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ICD-10-CM S43.411D, Sprain of right coracohumeral (ligament), subsequent encounter | No Prior Auth

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`S43.411D`, Sprain of right coracohumeral (ligament), subsequent encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.

Physical therapists must report patient contact time in 15-minute increments and bill using G0151 for physical therapy time reporting.

Clinical notes must be written and dated entries describing signs/symptoms, treatments, patient's reaction, and changes in condition as defined in 42 CFR §484.2.

Progress notes must be dated, signed summaries of care furnished and the patient's response during the given period as defined in 42 CFR §484.2.

Key Coverage Criteria

CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.

4 Active Policies

A53058, Billing and Coding: Home Health Physical Therapy

A53065, Billing and Coding: Outpatient Physical Therapy

A57079, Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma

A57311, Billing and Coding: Physical Therapy - Home Health

Related Codes

G57.52(4 policies)M24.211(4 policies)G56.02(4 policies)G57.51(4 policies)G57.61(4 policies)G57.62(4 policies)G56.01(4 policies)M24.212(4 policies)

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