Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 07.07.07f


Attachment:A

Policy #:07.07.07f

Description:ICD-10 Codes

Title:Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.




E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E08.621 Diabetes mellitus due to underlying condition with foot ulcer
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer
E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E09.621 Drug or chemical induced diabetes mellitus with foot ulcer
E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
I70.331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh
I70.332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf
I70.333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle
I70.334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot
I70.335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot
I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site
I70.341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh
I70.342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf
I70.343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle
I70.344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot
I70.345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot
I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site
I70.35 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration
I70.361 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg
I70.362 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, left leg
I70.363 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs
I70.368 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, other extremity
I70.369 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, unspecified extremity
I70.431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh
I70.432 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf
I70.433 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle
I70.434 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot
I70.435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site
I70.441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh
I70.442 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf
I70.443 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle
I70.444 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot
I70.445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot
I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site
I70.45 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
I70.461 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, right leg
I70.462 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, left leg
I70.463 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, bilateral legs
I70.468 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, other extremity
I70.469 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, unspecified extremity
I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh
I70.532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf
I70.533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle
I70.534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel and midfoot
I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot
I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site
I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh
I70.542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf
I70.543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle
I70.544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and midfoot
I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot
I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site
I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
I70.561 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, right leg
I70.562 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, left leg
I70.563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, bilateral legs
I70.568 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, other extremity
I70.569 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, unspecified extremity
I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh
I70.632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf
I70.633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle
I70.634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot
I70.635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot
I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site
I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh
I70.642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf
I70.643 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of ankle
I70.644 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of heel and midfoot
I70.645 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot
I70.648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.649 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site
I70.65 Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration
I70.661 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, right leg
I70.662 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, left leg
I70.663 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, bilateral legs
I70.668 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, other extremity
I70.669 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, unspecified extremity
I70.731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh
I70.732 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf
I70.733 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of ankle
I70.734 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of heel and midfoot
I70.735 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot
I70.738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.739 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site
I70.741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh
I70.742 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf
I70.743 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of ankle
I70.744 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of heel and midfoot
I70.745 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot
I70.748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.749 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site
I70.75 Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration
I70.761 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, right leg
I70.762 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, left leg
I70.763 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, bilateral legs
I70.768 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, other extremity
I70.769 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, unspecified extremity
I73.01 Raynaud's syndrome with gangrene
I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh
I83.002 Varicose veins of unspecified lower extremity with ulcer of calf
I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle
I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot
I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot
I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg
I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.019 Varicose veins of right lower extremity with ulcer of unspecified site
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.029 Varicose veins of left lower extremity with ulcer of unspecified site
I83.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation
I83.202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation
I83.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation
I83.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation
I83.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation
I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation
I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.019 Postthrombotic syndrome with ulcer of unspecified lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.039 Postthrombotic syndrome with ulcer and inflammation of unspecified lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.319 Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I87.339 Chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity
I96 Gangrene, not elsewhere classified
L89.000 Pressure ulcer of unspecified elbow, unstageable
L89.003 Pressure ulcer of unspecified elbow, stage 3
L89.004 Pressure ulcer of unspecified elbow, stage 4
L89.010 Pressure ulcer of right elbow, unstageable
L89.013 Pressure ulcer of right elbow, stage 3
L89.014 Pressure ulcer of right elbow, stage 4
L89.020 Pressure ulcer of left elbow, unstageable
L89.023 Pressure ulcer of left elbow, stage 3
L89.024 Pressure ulcer of left elbow, stage 4
L89.029 Pressure ulcer of left elbow, unspecified stage
L89.100 Pressure ulcer of unspecified part of back, unstageable
L89.103 Pressure ulcer of unspecified part of back, stage 3
L89.104 Pressure ulcer of unspecified part of back, stage 4
L89.110 Pressure ulcer of right upper back, unstageable
L89.113 Pressure ulcer of right upper back, stage 3
L89.114 Pressure ulcer of right upper back, stage 4
L89.120 Pressure ulcer of left upper back, unstageable
L89.123 Pressure ulcer of left upper back, stage 3
L89.124 Pressure ulcer of left upper back, stage 4
L89.130 Pressure ulcer of right lower back, unstageable
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.140 Pressure ulcer of left lower back, unstageable
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.150 Pressure ulcer of sacral region, unstageable
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.200 Pressure ulcer of unspecified hip, unstageable
L89.203 Pressure ulcer of unspecified hip, stage 3
L89.204 Pressure ulcer of unspecified hip, stage 4
L89.210 Pressure ulcer of right hip, unstageable
L89.213 Pressure ulcer of right hip, stage 3
L89.214 Pressure ulcer of right hip, stage 4
L89.220 Pressure ulcer of left hip, unstageable
L89.223 Pressure ulcer of left hip, stage 3
L89.224 Pressure ulcer of left hip, stage 4
L89.300 Pressure ulcer of unspecified buttock, unstageable
L89.303 Pressure ulcer of unspecified buttock, stage 3
L89.304 Pressure ulcer of unspecified buttock, stage 4
L89.310 Pressure ulcer of right buttock, unstageable
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.320 Pressure ulcer of left buttock, unstageable
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable
L89.500 Pressure ulcer of unspecified ankle, unstageable
L89.503 Pressure ulcer of unspecified ankle, stage 3
L89.504 Pressure ulcer of unspecified ankle, stage 4
L89.510 Pressure ulcer of right ankle, unstageable
L89.513 Pressure ulcer of right ankle, stage 3
L89.514 Pressure ulcer of right ankle, stage 4
L89.520 Pressure ulcer of left ankle, unstageable
L89.523 Pressure ulcer of left ankle, stage 3
L89.524 Pressure ulcer of left ankle, stage 4
L89.600 Pressure ulcer of unspecified heel, unstageable
L89.603 Pressure ulcer of unspecified heel, stage 3
L89.604 Pressure ulcer of unspecified heel, stage 4
L89.610 Pressure ulcer of right heel, unstageable
L89.613 Pressure ulcer of right heel, stage 3
L89.614 Pressure ulcer of right heel, stage 4
L89.620 Pressure ulcer of left heel, unstageable
L89.623 Pressure ulcer of left heel, stage 3
L89.624 Pressure ulcer of left heel, stage 4
L89.810 Pressure ulcer of head, unstageable
L89.813 Pressure ulcer of head, stage 3
L89.814 Pressure ulcer of head, stage 4
L89.890 Pressure ulcer of other site, unstageable
L89.893 Pressure ulcer of other site, stage 3
L89.894 Pressure ulcer of other site, stage 4
L89.93 Pressure ulcer of unspecified site, stage 3
L89.94 Pressure ulcer of unspecified site, stage 4
L89.95 Pressure ulcer of unspecified site, unstageable



Version Effective Date: 10/12/2016
Version Issued Date: 10/12/2016
Version Reissued Date: 06/20/2018

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