Does T81.31XA require prior authorization?

Yes, T81.31XA requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

`T81.31XA`, Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter

ICD-10-CM

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

The medical record must clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.

Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
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.
Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

A55909, Billing and Coding: Wound Care

WPS-J5-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

WPS-J5-L37228, Wound Care

A57594, Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

NGS-J6-L33563, Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

A56766, Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures

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

WPS-J8-L37228, Wound Care

WPS-J8-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

NGS-JK-L33563, Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

A56459, Billing and Coding: Debridement Services

A56421, Billing and Coding: CT of the Abdomen and Pelvis

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

HUMANA-WOUND-CARE-LA-MEDICAID, Wound Care

A58565, Billing and Coding: Wound and Ulcer Care