E08.37X3 — Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must document the clinical findings supporting the billed foot care service and be available upon request.
- Claims based on systemic-condition diagnosis codes with an asterisk must include the date patient was last seen (DPLS) and the NPI of the M.D. or D.O. actively managing the systemic condition in the medical record and/or claim.
- Claims asserting presumptive coverage or systemic-condition exceptions must include the systemic-condition diagnosis code (Group 1) and the valid billing modifier (Q7/Q8/Q9) on the claim.
- For mycotic nail services without systemic disease, medical records must document Group 2 or Group 3 diagnosis codes and the clinical findings (marked ambulation limitation, pain, or secondary infection) submitted on the claim.
Key Coverage Criteria
- 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.
- Claims asserting presumptive coverage must include a systemic-condition diagnosis from IOM 100-02 Ch.15 Section 290 Group 1 and a valid billing modifier Q7, Q8, or Q9.
- Mycotic nail debridement is covered when mycotic nails are present in the context of a systemic disease with class findings and the appropriate Q modifier on the claim.
- Mycotic nail debridement is covered without systemic disease if an ambulatory patient has marked limitation of ambulation, pain, or secondary infection from thickened/dystrophic infected toenail plate.
- Mycotic nail debridement is covered without systemic disease if a non-ambulatory patient has mycotic nails and suffers pain or secondary infection due to thickening and dystrophy of the infected toenail plate.
20 Active Policies
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A56916 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
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L38686 — Implantable Continuous Glucose Monitors (I-CGM)
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