T85.613D — Breakdown (mechanical) of artificial skin graft and decellularized allodermis, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
- When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
- Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.
- Physical therapists must report patient contact time in 15-minute increments and bill using G0151 for physical therapy time reporting.
Key Coverage Criteria
- 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.
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
6 Active Policies
A57207 — Billing and Coding: Lumbar MRI
A53058 — Billing and Coding: Home Health Physical Therapy
A57206 — Billing and Coding: Lumbar MRI
L34220 — Lumbar MRI
L34564 — Home Health Physical Therapy
Related Codes
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