Does L89.894 require prior authorization?

No, L89.894 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`L89.894`, Pressure ulcer of other site, stage 4

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for the HCPCS codes specified under Final Rule 1713 and the WOPD must be obtained prior to delivery.
Suppliers must retain evidence in their files that all related LCD coverage criteria have been met and make that evidence available to the DME MAC upon request.
Suppliers must add the KX modifier to E0194 on the initial claim only if all LCD criteria are met and evidence is retained; for each subsequent monthly claim, add KX only if the treating practitioner's monthly certification documents continued medical necessity and discontinue KX if criteria are not met.

The treating practitioner must document monthly in a written statement the need for the equipment, specifying the size of the ulcer, if the ulcer is not healing what other aspects of the care plan are being modified to promote healing, and that continued use is reasonable and necessary for wound management; the supplier must keep this on file and available for inspection.

Key Coverage Criteria

Pressure-reducing support surfaces (Group 3) including air-fluidized beds (HCPCS E0194) are covered under the Durable Medical Equipment benefit when reasonable and necessary and when the related LCD coverage criteria are met.
Heavy-duty and bariatric devices are included in Group 3 and coded as E0194 when they meet coverage criteria.
Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.
Therapeutic exercise (CPT 97110) is covered when used to address impairments of exercise tolerance due to cardiopulmonary impairments.

13 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

A55909, Billing and Coding: Wound Care

WPS-J5-L37228, Wound Care

A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services

WPS-J8-L37228, Wound Care

A57067, Billing and Coding: Outpatient Physical and Occupational Therapy Services

A58565, Billing and Coding: Wound and Ulcer Care

A52468, Pressure Reducing Support Surfaces - Group 3- Policy Article

A53057, Billing and Coding: Home Health Occupational Therapy

A53058, Billing and Coding: Home Health Physical Therapy

A53065, Billing and Coding: Outpatient Physical Therapy

A56459, Billing and Coding: Debridement Services

`L89.894`, Pressure ulcer of other site, stage 4

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

L89.894, Pressure ulcer of other site, stage 4

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`L89.894`, Pressure ulcer of other site, stage 4