Does L97.419 require prior authorization?

No, L97.419 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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`L97.419`, Non-pressure chronic ulcer of right heel and midfoot with unspecified severity

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

The final report must include an impression or summary statement, a specific or differential diagnosis if appropriate, and recommendations for follow-up when clinically applicable.
All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be available to the contractor upon request.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care.

Key Coverage Criteria

Doppler ultrasound (peripheral venous ultrasound) is the standard preoperative test to evaluate venous reflux in patients with chronic venous insufficiency.
CPT 93971 should be used to report either a limited bilateral duplex scan or a complete unilateral duplex scan for peripheral venous reflux evaluation.
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.

10 Active Policies

A56758, Billing and Coding: Non-Invasive Vascular Studies

NGS-J6-L33627, Non-Invasive Vascular Studies

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

FIRST_COAST-L33693, Peripheral Venous Ultrasound

A57125, Billing and Coding: Peripheral Venous Ultrasound

NOVITAS-JH-L35451, Peripheral Venous Ultrasound

NGS-JK-L33627, Non-Invasive Vascular Studies

A52993, Billing and Coding: Peripheral Venous Ultrasound

NOVITAS-JL-L35451, Peripheral Venous Ultrasound

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

`L97.419`, Non-pressure chronic ulcer of right heel and midfoot with unspecified severity

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

L97.419, Non-pressure chronic ulcer of right heel and midfoot with unspecified severity

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

`L97.419`, Non-pressure chronic ulcer of right heel and midfoot with unspecified severity