L97.405 — Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
- Diagnosis code(s) must best describe the patient’s condition for which the service was performed and a valid ICD-10-CM code is required on the claim.
- For an evaluation-only episode, the evaluation serves as the plan of care if it contains a diagnosis or a description from which a referring physician/NPP may determine a diagnosis, and the referral/order certifies the evaluation is needed.
- When a qualified professional allows a student to participate, the qualified professional must be present in the room, direct the service and make skilled judgments, not be treating another patient or performing other tasks, and must sign all documentation appropriately.
Key Coverage Criteria
- 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.
- Rehabilitative outpatient PT/OT is covered when the condition has potential to improve or is improving, maximum improvement is not yet attained, and anticipated improvement is attainable within a reasonable and generally predictable period.
- Coverage is allowed for maintenance therapy when the specialized skill, knowledge, and judgment of a qualified therapist are required to establish or design a maintenance program, to instruct caregivers/patients in the program, or to perform periodic reevaluations of the maintenance program.
2 Active Policies
A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
J06
L33631 — Outpatient Physical and Occupational Therapy Services
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.