S61.258A — Open bite of other finger without damage to nail, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
- Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
- When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.
- If CPT 97597 or 97598 is billed by a therapist while the patient is under a Home Health benefit, coverage depends on inclusion in the Home Health plan of care; if billed by a physician or non-physician practitioner it is paid under Part B even if the beneficiary has an active Home Health plan.
Key Coverage Criteria
- Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
- CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
- 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.
- IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
- 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.
6 Active Policies
A55909 — Billing and Coding: Wound Care
J05
A57554 — Billing and Coding: Immune Globulins
J05
L34771 — Immune Globulins
J05
L37228 — Wound Care
J05
A56459 — Billing and Coding: Debridement Services
Related Codes
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