S86.091A — Other specified injury of right Achilles tendon, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When routine foot care needs to meet one of the exclusions, include the applicable Q modifier on the claim: Q7 for 1 Class A finding, Q8 for 2 Class B findings, and Q9 for 1 Class B plus 2 Class C findings.
- For all foot-care claims report an appropriate foot/toe location modifier (e.g., LT, RT, TA, T1-T9) to identify laterality and specific toe when applicable.
- If a significant, separately identifiable evaluation and management service is provided on the same day as routine foot care, append modifier -25 to the E/M claim line.
- Total the number of keratotic lesions debrided and select the most appropriate CPT code 11055-11057 based on that total (example: code 11056 for two to four lesions).
Key Coverage Criteria
- Removal of corns and calluses of the feet must be billed using CPT codes 11055-11057 (paring/cutting of benign hyperkeratotic lesion) and the procedure code that most accurately describes the service performed should be reported.
- 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.
- Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
- Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
- Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
10 Active Policies
A56232 — Billing and Coding: Foot Care
J05
A52996 — Billing and Coding: Routine Foot Care
J12
L35138 — Routine Foot Care
J12
A56680 — Billing and Coding: Routine Foot Care
L34428 — Outpatient Physical Therapy
Related Codes
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