Does T31.55 require prior authorization?

No, T31.55 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`T31.55`, Burns involving 50-59% of body surface with 50-59% third degree burns

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium 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.
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.

13 Active Policies

WPS-J5-L34596, Immunizations

A56900, Billing and Coding: Immunizations

A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services

WPS-J8-L34596, Immunizations

A58873, Billing and Coding: Tetanus Immunization

NOVITAS-JH-L35434, Oximetry Services

NOVITAS-JL-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

A58872, Billing and Coding: Tetanus Immunization

A52438, Billing and Coding: Tetanus Immunization

A59186, Billing and Coding: Magnesium

A53065, Billing and Coding: Outpatient Physical Therapy

A57067, Billing and Coding: Outpatient Physical and Occupational Therapy Services

`T31.55`, Burns involving 50-59% of body surface with 50-59% third degree burns

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

T31.55, Burns involving 50-59% of body surface with 50-59% third degree burns

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`T31.55`, Burns involving 50-59% of body surface with 50-59% third degree burns