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.
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Modifier
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When to Use Modifier
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GA
Waiver of Liability Statement
Issued as Required by Payer
Policy, Individual Case
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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.
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–GX
Notice of Liability Issued,
Voluntary Under Payer Policy
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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.
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–GY
Notice of Liability Not Issued,
Not Required Under Payer
Policy
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Report Medicare statutorily excludes the item or service, or the item or service doesn’t meet the definition of a Medicare
benefit. Use this modifier combined with modifier –GX
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–GZ
Expect Item or Service
Denied as Not Reasonable
and Necessary
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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.
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Documentation Requirements
- All documentation must be maintained in the patient's medical record and made 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 documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- 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.
- 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.
