L94.2 — Calcinosis cutis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- If multiple or repeated I&Ds are performed for the same anatomic area, records must explain reasons for recurrence and measures taken to prevent recurrence; photographic or operative documentation may be requested for patterns suggestive of abuse.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Key Coverage Criteria
- 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).
- Excision of a benign skin lesion is covered when there is clinical suspicion of malignancy (e.g., ICD-10-CM D48.5) documented in the medical record.
- Removal is covered to address disturbance of skin sensation when documented (ICD-10-CM R20.0-R20.3, R20.8).
- Removal is covered when documented objective changes (e.g., increase in size) support a diagnosis warranting excision.
4 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
A57044 — Billing and Coding: Removal of Benign Skin Lesions
L34200 — Removal of Benign Skin Lesions
Related Codes
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