Does S81.031A require prior authorization?

No, S81.031A does not require prior authorization (high confidence). Covered without prior authorization.

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`S81.031A`, Puncture wound without foreign body, right knee, 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.

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.
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.

20 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

WPS-J5-L34771, Immune Globulins

WPS-J5-L37228, Wound Care

A55909, Billing and Coding: Wound Care

WPS-J5-L34596, Immunizations

A57554, Billing and Coding: Immune Globulins

A56900, Billing and Coding: Immunizations

WPS-J8-L34596, Immunizations

WPS-J8-L34771, Immune Globulins

WPS-J8-L37228, Wound Care

A58873, Billing and Coding: Tetanus Immunization

A58872, Billing and Coding: Tetanus Immunization

A56459, Billing and Coding: Debridement Services

A53065, Billing and Coding: Outpatient Physical Therapy

A57311, Billing and Coding: Physical Therapy - Home Health

A53058, Billing and Coding: Home Health Physical Therapy

A58565, Billing and Coding: Wound and Ulcer Care

A54767, Billing and Coding: Medicare Preventive Coverage for Certain Vaccines

A52438, Billing and Coding: Tetanus Immunization

`S81.031A`, Puncture wound without foreign body, right knee, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

S81.031A, Puncture wound without foreign body, right knee, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`S81.031A`, Puncture wound without foreign body, right knee, initial encounter