S00.542S — External constriction of oral cavity, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
- When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
- Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.
- Physical therapists must report patient contact time in 15-minute increments and bill using G0151 for physical therapy time reporting.
Key Coverage Criteria
- CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
- CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
- Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
- CPT 97032 (attended/manual electrical stimulation) is covered when delivered with direct 1-on-1 contact by qualified personnel (examples: direct motor point stimulation; FES/NMES when performed with therapeutic exercise, neuromuscular reeducation, or functional activities).
- CPT 97032 may be billed for the application, instruction, and adjustment of a TENS unit or other probe-based stimulation (including determining trigger points) when provided as an attended/manual modality.
- Non-implantable pelvic floor electrical stimulation (97032 for probes; G0283 for electrode-based delivery) is covered for treatment of stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
8 Active Policies
A53058 — Billing and Coding: Home Health Physical Therapy
A53064 — Billing and Coding: Outpatient Occupational Therapy
A53065 — Billing and Coding: Outpatient Physical Therapy
A56459 — Billing and Coding: Debridement Services
L34427 — Outpatient Occupational Therapy
Related Codes
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