Does L97.405 require prior authorization?

No, L97.405 does not require prior authorization (high confidence). No active policy covers this code.

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`L97.405`, Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis

ICD-10-CM

Prior Authorization

No Prior Auth Required

No active policy covers this code (high confidence)

Documentation Required

When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
Diagnosis code(s) must best describe the patient’s condition for which the service was performed and a valid ICD-10-CM code is required on the claim.
For an evaluation-only episode, the evaluation serves as the plan of care if it contains a diagnosis or a description from which a referring physician/NPP may determine a diagnosis, and the referral/order certifies the evaluation is needed.

When a qualified professional allows a student to participate, the qualified professional must be present in the room, direct the service and make skilled judgments, not be treating another patient or performing other tasks, and must sign all documentation appropriately.

When PTA/OTA services are furnished in a private practice office or physician/NPP office, documentation must reflect required direct supervision by a PT (for PTAs) or OT (for OTAs) in the private practice setting and compliance with enrollment rules if billed by a physician group under the therapist’s PIN/NPI.

Key Coverage Criteria

Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.

`L97.405`, Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis

Prior Authorization

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

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L97.405, Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis

Prior Authorization

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

`L97.405`, Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis