L98.416: Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis

Risk adjustment

L98.416 risk-adjusts. Under the CMS-HCC V28 model it maps to this category:

• HCC 380 Chronic Ulcer of Skin, Except Pressure, Through to Bone or Muscle1.078 RAF

Coefficient shown for the Community Non-dual Aged segment. A higher HCC in the same hierarchy will suppress this one, so capturing it does not always add score. Look up the whole chart to see which of its HCCs the hierarchy would zero.

Medicare coverage

L98.416 is named in 8 Medicare coverage policies: 7 listing it as supporting medical necessity, and 1 listing it as NOT covered. Which one applies depends on your Medicare contractor.

• A56566Billing and Coding: Outpatient Physical and Occupational Therapy Servicesnot covered
• A53057Billing and Coding: Home Health Occupational Therapy
• A53058Billing and Coding: Home Health Physical Therapy
• A53064Billing and Coding: Outpatient Occupational Therapy