L08.0 — Pyoderma
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient’s medical record must include the ordering provider’s assessment as it relates to the patient’s complaint for that visit.
- Medical records must contain relevant medical history and results of pertinent tests or procedures performed.
- For diagnostic tests, report the result of the test if known; otherwise report the symptoms that prompted performing the test.
- All services ordered or rendered to Medicare beneficiaries must be signed and dated; include a signed and dated office visit record or operative report in the medical record.
Key Coverage Criteria
- A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
- When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- CPT 97597, 97598, and 97602 are appropriate for medically necessary selective or non-selective debridement of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and removal of ground-in dirt (e.g., road abrasions) when supported by the medical record.
- Surgical debridement CPT codes 11000-11012 and 11042-11047 are appropriate to report when surgical removal of devitalized tissue is performed and the CPT code selected reflects the deepest tissue type actually removed.
- Paring codes CPT 11055-11057 may be used for paring/cutting of symptomatic hyperkeratosis when the medical record documents the lesion is symptomatic and thus medically necessary.
- Low-frequency, non-contact, non-thermal ultrasound (MIST therapy) CPT 97610 is allowable for treatment of a qualifying wound (one 97610 service per day).
7 Active Policies
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0660 — Knee Arthroplasty
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
A56459 — Billing and Coding: Debridement Services
A58565 — Billing and Coding: Wound and Ulcer Care
Related Codes
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