Does T81.42XA require prior authorization?

No, T81.42XA does not require prior authorization (high confidence). Covered without prior authorization.

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`T81.42XA`, Infection following a procedure, deep incisional surgical site, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

Key Coverage Criteria

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.
Follow-up or limited transthoracic echocardiography performed to evaluate a single specified cardiac problem or region must be billed with CPT 93308.
Limited Doppler/follow-up echocardiographic studies (for targeted velocity or gradient assessment) should be billed with CPT 93321 (e.g., tricuspid regurgitant velocity to estimate pulmonary artery systolic pressure or sequential transmitral velocity in mitral stenosis).
Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.

20 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

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

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

WPS-J5-L37228, Wound Care

A55909, Billing and Coding: Wound Care

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

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

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

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

NGS-JK-L33577, Transthoracic Echocardiography (TTE)

A56625, Billing and Coding: Echocardiography

A56809, Billing and Coding: Transesophageal Echocardiography (TEE)

`T81.42XA`, Infection following a procedure, deep incisional surgical site, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T81.42XA, Infection following a procedure, deep incisional surgical site, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T81.42XA`, Infection following a procedure, deep incisional surgical site, initial encounter