S20.01XA — Contusion of right breast, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation supporting services must be available to Medicare upon request.
- The medical record must contain the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.
- All services ordered or rendered must be signed and dated; signed and dated office visit records or operative reports must be in the record.
- A clear clinical indication for diagnostic mammogram, breast sonogram, breast MRI, or ductogram must be documented in the medical record and in the referral/order.
Key Coverage Criteria
- Diagnostic mammography, breast sonography (echography), breast MRI, and ductography are covered when a clear clinical indication for the test is documented in the medical record and in the referral/order.
- A diagnostic mammogram performed after an initial screening mammogram (conversion from screening to diagnostic) is allowable when the screening abnormality prompting additional views is documented in the record.
- A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
- When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
- For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.
6 Active Policies
A56766 — Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
L33563 — Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
A56448 — Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
A56459 — Billing and Coding: Debridement Services
Related Codes
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