Article Detail - JE Part A

Date Posted: October 10, 2024

This Local Coverage Article (LCA) has been revised under contractor numbers: 01111 (CA), 01211 (AS, GU, HI, NMI), 01311 (NV), and 01911 (CA, HI & Territories).

Effective Date: September 29, 2024

Summary of Changes:

CPT codes 22614 and 22585 were removed from the CPT/HCPCS Codes section under Group 1.

The following ICD-10-cm codes were added to the ICD-10-CM Codes that Support Medical Necessity section under Group 1: S12.01XB, S12.01XG, S12.01XK, S12.01XS, S12.02XA, S12.02XB, S12.02XD, S12.02XG, S12.02XK, S12.02XS, S12.030A, S12.030B, S12.030D, S12.030G, S12.030K, S12.030S, S12.031B, S12.031G, S12.031K, S12.031S, S12.040A, S12.040B, S12.040D, S12.040G, S12.040K, S12.040S, S12.041B, S12.041G, S12.041K, S12.041S, S12.090A, S12.090B, S12.090G, S12.090K, S12.090S, S12.091A, S12.091B, S12.091G, S12.091K, S12.091S, S12.100A, S12.100B, S12.100D, S12.100G, S12.100K, S12.100S, S12.101B, S12.101G, S12.101K, S12.101S, S12.110A, S12.110B, S12.110G, S12.110K, S12.110S, S12.111A, S12.111B, S12.111G, S12.111K, S12.111S, S12.120A, S12.120B, S12.120G, S12.120K, S12.120S, S12.131A, S12.131B, S12.131G, S12.131K, S12.131S, S12.14XA, S12.14XB, S12.14XD, S12.14XG, S12.14XK, S12.14XS, S12.150A, S12.150B, S12.150D, S12.150G, S12.150K, S12.150S, S12.151A, S12.151B, S12.151D, S12.151G, S12.151K, S12.151S, S12.190A, S12.190B, S12.190D, S12.190G, S12.190K, S12.190S, S12.191B, S12.191G, S12.191K, S12.191S, S12.200A, S12.200B, S12.200D, S12.200G, S12.200K, S12.200S, S12.201A, S12.201B, S12.201D, S12.201G, S12.201K, S12.201S, S12.231B, S12.231G, S12.231K, S12.231S, S12.24XA, S12.24XB, S12.24XG, S12.24XK, S12.24XS, S12.250A, S12.250B, S12.250D. S12.250G, S12.250K, S12.250S, S12.251A, S12.251B, S12.251D, S12.251G, S12.251K, S12.251S, S12.290A, S12.290B, S12.290D, S12.290G, S12.290K, S12.290S, S12.291A, S12.291B, S12.291D, S12.291G, S12.291K, S12.291S, S12.300A, S12.300B, S12.300D, S12.300G, S12.300K, S12.300S, S12.301A, S12.301B, S12.301D, S12.301G, S12.301K, S12.301S, S12.331B, S12.331G, S12.331K, S12.331S, S12.34XA, S12.34XB, S12.34XD, S12.34XG, S12.34XK, S12.34XS, S12.350A, S12.350B, S12.350D, S12.350G, S12.350K, S12.350S, S12.351B, S12.351D, S12.351G, S12.351K, S12.351S, S12.390A, S12.390B, S12.390D, S12.390G, S12.390K, S12.390S, S12.391B, S12.391G, S12.391K, S12.391S, S12.400A, S12.400B, S12.400D, S12.400G, S12.400K, S12.400S, S12.401B, S12.401D, S12.401G, S12.401K, S12.401S, S12.431A, S12.431B, S12.431G, S12.431K, S12.431S, S12.44XA, S12.44XB, S12.44XD, S12.44XG, S12.44XK, S12.44XS, S12.450A, S12.450B, S12.450D, S12.450G, S12.450K, S12.450S, S12.451A, S12.451B, S12.451D, S12.451G, S12.451K, S12.451S, S12.490A, S12.490B, S12.490D, S12.490G, S12.490K, S12.490S, S12.491A, S12.491B, S12.491G, S12.491K, S12.491S, S12.500A, S12.500B, S12.500D, S12.500G, S12.500K, S12.500S, S12.501A, S12.501B, S12.501G, S12.501K, S12.501S, S12.531A, S12.531B, S12.531G, S12.531K, S12.531S, S12.54XA, S12.54XB, S12.54XD, S12.54XG, S12.54XK, S12.54XS, S12.550A, S12.550B, S12.550D, S12.550G, S12.550K, S12.550S, S12.551A, S12.551B, S12.551D, S12.551G, S12.551K, S12.551S, S12.590A, S12.590B, S12.590D, S12.590G, S12.590K, S12.590S, S12.591B, S12.591G, S12.591K, S12.591S, S12.600A, S12.600B, S12.600D, S12.600G, S12.600K, S12.600S, S12.601B, S12.601G, S12.601K, S12.601S, S12.631A, S12.631B, S12.631D, S12.631G, S12.631K, S12.631S, S12.64XA, S12.64XB, S12.64XD, S12.64XG, S12.64XK, S12.64XS, S12.650A, S12.650B, S12.650D, S12.650G, S12.650K, S12.650S, S12.651A, S12.651B, S12.651D, S12.651G, S12.651K, S12.651S, S12.690A, S12.690B, S12.690D, S12.690G, S12.690K, S12.690S, S12.691B, S12.691G, S12.691K, S12.691S.

Effective Date: August 22, 2024

The following ICD-10-CM codes were added to the ICD-10-CM Codes that Support Medical Necessity section under Group 1: C41.2, G06.1, M06.88, M40.03, M40.12, M40.202, M40.292, M41.22, M43.12, M43.13, M46.21, M46.22, M46.23, M46.41, M46.42, M46.43, M46.51, M48.31, M48.32, M48.33, M48.42XA, M48.42XD, M48.42XG, M48.43XA, M48.43XG, M48.43XS, M48.51XA, M48.51XG, M48.51XS, M48.52XA, M48.52XG, M48.52XS, M48.53XA, M48.53XG,  M50.10, M50.120, M50.20 - M50.33, M53.2X3, M96.0, M96.1, S12.000A, S12.000B, S12.000D, S12.000G, S12.000K, S12.000S, S12.001A, S12.001B, S12.001D, S12.001G, S12.001K, S12.001S, S12.130A, S12.130B, S12.130D, S12.130G, S12.130K, S12.130S, S12.230A, S12.230B, S12.230D, S12.230G, S12.230K, S12.230S, S12.330A, S12.330B, S12.330D, S12.330G, S12.330K, S12.330S, S12.430A, S12.430B, S12.430D, S12.430G, S12.430K, S12.430S, S12.530A, S12.530B, S12.530D, S12.530G, S12.530K, S12.530S, S12.630A, S12.630B, S12.630D, S12.630G, S12.630K, S12.630S, S12.9XXA, S12.9XXD, S12.9XXS, S13.101A, S13.101D, S13.101S, S13.110A, S13.110D, S13.110S, S13.111A, S13.111D, S13.111S, S13.120A, S13.120D, S13.120S, S13.121A, S13.121D, S13.121S, S13.130A, S13.130D, S13.130S, S13.131A, S13.131D, S13.131S, S13.140A, S13.140D, S13.140S, S13.141A, S13.141D, S13.141S, S13.150A, S13.150D, S13.150S, S13.151A, S13.151D, S13.151S, S13.160A, S13.160D, S13.160S, S13.161A, S13.161D, S13.161S, S13.170A, S13.170D, S13.170S, S13.171A, S13.171D, S13.171S, S13.180A, S13.180D, S13.180S, S13.181A, S13.181D, S13.181S, S13.20XA, S13.20XD, S13.20XS, S13.29XA, S13.29XD, S13.29XS.

Updated language for modifier GX.

Visit the Noridian Active LCDs webpage to view the document or access it via the CMS MCD.