Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.01l


Attachment: A

Policy #:05.00.01l

Description:ICD-10 Codes

Title:Pneumatic Compression Therapy Devices


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.



I87.2 Venous insufficiency (chronic) (peripheral)

I89.0 Lymphedema, not elsewhere classified

I97.2 Postmastectomy lymphedema syndrome

L97.101 Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin

L97.102 Non-pressure chronic ulcer of unspecified thigh with fat layer exposed

L97.103 Non-pressure chronic ulcer of unspecified thigh with necrosis of muscle

L97.104 Non-pressure chronic ulcer of unspecified thigh with necrosis of bone

L97.105 Non-pressure chronic ulcer of unspecified thigh with muscle involvement without evidence of necrosis

L97.106 Non-pressure chronic ulcer of unspecified thigh with bone involvement without evidence of necrosis

L97.108 Non-pressure chronic ulcer of unspecified thigh with other specified severity

L97.109 Non-pressure chronic ulcer of unspecified thigh with unspecified severity

L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin

L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed

L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle

L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone

L97.115 Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of necrosis

L97.116 Non-pressure chronic ulcer of right thigh with bone involvement without evidence of necrosis

L97.118 Non-pressure chronic ulcer of right thigh with other specified severity

L97.119 Non-pressure chronic ulcer of right thigh with unspecified severity

L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin

L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed

L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle

L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone

L97.125 Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of necrosis

L97.126 Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necrosis

L97.128 Non-pressure chronic ulcer of left thigh with other specified severity

L97.129 Non-pressure chronic ulcer of left thigh with unspecified severity

L97.201 Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin

L97.202 Non-pressure chronic ulcer of unspecified calf with fat layer exposed

L97.203 Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

L97.204 Non-pressure chronic ulcer of unspecified calf with necrosis of bone

L97.205 Non-pressure chronic ulcer of unspecified calf with muscle involvement without evidence of necrosis

L97.206 Non-pressure chronic ulcer of unspecified calf with bone involvement without evidence of necrosis

L97.208 Non-pressure chronic ulcer of unspecified calf with other specified severity

L97.209 Non-pressure chronic ulcer of unspecified calf with unspecified severity

L97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skin

L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed

L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle

L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone

L97.215 Non-pressure chronic ulcer of right calf with muscle involvement without evidence of necrosis

L97.216 Non-pressure chronic ulcer of right calf with bone involvement without evidence of necrosis

L97.218 Non-pressure chronic ulcer of right calf with other specified severity

L97.219 Non-pressure chronic ulcer of right calf with unspecified severity

L97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skin

L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed

L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle

L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone

L97.225 Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necrosis

L97.226 Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis

L97.228 Non-pressure chronic ulcer of left calf with other specified severity

L97.229 Non-pressure chronic ulcer of left calf with unspecified severity

L97.301 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin

L97.302 Non-pressure chronic ulcer of unspecified ankle with fat layer exposed

L97.303 Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle

L97.304 Non-pressure chronic ulcer of unspecified ankle with necrosis of bone

L97.305 Non-pressure chronic ulcer of unspecified ankle with muscle involvement without evidence of necrosis

L97.306 Non-pressure chronic ulcer of unspecified ankle with muscle involvement without evidence of necrosis

L97.308 Non-pressure chronic ulcer of unspecified ankle with other specified severity

L97.309 Non-pressure chronic ulcer of unspecified ankle with unspecified severity

L97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin

L97.312 Non-pressure chronic ulcer of right ankle with fat layer exposed

L97.313 Non-pressure chronic ulcer of right ankle with necrosis of muscle

L97.314 Non-pressure chronic ulcer of right ankle with necrosis of bone

L97.315 Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of necrosis

L97.316 Non-pressure chronic ulcer of right ankle with bone involvement without evidence of necrosis

L97.318 Non-pressure chronic ulcer of right ankle with other specified severity

L97.319 Non-pressure chronic ulcer of right ankle with unspecified severity

L97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin

L97.322 Non-pressure chronic ulcer of left ankle with fat layer exposed

L97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscle

L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone

L97.325 Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of necrosis

L97.326 Non-pressure chronic ulcer of left ankle with bone involvement without evidence of necrosis

L97.328 Non-pressure chronic ulcer of left ankle with other specified severity

L97.329 Non-pressure chronic ulcer of left ankle with unspecified severity

L97.401 Non-pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skin

L97.402 Non-pressure chronic ulcer of unspecified heel and midfoot with fat layer exposed

L97.403 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of muscle

L97.404 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of bone

L97.405 Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without evidence of necrosis

L97.406 Non-pressure chronic ulcer of unspecified heel and midfoot with bone involvement without evidence of necrosis

L97.408 Non-pressure chronic ulcer of unspecified heel and midfoot with other specified severity

L97.409 Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity

L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin

L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed

L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle

L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone

L97.415 Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without evidence of necrosis

L97.416 Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis

L97.418 Non-pressure chronic ulcer of right heel and midfoot with other specified severity

L97.419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity

L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin

L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed

L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle

L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone

L97.425 Non-pressure chronic ulcer of left heel and midfoot with muscle involvement without evidence of necrosis

L97.426 Non-pressure chronic ulcer of left heel and midfoot with bone involvement without evidence of necrosis

L97.428 Non-pressure chronic ulcer of left heel and midfoot with other specified severity

L97.429 Non-pressure chronic ulcer of left heel and midfoot with unspecified severity

L97.501 Non-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin

L97.502 Non-pressure chronic ulcer of other part of unspecified foot with fat layer exposed

L97.503 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of muscle

L97.504 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of bone

L97.505 Non-pressure chronic ulcer of other part of unspecified foot with muscle involvement without evidence of necrosis

L97.506 Non-pressure chronic ulcer of other part of unspecified foot with bone involvement without evidence of necrosis

L97.508 Non-pressure chronic ulcer of other part of unspecified foot with other specified severity

L97.509 Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity

L97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin

L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed

L97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle

L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone

L97.515 Non-pressure chronic ulcer of other part of right foot with muscle involvement without evidence of necrosis

L97.516 Non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis

L97.518 Non-pressure chronic ulcer of other part of right foot with other specified severity

L97.519 Non-pressure chronic ulcer of other part of right foot with unspecified severity

L97.521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin

L97.522 Non-pressure chronic ulcer of other part of left foot with fat layer exposed

L97.523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscle

L97.524 Non-pressure chronic ulcer of other part of left foot with necrosis of bone

L97.525 Non-pressure chronic ulcer of other part of left foot with muscle involvement without evidence of necrosis

L97.526 Non-pressure chronic ulcer of other part of left foot with bone involvement without evidence of necrosis

L97.528 Non-pressure chronic ulcer of other part of left foot with other specified severity

L97.529 Non-pressure chronic ulcer of other part of left foot with unspecified severity

L97.801 Non-pressure chronic ulcer of other part of unspecified lower leg limited to breakdown of skin

L97.802 Non-pressure chronic ulcer of other part of unspecified lower leg with fat layer exposed

L97.803 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of muscle

L97.804 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of bone

L97.805 Non-pressure chronic ulcer of other part of unspecified lower leg with muscle involvement without evidence of necrosis

L97.806 Non-pressure chronic ulcer of other part of unspecified lower leg with bone involvement without evidence of necrosis

L97.808 Non-pressure chronic ulcer of other part of unspecified lower leg with other specified severity

L97.809 Non-pressure chronic ulcer of other part of unspecified lower leg with unspecified severity

L97.811 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin

L97.812 Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed

L97.813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle

L97.814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone

L97.815 Non-pressure chronic ulcer of other part of right lower leg with muscle involvement without evidence of necrosis

L97.816 Non-pressure chronic ulcer of other part of right lower leg with bone involvement without evidence of necrosis

L97.818 Non-pressure chronic ulcer of other part of right lower leg with other specified severity

L97.819 Non-pressure chronic ulcer of other part of right lower leg with unspecified severity

L97.821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin

L97.822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed

L97.823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle

L97.824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone

L97.825 Non-pressure chronic ulcer of other part of left lower leg with muscle involvement without evidence of necrosis

L97.826 Non-pressure chronic ulcer of other part of left lower leg with bone involvement without evidence of necrosis

L97.828 Non-pressure chronic ulcer of other part of left lower leg with other specified severity

L97.829 Non-pressure chronic ulcer of other part of left lower leg with unspecified severity

L97.901 Non-pressure chronic ulcer of unspecified part of unspecified lower leg limited to breakdown of skin

L97.902 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with fat layer exposed

L97.903 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of muscle

L97.904 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of bone

L97.905 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with muscle involvement without evidence of necrosis

L97.906 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with bone involvement without evidence of necrosis

L97.908 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with other specified severity

L97.909 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity

L97.911 Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin

L97.912 Non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed

L97.913 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of muscle

L97.914 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of bone

L97.915 Non-pressure chronic ulcer of unspecified part of right lower leg with muscle involvement without evidence of necrosis

L97.916 Non-pressure chronic ulcer of unspecified part of right lower leg with bone involvement without evidence of necrosis

L97.918 Non-pressure chronic ulcer of unspecified part of right lower leg with other specified severity

L97.919 Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity

L97.921 Non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin

L97.922 Non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed

L97.923 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle

L97.924 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of bone

L97.925 Non-pressure chronic ulcer of unspecified part of left lower leg with muscle involvement without evidence of necrosis

L97.926 Non-pressure chronic ulcer of unspecified part of left lower leg with bone involvement without evidence of necrosis

L97.928 Non-pressure chronic ulcer of unspecified part of left lower leg with other specified severity

L97.929 Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity

Q82.0 Hereditary lymphedema

Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 03/13/2019

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