S40.261D — Insect bite (nonvenomous) of right shoulder, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- All services ordered or rendered to Medicare beneficiaries must be signed and dated; include a signed and dated office visit record or operative report in the medical record.
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.
- Debridement is covered for any wound requiring removal of deep-seated foreign material, devitalized, necrotic, or nonviable tissue at the level of skin, subcutaneous tissue, fascia, muscle, or bone to promote wound healing or prepare for surgical intervention.
- Debridement for chronic osteomyelitis and osteomyelitis associated with an open wound is covered.
- CPT codes 11000 and 11001 apply for removal of extensive eczematous or infected skin when the involvement is extensive (e.g., rapidly spreading necrotizing process, severe eczema, bullous disease, extensive trauma, autoimmune skin disease).
- CPT codes 11042-11047 are appropriate for debridement of relatively localized areas involving contiguous underlying structures (e.g., skin ulcers, circumscribed dermal infections, deep-seated debris).
2 Active Policies
A56459 — Billing and Coding: Debridement Services
L34032 — Debridement Services
Related Codes
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