Does O91.011 require prior authorization?

No, O91.011 does not require prior authorization (high confidence). Covered without prior authorization.

`O91.011`, Infection of nipple associated with pregnancy, first trimester

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical record must include relevant history, physical exam, and signs/symptoms that required the I&D procedure; diagnostic test results or the symptoms prompting tests must be recorded.
Pre-operative documentation must record size, location and appearance of the abscess/collection; the operative note must describe the procedure, equipment used, and approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, bloody, frank pus) of material drained.
If multiple or repeated I&Ds are performed for the same anatomic area, records must explain reasons for recurrence and measures taken to prevent recurrence; photographic or operative documentation may be requested for patterns suggestive of abuse.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.
CPT code 10140 is payable only when billed with the specified ICD-10-CM codes listed in the policy (multiple S- and L- codes for traumatic or specific skin conditions as enumerated).
Incision and drainage (I&D) is covered for treatment of abscesses, defined as a circumscribed collection of pus in any location causing infection.
I&D of non-abscess fluid collections (e.g., hematoma, seroma, cyst, bulla) is covered when medically necessary because of pain, inflammation, or infection.
I&D is covered for specific clinical entities including carbuncle, suppurative hidradenitis (hidradenitis suppurativa), cutaneous or subcutaneous abscess, furuncle, post-operative wound infections, and paronychia when criteria for abscess or medical necessity are met.

NGS-J6-L33563, Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

A56766, Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures

NGS-JK-L33563, Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

Ask Backwork about documentation requirements, denial risks, or coverage in your state.