SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Urodynamics

A56802

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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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General Information

Source Article ID
N/A
Article ID
A56802
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Urodynamics
Article Type
Billing and Coding
Original Effective Date
09/19/2019
Revision Effective Date
10/05/2023
Revision Ending Date
11/15/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34056-Urodynamics.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

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.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Cystometrogram, simple/complex (CPT code 51725/51726)
is used to evaluate detrusor contractions and abnormalities of bladder compliance, to measure post-voiding residual, to determine bladder capacity and to detect DSD (detrusor sphincter dyssynergia). Normal results are expected in stress incontinence.
Complex cystometrogram involves the use of calibrated electronic equipment to measure intra-abdominal, total bladder, and true detrusor pressures simultaneously. Its purpose is to differentiate an involuntary detrusor contraction or reversed bladder compliance from an increase in intra-abdominal pressure. False positives may be a problem, especially in the elderly.

Uroflowmetry, simple/complex (CPT code 51736/51741)
measures the urine flow rate visually, electronically or with the use of a disposable unit. The flow rate reflects the combined activity of the detrusor muscle, bladder neck, and urethral function. Decreased flow rate may be due to poor detrusor function from, for example, neurologic lesions, obstructing BPH, or cystocele. Increased flow rate may indicate poor urethral function causing, for example, stress urinary incontinence (SUI) or intrinsic sphincter dysfunction (ISD).

Urethral pressure profile studies (CPT code 51727)
measure resting and dynamic pressures along the length of the urethra responsible for maintaining continence. This test has limited applications, e.g. artificial urinary sphincter. Urethral pressure studies should be reserved for those patients in whom other tests are inconclusive. The test is performed to rule out severe urethral incompetence.

Stimulus Evoked Response (CPT code 51792)
has a limited application in practical urology but can be used to evaluate cases of suspected cauda equina syndrome.

Voiding Pressure Studies (VP) (CPT code 51728/51729)
can measure detrusor contractility and detect outlet pressure obstruction if the patient is able to void. Simultaneous measurement of detrusor and urethral pressures during voiding is especially helpful in diagnosing urodynamic obstruction.

Intra-abdominal Voiding Pressure (AP) (CPT code 51797)
can contribute to the evaluation of true detrusor muscle function by accounting for any component of intra-abdominal pressure in the bladder pressure voiding curve.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.

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

Documentation must be available to Medicare upon request.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
074x Clinic - Outpatient Rehabilitation Facility (ORF)
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0360 Operating Room Services - General Classification
0402 Other Imaging Services - Ultrasound
045X Emergency Room - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
076X Specialty Services - General Classification
092X Other Diagnostic Services - General Classification
096X Professional Fees - General Classification
N/A

CPT/HCPCS Codes

Group 1

(9 Codes)
Group 1 Paragraph

CPT codes 51772 and 51795 were deleted 12/31/2009.

Group 1 Codes
Code Description
51725 SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER)
51726 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT);
51727 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH URETHRAL PRESSURE PROFILE STUDIES (IE, URETHRAL CLOSURE PRESSURE PROFILE), ANY TECHNIQUE
51728 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE), ANY TECHNIQUE
51729 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE) AND URETHRAL PRESSURE PROFILE STUDIES (IE, URETHRAL CLOSURE PRESSURE PROFILE), ANY TECHNIQUE
51736 SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH FLOW RATE, MECHANICAL UROFLOWMETER)
51741 COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC EQUIPMENT)
51792 STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF BULBOCAVERNOSUS REFLEX LATENCY TIME)
51797 VOIDING PRESSURE STUDIES, INTRA-ABDOMINAL (IE, RECTAL, GASTRIC, INTRAPERITONEAL) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(339 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code 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 this determination.

Group 1 Codes
Code Description
A18.13 Tuberculosis of other urinary organs
A52.11 - A52.17 Tabes dorsalis - General paresis
A52.19 Other symptomatic neurosyphilis
A52.3 Neurosyphilis, unspecified
A80.9 Acute poliomyelitis, unspecified
C61 Malignant neoplasm of prostate
C70.1 Malignant neoplasm of spinal meninges
C72.0 Malignant neoplasm of spinal cord
C72.1 Malignant neoplasm of cauda equina
C79.82 Secondary malignant neoplasm of genital organs
D29.1 Benign neoplasm of prostate
D33.4 Benign neoplasm of spinal cord
D40.0 Neoplasm of uncertain behavior of prostate
D49.4 Neoplasm of unspecified behavior of bladder
D49.511 Neoplasm of unspecified behavior of right kidney
D49.512 Neoplasm of unspecified behavior of left kidney
D49.59 Neoplasm of unspecified behavior of other genitourinary organ
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.40 - E10.44 Type 1 diabetes mellitus with diabetic neuropathy, unspecified - Type 1 diabetes mellitus with diabetic amyotrophy
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.65 Type 1 diabetes mellitus with hyperglycemia
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
E11.41 - E11.44 Type 2 diabetes mellitus with diabetic mononeuropathy - Type 2 diabetes mellitus with diabetic amyotrophy
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.65 Type 2 diabetes mellitus with hyperglycemia
F45.8 Other somatoform disorders
F98.0 Enuresis not due to a substance or known physiological condition
G04.1 Tropical spastic paraplegia
G04.90 Encephalitis and encephalomyelitis, unspecified
G04.91 Myelitis, unspecified
G12.21 Amyotrophic lateral sclerosis
G20.A1 Parkinson's disease without dyskinesia, without mention of fluctuations
G20.A2 Parkinson's disease without dyskinesia, with fluctuations
G20.B1 Parkinson's disease with dyskinesia, without mention of fluctuations
G20.B2 Parkinson's disease with dyskinesia, with fluctuations
G21.4 Vascular parkinsonism
G24.1 Genetic torsion dystonia
G35 Multiple sclerosis
G37.4 Subacute necrotizing myelitis of central nervous system
G60.9 Hereditary and idiopathic neuropathy, unspecified
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.50 - G82.54 Quadriplegia, unspecified - Quadriplegia, C5-C7 incomplete
G83.4 Cauda equina syndrome
M46.41 - M46.47 Discitis, unspecified, occipito-atlanto-axial region - Discitis, unspecified, lumbosacral region
M50.80 Other cervical disc disorders, unspecified cervical region
M50.81 Other cervical disc disorders, high cervical region
M50.821 Other cervical disc disorders at C4-C5 level
M50.822 Other cervical disc disorders at C5-C6 level
M50.823 Other cervical disc disorders at C6-C7 level
M50.83 Other cervical disc disorders, cervicothoracic region
M50.91 Cervical disc disorder, unspecified, high cervical region
M50.921 Unspecified cervical disc disorder at C4-C5 level
M50.922 Unspecified cervical disc disorder at C5-C6 level
M50.93 Cervical disc disorder, unspecified, cervicothoracic region
M51.84 - M51.87 Other intervertebral disc disorders, thoracic region - Other intervertebral disc disorders, lumbosacral region
N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified
N13.2 Hydronephrosis with renal and ureteral calculous obstruction
N13.39 Other hydronephrosis
N13.71 Vesicoureteral-reflux without reflux nephropathy
N13.721 Vesicoureteral-reflux with reflux nephropathy without hydroureter, unilateral
N13.731 Vesicoureteral-reflux with reflux nephropathy with hydroureter, unilateral
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N31.0 - N31.2 Uninhibited neuropathic bladder, not elsewhere classified - Flaccid neuropathic bladder, not elsewhere classified
N31.8 Other neuromuscular dysfunction of bladder
N32.0 Bladder-neck obstruction
N32.81 Overactive bladder
N35.010 - N35.013 Post-traumatic urethral stricture, male, meatal - Post-traumatic anterior urethral stricture
N35.016 Post-traumatic urethral stricture, male, overlapping sites
N35.021 Urethral stricture due to childbirth
N35.028 Other post-traumatic urethral stricture, female
N35.811 - N35.814 Other urethral stricture, male, meatal - Other anterior urethral stricture, male
N35.816 Other urethral stricture, male, overlapping sites
N35.82 Other urethral stricture, female
N36.0 Urethral fistula
N36.1 Urethral diverticulum
N36.41 - N36.44 Hypermobility of urethra - Muscular disorders of urethra
N36.8 Other specified disorders of urethra
N37 Urethral disorders in diseases classified elsewhere
N39.3 Stress incontinence (female) (male)
N39.41 - N39.46 Urge incontinence - Mixed incontinence
N39.490 Overflow incontinence
N39.498 Other specified urinary incontinence
N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms
N40.3 Nodular prostate with lower urinary tract symptoms
N42.81 - N42.83 Prostatodynia syndrome - Cyst of prostate
N42.89 Other specified disorders of prostate
N81.0 Urethrocele
N81.11 Cystocele, midline
N81.12 Cystocele, lateral
N81.6 Rectocele
N81.81 Perineocele
N81.9 Female genital prolapse, unspecified
N82.0 Vesicovaginal fistula
N82.1 Other female urinary-genital tract fistulae
N99.110 - N99.113 Postprocedural urethral stricture, male, meatal - Postprocedural anterior bulbous urethral stricture, male
N99.116 Postprocedural urethral stricture, male, overlapping sites
N99.12 Postprocedural urethral stricture, female
Q05.0 - Q05.3 Cervical spina bifida with hydrocephalus - Sacral spina bifida with hydrocephalus
Q05.5 - Q05.8 Cervical spina bifida without hydrocephalus - Sacral spina bifida without hydrocephalus
Q07.00 - Q07.03 Arnold-Chiari syndrome without spina bifida or hydrocephalus - Arnold-Chiari syndrome with spina bifida and hydrocephalus
Q62.11 Congenital occlusion of ureteropelvic junction
Q62.12 Congenital occlusion of ureterovesical orifice
Q62.2 Congenital megaureter
Q62.39 Other obstructive defects of renal pelvis and ureter
Q64.11 Supravesical fissure of urinary bladder
Q64.2 Congenital posterior urethral valves
Q64.31 - Q64.33 Congenital bladder neck obstruction - Congenital stricture of urinary meatus
Q64.5 Congenital absence of bladder and urethra
Q64.6 Congenital diverticulum of bladder
Q64.71 - Q64.75 Congenital prolapse of urethra - Double urinary meatus
R30.0 Dysuria
R32 Unspecified urinary incontinence
R33.0 Drug induced retention of urine
R33.8 Other retention of urine
R33.9 Retention of urine, unspecified
R34 Anuria and oliguria
R35.0 Frequency of micturition
R35.1 Nocturia
R39.11 - R39.14 Hesitancy of micturition - Feeling of incomplete bladder emptying
R39.16 Straining to void
S12.000A Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture
S12.000B Unspecified displaced fracture of first cervical vertebra, initial encounter for open fracture
S12.001A Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture
S12.001B Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for open fracture
S12.100A Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture
S12.100B Unspecified displaced fracture of second cervical vertebra, initial encounter for open fracture
S12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture
S12.101B Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for open fracture
S12.200A Unspecified displaced fracture of third cervical vertebra, initial encounter for closed fracture
S12.200B Unspecified displaced fracture of third cervical vertebra, initial encounter for open fracture
S12.201A Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for closed fracture
S12.201B Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for open fracture
S12.300A Unspecified displaced fracture of fourth cervical vertebra, initial encounter for closed fracture
S12.300B Unspecified displaced fracture of fourth cervical vertebra, initial encounter for open fracture
S12.301A Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for closed fracture
S12.301B Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for open fracture
S12.400A Unspecified displaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.400B Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture
S12.401A Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.401B Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for open fracture
S12.500A Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture
S12.500B Unspecified displaced fracture of sixth cervical vertebra, initial encounter for open fracture
S12.501A Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fracture
S12.501B Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for open fracture
S12.600A Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture
S12.600B Unspecified displaced fracture of seventh cervical vertebra, initial encounter for open fracture
S12.601A Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture
S12.601B Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for open fracture
S14.0XXA Concussion and edema of cervical spinal cord, initial encounter
S14.101A Unspecified injury at C1 level of cervical spinal cord, initial encounter
S14.102A Unspecified injury at C2 level of cervical spinal cord, initial encounter
S14.103A Unspecified injury at C3 level of cervical spinal cord, initial encounter
S14.104A Unspecified injury at C4 level of cervical spinal cord, initial encounter
S14.105A Unspecified injury at C5 level of cervical spinal cord, initial encounter
S14.106A Unspecified injury at C6 level of cervical spinal cord, initial encounter
S14.107A Unspecified injury at C7 level of cervical spinal cord, initial encounter
S14.108A Unspecified injury at C8 level of cervical spinal cord, initial encounter
S14.111A Complete lesion at C1 level of cervical spinal cord, initial encounter
S14.112A Complete lesion at C2 level of cervical spinal cord, initial encounter
S14.113A Complete lesion at C3 level of cervical spinal cord, initial encounter
S14.114A Complete lesion at C4 level of cervical spinal cord, initial encounter
S14.115A Complete lesion at C5 level of cervical spinal cord, initial encounter
S14.116A Complete lesion at C6 level of cervical spinal cord, initial encounter
S14.117A Complete lesion at C7 level of cervical spinal cord, initial encounter
S14.118A Complete lesion at C8 level of cervical spinal cord, initial encounter
S14.121A Central cord syndrome at C1 level of cervical spinal cord, initial encounter
S14.122A Central cord syndrome at C2 level of cervical spinal cord, initial encounter
S14.123A Central cord syndrome at C3 level of cervical spinal cord, initial encounter
S14.124A Central cord syndrome at C4 level of cervical spinal cord, initial encounter
S14.125A Central cord syndrome at C5 level of cervical spinal cord, initial encounter
S14.126A Central cord syndrome at C6 level of cervical spinal cord, initial encounter
S14.127A Central cord syndrome at C7 level of cervical spinal cord, initial encounter
S14.128A Central cord syndrome at C8 level of cervical spinal cord, initial encounter
S14.131A Anterior cord syndrome at C1 level of cervical spinal cord, initial encounter
S14.132A Anterior cord syndrome at C2 level of cervical spinal cord, initial encounter
S14.133A Anterior cord syndrome at C3 level of cervical spinal cord, initial encounter
S14.134A Anterior cord syndrome at C4 level of cervical spinal cord, initial encounter
S14.135A Anterior cord syndrome at C5 level of cervical spinal cord, initial encounter
S14.136A Anterior cord syndrome at C6 level of cervical spinal cord, initial encounter
S14.137A Anterior cord syndrome at C7 level of cervical spinal cord, initial encounter
S14.138A Anterior cord syndrome at C8 level of cervical spinal cord, initial encounter
S14.141A Brown-Sequard syndrome at C1 level of cervical spinal cord, initial encounter
S14.142A Brown-Sequard syndrome at C2 level of cervical spinal cord, initial encounter
S14.143A Brown-Sequard syndrome at C3 level of cervical spinal cord, initial encounter
S14.144A Brown-Sequard syndrome at C4 level of cervical spinal cord, initial encounter
S14.145A Brown-Sequard syndrome at C5 level of cervical spinal cord, initial encounter
S14.146A Brown-Sequard syndrome at C6 level of cervical spinal cord, initial encounter
S14.147A Brown-Sequard syndrome at C7 level of cervical spinal cord, initial encounter
S14.148A Brown-Sequard syndrome at C8 level of cervical spinal cord, initial encounter
S14.151A Other incomplete lesion at C1 level of cervical spinal cord, initial encounter
S14.152A Other incomplete lesion at C2 level of cervical spinal cord, initial encounter
S14.153A Other incomplete lesion at C3 level of cervical spinal cord, initial encounter
S14.154A Other incomplete lesion at C4 level of cervical spinal cord, initial encounter
S14.155A Other incomplete lesion at C5 level of cervical spinal cord, initial encounter
S14.156A Other incomplete lesion at C6 level of cervical spinal cord, initial encounter
S14.157A Other incomplete lesion at C7 level of cervical spinal cord, initial encounter
S14.158A Other incomplete lesion at C8 level of cervical spinal cord, initial encounter
S22.019A Unspecified fracture of first thoracic vertebra, initial encounter for closed fracture
S22.019B Unspecified fracture of first thoracic vertebra, initial encounter for open fracture
S22.029A Unspecified fracture of second thoracic vertebra, initial encounter for closed fracture
S22.029B Unspecified fracture of second thoracic vertebra, initial encounter for open fracture
S22.039A Unspecified fracture of third thoracic vertebra, initial encounter for closed fracture
S22.039B Unspecified fracture of third thoracic vertebra, initial encounter for open fracture
S22.049A Unspecified fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.049B Unspecified fracture of fourth thoracic vertebra, initial encounter for open fracture
S22.059A Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.059B Unspecified fracture of T5-T6 vertebra, initial encounter for open fracture
S22.069A Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.069B Unspecified fracture of T7-T8 vertebra, initial encounter for open fracture
S22.079A Unspecified fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.079B Unspecified fracture of T9-T10 vertebra, initial encounter for open fracture
S22.089A Unspecified fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.089B Unspecified fracture of T11-T12 vertebra, initial encounter for open fracture
S24.0XXA Concussion and edema of thoracic spinal cord, initial encounter
S24.101A Unspecified injury at T1 level of thoracic spinal cord, initial encounter
S24.102A Unspecified injury at T2-T6 level of thoracic spinal cord, initial encounter
S24.103A Unspecified injury at T7-T10 level of thoracic spinal cord, initial encounter
S24.104A Unspecified injury at T11-T12 level of thoracic spinal cord, initial encounter
S24.111A Complete lesion at T1 level of thoracic spinal cord, initial encounter
S24.112A Complete lesion at T2-T6 level of thoracic spinal cord, initial encounter
S24.113A Complete lesion at T7-T10 level of thoracic spinal cord, initial encounter
S24.114A Complete lesion at T11-T12 level of thoracic spinal cord, initial encounter
S24.131A Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter
S24.132A Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial encounter
S24.133A Anterior cord syndrome at T7-T10 level of thoracic spinal cord, initial encounter
S24.134A Anterior cord syndrome at T11-T12 level of thoracic spinal cord, initial encounter
S24.141A Brown-Sequard syndrome at T1 level of thoracic spinal cord, initial encounter
S24.142A Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, initial encounter
S24.143A Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, initial encounter
S24.144A Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, initial encounter
S24.151A Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter
S24.152A Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial encounter
S24.153A Other incomplete lesion at T7-T10 level of thoracic spinal cord, initial encounter
S24.154A Other incomplete lesion at T11-T12 level of thoracic spinal cord, initial encounter
S32.019A Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture
S32.019B Unspecified fracture of first lumbar vertebra, initial encounter for open fracture
S32.029A Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture
S32.029B Unspecified fracture of second lumbar vertebra, initial encounter for open fracture
S32.039A Unspecified fracture of third lumbar vertebra, initial encounter for closed fracture
S32.039B Unspecified fracture of third lumbar vertebra, initial encounter for open fracture
S32.049A Unspecified fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.049B Unspecified fracture of fourth lumbar vertebra, initial encounter for open fracture
S32.059A Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.10XA Unspecified fracture of sacrum, initial encounter for closed fracture
S32.10XB Unspecified fracture of sacrum, initial encounter for open fracture
S32.2XXA Fracture of coccyx, initial encounter for closed fracture
S32.2XXB Fracture of coccyx, initial encounter for open fracture
S34.01XA Concussion and edema of lumbar spinal cord, initial encounter
S34.02XA Concussion and edema of sacral spinal cord, initial encounter
S34.101A Unspecified injury to L1 level of lumbar spinal cord, initial encounter
S34.102A Unspecified injury to L2 level of lumbar spinal cord, initial encounter
S34.103A Unspecified injury to L3 level of lumbar spinal cord, initial encounter
S34.104A Unspecified injury to L4 level of lumbar spinal cord, initial encounter
S34.105A Unspecified injury to L5 level of lumbar spinal cord, initial encounter
S34.111A Complete lesion of L1 level of lumbar spinal cord, initial encounter
S34.112A Complete lesion of L2 level of lumbar spinal cord, initial encounter
S34.113A Complete lesion of L3 level of lumbar spinal cord, initial encounter
S34.114A Complete lesion of L4 level of lumbar spinal cord, initial encounter
S34.115A Complete lesion of L5 level of lumbar spinal cord, initial encounter
S34.121A Incomplete lesion of L1 level of lumbar spinal cord, initial encounter
S34.122A Incomplete lesion of L2 level of lumbar spinal cord, initial encounter
S34.123A Incomplete lesion of L3 level of lumbar spinal cord, initial encounter
S34.124A Incomplete lesion of L4 level of lumbar spinal cord, initial encounter
S34.125A Incomplete lesion of L5 level of lumbar spinal cord, initial encounter
S34.131A Complete lesion of sacral spinal cord, initial encounter
S34.132A Incomplete lesion of sacral spinal cord, initial encounter
S34.3XXA Injury of cauda equina, initial encounter
T79.5XXA Traumatic anuria, initial encounter
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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

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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
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
074x Clinic - Outpatient Rehabilitation Facility (ORF)
085x Critical Access Hospital
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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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.


Code Description
0360 Operating Room Services - General Classification
0402 Other Imaging Services - Ultrasound
045X Emergency Room - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
076X Specialty Services - General Classification
092X Other Diagnostic Services - General Classification
096X Professional Fees - General Classification
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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
10/05/2023 R6

Revision Effective: 10/05/2023

Revision Explanation: Annual review, no changes.

10/01/2023 R5

Revision Effective: 10/01/2023

Revision Explanation: Annual ICD-10 update. Changes made to Group 1 - deleted: G20 and added: G20.A1 G20.A2 G20.B1 and G20.B2 

10/06/2022 R4

Revision Effective: 10/06/2022

Revision Explanation: Annual review, no changes

09/30/2021 R3

Revision Effective: N/A

Revision Explanation: Annual review, no changes

09/19/2019 R2

Revision Effective: N/A

Revision Explanation: Annual review, no changes

09/19/2019 R1

Revision Effective: n/a

Revision Explanation: corrected title of article 

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34056 - Urodynamics
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
11/07/2023 11/16/2023 - N/A Currently in Effect View
09/29/2023 10/05/2023 - 11/15/2023 Superseded You are here
09/08/2023 10/01/2023 - 10/04/2023 Superseded View
09/26/2022 10/06/2022 - 09/30/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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