L03.213 — Periorbital cellulitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
- Billing and coding guidance in this policy complements and references Local Coverage Determination L34425; claims should be supported per the documentation requirements specified in LCD L34425.
- Medical record must include relevant history, physical exam, and signs/symptoms that required the I&D procedure; diagnostic test results or the symptoms prompting tests must be recorded.
- Pre-operative documentation must record size, location and appearance of the abscess/collection; the operative note must describe the procedure, equipment used, and approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, bloody, frank pus) of material drained.
Key Coverage Criteria
- No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
- Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
- For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.
- CPT code 10140 is payable only when billed with the specified ICD-10-CM codes listed in the policy (multiple S- and L- codes for traumatic or specific skin conditions as enumerated).
- Ultrasound of soft tissues of the head and neck is covered when it is reasonable and necessary as defined by Local Coverage Determination L34027.
- Incision and drainage (I&D) is covered for treatment of abscesses, defined as a circumscribed collection of pus in any location causing infection.
10 Active Policies
A56766 — Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
L33563 — Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
L34027 — Ultrasound, Soft Tissues of Head and Neck
J09
A57029 — Billing and Coding: Ultrasound, Soft Tissues of Head and Neck
J09
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.