Does S96.999S require prior authorization?

No, S96.999S does not require prior authorization (high confidence). Covered without prior authorization.

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`S96.999S`, Other specified injury of unspecified muscle and tendon at ankle and foot level, unspecified foot, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For ICD-10-CM codes designated with an asterisk, the patient must be under the active care of a MD/DO who documents the condition and the claim must include the attending physician's name and NPI in CMS-1500 blocks 17/17B, the date patient was last seen (DPLS) in block 19, and the complicating systemic disease in block 21.
All claims for routine foot care based on a systemic condition must include a billing indicator modifier Q7, Q8, or Q9 as appropriate to be considered for payment.
Mycotic nail services should be coded with ICD-10-CM B35.1 as primary and one of the listed secondary diagnosis codes (L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, R26.2); systemic condition modifiers are not required for these mycotic nail–based services.

Clinical trial/reporting deficiencies noted: many studies lacked standardized reporting of laser parameters, allocation concealment, blinding, withdrawals, and treatment protocols — implying that documentation of laser parameters (wavelength, power, J/cm2, duration, frequency) would be important though not formally required in this text.

Key Coverage Criteria

Nail debridement (CPT 11720 or 11721) for mycotic nails is covered when billed with ICD-10-CM B35.1 as the primary diagnosis and one of the following as a secondary diagnosis: L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, or R26.2.
Routine foot care services are covered when the patient has one of the specified systemic conditions (e.g., diabetes mellitus; arteriosclerosis obliterans; Buerger's disease; chronic thrombophlebitis; peripheral neuropathies of the feet including those associated with malnutrition, alcoholism, malabsorption, pernicious anemia, carcinoma, drugs/toxins, multiple sclerosis, uremia, traumatic injury, leprosy/neurosyphilis, hereditary disorders including hereditary sensory radicular neuropathy, Fabry [...]
A presumption of coverage for routine foot care exists when the physician rendering the service documents and bills using modifier Q7 (one Class A finding), Q8 (two Class B findings), or Q9 (one Class B plus two Class C findings) and a systemic condition diagnosis from the listed conditions is present.
Peri-implant mucositis (p-iM)
Aggressive periodontitis (as adjunct to scaling and root planing [SRP])
Skin burns (experimental models; LLLT to accelerate healing)

3 Active Policies

AETNA-CPB-0210, Phonophoresis

AETNA-CPB-0363, Cold Laser and High-Power Laser Therapies

A56680, Billing and Coding: Routine Foot Care

`S96.999S`, Other specified injury of unspecified muscle and tendon at ankle and foot level, unspecified foot, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

S96.999S, Other specified injury of unspecified muscle and tendon at ankle and foot level, unspecified foot, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

`S96.999S`, Other specified injury of unspecified muscle and tendon at ankle and foot level, unspecified foot, sequela