S01.25XD — Open bite of nose, subsequent encounter
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.
- COVID-19 vaccines are covered under Medicare Part B (see CMS guidance for vaccine pricing and coding).
- Seasonal influenza vaccine is covered once per flu season (use codes 90635, 90637, 90638, 90653-90657, 90660-90662, 90672-90674, 90682, 90685-90689, 90694, 90695, 90756, Q2034-Q2039).
- Pneumococcal vaccine is covered as an initial dose for Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B (use codes 90670, 90671, 90677, 90732).
15 Active Policies
A58873 — Billing and Coding: Tetanus Immunization
J09
A58872 — Billing and Coding: Tetanus Immunization
J12
A54767 — Billing and Coding: Medicare Preventive Coverage for Certain Vaccines
A56459 — Billing and Coding: Debridement Services
A56658 — Billing and Coding: Cosmetic and Reconstructive Surgery
Related Codes
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