D68.1 — Hereditary factor XI deficiency
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical records must clearly document the diagnosis, specific foot findings, and the clinical rationale that treatment was medically necessary and that withholding care would be hazardous to the beneficiary.
- For the policy’s asterisked/complicating conditions, include the name of the primary physician (MD or DO) who made the diagnosis and the approximate date of the last visit; this information must be included in the medical record and entered on the appropriate claim forms or electronic equivalent when billing Medicare.
- Follow CMS website instructions for billing Part A and Part B claims and Noridian guidance for JE Part B claims; include required claim form entries/electronic equivalents.
- Document provider licensure and ensure services are rendered by a certified physician, podiatrist, or non-physician practitioner within scope of State licensure when billing for routine foot care.
Key Coverage Criteria
- Routine foot care is covered only when clinical documentation demonstrates the patient’s condition warrants the provider to render the services and that failure to provide the services would be hazardous to the beneficiary due to underlying medical condition(s), per CMS Pub 100-02, Ch.15, §290.
- Loeys-Dietz syndrome (TGFBR1, TGFBR2): Testing medically necessary when: asymptomatic individual has affected first-degree relative with known deleterious mutation (test for familial mutation); or to confirm diagnosis in individual with LDS characteristics (begin with TGFBR2 sequencing, then TGFBR1 if negative).
- I42.0 Dilated cardiomyopathy [hereditary]
- I49.01 Ventricular fibrillation
- I71.01 Dissection of thoracic aorta
- Von Hippel-Lindau syndrome (VHL)
4 Active Policies
CIGNA-0538 — Flow Cytometry - (0538)
A57957 — Billing and Coding: Routine Foot Care
AETNA-CPB-0140 — Genetic Testing
A57954 — Billing and Coding: Routine Foot Care
Related Codes
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