MEDICARE ATTACHMENT
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Medicare attachment is only necessary for paper claims (HCFA-1500) with any x-ray date greater than one year prior to date of service. The x-ray must show evidence of a permanent condition (i.e. scoliosis).

The attachment must be an 8 1/2 x 11 inch piece of paper with the patient's name, HIC number, dates of service on the HCFA-1500, x-ray date followed by the letter C and optional ICD-9 code for the permanent condition on the x-ray.

A suggested format of the attachment is linked below. Electronic filers are not required to change their billing format. Any paper claim filed and/or received after May 1, 1998 must follow this new format. Paper claims with x-ray dates within one year prior to the date of service require no attachment.

You may print these with your browser print button.

Sample Form        Completed Sample Form

HCFA-1500 claim form requirements do not permit the appending of any alphabetical characters, such as "C" to information required in item 19. If the x-ray is not reasonable or proximate (taken one year prior to date of service) and one of the diagnoses designated as permanent and/or chronic is not listed on an attachment, the claim will be denied as not medically necessary.

The ICD-9 code supporting the permanent and/or chronic condition must be indicated in the appropriate Documentation Record on electronic claims or on an attachment to the HCFA-1500. If paper claims are submitted, attach a full size sheet of paper with the beneficiary's name, health insurance claim number, date of service, and documentation supporting the permanent and/or chronic condition of the patient (see samples above).

Limitations of liability and refund requirements apply to these services. If advance notice is given, modifier GA (advance notice has been given to the beneficiary) must be indicated on the claim.

The following ICD-9 codes are acceptable to support permanent and/or chronic conditions:

713.00 - 713.89Arthropathy
714.0, 714.30 - 714.4Rheumatoid arthritis
715.9Osteoarthrosis unspecified (spine)
720.0 - 720.9Ankylosing spondylopathies
721.0Cervical spondylosis without myelopathy
721.2Thoracic spondylosis without myelopathy
721.3Lumbosacral spondylosis without myelopathy
721.5Kissing Spine
721.6Ankylosing vertebral hyperostosis
721.7Traumatic spondylopathy
721.90 - 721.91Spondylosis
722.0 - 722.2Intervertebral disc disorders
722.4 - 722.9Intervertebral disorder
723.0Spinal stenosis in cervical region
723.6Panniculitis specified as affecting neck
723.7Ossification of posterior longitudinal ligament in cervical region
723.8Other syndromes affecting cervical region
724.00 - 724.09Spinal stenosis, other than cervical
737.3 - 737.39Kyphoscoliosis and scoliosis
737.10 - 737.19Kyphosis
738.4Acquired spondylolisthesis
754.2Scoliosis
756.11Spondylolysis
756.12Spondylolisthesis
756.14Hemivertebra
756.15Fusion of spine (vertebra), congenital
756.16Klippel Feil syndrome
756.17Spina bifida occulta


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