SUPERSEDED LCD Reference Article Article

Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees

A54063

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54063
Original ICD-9 Article ID
A53751
Article Title
Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
04/09/2018
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

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Article Guidance

Article Text

This article is being published to update the provider community on coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees.

National Coverage Determination (NCD) 150.9 issued in 2004 describes Medicare coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees. In this NCD, non-covered indications are:

    • Arthroscopic lavage used alone for the osteoarthritic knee
    • Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,
    • Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis


CPT 29871 – Arthroscopy, knee, surgical; for infection, lavage and drainage is used to describe the service covered by NCD 150.9.

All other indications for coverage of arthroscopic lavage remain at Contractor discretion.

Resources:
NCD 150.9 Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
CMS Change Request 3281

Response To Comments

Number Comment Response
1
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Coding Information

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.

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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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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that are Covered

Group 1

(18 Codes)
Group 1 Paragraph

Diagnoses determined by Noridian to be covered for this procedure are:

Group 1 Codes
Code Description
A18.02 Tuberculous arthritis of other joints
A39.83 Meningococcal arthritis
A39.84 Postmeningococcal arthritis
A54.42 Gonococcal arthritis
M00.061 Staphylococcal arthritis, right knee
M00.062 Staphylococcal arthritis, left knee
M00.069 Staphylococcal arthritis, unspecified knee
M00.161 Pneumococcal arthritis, right knee
M00.162 Pneumococcal arthritis, left knee
M00.261 Other streptococcal arthritis, right knee
M00.262 Other streptococcal arthritis, left knee
M00.269 Other streptococcal arthritis, unspecified knee
M00.861 Arthritis due to other bacteria, right knee
M00.862 Arthritis due to other bacteria, left knee
M00.869 Arthritis due to other bacteria, unspecified knee
M01.X61 Direct infection of right knee in infectious and parasitic diseases classified elsewhere
M01.X62 Direct infection of left knee in infectious and parasitic diseases classified elsewhere
M01.X69 Direct infection of unspecified knee in infectious and parasitic diseases classified elsewhere
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ICD-10-CM Codes that are Not Covered

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

N/A

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
04/09/2018 R2

Jurisdiction F Part B (JFB) Article number A54063 revised to combine the Jurisdiction F Part A (JEA) Article A54062 contract number so that both JFA and JFB will have the same final Medicare Coverage Database (MCD) Article number A54063 effective 04/09/18. No change in coverage was made.

10/01/2015 R1 The article is revised to remove ICD-9-CM codes in the article text section and remove ICD10 codes M02.861, M02.862, and M02.869 added in error.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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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
11/08/2023 04/09/2018 - N/A Currently in Effect View
09/29/2020 04/09/2018 - N/A Superseded View
03/27/2018 04/09/2018 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • 29871
  • osteoarthritis
  • arthroscopy
  • lavage
  • debridement