S38.1XXA — Crushing injury of abdomen, lower back, and pelvis, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- The patient’s medical record must include the ordering provider’s assessment as it relates to the patient’s complaint for that visit.
- Medical records must contain relevant medical history and results of pertinent tests or procedures performed.
- For diagnostic tests, report the result of the test if known; otherwise report the symptoms that prompted performing the test.
Key Coverage Criteria
- 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.
- CPT code 10140 is payable only when billed with the specified ICD-10-CM codes listed in the policy (multiple S- and L- codes for traumatic or specific skin conditions as enumerated).
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
10 Active Policies
L33563 — Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
A56766 — Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
A56459 — Billing and Coding: Debridement Services
A57206 — Billing and Coding: Lumbar MRI
L34220 — Lumbar MRI
Related Codes
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