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L.1.04.400
Burn garments (burn anti-pressure garments) include gloves, face hoods, chin straps, jackets, pants, leotards, hose, or entire body suits (body gloves) which provide pressure to burned areas to help with healing.
Inflatable compression garments or individually fitted prescription graded compression stockings provide gentle pressure to either arms or legs, to avoid swelling and other problems. Often, gradient compression stockings are prescribed for prevention of post-operative thrombosis.
A prosthetic sheath may be used alone, placed directly on an amputated limb, or under a prosthetic sock. These garments wick away moisture and help prevent skin breakdown.
Burn garments are considered medically necessary when prescribed by a physician for treatment of any of the following:
third degree burns
deep second degree burns
areas of skin which have received a skin graft
Burn anti-pressure garments for treatment of any other disorders are not covered.
Gradient (or graded) compression stocking may be considered medically necessary when prescribed by a physician for treatment of lymphedema, venous stasis or any of the following:
Varicose veins (except spider veins)
Chronic venous insufficiency
Venous stasis disease
Venous valvular insufficiency
Venous insufficiency
Post thrombotic syndrome
Venous ulcer (stasis ulcer), including ANY ONE of the following:
Edema
Venous
Lymph
Post traumatic
Post surgical
Lipedema
Angiodysplasia
Prevention of thrombosis post-operatively
Post sclerotherapy
Thrombosis prevention
Venous eczema
Lipodermatosclerosis
The degree of pressure required must be at least 25mm Hg.
Four (4) pair of compression stockings are covered for a 12-month period of time.
One post-mastectomy camisole may be covered immediately following mastectomy.
Two post-mastectomy bras and one breast prosthesis are covered following mastectomy. Thereafter, the two bras may be replaced once a year and the prosthesis replaced once every three to five years.
Sport bras are not covered.
Seven (7) prosthetic sheaths and seven (7) pair of prosthetic socks are covered per year.
None
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Reimbursement for the fitting of garments is not covered.
These items are major medical supplies, not Durable Medical Equipment, and are subject to the deductible as specified in the Member's individual contract.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/19/2002: Managed Care Requirements deleted, table added
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
11/5/2003: Code Reference section updated, ICD-9 diagnosis code 454.0, 454.1, 454.2, 454.8, 454.9, 457.0, 459.10, 459.11, 459.12, 459.13, 459.19, 459.2, 459.30, 459.31, 459.32, 459.33, 459.39, 459.89, 941.49, 942.20, 942.25, 942.43, 942.53, 942.54, 943.30, 944.38, 944.48, 944.58 added
5/27/2004: Code Reference section updated, HCPCS L8195 added, HCPCS L8100, L8110, L8120, L8130, L8140, L8150, L8160, L8170, L8180, L8190, L8200, L8210, L8220, L8230, L8239 description revised.
3/27/2006: Coding updated. HCPCS 2006 revisions added to policy.
3/28/2006: Policy reviewed, no changes.
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions.
12/15/2009: Code Section updated with 2010 CPT/HCPCS revisions.
4/22/2010: Policy statement revised to change "gradient pressure aids" to "gradient compression stockings" and included medical indications for the compression stockings. The number of pair of compression stockings was changed from seven (7) pair per year to four (4) pair for a 12-month period of time. Removed outdated source and added Centers for Medicare and Medicaid Services in the Sources section. Added the following verbiage in the Code Reference section: "*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section." Added ICD- 9 Diagnosis codes 451.0 - 451.2 and 747.64 to the Covered Codes Table; and revised the description of ICD-9 diagnosis code 757.0.
11/29/2012: Policy statement revised to state that one post-mastectomy camisole may be covered immediately following mastectomy. Added S8460 to the Covered Codes table.
02/20/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes A6542 and A6543 from the Code Reference section.
09/01/2015: Code Reference section updated for ICD-10.
04/26/2016: Policy Guidelines updated to add medically necessary definition.
05/31/2016: Policy number L.1.04.400 added.
09/29/2017: Code Reference section updated to revise description for ICD-10 diagnosis codes I83.811 - I83.899. Effective 10/01/2017.
01/24/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
03/31/2023: Code Reference section updated to add new HCPCS code E0677, effective 04/01/2023.
10/18/2023: Policy reviewed; no changes.
12/21/2023: Code Reference section updated to add new 2024 HCPCS codes A6520, A6521, A6522, A6523, A6524, A6525, A6526, A6527, A6528, A6529, A6552, A6553, A6554, A6555, A6556, A6557, A6558, A6559, A6560, A6561, A6562, A6563, A6564, A6565, A6566, A6567, A6568, A6569, A6570, A6571, A6572, A6573, A6574, A6575, A6576, A6577, A6578, A6579, A6580, A6581, A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6589, A6593, A6594, A6595, A6596, A6597, A6598, A6599, A6600, A6601, A6602, A6603, A6604, A6605, A6606, A6607, A6608, A6609, A6610, E0678, E0679, and E0682. Revised the code descriptions for HCPCS codes A6531, A6532, and A6545, effective 01/01/2024.
12/04/2024: Policy reviewed; no changes.
04/01/2025: Code Reference section updated to add new HCPCS codes A6515, A6516, A6517, A6518, A6519, and A6611, effective 04/01/2025.
Centers for Medicare and Medicaid Services
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Code Number | Description | ||
CPT-4 | |||
HCPCS | |||
A4490 | Surgical stockings; above knee length, each | ||
A4495 | Surgical stockings; thigh length, each | ||
A4500 | Surgical stockings; below knee length, each | ||
A4510 | Surgical stockings; full length, each | ||
A6501 | Compression burn garment, bodysuit (head to foot), custom fabricated | ||
A6502 | Compression burn garment, chin strap, custom fabricated | ||
A6503 | Compression burn garment, facial hood, custom fabricated | ||
A6504 | Compression burn garment, glove to wrist, custom fabricated | ||
A6505 | Compression burn garment, glove to elbow, custom fabricated | ||
A6506 | Compression burn garment, glove to axilla, custom fabricated | ||
A6507 | Compression burn garment, foot to knee length, custom fabricated | ||
A6508 | Compression burn garment, foot to thigh length, custom fabricated | ||
A6509 | Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated | ||
A6510 | Compression burn garment, trunk, including arms down to leg opening (leotard), custom fabricated | ||
A6511 | Compression burn garment, lower trunk including leg openings (panty), custom fabricated | ||
A6512 | Compression burn garment, not otherwise classified | ||
A6513 | Compression burn mask, face and/or neck, plastic or equal, custom fabricated | ||
A6515 | Gradient compression wrap with adjustable straps, full leg, each, custom (New 04/01/2025) | ||
A6516 | Gradient compression wrap with adjustable straps, foot, each, custom (New 04/01/2025) | ||
A6517 | Gradient compression wrap with adjustable straps, below knee, each, custom (New 04/01/2025) | ||
A6518 | Gradient compression wrap with adjustable straps, arm, each, custom (New 04/01/2025) | ||
A6519 | Gradient compression garment, not otherwise specified, for nighttime use, each (New 04/01/2025) | ||
A6520 | Gradient compression garment, glove, padded, for nighttime use, each | ||
A6521 | Gradient compression garment, glove, padded, for nighttime use, custom, each | ||
A6522 | Gradient compression garment, arm, padded, for nighttime use, each | ||
A6523 | Gradient compression garment, arm, padded, for nighttime use, custom, each | ||
A6524 | Gradient compression garment, lower leg and foot, padded, for nighttime use, each | ||
A6525 | Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each | ||
A6526 | Gradient compression garment, full leg and foot, padded, for nighttime use, each | ||
A6527 | Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each | ||
A6528 | Gradient compression garment, bra, for nighttime use, each | ||
A6529 | Gradient compression garment, bra, for nighttime use, custom, each | ||
A6530 | Gradient compression stocking, below knee, 18-30 mmhg, each | ||
A6531 | Gradient compression stocking, below knee, 30-40 mmhg, used as a surgical dressing, each | ||
A6532 | Gradient compression stocking, below knee, 40-50 mmhg, used as a surgical dressing, each | ||
A6533 | Gradient compression stocking, thigh length, 18-30 mmhg, each | ||
A6534 | Gradient compression stocking, thigh length, 30-40 mmhg, each | ||
A6535 | Gradient compression stocking, thigh length, 40-50 mmhg, each | ||
A6536 | Gradient compression stocking, full length/chap style, 18-30 mmhg, each | ||
A6537 | Gradient compression stocking, full length/chap style, 30-40 mmhg, each | ||
A6538 | Gradient compression stocking, full length/chap style, 40-50 mmhg, each | ||
A6539 | Gradient compression stocking, waist length, 18-30 mmhg, each | ||
A6540 | Gradient compression stocking, waist length, 30-40 mmhg, each | ||
A6541 | Gradient compression stocking, waist length, 40-50 mmhg, each | ||
A6544 | Gradient compression stocking, garter belt | ||
A6545 | Gradient compression wrap, non-elastic, below knee, 30-50 mmhg, used as a surgical dressing, each | ||
A6549 | Gradient compression stocking, not otherwise specified | ||
A6552 | Gradient compression stocking, below knee, 30-40 mmhg, each | ||
A6553 | Gradient compression stocking, below knee, 30-40 mmhg, custom, each | ||
A6554 | Gradient compression stocking, below knee, 40 mmhg or greater, each | ||
A6555 | Gradient compression stocking, below knee, 40 mmhg or greater, custom, each | ||
A6556 | Gradient compression stocking, thigh length, 18-30 mmhg, custom, each | ||
A6557 | Gradient compression stocking, thigh length, 30-40 mmhg, custom, each | ||
A6558 | Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each | ||
A6559 | Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each | ||
A6560 | Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each | ||
A6561 | Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each | ||
A6562 | Gradient compression stocking, waist length, 18-30 mmhg, custom, each | ||
A6563 | Gradient compression stocking, waist length, 30-40 mmhg, custom, each | ||
A6564 | Gradient compression stocking, waist length, 40 mmhg or greater, custom, each | ||
A6565 | Gradient compression gauntlet, custom, each | ||
A6566 | Gradient compression garment, neck/head, each | ||
A6567 | Gradient compression garment, neck/head, custom, each | ||
A6568 | Gradient compression garment, torso and shoulder, each | ||
A6569 | Gradient compression garment, torso/shoulder, custom, each | ||
A6570 | Gradient compression garment, genital region, each | ||
A6571 | Gradient compression garment, genital region, custom, each | ||
A6572 | Gradient compression garment, toe caps, each | ||
A6573 | Gradient compression garment, toe caps, custom, each | ||
A6574 | Gradient compression arm sleeve and glove combination, custom, each | ||
A6575 | Gradient compression arm sleeve and glove combination, each | ||
A6576 | Gradient compression arm sleeve, custom, medium weight, each | ||
A6577 | Gradient compression arm sleeve, custom, heavy weight, each | ||
A6578 | Gradient compression arm sleeve, each | ||
A6579 | Gradient compression glove, custom, medium weight, each | ||
A6580 | Gradient compression glove, custom, heavy weight, each | ||
A6581 | Gradient compression glove, each | ||
A6582 | Gradient compression gauntlet, each | ||
A6583 | Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each | ||
A6584 | Gradient compression wrap with adjustable straps, not otherwise specified | ||
A6585 | Gradient pressure wrap with adjustable straps, above knee, each | ||
A6586 | Gradient pressure wrap with adjustable straps, full leg, each | ||
A6587 | Gradient pressure wrap with adjustable straps, foot, each | ||
A6588 | Gradient pressure wrap with adjustable straps, arm, each | ||
A6589 | Gradient pressure wrap with adjustable straps, bra, each | ||
A6593 | Accessory for gradient compression garment or wrap with adjustable straps, not-otherwise specified | ||
A6594 | Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each | ||
A6595 | Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each | ||
A6596 | Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each | ||
A6597 | Gradient compression bandage roll, elastic long stretch, linear yard, any width, each | ||
A6598 | Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each | ||
A6599 | Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each | ||
A6600 | Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each | ||
A6601 | Gradient compression bandaging supply, high density foam pad, any size or shape, each | ||
A6602 | Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each | ||
A6603 | Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each | ||
A6604 | Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each | ||
A6605 | Gradient compression bandaging supply, padded foam, per linear yard, any width, each | ||
A6606 | Gradient compression bandaging supply, padded textile, per linear yard, any width, each | ||
A6607 | Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each | ||
A6608 | Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each | ||
A6609 | Gradient compression bandaging supply, not otherwise specified | ||
A6610 | Gradient compression stocking, below knee, 18-30 mmhg, custom, each | ||
A6611 | Gradient compression wrap with adjustable straps, above knee, each, custom (New 04/01/2025) | ||
E0677 | Non-pneumatic sequential compression garment, trunk | ||
E0678 | Non-pneumatic sequential compression garment, full leg | ||
E0679 | Non-pneumatic sequential compression garment, half leg | ||
E0682 | Non-pneumatic sequential compression garment, full arm | ||
L8000 | Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type | ||
L8010 | Mastectomy sleeve | ||
L8020 | Mastectomy form | ||
L8030 | Silicone or equal | ||
L8031 | Breast Prosthesis, silicone or equal, with integral adhesive | ||
S8460 | Camisole, postmastectomy | ||
ICD-9 Procedure | ICD-10 Procedure | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
451.0 | Phlebitis and thrombophlebitis of superficial vessels of lower extremities | I80.00 – I80.03 | Phlebitis and thrombophlebitis of superficial vessels of lower of lower extremities |
451.11 | Phlebitis and thrombophlebitis of femoral vein (deep) (superficial) | I80.10 – I80.13 | Phlebitis and thrombophlebitis of femoral vein |
451.19 | Phlebitis and thrombophlebitis of other deep vessels of lower extremities | I80.201 – I80.209 | Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities |
I80.221 – I80.229 | Phlebitis and thrombophlebitis of popliteal vein | ||
I80.231 – I80.239 | Phlebitis and thrombophlebitis of tibial vein | ||
I80.291 – I80.299 | Phlebitis and thrombophlebitis of other deep vessels of lower extremities | ||
451.2 | Phlebitis and thrombophlebitis of lower extremities, unspecified | I80.3 | Phlebitis and thrombophlebitis of lower extremities, unspecified |
454.0 | Varicose veins of lower extremities with ulcer | I83.001 - I83.029 | Varicose veins of lower extremities |
454.1 | Varicose veins of lower extremities with inflammation | I83.10 - I83.12 | Varicose veins of lower extremities with inflammation |
454.2 | Varicose veins of lower extremities with ulcer and inflammation | I83.201 - I83.229 | Varicose veins of lower extremities with ulcer and inflammation |
454.8 | Varicose veins of the lower extremities with other complications | I83.811 - I83.899 | Varicose veins of lower extremities with other complications |
454.9 | Asymptomatic varicose veins of lower extremities | I83.90 - I83.93 | Asymptomatic varicose veins of lower extremities |
457.0 | Postmastectomy lymphedema syndrome | I97.2 | Postmastectomy lymphedema syndrome |
457.1 | Other noninfectious lymphedema | I89.0 | Lymphedema, not elsewhere classified |
459.10 | Postphlebitic syndrome without complications | I87.001 - I87.009 | Postthrombotic syndrome without complications |
459.11 | Postphlebitic syndrome with ulcer | I87.011 - I87.019 | Postthrombotic syndrome with ulcer |
459.12 | Postphlebitic syndrome with inflammation | I87.021 - I87.029 | Postthrombotic syndrome with inflammation |
459.13 | Postphlebitic syndrome with ulcer and inflammation | I87.031 - I87.039 | Postthrombotic syndrome with ulcer and inflammation |
459.19 | Postphlebitic syndrome with other complication | I87.091 - I87.099 | Postthrombotic syndrome with other complications |
459.2 | Compression of vein | I87.1 | Compression of vein |
459.30 | Chronic venous hypertension without complications | I87.301 - I87.309 | Chronic venous hypertension (idiopathic) |
459.31 | Chronic venous hypertension with ulcer | I87.311 - I87.319 | Chronic venous hypertension (idiopathic) with ulcer |
459.32 | Chronic venous hypertension with inflammation | I87.321 - I87.329 | Chronic venous hypertension (idiopathic) with inflammation |
459.33 | Chronic venous hypertension with ulcer and inflammation | I87.331 - I87.339 | Chronic venous hypertension (idiopathic) with ulcer and inflammation |
459.39 | Chronic venous hypertension with other complication | I87.391 - I87.399 | Chronic venous hypertension (idiopathic) with other complications |
459.81 | Venous peripheral insufficiency, unspecified | I87.2 | Venous insufficiency (chronic) (peripheral) |
459.89 | Other specified circulatory system disorders | I87.8 | Other specified disorders of veins |
I99.8 | Other disorders of circulatory systems | ||
747.64 | Lower limb vessel anomaly | Q27.32 | Arteriovenous malformation of vessel of lower limb |
757.0 | Hereditary edema of legs | Q82.0 | Hereditary lymphedema |
Burns of face, head & neck: For the burn code range, the appropriate 7th character is to be added to each code to specify the episode of care. | |||
941.20 | Head - second degree | T20.20X, T20.60X | Burn or corrosion of second degree of head, face, and neck, unspecified site |
941.21 | Ear - second degree | T20.211 - T20.219, T20.611 - T20.619 | Burn or corrosion of second degree of ear |
941.22 | Ear - second degree | T26.40X - T26.42X | Burn of eye and adnexa, part unspecified |
941.23 | Lips - second degree | T20.22X, T20.62X | Burn or corrosion of second degree of lip(s) |
941.24 | Chin - second degree | T20.23X, T20.63X | Burn or corrosion of second degree of chin |
941.25 | Nose - second degree | T20.24X, T20.64X | Burn or corrosion of second degree of nose |
941.26 | Scalp - second degree | T20.25X, T20.65X | Burn or corrosion of second degree of scalp |
941.27 | Forehead - second degree Cheek - second degree | T20.26X, T20.66X | Burn or corrosion of second degree of forehead and cheek |
941.28 | Neck - second degree | T20.27X, T20.67X | Burn or corrosion of second degree of neck |
941.29 | Multiple sites - second degree | T20.29X, T20.69X | Burn or corrosion of second degree of multiple sites of head |
941.30 | Head - third degree | T20.30X, T20.70X | Burn or corrosion of third degree of head, face, and neck, unspecified site |
941.31 | Ear - third degree | T20.311 - T20.319. T20.711 - T20.719 | Burn or corrosion of third degree of ear |
941.32 | Ear - third degree | T26.40X - T26.42X | Burn or corrosion of third degree of eye |
941.33 | Lips - third degree | T20.32X, T20.72X | Burn or corrosion of third degree of lip(s) |
941.34 | Chin - third degree | T20.33X, T20.73X | Burn or corrosion of third degree of chin |
941.35 | Nose - third degree | T20.34X, T20.74X | Burn or corrosion of third degree of nose |
941.36 | Scalp - third degree | T20.35X, T20.75X | Burn or corrosion of third degree of scalp |
941.37 | Forehead - third degree, Cheek - third degree | T20.36X, T20.76X | Burn or corrosion of third degree of forehead and cheek |
941.38 | Neck - third degree | T20.37X, T20.77X | Burn or corrosion of third degree of neck |
941.39 | Multiple sites - third degree | T20.39X, T20.79X | Burn or corrosion of third degree of multiple sites of head |
941.40 | Head - deep | T20.30X, T20.70X | Burn or corrosion of third degree of head, face, and neck, unspecified site |
941.41 | Ear - deep | T20.311 - T20.319. T20.711 - T20.719 | Burn or corrosion of third degree of ear |
941.42 | Ear - deep | T26.40X - T26.42X | Burn or corrosion of third degree of eye |
941.43 | Lips - deep | T20.32X, T20.72X | Burn or corrosion of third degree of lip(s) |
941.44 | Chin - deep | T20.33X, T20.73X | Burn or corrosion of third degree of chin |
941.45 | Nose - deep | T20.34X, T20.74X | Burn or corrosion of third degree of nose |
941.46 | Scalp - deep | T20.35X, T20.75X | Burn or corrosion of third degree of scalp |
941.47 | Forehead – deep, Cheek - deep | T20.36X, T20.76X | Burn or corrosion of third degree of forehead and cheek |
941.48 | Neck - deep | T20.37X, T20.77X | Burn or corrosion of third degree of neck |
941.49 | Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except with eye) of face, head, and neck, without mention of loss of a body part | T20.39X, T20.79X | Burn or corrosion of third degree of multiple sites of head |
941.50 | Head - with loss of body part | T20.30X, T20.70X | Burn or corrosion of third degree of head, face, and neck, unspecified site |
941.51 | Ear - with loss of body part | T20.319, T20.719 | Burn or corrosion of third degree of unspecified ear |
941.52 | Ear - with loss of body part | T26.20X - T26.22X | Burn with resulting rupture and destruction of eyeball |
941.53 | Lips - with loss of body part | T20.32X, T20.72X | Burn or corrosion of third degree of lip(s) |
941.54 | Chin - with loss of body part | T20.33X, T20.73X | Burn or corrosion of third degree of chin |
941.55 | Nose - with loss of body part | T20.34X, T20.74X | Burn or corrosion of third degree of nose |
941.56 | Scalp - with loss of body part | T20.35X, T20.75X | Burn or corrosion of third degree of scalp |
941.57 | Cheek - with loss of body part, Forehead - with loss of body part | T20.36X, T20.76X | Burn or corrosion of third degree of forehead and cheek |
941.58 | Neck - with loss of body part | T20.37X, T20.77X | Burn or corrosion of third degree of neck |
941.59 | Multiple sites - with loss of body part | T20.39X, T20.79X | Burn or corrosion of third degree of multiple sites of head |
Burns of the trunk : For the burn code range, the appropriate 7th character is to be added to each code to specify the episode of care. | |||
942.20 | Blisters with epidermal loss due to burn (second degree) of unspecified site of trunk | T21.20X, T21.60X | Burn or corrosion of second degree of trunk, unspecified site |
942.21 | Breast - second degree | T21.21X, T21.61X | Burn or corrosion of second degree of chest wall |
942.22 | Chest - second degree | T21.21X, T21.61X | Burn or corrosion of second degree of chest wall |
942.23 | Abdomen - second degree | T21.22X, T21.61X | Burn or corrosion of second degree of abdominal wall |
942.24 | Back - second degree | T21.23X - T21.25X, T21.63X - T21.65X | Burn or corrosion of second degree of back |
942.25 | Blisters with epidermal loss due to burn (second degree) of genitalia | T21.26X, T21.27X, T21.66X, T21.67X | Burn or corrosion of second degree of genitalia |
942.29 | Multiple sites - second degree | T21.29X, T21.69X | Burn or corrosion of second degree of other site of trunk |
942.30 | Trunk - third degree | T21.30X, T21.70X | Burn or corrosion of third degree of trunk, unspecified site |
942.31, 942.32 | Breast - third degree, Chest - third degree | T21.31X, T21.71X | Burn or corrosion of third degree of chest wall |
942.33 | Abdomen - third degree | T21.32X, T21.72X | Burn or corrosion of third degree of abdominal wall |
942.34 | Back - third degree | T21.33X - T21.35X , T21.73X - T21.75X | Burn or corrosion of third degree of back |
942.35 | External - third degree | T21.36X, T21.37X, T21.76X, T21.77X | Burn or corrosion of third degree of genitalia |
942.39 | Multiple sites - third degree | T21.39X, T21.79X | Burn or corrosion of third degree of other site of trunk |
942.40 | Trunk - deep | T21.30X, T21.70X | Burn or corrosion of third degree of trunk, unspecified site |
942.41, 942.42 | Breast – deep, Chest - deep | T21.31X, T21.71X | Burn or corrosion of third degree of chest wall |
942.43 | Deep necrosis of underlying tissues due to burn (deep third degree) of abdominal wall, without mention of loss of a body part | T21.32X, T21.72X | Burn or corrosion of third degree of abdominal wall |
942.44 | Back - loss of body part | T21.33X - T21.35X, T21.73X - T21.75X | Burn or corrosion of third degree of back |
942.45 | External - deep | T21.36X, T21.37X, T21.76X, T21.77X | Burn or corrosion of third degree of genitalia |
942.49 | Multiple sites - deep | T21.39X, T21.79X | Burn or corrosion of third degree of other site of trunk |
942.50 | Trunk - with loss of body part | T21.30X, T21.70X | Burn or corrosion of third degree of trunk, unspecified site |
942.51, 942.52 | Breast - with loss of body part, Chest - with loss of body part | T21.31X, T21.71X | Burn or corrosion of third degree of chest wall |
942.53 | Deep necrosis of underlying tissues due to burn (deep third degree) of abdominal wall with loss of a body part | T21.32X, T21.72X | Burn or corrosion of third degree of abdominal wall |
942.54 | Deep necrosis of underlying tissues due to burn (deep third degree) of back (any part), with loss of a body part | T21.33X, T21.73X | Burn of third degree of upper back |
942.55 | External - with loss of body part | T21.36X, T21.37X, T21.76X, T21.77X | Burn or corrosion of third degree of genitalia |
942.59 | Multiple sites - with loss of body part | T21.39X, T21.79X | Burn or corrosion of third degree of other site of trunk |
Burn of upper limb, except wrist & hand: For the burn code range, the appropriate 7th character is to be added to each code to specify the episode of care. | |||
943.20 | Arm - Second degree | T22.20X, T22.60X | Burn or corrosion of second degree of shoulder and upper limb, except wrist and hand, unspecified site |
943.21 | Forearms - second degree | T22.211 - T22.219, T22.611 - T22.619 | Burn or corrosion of second degree of forearm |
943.22 | Elbow - second degree | T22.221 - T22.229, T22.621 - T22.629 | Burn or corrosion of second degree of elbow |
943.23 | Upper Arm - second degree | T22.231 - T22.239, T22.631 - T22.639 | Burn or corrosion of second degree of upper arm |
943.24 | Axilla - second degree | T22.241 - T22.249, T22.641 - T22.649 | Burn or corrosion of second degree of axilla |
943.25 | Shoulder - second degree | T22.251 - T22.259, T22.651 - T22.659 | Burn or corrosion of second degree of shoulder |
943.26 | Scapular region - second degree | T22.261 - T22.269, T22.661 - T22.669 | Burn or corrosion of second degree of scapular |
943.29 | Lower Arm - second degree | T22.291 - T22.299, T22.691 - T22.699 | Burn or corrosion of second degree of upper arm |
943.30 | Full-thickness skin loss due to burn (third degree nos) of unspecified site of upper limb | T22.30X, T22.70X | Burn or corrosion of third degree of shoulder and upper limb, except wrist and hand, unspecified site |
943.31 | Forearms - third degree | T22.311 - T22.319, T22.711 - T22.719 | Burn or corrosion of third degree of forearm |
943.32 | Elbow - third degree | T22.321 - T22.329, T22.721 - T22.729 | Burn or corrosion of third degree of elbow |
943.33 | Upper Arm - third degree | T22.331 - T22.339, T22.731 - T22.739 | Burn or corrosion of third degree of upper arm |
943.34 | Axilla - third degree | T22.341 - T22.349, T22.741 - T22.749 | Burn or corrosion of third degree of axilla |
943.35 | Shoulder - second degree | T22.351 - T22.359, T22.751 - T22.759 | Burn or corrosion of third degree of shoulder |
943.36 | Scapular region - third degree | T22.361 - T22.369, T22.761 - T22.769 | Burn or corrosion of third degree of scapular |
943.39 | Lower Arm - third degree | T22.391 - T22.399, T22.791 - T22.799 | Burn or corrosion of multiple sites of shoulder and upper limb, except wrist and hand |
943.40 | Arm - deep | T22.30X, T22.70X | Burn or corrosion of third degree of shoulder and upper limb, except wrist and hand, unspecified site |
943.41 | Forearms - deep | T22.311 - T22.319, T22.711 - T22.719 | Burn or corrosion of third degree of forearm |
943.42 | Elbow - deep | T22.321 - T22.329, T22.721 - T22.729 | Burn or corrosion of third degree of elbow |
943.43 | Upper Arm - deep | T22.331 - T22.339, T22.731 - T22.739 | Burn or corrosion of third degree of upper arm |
943.44 | Axilla - deep | T22.341 - T22.349, T22.741 - T22.749 | Burn or corrosion of third degree of axilla |
943.45 | Shoulder - deep | T22.351 - T22.359, T22.751 - T22.759 | Burn or corrosion of third degree of shoulder |
943.46 | Scapular region - deep | T22.361 - T22.369, T22.761 - T22.769 | Burn or corrosion of third degree of scapular |
943.49 | Lower Arm - deep | T22.391 - T22.399, T22.791 - T22.799 | Burn or corrosion of multiple sites of shoulder and upper limb, except wrist and hand |
943.50 | Arm - with loss of body part | T22.30X, T22.70X | Burn or corrosion of third degree of shoulder and upper limb, except wrist and hand, unspecified site |
943.51 | Forearms - with loss of body part | T22.311 - T22.319, T22.711 - T22.719 | Burn or corrosion of third degree of forearm |
943.52 | Elbow - with loss of body part | T22.321 - T22.329, T22.721 - T22.729 | Burn or corrosion of third degree of elbow |
943.53 | Upper Arm - with loss of body part | T22.331 - T22.339, T22.731 - T22.739 | Burn or corrosion of third degree of upper arm |
943.54 | Axilla - with loss of body part | T22.341 - T22.349, T22.741 - T22.749 | Burn or corrosion of third degree of axilla |
943.55 | Shoulder - with loss of body part | T22.351 - T22.359, T22.751 - T22.759 | Burn or corrosion of third degree of shoulder |
943.56 | Scapular region - with loss of body part | T22.361 - T22.369, T22.761 - T22.769 | Burn or corrosion of third degree of scapular |
943.59 | Lower Arm - with loss of body part | T22.391 - T22.399, T22.791 - T22.799 | Burn or corrosion of multiple sites of shoulder and upper limb, except wrist and hand |
Burns of wrists & hands: For the burn code range, the appropriate 7th character is to be added to each code to specify the episode of care. | |||
944.20 | Hand(s) (phalanges) (and wrist) - second degree | T23.201 - T23.209, T23.601 - T23.609 | Burn or corrosion of second degree of hand |
944.21 | Finger - second degree | T23.221 - T23.229, T23.621 - T23.629 | Burn or corrosion of second degree of finger |
944.22 | Thumb(s) - second degree | T23.211 - T23.219, T23.611 - T23.619 | Burn or corrosion of second degree of thumb |
944.23 | Multiple - second degree | T23.231 - T23.239, T23.631 - T23.639 | Burn or corrosion of second degree of multiple fingers (nail), not including thumb |
944.24 | Thumb - second degree | T23.241 - T23.249, T23.641 - T23.649 | Burn or corrosion of second degree of multiple fingers (nail), including thumb |
944.25 | Palm(s) - second degree | T23.251 - T23.259, T23.651 - T23.659 | Burn or corrosion of second degree of palm |
944.26 | Back - second degree | T23.261 - T23.269, T23.661 - T23.669 | Burn or corrosion of second degree of back of hand |
944.27 | Wrist - second degree | T23.271 - T23.279, T23.671 - T23.679 | Burn or corrosion of second degree of wrist |
944.28 | Multiple sites - second degree | T23.291 - T23.299, T23.691 - T23.699 | Burn or corrosion of second degree of multiple sites of wrist and hand |
944.30 | Hand(s) (phalanges) (and wrist) - third degree | T23.301 - T23.309, T23.701 - T23.709 | Burn or corrosion of third degree of hand, unspecified site |
944.31 | Finger - third degree | T23.321 - T23.329, T23.721 - T23.729 | Burn or corrosion of third degree of single finger (nail) except thumb |
944.32 | Thumb(s) - third degree | T23.311 - T23.319, T23.711 - T23.719 | Burn or corrosion of third degree of thumb |
944.33 | Multiple - third degree | T23.331 - T23.339, T23.731 - T23.739 | Burn or corrosion of third degree of multiple fingers (nail), not including thumb |
944.34 | Thumb - third degree | T23.341 - T23.349, T23.741 - T23.749 | Burn or corrosion of third degree of multiple fingers (nail), including thumb |
944.35 | Palm(s) - third degree | T23.351 - T23.359, T23.751 - T23.749 | Burn or corrosion of third degree of palm |
944.36 | Back - third degree | T23.361 - T23.369, T23.761 - T23.769 | Burn or corrosion of third degree of back of hand |
944.37 | Wrist - third degree | T23.371 - T23.379, T23.771 - T23.779 | Burn or corrosion of third degree of back of wrist |
944.38 | Full-thickness skin loss due to burn (third degree nos) of multiple sites of wrist(s) and hand(s) | T23.391 - T23.399, T23.791 - T23.799 | Burn or corrosion of third degree of multiple sites of wrist and hand |
944.40 | Hand(s) (phalanges) (and wrist) - deep | T23.301 - T23.309, T23.701 - T23.709 | Burn or corrosion of third degree of hand, unspecified site |
944.41 | Finger - deep | T23.321 - T23.329, T23.721 - T23.729 | Burn or corrosion of third degree of single finger (nail) except thumb |
944.42 | Thumb(s) - deep | T23.311 - T23.319, T23.711 - T23.719 | Burn or corrosion of third degree of thumb |
944.43 | Multiple - deep | T23.331 - T23.339, T23.731 - T23.739 | Burn or corrosion of third degree of multiple fingers (nail), not including thumb |
944.44 | Thumb - deep | T23.341 - T23.349, T23.741 - T23.749 | Burn or corrosion of third degree of multiple fingers (nail), including thumb |
944.45 | Palm(s) - deep | T23.351 - T23.359, T23.751 - T23.749 | Burn or corrosion of third degree of palm |
944.46 | Back - deep | T23.361 - T23.369, T23.761 - T23.769 | Burn or corrosion of third degree of back of hand |
944.47 | Wrist - deep | T23.371 - T23.379, T23.771 - T23.779 | Burn or corrosion of third degree of back of wrist |
944.48 | Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of wrist(s) and hand(s), without mention of loss of a body part | T23.391 - T23.399, T23.791 - T23.799 | Burn or corrosion of third degree of multiple sites of wrist and hand |
944.50 | Hand(s) (phalanges) (and wrist) - with loss of body part | T23.301 - T23.309, T23.701 - T23.709 | Burn or corrosion of third degree of hand, unspecified site |
944.51 | Finger - with loss of body part | T23.321 - T23.329, T23.721 - T23.729 | Burn or corrosion of third degree of single finger (nail) except thumb |
944.52 | Thumb(s) - with loss of body part | T23.311 - T23.319, T23.711 - T23.719 | Burn or corrosion of third degree of thumb |
944.53 | Multiple - with loss of body part | T23.331 - T23.339, T23.731 - T23.739 | Burn or corrosion of third degree of multiple fingers (nail), not including thumb |
944.54 | Thumb - with loss of body part | T23.341 - T23.349, T23.741 - T23.749 | Burn or corrosion of third degree of multiple fingers (nail), including thumb |
944.55 | Palm(s) - with loss of body part | T23.351 - T23.359, T23.751 - T23.749 | Burn or corrosion of third degree of palm |
944.56 | Back - with loss of body part | T23.361 - T23.369, T23.761 - T23.769 | Burn or corrosion of third degree of back of hand |
944.57 | Wrist - with loss of body part | T23.371 - T23.379, T23.771 - T23.779 | Burn or corrosion of third degree of back of wrist |
944.58 | Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of wrist(s) and hand(s), with loss of a body part | T23.391 - T23.399, T23.791 - T23.799 | Burn or corrosion of third degree of multiple sites of wrist and hand |
Burn of lower limbs: For the burn code range, the appropriate 7th character is to be added to each code to specify the episode of care. | |||
945.20 | Knee with other site(s) - second degree | T24.201 - T24.209, T24.601 - T24.609 | Burn or corrosion of second degree of unspecified site of lower limb, except ankle and foot |
945.21 | Toe nail - second degree | T25.231 - T25.239, T25.631 - T25.639 | Burn or corrosion of second degree of toe(s) (nail) |
945.22 | Foot - second degree | T25.221 - T25.229, T25.621 - T25.629 | Burn or corrosion of second degree of foot |
945.23 | Ankle - second degree | T25.211 - T25.219, T25.611 - T25.619 | Burn or corrosion of second degree of ankle |
945.24 | Lower - second degree | T24.231 - T24.239, T24.631 - T24.639 | Burn or corrosion of second degree of lower leg |
945.25 | Knee - second degree | T24.221 - T24.229, T24.621 - T24.629 | Burn or corrosion of second degree of knee |
945.26 | Thigh - second degree | T24.211 - T24.219, T24.611 - T24.619 | Burn or corrosion of second degree of thigh |
945.29 | Multiple sites - second degree | T24.291 - T24.299, T24.691 - T24.699 | Burn or corrosion of second degree of multiple sites of lower limb, except ankle and foot |
T25.291 - T25.299, T25.691 - T25.699 | Burn or corrosion of second degree of multiple sites of ankle and foot | ||
945.30 | Knee with other site(s) - third degree | T24.301 - T24.309, T24.701 - T24.709 | Burn or corrosion of third degree of unspecified site lower limb, except ankle and foot |
945.31 | Toe nail - third degree | T25.331 - T25.339, T25.731 - T25.739 | Burn or corrosion of third degree of toe(s) (nail) |
945.32 | Foot - third degree | T25.321 - T25.329, T25.721 - T25.729 | Burn or corrosion of third degree of foot |
945.33 | Ankle - third degree | T25.311 - T25.319, T25.711 - T25.719 | Burn or corrosion of third degree of ankle |
945.34 | Lower - third degree | T24.331 - T24.339, T24.731 - T24.739 | Burn or corrosion of third degree of lower leg |
945.35 | Knee - third degree | T24.321 - T24.329, T24.721 - T24.729 | Burn or corrosion of third degree of knee |
945.36 | Thigh - third degree | T24.311 - T24.319, T24.711 - T24.719 | Burn or corrosion of third degree of thigh |
945.39 | Multiple sites - third degree | T24.391 - T24.399, T24.791 - T24.799 | Burn or corrosion of third degree of multiple sites of lower limb, except ankle and foot |
T25.391 - T25.399, T25.791 - T25.799 | Burn or corrosion of third degree of multiple sites of ankle and foot | ||
945.40 | Knee with other site(s) - deep | T24.301 - T24.309, T24.701 - T24.709 | Burn or corrosion of third degree of unspecified site lower limb, except ankle and foot |
945.41 | Toe nail - deep | T25.331 - T25.339, T25.731 - T25.739 | Burn or corrosion of third degree of toe(s) (nail) |
945.42 | Foot - deep | T25.321 - T25.329, T25.721 - T25.729 | Burn or corrosion of third degree of foot |
945.43 | Ankle - deep | T25.311 - T25.319, T25.711 - T25.719 | Burn or corrosion of third degree of ankle |
945.44 | Lower - deep | T24.331 - T24.339, T24.731 - T24.739 | Burn or corrosion of third degree of lower leg |
945.45 | Knee - deep | T25.321 - T25.329, T25.721 - T25.729 | Burn or corrosion of third degree of foot |
945.46 | Thigh - deep | T24.311 - T24.319, T24.711 - T24.719 | Burn or corrosion of third degree of thigh |
945.49 | Multiple sites - deep | T24.391 - T24.399, T24.791 - T24.799 | Burn or corrosion of third degree of multiple sites of lower limb, except ankle and foot |
T25.391 - T25.399, T25.791 - T25.799 | Burn or corrosion of third degree of multiple sites of ankle and foot | ||
945.50 | Knee with other site(s) - with loss of body part | T24.301 - T24.309, T24.701 - T24.709 | Burn or corrosion of third degree of unspecified site lower limb, except ankle and foot |
945.51 | Toe nail - with loss of body part | T25.331 - T25.339, T25.731 - T25.739 | Burn or corrosion of third degree of toe(s) (nail) |
945.52 | Foot - with loss of body part | T25.321 - T25.329, T25.721 - T25.729 | Burn or corrosion of third degree of foot |
945.53 | Ankle - with loss of body part | T25.311 - T25.319, T25.711 - T25.719 | Burn or corrosion of third degree of ankle |
945.54 | Lower - with loss of body part | T24.331 - T24.339, T24.731 - T24.739 | Burn or corrosion of third degree of lower leg |
945.55 | Knee - with loss of body part | T25.321 - T25.329, T25.721 - T25.729 | Burn or corrosion of third degree of foot |
945.56 | Thigh - with loss of body part | T24.311 - T24.319, T24.711 - T24.719 | Burn or corrosion of third degree of thigh |
945.59 | Multiple sites - with loss of body part | T24.391 - T24.399, T24.791 - T24.799 | Burn or corrosion of third degree of multiple sites of lower limb, except ankle and foot |
T25.391 - T25.399, T25.791 - T25.799 | Burn or corrosion of third degree of multiple sites of ankle and foot | ||
Burn of multiple specified sites: | |||
946.2 | Specified sites - second degree | T30.0, T30.4 | Burn or corrosion of unspecified body region, unspecified degree |
946.3 | Specified sites - third degree | ||
946.5 | Specified sites - with loss of body part | ||
946.4 | Specified sites - deep | T30.0 | Burn of unspecified body region, unspecified degree |
Burn, unspecified: | |||
949.2 | Unspecified site - second degree | T30.0 | Burn of unspecified body region, unspecified degree |
949.3 | Unspecified site - third degree | ||
949.4 | Unspecified site - deep | ||
949.5 | Unspecified site - with loss of body part | T30.0, T30.4 | Burn or corrosion of unspecified body region, unspecified degree |
997.99 | Lymphedema, surgical | I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
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