S40.242A — External constriction of left shoulder, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must include a valid ICD-10-CM diagnosis code that best describes the condition prompting the immunization; claims without a valid diagnosis code will be returned as incomplete under Section 1833(e).
- When a referring/ordering physician is required, the name and NPI of that physician must be reported on the claim.
- For outpatient services likely to be noncovered, use ABN procedures: use modifier -GA with a signed CMS‑R‑131 ABN (or -GZ if no ABN), and for Part A submissions include occurrence code 32 and the ABN date.
- Hospital inpatient claims must report principal diagnosis in UB‑04 FL67 and admitting diagnosis in FL69; up to eight additional ICD-10-CM codes in FL67A‑67Q as applicable.
Key Coverage Criteria
- One tetanus booster dose is covered for a patient who completed primary immunization, has sustained a high‑risk wound (anaerobic conditions or probable exposure to tetanus spores), and has not received a booster within the past 5 years.
- For clean, minor, uncontaminated wounds, a tetanus booster is covered only if the last booster was >10 years ago (booster every 10 years for most recipients).
- Tetanus toxoid injections (including primary series completion) are covered when given for an acute injury if the patient has not received primary immunization or the patient's primary immunization status is unknown; unknown/uncertain histories should be treated as unvaccinated.
- For inadequately vaccinated patients of any age, completion of the primary tetanus vaccination series should be ensured at discharge or follow-up after an injury and is covered in that context.
- 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.
11 Active Policies
L37228 — Wound Care
J05
A55909 — Billing and Coding: Wound Care
J05
A56900 — Billing and Coding: Immunizations
J05
L34596 — Immunizations
J05
A56459 — Billing and Coding: Debridement Services
Related Codes
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