About this policy
The following coding and billing guidance is to be used with its associated Local coverage determination. Other requirements The medical record documentation must support the medical necessity of the services as directed in this policy. All documentation must be maintained in the patient’s medical record and available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). Documentation must support CMS ‘signature requirements’ as described in the Medicare Program Integrity Manual (Pub. 100-08), Chapter 3. A pre-operative exam and operative report must be available. The submitted medical record must support the use of the selected ICD10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
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 |
|---|---|---|
| 15822 | HCPCS | Covered |
| 15823 | HCPCS | Covered |
| 67900 | HCPCS | Covered |
| 67901 | HCPCS | Covered |
| 67902 | HCPCS | Covered |
| 67903 | HCPCS | Covered |
| 67904 | HCPCS | Covered |
| 67906 | HCPCS | Covered |
| 67908 | HCPCS | Covered |
| 67909 | HCPCS | Covered |
| H02.31 | ICD10CM | Covered |
| H02.34 | ICD10CM | Covered |
| H02.401 | ICD10CM | Covered |
| H02.402 | ICD10CM | Covered |