Does S31.541A require prior authorization?

No, S31.541A does not require prior authorization (high confidence). Covered without prior authorization.

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`S31.541A`, Puncture wound with foreign body of unspecified external genital organs, male, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must include a valid ICD-10-CM diagnosis code that best describes the condition prompting the immunization; claims without a valid diagnosis code will be returned as incomplete under Section 1833(e).
When a referring/ordering physician is required, the name and NPI of that physician must be reported on the claim.
For outpatient services likely to be noncovered, use ABN procedures: use modifier -GA with a signed CMS‑R‑131 ABN (or -GZ if no ABN), and for Part A submissions include occurrence code 32 and the ABN date.

Hospital inpatient claims must report principal diagnosis in UB‑04 FL67 and admitting diagnosis in FL69; up to eight additional ICD-10-CM codes in FL67A‑67Q as applicable.

Hospital outpatient claims must report the full ICD-10-CM code in FL67; if no definitive diagnosis, report the presenting symptom, and if no referring diagnosis use Z00.00‑Z13.9.

Refer to NCCI and OPPS edits before billing; procedure codes may be subject to NCCI or OPPS packaging edits.

Key Coverage Criteria

One tetanus booster dose is covered for a patient who completed primary immunization, has sustained a high‑risk wound (anaerobic conditions or probable exposure to tetanus spores), and has not received a booster within the past 5 years.
For clean, minor, uncontaminated wounds, a tetanus booster is covered only if the last booster was >10 years ago (booster every 10 years for most recipients).
Tetanus toxoid injections (including primary series completion) are covered when given for an acute injury if the patient has not received primary immunization or the patient's primary immunization status is unknown; unknown/uncertain histories should be treated as unvaccinated.
For inadequately vaccinated patients of any age, completion of the primary tetanus vaccination series should be ensured at discharge or follow-up after an injury and is covered in that context.

1 Active Policy

A52438, Billing and Coding: Tetanus Immunization

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S31.541A, Puncture wound with foreign body of unspecified external genital organs, male, initial encounter