L97.413 — Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The final report must include an impression or summary statement, a specific or differential diagnosis if appropriate, and recommendations for follow-up when clinically applicable.
- All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Doppler ultrasound (peripheral venous ultrasound) is the standard preoperative test to evaluate venous reflux in patients with chronic venous insufficiency.
- CPT 93971 should be used to report either a limited bilateral duplex scan or a complete unilateral duplex scan for peripheral venous reflux evaluation.
- Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
- CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
- 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.
20 Active Policies
L37228 — Wound Care
J05
A55909 — Billing and Coding: Wound Care
J05
A57593 — Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies
J05
L35761 — Non-Invasive Peripheral Arterial Vascular Studies
J05
L35751 — Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.