I96, Gangrene, not elsewhere classified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
- Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
- When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.
- If CPT 97597 or 97598 is billed by a therapist while the patient is under a Home Health benefit, coverage depends on inclusion in the Home Health plan of care; if billed by a physician or non-physician practitioner it is paid under Part B even if the beneficiary has an active Home Health plan.
Key Coverage Criteria
- Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
- CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
- MRA is covered to evaluate blood flow in the internal carotid vessels of the head and neck.
- MRA of peripheral arteries of the lower extremities is covered to determine the presence and extent of peripheral vascular disease and may substitute for conventional angiography (CA).
- MRA is covered for pre-operative evaluation of patients undergoing elective abdominal aortic aneurysm (AAA) repair when it is comparable to CA for determining extent of AAA and evaluating aortoiliac occlusive disease and renal artery pathology necessary for surgical planning.
- MRA of the renal arteries and aortoiliac arteries (in the absence of AAA or aortic dissection) is covered when MRA is expected to avoid CA, physician history/physical and standard assessments are insufficient, and obtaining MRA has a high probability of positively affecting patient management.
20 Active Policies
CGS-L34032, Debridement Services
J15
CGS-L34045, Non-Invasive Vascular Studies
J15
A57594, Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
J5
A55909, Billing and Coding: Wound Care
J5
A57593
Related Codes
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