Does M79.674 require prior authorization?

No, M79.674 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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`M79.674`, Pain in right toe(s)

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

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.
For mycotic nail services without systemic disease, medical records must document Group 2 or Group 3 diagnosis codes and the clinical findings (marked ambulation limitation, pain, or secondary infection) submitted 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-L34200, Removal of Benign Skin Lesions

J15

CGS-J15-L34246, Routine Foot Care and Debridement of Nails

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L35897

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M79.674, Pain in right toe(s)