Does E08.638 require prior authorization?

No, E08.638 does not require prior authorization (high confidence). Covered without prior authorization.

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`E08.638`, Diabetes mellitus due to underlying condition with other oral complications

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical records must document the clinical findings supporting the billed foot care service and be available upon request.
Claims based on systemic-condition diagnosis codes with an asterisk must include the date patient was last seen (DPLS) and the NPI of the M.D. or D.O. actively managing the systemic condition in the medical record and/or claim.
Claims asserting presumptive coverage or systemic-condition exceptions must include the systemic-condition diagnosis code (Group 1) and the valid billing modifier (Q7/Q8/Q9) on the claim.

Key Coverage Criteria

Foot care services are covered when the beneficiary has a listed systemic condition that justifies coverage per Medicare Benefit Policy Manual Pub.100-02, Ch.15, Section 290.4D.
For diagnosis codes designated by an asterisk, the patient must be under the active care of an M.D. or D.O., documented as having been seen for the complicating disease within the 6 months prior to service.
Claims asserting presumptive coverage must include a systemic-condition diagnosis from IOM 100-02 Ch.15 Section 290 Group 1 and a valid billing modifier Q7, Q8, or Q9.
Mycotic nail debridement is covered when mycotic nails are present in the context of a systemic disease with class findings and the appropriate Q modifier on the claim.
Mycotic nail debridement is covered without systemic disease if an ambulatory patient has marked limitation of ambulation, pain, or secondary infection from thickened/dystrophic infected toenail plate.
Mycotic nail debridement is covered without systemic disease if a non-ambulatory patient has mycotic nails and suffers pain or secondary infection due to thickening and dystrophy of the infected toenail plate.

20 Active Policies

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

CGS-J15-L38662, Implantable Continuous Glucose Monitors (I-CGM)

J15

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

CGS-J18-L38662, Implantable Continuous Glucose Monitors (I-CGM)

J18

WPS-J5-L35490, Category III Codes

A58213, Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)

A56232, Billing and Coding: Foot Care

WPS-J5-L38686, Implantable Continuous Glucose Monitors (I-CGM)

A56726, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

NGS-J6-L38623, Implantable Continuous Glucose Monitors (I-CGM)

A58116, Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)

NGS-J6-L33567, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

WPS-J8-L38686, Implantable Continuous Glucose Monitors (I-CGM)

WPS-J8-L35490, Category III Codes

A58136, Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)

FIRST_COAST-L38664, Implantable Continuous Glucose Monitors (I-CGM)

NOVITAS-JH-L38617, Implantable Continuous Glucose Monitors (I-CGM)

NOVITAS-JH-L35138, Routine Foot Care

NGS-JK-L33567, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

NGS-JK-L38623, Implantable Continuous Glucose Monitors (I-CGM)

`E08.638`, Diabetes mellitus due to underlying condition with other oral complications

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

E08.638, Diabetes mellitus due to underlying condition with other oral complications

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`E08.638`, Diabetes mellitus due to underlying condition with other oral complications