Q81.9 — Epidermolysis bullosa, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical records must clearly document medical necessity and an explicit rationale for why removal is not cosmetic when billing CPT 17106-17108.
- Coding and billing guidance must be used with the associated Local Coverage Determination; coverage details for CPT 11055-11057 are delineated in the Medicare Internet-Only Manual and should be followed for claims.
- Claims must include an ICD-10-CM diagnosis code that represents the reason for the procedure, billed to the highest level of specificity and linked to the appropriate procedure code.
- Medical records must support that a surgical debridement was performed when billing surgical debridement CPT codes (11000-11012, 11042-11047).
Key Coverage Criteria
- Removal of benign skin lesions billed with CPT 17106, 17107, or 17108 is covered only when clinical records document medical necessity and explicitly state why the procedure is not cosmetic.
- Treatment of hyperkeratotic lesions (e.g., corns and calluses) billed with CPT 11055, 11056, or 11057 is covered as described in the Medicare Internet-Only Manual.
- 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).
9 Active Policies
A57162 — Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
AETNA-CPB-0355 — Extracorporeal Immunoadsorption (Prosorba Column)
AETNA-CPB-0606 — Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications
ANTHEM-CG-SURG-127 — CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
A57161 — Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
Related Codes
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