S86.199S — Other injury of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For ICD-10-CM codes designated with an asterisk, the patient must be under the active care of a MD/DO who documents the condition and the claim must include the attending physician's name and NPI in CMS-1500 blocks 17/17B, the date patient was last seen (DPLS) in block 19, and the complicating systemic disease in block 21.
- All claims for routine foot care based on a systemic condition must include a billing indicator modifier Q7, Q8, or Q9 as appropriate to be considered for payment.
- Mycotic nail services should be coded with ICD-10-CM B35.1 as primary and one of the listed secondary diagnosis codes (L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, R26.2); systemic condition modifiers are not required for these mycotic nail–based services.
Key Coverage Criteria
- Nail debridement (CPT 11720 or 11721) for mycotic nails is covered when billed with ICD-10-CM B35.1 as the primary diagnosis and one of the following as a secondary diagnosis: L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, or R26.2.
- Routine foot care services are covered when the patient has one of the specified systemic conditions (e.g., diabetes mellitus; arteriosclerosis obliterans; Buerger's disease; chronic thrombophlebitis; peripheral neuropathies of the feet including those associated with malnutrition, alcoholism, malabsorption, pernicious anemia, carcinoma, drugs/toxins, multiple sclerosis, uremia, traumatic injury, leprosy/neurosyphilis, hereditary disorders including hereditary sensory radicular neuropathy, Fabry [...]
- A presumption of coverage for routine foot care exists when the physician rendering the service documents and bills using modifier Q7 (one Class A finding), Q8 (two Class B findings), or Q9 (one Class B plus two Class C findings) and a systemic condition diagnosis from the listed conditions is present.
- Routine foot care that is necessary and an integral part of an otherwise covered Medicare service is covered.
- Treatment of warts on the foot (e.g., plantar warts) is covered.
- Routine foot care is covered when the patient has systemic conditions (metabolic, neurologic, or peripheral vascular disease) that affect the feet.
3 Active Policies
AETNA-CPB-0210 — Phonophoresis
A56680 — Billing and Coding: Routine Foot Care
L37643 — Routine Foot Care
Related Codes
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