B42.1 — Lymphocutaneous sporotrichosis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be made available to the contractor upon request.
- The record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- The provider must document the affected nail(s), clinical evidence of mycosis, and the manner and extent to which the nail(s) were debrided.
Key Coverage Criteria
- Nail debridement is covered only when the service meets all indications and limitations specified in LCD L33922 and applicable CMS medical necessity and payment rules.
- Nail debridement for symptomatic mycotic nails is covered when there is documented clinical evidence of mycosis and qualifying symptoms for toenail debridement.
- Clinical evidence of mycotic (fungal) infection of the nail demonstrated by discoloration, onycholysis, subungual debris, thickening, or secondary skin infection.
- For mycotic toenails, debridement is covered only when the medical record documents either: (a) an ambulatory patient with marked limitation of ambulation, pain, or secondary infection from thickening/dystrophy of the infected toenail plate(s); or (b) a non-ambulatory patient with pain or secondary infection from thickening/dystrophy of the infected toenail plate(s).
- Appropriate antifungal treatment must be used for nail debridement to be considered medically necessary and reimbursable unless a contraindication to antifungal therapy is documented in the medical record.
- An underlying systemic condition is not required for coverage of mycotic nail care.
2 Active Policies
A57672 — Billing and Coding: Nail Debridement
L33922 — Nail Debridement
Related Codes
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