LCD Reference Article Billing and Coding Article

Billing and Coding: Cervical Fusion

A59645

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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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59645
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Cervical Fusion
Article Type
Billing and Coding
Original Effective Date
07/07/2024
Revision Effective Date
08/22/2024
Revision Ending Date
N/A
Retirement Date
N/A

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 © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the 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

Refer to the Local Coverage Determination (LCD) L39762 Cervical Fusion for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.

Coding Guidance

Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

This policy applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).

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.

 

Modifier

When to Use Modifier

GA

Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case

Report when you issue a mandatory ABN for a service as required and keep it on file. You don’t need to submit a copy of the ABN, but you must make it available on request. Use the –GA modifier when both covered and non-covered services appear on an ABN-related claim.

–GX

Notice of Liability Issued, Voluntary Under Payer Policy

Report when you issue a voluntary ABN for a service we never cover because it’s statutorily excluded or isn’t a Medicare benefit. Use this modifier combined with modifier –GY.

–GY

Notice of Liability Not Issued, Not Required Under Payer Policy

Report Medicare statutorily excludes the item or service, or the item or service doesn’t meet the definition of a Medicare benefit. 

–GZ

Expect Item or Service Denied as Not Reasonable and Necessary

Report when you expect we’ll deny payment of the item or service because it’s medically unnecessary and you didn’t issue an ABN.

 

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

The operative note should include the procedure performed and any associated/additional procedures performed at the same time.

  1. The patient’s medical record should include, but is not limited to:
    • The assessment of the patient by the performing 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.)
    • Documentation to support the medical necessity of the procedure(s).

Use of Biologicals

There are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180 Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

Please accept the License to see the 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 Support Medical Necessity

Group 1

(182 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
C41.2 Malignant neoplasm of vertebral column
G06.1 Intraspinal abscess and granuloma
M06.88 Other specified rheumatoid arthritis, vertebrae
M40.03 Postural kyphosis, cervicothoracic region
M40.12 Other secondary kyphosis, cervical region
M40.202 Unspecified kyphosis, cervical region
M40.292 Other kyphosis, cervical region
M41.22 Other idiopathic scoliosis, cervical region
M43.12 Spondylolisthesis, cervical region
M43.13 Spondylolisthesis, cervicothoracic region
M46.21 Osteomyelitis of vertebra, occipito-atlanto-axial region
M46.22 Osteomyelitis of vertebra, cervical region
M46.23 Osteomyelitis of vertebra, cervicothoracic region
M46.31 Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region
M46.32 Infection of intervertebral disc (pyogenic), cervical region
M46.33 Infection of intervertebral disc (pyogenic), cervicothoracic region
M46.41 Discitis, unspecified, occipito-atlanto-axial region
M46.42 Discitis, unspecified, cervical region
M46.43 Discitis, unspecified, cervicothoracic region
M46.51 Other infective spondylopathies, occipito-atlanto-axial region
M48.01 Spinal stenosis, occipito-atlanto-axial region
M48.02 Spinal stenosis, cervical region
M48.03 Spinal stenosis, cervicothoracic region
M48.31 Traumatic spondylopathy, occipito-atlanto-axial region
M48.32 Traumatic spondylopathy, cervical region
M48.33 Traumatic spondylopathy, cervicothoracic region
M48.42XA Fatigue fracture of vertebra, cervical region, initial encounter for fracture
M48.42XD Fatigue fracture of vertebra, cervical region, subsequent encounter for fracture with routine healing
M48.42XG Fatigue fracture of vertebra, cervical region, subsequent encounter for fracture with delayed healing
M48.43XA Fatigue fracture of vertebra, cervicothoracic region, initial encounter for fracture
M48.43XG Fatigue fracture of vertebra, cervicothoracic region, subsequent encounter for fracture with delayed healing
M48.43XS Fatigue fracture of vertebra, cervicothoracic region, sequela of fracture
M48.51XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture
M48.51XG Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, subsequent encounter for fracture with delayed healing
M48.51XS Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, sequela of fracture
M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture
M48.52XG Collapsed vertebra, not elsewhere classified, cervical region, subsequent encounter for fracture with delayed healing
M48.52XS Collapsed vertebra, not elsewhere classified, cervical region, sequela of fracture
M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture
M48.53XG Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with delayed healing
M50.01 Cervical disc disorder with myelopathy, high cervical region
M50.021 Cervical disc disorder at C4-C5 level with myelopathy
M50.022 Cervical disc disorder at C5-C6 level with myelopathy
M50.023 Cervical disc disorder at C6-C7 level with myelopathy
M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region
M50.11 Cervical disc disorder with radiculopathy, high cervical region
M50.120 Mid-cervical disc disorder, unspecified level
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M50.20 - M50.33 Other cervical disc displacement, unspecified cervical region - Other cervical disc degeneration, cervicothoracic region
M53.2X1 Spinal instabilities, occipito-atlanto-axial region
M53.2X2 Spinal instabilities, cervical region
M53.2X3 Spinal instabilities, cervicothoracic region
M54.11 Radiculopathy, occipito-atlanto-axial region
M54.12 Radiculopathy, cervical region
M54.13 Radiculopathy, cervicothoracic region
M96.0 Pseudarthrosis after fusion or arthrodesis
M96.1 Postlaminectomy syndrome, not elsewhere classified
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
S12.000D Unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing
S12.000G Unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with delayed healing
S12.000K Unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with nonunion
S12.000S Unspecified displaced fracture of first cervical vertebra, sequela
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
S12.001D Unspecified nondisplaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing
S12.001G Unspecified nondisplaced fracture of first cervical vertebra, subsequent encounter for fracture with delayed healing
S12.001K Unspecified nondisplaced fracture of first cervical vertebra, subsequent encounter for fracture with nonunion
S12.001S Unspecified nondisplaced fracture of first cervical vertebra, sequela
S12.130A Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture
S12.130B Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open fracture
S12.130D Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, subsequent encounter for fracture with routine healing
S12.130G Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, subsequent encounter for fracture with delayed healing
S12.130K Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, subsequent encounter for fracture with nonunion
S12.130S Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, sequela
S12.230A Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture
S12.230B Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open fracture
S12.230D Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, subsequent encounter for fracture with routine healing
S12.230G Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, subsequent encounter for fracture with delayed healing
S12.230K Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, subsequent encounter for fracture with nonunion
S12.230S Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, sequela
S12.330A Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture
S12.330B Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture
S12.330D Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, subsequent encounter for fracture with routine healing
S12.330G Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, subsequent encounter for fracture with delayed healing
S12.330K Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, subsequent encounter for fracture with nonunion
S12.330S Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, sequela
S12.430A Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.430B Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture
S12.430D Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, subsequent encounter for fracture with routine healing
S12.430G Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, subsequent encounter for fracture with delayed healing
S12.430K Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, subsequent encounter for fracture with nonunion
S12.430S Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, sequela
S12.530A Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture
S12.530B Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture
S12.530D Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, subsequent encounter for fracture with routine healing
S12.530G Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, subsequent encounter for fracture with delayed healing
S12.530K Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, subsequent encounter for fracture with nonunion
S12.530S Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, sequela
S12.630A Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture
S12.630B Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture
S12.630D Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, subsequent encounter for fracture with routine healing
S12.630G Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, subsequent encounter for fracture with delayed healing
S12.630K Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, subsequent encounter for fracture with nonunion
S12.630S Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, sequela
S12.9XXA Fracture of neck, unspecified, initial encounter
S12.9XXD Fracture of neck, unspecified, subsequent encounter
S12.9XXS Fracture of neck, unspecified, sequela
S13.101A Dislocation of unspecified cervical vertebrae, initial encounter
S13.101D Dislocation of unspecified cervical vertebrae, subsequent encounter
S13.101S Dislocation of unspecified cervical vertebrae, sequela
S13.110A Subluxation of C0/C1 cervical vertebrae, initial encounter
S13.110D Subluxation of C0/C1 cervical vertebrae, subsequent encounter
S13.110S Subluxation of C0/C1 cervical vertebrae, sequela
S13.111A Dislocation of C0/C1 cervical vertebrae, initial encounter
S13.111D Dislocation of C0/C1 cervical vertebrae, subsequent encounter
S13.111S Dislocation of C0/C1 cervical vertebrae, sequela
S13.120A Subluxation of C1/C2 cervical vertebrae, initial encounter
S13.120D Subluxation of C1/C2 cervical vertebrae, subsequent encounter
S13.120S Subluxation of C1/C2 cervical vertebrae, sequela
S13.121A Dislocation of C1/C2 cervical vertebrae, initial encounter
S13.121D Dislocation of C1/C2 cervical vertebrae, subsequent encounter
S13.121S Dislocation of C1/C2 cervical vertebrae, sequela
S13.130A Subluxation of C2/C3 cervical vertebrae, initial encounter
S13.130D Subluxation of C2/C3 cervical vertebrae, subsequent encounter
S13.130S Subluxation of C2/C3 cervical vertebrae, sequela
S13.131A Dislocation of C2/C3 cervical vertebrae, initial encounter
S13.131D Dislocation of C2/C3 cervical vertebrae, subsequent encounter
S13.131S Dislocation of C2/C3 cervical vertebrae, sequela
S13.140A Subluxation of C3/C4 cervical vertebrae, initial encounter
S13.140D Subluxation of C3/C4 cervical vertebrae, subsequent encounter
S13.140S Subluxation of C3/C4 cervical vertebrae, sequela
S13.141A Dislocation of C3/C4 cervical vertebrae, initial encounter
S13.141D Dislocation of C3/C4 cervical vertebrae, subsequent encounter
S13.141S Dislocation of C3/C4 cervical vertebrae, sequela
S13.150A Subluxation of C4/C5 cervical vertebrae, initial encounter
S13.150D Subluxation of C4/C5 cervical vertebrae, subsequent encounter
S13.150S Subluxation of C4/C5 cervical vertebrae, sequela
S13.151A Dislocation of C4/C5 cervical vertebrae, initial encounter
S13.151D Dislocation of C4/C5 cervical vertebrae, subsequent encounter
S13.151S Dislocation of C4/C5 cervical vertebrae, sequela
S13.160A Subluxation of C5/C6 cervical vertebrae, initial encounter
S13.160D Subluxation of C5/C6 cervical vertebrae, subsequent encounter
S13.160S Subluxation of C5/C6 cervical vertebrae, sequela
S13.161A Dislocation of C5/C6 cervical vertebrae, initial encounter
S13.161D Dislocation of C5/C6 cervical vertebrae, subsequent encounter
S13.161S Dislocation of C5/C6 cervical vertebrae, sequela
S13.170A Subluxation of C6/C7 cervical vertebrae, initial encounter
S13.170D Subluxation of C6/C7 cervical vertebrae, subsequent encounter
S13.170S Subluxation of C6/C7 cervical vertebrae, sequela
S13.171A Dislocation of C6/C7 cervical vertebrae, initial encounter
S13.171D Dislocation of C6/C7 cervical vertebrae, subsequent encounter
S13.171S Dislocation of C6/C7 cervical vertebrae, sequela
S13.180A Subluxation of C7/T1 cervical vertebrae, initial encounter
S13.180D Subluxation of C7/T1 cervical vertebrae, subsequent encounter
S13.180S Subluxation of C7/T1 cervical vertebrae, sequela
S13.181A Dislocation of C7/T1 cervical vertebrae, initial encounter
S13.181D Dislocation of C7/T1 cervical vertebrae, subsequent encounter
S13.181S Dislocation of C7/T1 cervical vertebrae, sequela
S13.20XA Dislocation of unspecified parts of neck, initial encounter
S13.20XD Dislocation of unspecified parts of neck, subsequent encounter
S13.20XS Dislocation of unspecified parts of neck, sequela
S13.29XA Dislocation of other parts of neck, initial encounter
S13.29XD Dislocation of other parts of neck, subsequent encounter
S13.29XS Dislocation of other parts of neck, sequela
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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

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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
N/A N/A
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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
08/22/2024 R1

Effective 8/22/24 - Removed "Use this modifier combined with modifier GX" found under Coding Guidance and added ICD-10-cm codes to Group 1.

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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
08/30/2024 08/22/2024 - N/A Currently in Effect You are here
05/17/2024 07/07/2024 - 08/21/2024 Superseded View

Keywords

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