About this policy
The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L36000 Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain. Documentation Requirements 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)). The record must include the name of the physician or non-physician practitioner responsible for and providing the care of the patient.
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 |
|---|---|---|
| 27279 | HCPCS | Covered |
| M43.18 | ICD10CM | Covered |
| M46.1 | ICD10CM | Covered |
| M53.3 | ICD10CM | Covered |
| M53.88 | ICD10CM | Covered |
| M99.04 | ICD10CM | Covered |
| Q74.2 | ICD10CM | Covered |
| S33.2XXA | ICD10CM | Covered |
| S33.2XXD | ICD10CM | Covered |
| S33.2XXS | ICD10CM | Covered |
| S33.6XXD | ICD10CM | Covered |
| S33.6XXS | ICD10CM | Covered |