S21.309A — Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must follow the complementary Local Coverage Determination (LCD L34430) and, when CPT 97000–97799 are used by PT/OT, must include documentation that the services meet the coverage and documentation requirements for physical or occupational therapy.
- Maintain all documentation in the patient's medical record and make it available to the contractor upon request; every page must be legible and include appropriate patient identification and dates of service.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.
- 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
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Coverage of transesophageal echocardiogram (TEE) is determined by the reasonable and necessary clinical criteria in Local Coverage Determination L33756; refer to LCD L33756 for specific covered indications.
- Echocardiograms performed as part of the CAMZYOS REMS program are covered when billed with modifier KX and all REMS program requirements are met for patients with NYHA Class II–III obstructive hypertrophic cardiomyopathy (I42.1).
- An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
- A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).
- Rhythm ECGs are covered when used to evaluate signs or symptoms suggesting a cardiac rhythm disorder.
13 Active Policies
A57179 — Billing and Coding: Transesophageal Echocardiogram
J09
L33756 — Transesophageal Echocardiogram
J09
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A57205 — Billing and Coding: Oximetry Services
J12
A57414
Related Codes
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