Does S96.091A require prior authorization?

No, S96.091A does not require prior authorization (high confidence). Covered without prior authorization.

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`S96.091A`, Other injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

When routine foot care needs to meet one of the exclusions, include the applicable Q modifier on the claim: Q7 for 1 Class A finding, Q8 for 2 Class B findings, and Q9 for 1 Class B plus 2 Class C findings.
For all foot-care claims report an appropriate foot/toe location modifier (e.g., LT, RT, TA, T1-T9) to identify laterality and specific toe when applicable.
If a significant, separately identifiable evaluation and management service is provided on the same day as routine foot care, append modifier -25 to the E/M claim line.

When reporting an ICD-10-CM code that falls under the active care requirement, report the date the beneficiary was last seen by the MD, DO, or qualified NPP responsible for treating the underlying condition in line 19 of the CMS-1500 or the electronic equivalent.

Key Coverage Criteria

Removal of corns and calluses of the feet must be billed using CPT codes 11055-11057 (paring/cutting of benign hyperkeratotic lesion) and the procedure code that most accurately describes the service performed should be reported.
Foot care services are covered when the beneficiary has a listed systemic condition that justifies coverage per Medicare Benefit Policy Manual Pub.100-02, Ch.15, Section 290.4D.
For diagnosis codes designated by an asterisk, the patient must be under the active care of an M.D. or D.O., documented as having been seen for the complicating disease within the 6 months prior to service.
Claims asserting presumptive coverage must include a systemic-condition diagnosis from IOM 100-02 Ch.15 Section 290 Group 1 and a valid billing modifier Q7, Q8, or Q9.
Mycotic nail debridement is covered when mycotic nails are present in the context of a systemic disease with class findings and the appropriate Q modifier on the claim.
Mycotic nail debridement is covered without systemic disease if an ambulatory patient has marked limitation of ambulation, pain, or secondary infection from thickened/dystrophic infected toenail plate.

6 Active Policies

A56232, Billing and Coding: Foot Care

NOVITAS-JH-L35138, Routine Foot Care

NOVITAS-JL-L35138, Routine Foot Care

A52996, Billing and Coding: Routine Foot Care

AETNA-CPB-0210, Phonophoresis

A56680, Billing and Coding: Routine Foot Care

`S96.091A`, Other injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

S96.091A, Other injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`S96.091A`, Other injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter