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ICD-10-CM S90.425D, Blister (nonthermal), left lesser toe(s), subsequent encounter | No Prior Auth

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`S90.425D`, Blister (nonthermal), left lesser toe(s), subsequent encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The patient’s medical record must include the ordering provider’s assessment as it relates to the patient’s complaint for that visit.
Medical records must contain relevant medical history and results of pertinent tests or procedures performed.
For diagnostic tests, report the result of the test if known; otherwise report the symptoms that prompted performing the test.

All services ordered or rendered to Medicare beneficiaries must be signed and dated; include a signed and dated office visit record or operative report in the medical record.

An Advance Beneficiary Notice of Non-coverage (ABN) should use Form CMS-R-131 and must be signed by the beneficiary when applicable; for Part A MAC claims include occurrence code 32 and the ABN date.

Providers should check NCCI edits and OPPS packaging edits prior to billing Medicare as procedure codes may be subject to these edits.

Key Coverage Criteria

A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Debridement is covered for any wound requiring removal of deep-seated foreign material, devitalized, necrotic, or nonviable tissue at the level of skin, subcutaneous tissue, fascia, muscle, or bone to promote wound healing or prepare for surgical intervention.
Debridement for chronic osteomyelitis and osteomyelitis associated with an open wound is covered.
CPT codes 11000 and 11001 apply for removal of extensive eczematous or infected skin when the involvement is extensive (e.g., rapidly spreading necrotizing process, severe eczema, bullous disease, extensive trauma, autoimmune skin disease).
CPT codes 11042-11047 are appropriate for debridement of relatively localized areas involving contiguous underlying structures (e.g., skin ulcers, circumscribed dermal infections, deep-seated debris).

3 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

A56459, Billing and Coding: Debridement Services

Related Codes

11001(3 policies)11042(3 policies)11043(3 policies)11044(3 policies)11045(3 policies)11046(3 policies)11047(3 policies)11000(3 policies)

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