
| G43.C1 | ICD10CM | Covered |
| G43.D0 | ICD10CM | Covered |
| G43.D1 | ICD10CM | Covered |
| G44.1 | ICD10CM | Covered |
| G44.209 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G54.1 | ICD10CM | Covered |
| G54.2 | ICD10CM | Covered |
| G54.3 | ICD10CM | Covered |
| G54.4 | ICD10CM | Covered |
| G54.8 | ICD10CM | Covered |
| G55 | ICD10CM | Covered |
| G57.01 | ICD10CM | Covered |
| G57.02 | ICD10CM | Covered |
| G57.03 | ICD10CM | Covered |
| G57.21 | ICD10CM | Covered |
| G57.22 | ICD10CM | Covered |
| G57.23 | ICD10CM | Covered |
| G57.91 | ICD10CM | Covered |
| G57.92 | ICD10CM | Covered |
| G57.93 | ICD10CM | Covered |
| M12.311 | ICD10CM | Covered |
| M12.312 | ICD10CM | Covered |
| M12.351 | ICD10CM | Covered |
| M12.352 | ICD10CM | Covered |
| M12.361 | ICD10CM | Covered |
| M12.362 | ICD10CM | Covered |
| M12.371 | ICD10CM | Covered |
| M12.372 | ICD10CM | Covered |
| M12.38 | ICD10CM | Covered |
| M12.39 | ICD10CM | Covered |
| M12.411 | ICD10CM | Covered |
| M12.412 | ICD10CM | Covered |
| M12.451 | ICD10CM | Covered |
| M12.452 | ICD10CM | Covered |
| M12.461 | ICD10CM | Covered |
| M12.462 | ICD10CM | Covered |
| M12.471 | ICD10CM | Covered |
| M12.472 | ICD10CM | Covered |
| M12.48 | ICD10CM | Covered |
| M12.49 | ICD10CM | Covered |
| M15.4 | ICD10CM | Covered |
| M15.8 | ICD10CM | Covered |
| M16.0 | ICD10CM | Covered |
| M16.11 | ICD10CM | Covered |
| M16.12 | ICD10CM | Covered |
| M25.011 | ICD10CM | Covered |
| M25.012 | ICD10CM | Covered |
| M25.051 | ICD10CM | Covered |
| M25.052 | ICD10CM | Covered |
| M25.061 | ICD10CM | Covered |
| M25.062 | ICD10CM | Covered |
| M25.071 | ICD10CM | Covered |
| M25.072 | ICD10CM | Covered |
| M25.074 | ICD10CM | Covered |
| M25.075 | ICD10CM | Covered |
| M25.08 | ICD10CM | Covered |
| M25.451 | ICD10CM | Covered |
| M25.452 | ICD10CM | Covered |
| M25.461 | ICD10CM | Covered |
| M25.462 | ICD10CM | Covered |
| M25.471 | ICD10CM | Covered |
| M25.472 | ICD10CM | Covered |
| M25.474 | ICD10CM | Covered |
| M25.475 | ICD10CM | Covered |
| M25.511 | ICD10CM | Covered |
| M25.512 | ICD10CM | Covered |
| M25.551 | ICD10CM | Covered |
| M25.552 | ICD10CM | Covered |
| M25.561 | ICD10CM | Covered |
| M25.562 | ICD10CM | Covered |
| M25.571 | ICD10CM | Covered |
| M25.572 | ICD10CM | Covered |
| M25.611 | ICD10CM | Covered |
| M25.612 | ICD10CM | Covered |
| M25.651 | ICD10CM | Covered |
| M25.652 | ICD10CM | Covered |
| M25.661 | ICD10CM | Covered |
| M25.662 | ICD10CM | Covered |
| M25.671 | ICD10CM | Covered |
| M25.672 | ICD10CM | Covered |
| M25.674 | ICD10CM | Covered |
| M25.675 | ICD10CM | Covered |
| M25.811 | ICD10CM | Covered |
| M25.812 | ICD10CM | Covered |
| M25.851 | ICD10CM | Covered |
| M25.852 | ICD10CM | Covered |
| M25.861 | ICD10CM | Covered |
| M25.862 | ICD10CM | Covered |
| M25.871 | ICD10CM | Covered |
| M25.872 | ICD10CM | Covered |
| M43.01 | ICD10CM | Covered |
| M43.02 | ICD10CM | Covered |
| M43.03 | ICD10CM | Covered |
| M43.04 | ICD10CM | Covered |
| M43.05 | ICD10CM | Covered |
| M43.06 | ICD10CM | Covered |
| M43.07 | ICD10CM | Covered |
| M43.08 | ICD10CM | Covered |
| M43.09 | ICD10CM | Covered |
| M43.11 | ICD10CM | Covered |
| M43.12 | ICD10CM | Covered |
| M43.13 | ICD10CM | Covered |
| M43.14 | ICD10CM | Covered |
| M43.15 | ICD10CM | Covered |
| M43.16 | ICD10CM | Covered |
| M43.17 | ICD10CM | Covered |
| M43.18 | ICD10CM | Covered |
| M43.19 | ICD10CM | Covered |
| M43.27 | ICD10CM | Covered |
| M43.28 | ICD10CM | Covered |
| M43.6 | ICD10CM | Covered |
| M46.01 | ICD10CM | Covered |
| M46.02 | ICD10CM | Covered |
| M46.03 | ICD10CM | Covered |
| M46.04 | ICD10CM | Covered |
| M46.05 | ICD10CM | Covered |
| M46.06 | ICD10CM | Covered |
| M46.07 | ICD10CM | Covered |
| M46.08 | ICD10CM | Covered |
| M46.09 | ICD10CM | Covered |
| M46.41 | ICD10CM | Covered |
| M46.42 | ICD10CM | Covered |
| M46.43 | ICD10CM | Covered |
| M46.44 | ICD10CM | Covered |
| M46.45 | ICD10CM | Covered |
| M46.46 | ICD10CM | Covered |
| M46.47 | ICD10CM | Covered |
| M47.24 | ICD10CM | Covered |
| M47.25 | ICD10CM | Covered |
| M47.26 | ICD10CM | Covered |
| M47.27 | ICD10CM | Covered |
| M47.28 | ICD10CM | Covered |
| M47.811 | ICD10CM | Covered |
| M47.812 | ICD10CM | Covered |
| M47.813 | ICD10CM | Covered |
| M47.814 | ICD10CM | Covered |
| M47.815 | ICD10CM | Covered |
| M47.816 | ICD10CM | Covered |
| M47.817 | ICD10CM | Covered |
| M47.818 | ICD10CM | Covered |
| M48.01 | ICD10CM | Covered |
| M48.02 | ICD10CM | Covered |
| M48.03 | ICD10CM | Covered |
| M48.04 | ICD10CM | Covered |
| M48.05 | ICD10CM | Covered |
| M48.061 | ICD10CM | Covered |
| M48.062 | ICD10CM | Covered |
| M48.07 | ICD10CM | Covered |
| M48.11 | ICD10CM | Covered |
| M48.12 | ICD10CM | Covered |
| M48.13 | ICD10CM | Covered |
| M48.14 | ICD10CM | Covered |
| M48.15 | ICD10CM | Covered |
| M48.16 | ICD10CM | Covered |
| M48.17 | ICD10CM | Covered |
| M48.18 | ICD10CM | Covered |
| M48.19 | ICD10CM | Covered |
| M48.31 | ICD10CM | Covered |
| M48.32 | ICD10CM | Covered |
| M48.33 | ICD10CM | Covered |
| M48.34 | ICD10CM | Covered |
| M48.35 | ICD10CM | Covered |
| M48.36 | ICD10CM | Covered |
| M48.37 | ICD10CM | Covered |
| M48.38 | ICD10CM | Covered |
| M50.11 | ICD10CM | Covered |
| M50.120 | ICD10CM | Covered |
| M50.121 | ICD10CM | Covered |
| M50.122 | ICD10CM | Covered |
| M50.123 | ICD10CM | Covered |
| M50.13 | ICD10CM | Covered |
| M50.21 | ICD10CM | Covered |
| M50.220 | ICD10CM | Covered |
| M50.221 | ICD10CM | Covered |
| M50.222 | ICD10CM | Covered |
| M50.223 | ICD10CM | Covered |
| M50.23 | ICD10CM | Covered |
| M50.31 | ICD10CM | Covered |
| M50.320 | ICD10CM | Covered |
| M50.321 | ICD10CM | Covered |
| M50.322 | ICD10CM | Covered |
| M50.323 | ICD10CM | Covered |
| M50.33 | ICD10CM | Covered |
| M50.81 | ICD10CM | Covered |
| M50.820 | ICD10CM | Covered |
| M50.821 | ICD10CM | Covered |
| M50.822 | ICD10CM | Covered |
| M50.823 | ICD10CM | Covered |
| M50.83 | ICD10CM | Covered |
| M50.91 | ICD10CM | Covered |
| M50.920 | ICD10CM | Covered |
| M50.921 | ICD10CM | Covered |
| M50.922 | ICD10CM | Covered |
| M50.923 | ICD10CM | Covered |
| M50.93 | ICD10CM | Covered |
| M51.14 | ICD10CM | Covered |
| M51.15 | ICD10CM | Covered |
| M51.16 | ICD10CM | Covered |
| M51.17 | ICD10CM | Covered |
| M51.24 | ICD10CM | Covered |
| M51.25 | ICD10CM | Covered |
| M51.26 | ICD10CM | Covered |
| M51.27 | ICD10CM | Covered |
| M51.34 | ICD10CM | Covered |
| M51.35 | ICD10CM | Covered |
| M51.360 | ICD10CM | Covered |
| M51.361 | ICD10CM | Covered |
| M51.362 | ICD10CM | Covered |
| M51.370 | ICD10CM | Covered |
| M51.371 | ICD10CM | Covered |
| M51.372 | ICD10CM | Covered |
| M51.84 | ICD10CM | Covered |
| M51.85 | ICD10CM | Covered |
| M51.86 | ICD10CM | Covered |
| M51.87 | ICD10CM | Covered |
| M53.0 | ICD10CM | Covered |
| M53.1 | ICD10CM | Covered |
| M53.2X7 | ICD10CM | Covered |
| M53.2X8 | ICD10CM | Covered |
| M53.86 | ICD10CM | Covered |
| M53.87 | ICD10CM | Covered |
| M53.88 | ICD10CM | Covered |
| M54.11 | ICD10CM | Covered |
| M54.12 | ICD10CM | Covered |
| M54.13 | ICD10CM | Covered |
| M54.14 | ICD10CM | Covered |
| M54.15 | ICD10CM | Covered |
| M54.16 | ICD10CM | Covered |
| M54.17 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| M54.31 | ICD10CM | Covered |
| M54.32 | ICD10CM | Covered |
| M54.41 | ICD10CM | Covered |
| M54.42 | ICD10CM | Covered |
| M54.50 | ICD10CM | Covered |
| M54.51 | ICD10CM | Covered |
| M54.59 | ICD10CM | Covered |
| M54.6 | ICD10CM | Covered |
| M60.811 | ICD10CM | Covered |
| M60.812 | ICD10CM | Covered |
| M60.851 | ICD10CM | Covered |
| M60.852 | ICD10CM | Covered |
| M60.861 | ICD10CM | Covered |
| M60.862 | ICD10CM | Covered |
| M60.871 | ICD10CM | Covered |
| M60.872 | ICD10CM | Covered |
| M60.88 | ICD10CM | Covered |
| M60.89 | ICD10CM | Covered |
| M62.49 | ICD10CM | Covered |
| M62.830 | ICD10CM | Covered |
| M62.838 | ICD10CM | Covered |
| M62.85 | ICD10CM | Covered |
| M79.11 | ICD10CM | Covered |
| M79.12 | ICD10CM | Covered |
| M79.18 | ICD10CM | Covered |
| M79.7 | ICD10CM | Covered |
| M96.1 | ICD10CM | Covered |
| M99.00 | ICD10CM | Covered |
| M99.01 | ICD10CM | Covered |
| M99.02 | ICD10CM | Covered |
| M99.03 | ICD10CM | Covered |
| M99.04 | ICD10CM | Covered |
| M99.05 | ICD10CM | Covered |
| M99.20 | ICD10CM | Covered |
| M99.21 | ICD10CM | Covered |
| M99.22 | ICD10CM | Covered |
| M99.23 | ICD10CM | Covered |
| M99.30 | ICD10CM | Covered |
| M99.31 | ICD10CM | Covered |
| M99.32 | ICD10CM | Covered |
| M99.33 | ICD10CM | Covered |
| M99.40 | ICD10CM | Covered |
| M99.41 | ICD10CM | Covered |
| M99.42 | ICD10CM | Covered |
| M99.43 | ICD10CM | Covered |
| M99.50 | ICD10CM | Covered |
| M99.51 | ICD10CM | Covered |
| M99.52 | ICD10CM | Covered |
| M99.53 | ICD10CM | Covered |
| M99.60 | ICD10CM | Covered |
| M99.61 | ICD10CM | Covered |
| M99.62 | ICD10CM | Covered |
| M99.63 | ICD10CM | Covered |
| M99.70 | ICD10CM | Covered |
| M99.71 | ICD10CM | Covered |
| M99.72 | ICD10CM | Covered |
| M99.73 | ICD10CM | Covered |
| Q76.2 | ICD10CM | Covered |
| R26.2 | ICD10CM | Covered |
| R29.4 | ICD10CM | Covered |
| R51.0 | ICD10CM | Covered |
| R51.9 | ICD10CM | Covered |
| S13.4XXA | ICD10CM | Covered |
| S13.8XXA | ICD10CM | Covered |
| S16.1XXA | ICD10CM | Covered |
| S23.3XXA | ICD10CM | Covered |
| S23.8XXA | ICD10CM | Covered |
| S29.012A | ICD10CM | Covered |
| S33.5XXA | ICD10CM | Covered |
| S33.6XXA | ICD10CM | Covered |
| S33.8XXA | ICD10CM | Covered |
| S39.012A | ICD10CM | Covered |
| S39.013A | ICD10CM | Covered |