SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

A57431

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57431
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
Article Type
Billing and Coding
Original Effective Date
10/10/2019
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.


Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See Indications and Limitations of Coverage section) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Medical record documentation must be available to Medicare upon request.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(19 Codes)
Group 1 Paragraph

The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the determination.

Group 1 Codes
Code Description
M43.27 Fusion of spine, lumbosacral region
M43.28 Fusion of spine, sacral and sacrococcygeal region
M46.1 Sacroiliitis, not elsewhere classified
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M53.2X7 Spinal instabilities, lumbosacral region
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M53.3 Sacrococcygeal disorders, not elsewhere classified
M53.87 Other specified dorsopathies, lumbosacral region
M53.88 Other specified dorsopathies, sacral and sacrococcygeal region
M99.14 Subluxation complex (vertebral) of sacral region
S33.2XXA Dislocation of sacroiliac and sacrococcygeal joint, initial encounter
S33.2XXD Dislocation of sacroiliac and sacrococcygeal joint, subsequent encounter
S33.2XXS Dislocation of sacroiliac and sacrococcygeal joint, sequela
S33.6XXA Sprain of sacroiliac joint, initial encounter
S33.6XXD Sprain of sacroiliac joint, subsequent encounter
S33.6XXS Sprain of sacroiliac joint, sequela
S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter
S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter
S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

Any ICD-10-CM diagnosis code not listed in the ICD-10-CM Code that supports medical necessity section

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/20/2023 10/10/2019 - N/A Currently in Effect View
10/04/2019 10/10/2019 - N/A Superseded You are here

Keywords

  • iFuse