A52.16 — Charcot's arthropathy (tabetic)
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Specified HCPCS codes require a face-to-face encounter and Written Order Prior to Delivery (WOPD) per Final Rule 1713; failure to obtain WOPD prior to delivery results in denial.
- Supplier must include diagnosis code(s) on the claim line for HCPCS L4396, L4397, L4392 and L4631.
- For custom-fabricated orthoses, the supplier's records must document medical necessity for a custom device rather than a prefabricated orthosis and be available upon request.
- Supplier records must show the product specified by the treating practitioner, the treating practitioner's medical record that justifies the type of product (prefabricated versus custom), and detailed justification for the HCPCS code billed.
Key Coverage Criteria
- Ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) are covered when they are rigid or semi-rigid devices used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
- Coverage requires that reasonable and necessary (R&N) medical necessity criteria in the related Local Coverage Determination (LCD) are met for the beneficiary's diagnosis or functional deficit.
- An orthosis provided within two days prior to discharge to home is eligible for DME MAC coverage if it is medically necessary after discharge and was not needed for inpatient treatment or rehabilitation.
- Removal of corns and calluses of the feet must be billed using CPT codes 11055-11057 (paring/cutting of benign hyperkeratotic lesion) and the procedure code that most accurately describes the service performed should be reported.
- Foot care services are covered when the beneficiary has a listed systemic condition that justifies coverage per Medicare Benefit Policy Manual Pub.100-02, Ch.15, Section 290.4D.
- For diagnosis codes designated by an asterisk, the patient must be under the active care of an M.D. or D.O., documented as having been seen for the complicating disease within the 6 months prior to service.
20 Active Policies
A56232 — Billing and Coding: Foot Care
J05
L33576 — Urodynamics
J06
L33636 — Routine Foot Care and Debridement of Nails
J06
A57455 — Billing and Coding: Urodynamics
J06
A57759 — Billing and Coding: Routine Foot Care and Debridement of Nails
Related Codes
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