L89.619 — Pressure ulcer of right heel, unspecified stage
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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.
- Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
- Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
- Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
- Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.
6 Active Policies
A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
J06
L33631 — Outpatient Physical and Occupational Therapy Services
J06
A56459 — Billing and Coding: Debridement Services
A57067 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
L34032
Related Codes
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