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Total Disc Arthroplasty Benefit Changes for CSHCN Effective September 1, 2021

Last updated on 7/16/2021

Effective for dates of service on or after September 1, 2021, total disc arthroplasty benefits will change for the Children with Special Health Care Needs (CSHCN) Services Program. Procedure codes 22551 and 22856 are now payable to ambulatory surgical center providers for services rendered in the outpatient hospital setting.

Procedures codes 22551 and 22552 may be reimbursed for clients who are 18 years of age and older as follows:

Types of Services Place of Service Provider Type
Surgery Inpatient Hospital Physician
Assistant Surgery Inpatient Hospital Advanced Practice Registered Nurse (APRN) and Physician

Procedure codes 22856, 22858, and 22861 may be reimbursed for clients who are 18 years of age and older as follows:

Types of Services Place of Service Provider Type
Surgery Inpatient and Outpatient Hospital Physician
Assistant Surgery Inpatient and Outpatient Hospital Advanced Practice Registered Nurse (APRN) and Physician

Procedure codes 22856, 22858, and 22861 will be restricted to the following diagnoses:

Diagnosis Codes
M4712 M4722 M47812 M4802 M5000 M5001 M50020
M50021 M50022 M50023 M5011 M50121 M50122 M50123
M5020 M5021 M50220 M50221 M50222 M50223 M5030
M5031 M50320 M50321 M50322 M50323 M961  

Procedure code 22864 may be reimbursed for clients who are 18 years of age and older as follows:

Types of Services Place of Service Provider Type
Surgery Inpatient and Outpatient Hospital Physician
Assistant Surgery Inpatient and Outpatient Hospital Advanced Practice Registered Nurse (APRN) and Physician

Procedure code 22864 will be restricted to the following diagnoses:

Diagnosis Codes            
G542 G549 M4802 M5000 M5001 M50020 M50021
M50022 M50023 M5003 M5010 M5011 M50120 M50121
M50122 M50123 M5013 M5020 M5021 M50220 M50221
M50222 M50223 M5023 M5030 M5031 M50320 M50321
M50322 M50323 M5033 M5080 M5081 M50820 M50821
M50822 M50823 M5083 M5090 M5091 M50920 M50921
M50922 M50923 M5093 M531 M532X2 M960 T84028A
T8498A T84226A T84498A T8484XA      

For more information, call the TMHP Contact Center at 800-925-9126.