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PLA Codes

Laboratory Fee Schedule

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CMS Transmittals



National Coverage Determination
Procedure Code: G0281
Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds
CMS Policy Number: 270.1
Back to NCD List



To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

ICD-10Descriptor
E08.621 Diabetes mellitus due to underlying condition w foot ulcer
E08.622 Diabetes due to underlying condition w oth skin ulcer
E09.621 Drug or chemical induced diabetes mellitus with foot ulcer
E09.622 Drug or chemical induced diabetes mellitus w oth skin ulcer
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
I70.231 Athscl native arteries of right leg w ulceration of thigh
I70.232 Athscl native arteries of right leg w ulceration of calf
I70.233 Athscl native arteries of right leg w ulceration of ankle
I70.234 Athscl native art of right leg w ulcer of heel and midfoot
I70.235 Athscl native arteries of right leg w ulcer oth prt foot
I70.238 Athscl natv art of right leg w ulcer oth prt lower right leg
I70.241 Athscl native arteries of left leg w ulceration of thigh
I70.242 Athscl native arteries of left leg w ulceration of calf
I70.243 Athscl native arteries of left leg w ulceration of ankle
I70.244 Athscl native art of left leg w ulcer of heel and midfoot
I70.245 Athscl native arteries of left leg w ulceration oth prt foot
I70.248 Athscl native art of left leg w ulcer oth prt lower left leg
I70.25 Athscl native arteries of extremities w ulceration
I70.331 Athscl unsp type bypass of the right leg w ulcer of thigh
I70.332 Athscl unsp type bypass of the right leg w ulcer of calf
I70.333 Athscl unsp type bypass of the right leg w ulcer of ankle
I70.334 Athscl unsp type bypass of r leg w ulcer of heel and midft
I70.335 Athscl unsp type bypass of right leg w ulcer oth prt foot
I70.338 Athscl unsp type bypass of right leg w ulcer oth prt low leg
I70.341 Athscl unsp type bypass of the left leg w ulcer of thigh
I70.342 Athscl unsp type bypass of the left leg w ulceration of calf
I70.343 Athscl unsp type bypass of the left leg w ulcer of ankle
I70.344 Athscl unsp type bypass of left leg w ulc of heel and midft
I70.345 Athscl unsp type bypass of the left leg w ulcer oth prt foot
I70.348 Athscl unsp type bypass of left leg w ulcer oth prt low leg
I70.35 Athscl unsp type bypass graft(s) of extremity w ulceration
I70.431 Athscl autol vein bypass of the right leg w ulcer of thigh
I70.432 Athscl autol vein bypass of the right leg w ulcer of calf
I70.433 Athscl autol vein bypass of the right leg w ulcer of ankle
I70.434 Athscl autol vein bypass of r leg w ulcer of heel and midft
I70.435 Athscl autol vein bypass of right leg w ulcer oth prt foot
I70.438 Athscl autol vein bypass of r leg w ulcer oth prt low leg
I70.441 Athscl autol vein bypass of the left leg w ulcer of thigh
I70.442 Athscl autol vein bypass of the left leg w ulcer of calf
I70.443 Athscl autol vein bypass of the left leg w ulcer of ankle
I70.444 Athscl autol vein bypass of left leg w ulc of heel and midft
I70.445 Athscl autol vein bypass of left leg w ulcer oth prt foot
I70.448 Athscl autol vein bypass of left leg w ulcer oth prt low leg
I70.45 Athscl autologous vein bypass of extremity w ulceration
I70.531 Athscl nonaut bio bypass of the right leg w ulcer of thigh
I70.532 Athscl nonaut bio bypass of the right leg w ulcer of calf
I70.533 Athscl nonaut bio bypass of the right leg w ulcer of ankle
I70.534 Athscl nonaut bio bypass of r leg w ulcer of heel and midft
I70.535 Athscl nonaut bio bypass of right leg w ulcer oth prt foot
I70.538 Athscl nonaut bio bypass of r leg w ulcer oth prt low leg
I70.541 Athscl nonaut bio bypass of the left leg w ulcer of thigh
I70.542 Athscl nonaut bio bypass of the left leg w ulcer of calf
I70.543 Athscl nonaut bio bypass of the left leg w ulcer of ankle
I70.544 Athscl nonaut bio bypass of left leg w ulc of heel and midft
I70.545 Athscl nonaut bio bypass of left leg w ulcer oth prt foot
I70.548 Athscl nonaut bio bypass of left leg w ulcer oth prt low leg
I70.55 Athscl nonautologous bio bypass of extremity w ulceration
I70.631 Athscl nonbiol bypass of the right leg w ulceration of thigh
I70.632 Athscl nonbiol bypass of the right leg w ulceration of calf
I70.633 Athscl nonbiol bypass of the right leg w ulceration of ankle
I70.634 Athscl nonbiol bypass of right leg w ulcer of heel and midft
I70.635 Athscl nonbiol bypass of the right leg w ulcer oth prt foot
I70.638 Athscl nonbiol bypass of right leg w ulcer oth prt low leg
I70.641 Athscl nonbiol bypass of the left leg w ulceration of thigh
I70.642 Athscl nonbiol bypass of the left leg w ulceration of calf
I70.643 Athscl nonbiol bypass of the left leg w ulceration of ankle
I70.644 Athscl nonbiol bypass of left leg w ulcer of heel and midft
I70.648 Athscl nonbiol bypass of left leg w ulcer oth prt low leg
I70.65 Athscl nonbiological bypass of extremity w ulceration
I70.731 Athscl type of bypass of the right leg w ulceration of thigh
I70.732 Athscl type of bypass of the right leg w ulceration of calf
I70.733 Athscl type of bypass of the right leg w ulceration of ankle
I70.734 Athscl type of bypass of right leg w ulcer of heel and midft
I70.735 Athscl type of bypass of the right leg w ulcer oth prt foot
I70.738 Athscl type of bypass of right leg w ulcer oth prt low leg
I70.741 Athscl type of bypass of the left leg w ulceration of thigh
I70.742 Athscl type of bypass of the left leg w ulceration of calf
I70.743 Athscl type of bypass of the left leg w ulceration of ankle
I70.744 Athscl type of bypass of left leg w ulcer of heel and midft
I70.745 Athscl type of bypass of the left leg w ulcer oth prt foot
I70.748 Athscl type of bypass of left leg w ulcer oth prt low leg
I70.75 Athscl type of bypass graft(s) of extremity w ulceration
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 r low extrem w ulcer of heel and midfoot
I83.015 Varicose veins of r low extrem w ulcer oth part of foot
I83.018 Varicose veins of r low extrem w ulcer oth part of lower leg
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 l low extrem w ulcer of heel and midfoot
I83.025 Varicose veins of l low extrem w ulcer oth part of foot
I83.028 Varicose veins of l low extrem w ulcer oth part of lower leg
I83.211 Varicos vn of r low extrem w ulc of thigh and inflammation
I83.212 Varicos vn of r low extrem w ulc of calf and inflammation
I83.213 Varicos vn of r low extrem w ulc of ankle and inflammation
I83.214 Varicos vn of r low extrem w ulc of heel & midft and inflam
I83.215 Varicos vn of r low extrem w ulc oth part of foot and inflam
I83.218 Varicos vn of r low extrem w ulc oth prt low extrm & inflam
I83.221 Varicos vn of l low extrem w ulc of thigh and inflammation
I83.222 Varicos vn of l low extrem w ulc of calf and inflammation
I83.223 Varicos vn of l low extrem w ulc of ankle and inflammation
I83.224 Varicos vn of l low extrem w ulc of heel & midft and inflam
I83.225 Varicos vn of l low extrem w ulc oth part of foot and inflam
I83.228 Varicos vn of l low extrem w ulc oth prt low extrm & inflam
I87.311 Chronic venous hypertension w ulcer of r low extrem
I87.312 Chronic venous hypertension w ulcer of l low extrem
I87.313 Chronic venous hypertension w ulcer of bilateral low extrm
I87.331 Chronic venous htn w ulcer and inflammation of r low extrem
I87.332 Chronic venous htn w ulcer and inflammation of l low extrem
I87.333 Chronic venous htn w ulcer and inflam of bilateral low extrm
L89.013 Pressure ulcer of right elbow, stage 3
L89.014 Pressure ulcer of right elbow, stage 4
L89.023 Pressure ulcer of left elbow, stage 3
L89.024 Pressure ulcer of left elbow, stage 4
L89.113 Pressure ulcer of right upper back, stage 3
L89.114 Pressure ulcer of right upper back, stage 4
L89.123 Pressure ulcer of left upper back, stage 3
L89.124 Pressure ulcer of left upper back, stage 4
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.213 Pressure ulcer of right hip, stage 3
L89.214 Pressure ulcer of right hip, stage 4
L89.223 Pressure ulcer of left hip, stage 3
L89.224 Pressure ulcer of left hip, stage 4
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.43 Pressr ulcer of contig site of back, buttock and hip, stg 3
L89.44 Pressr ulcer of contig site of back, buttock and hip, stg 4
L89.513 Pressure ulcer of right ankle, stage 3
L89.514 Pressure ulcer of right ankle, stage 4
L89.523 Pressure ulcer of left ankle, stage 3
L89.524 Pressure ulcer of left ankle, stage 4
L89.613 Pressure ulcer of right heel, stage 3
L89.614 Pressure ulcer of right heel, stage 4
L89.623 Pressure ulcer of left heel, stage 3
L89.624 Pressure ulcer of left heel, stage 4
L89.813 Pressure ulcer of head, stage 3
L89.814 Pressure ulcer of head, stage 4
L89.893 Pressure ulcer of other site, stage 3
L89.894 Pressure ulcer of other site, stage 4
L97.112 Non-prs chronic ulcer of right thigh w fat layer exposed
L97.113 Non-prs chronic ulcer of right thigh w necrosis of muscle
L97.114 Non-pressure chronic ulcer of right thigh w necrosis of bone
L97.115 Non-prs chr ulcer of r thigh with msl invl w/o evd of necr
L97.116 Non-prs chr ulcer of r thigh with bone invl w/o evd of necr
L97.118 Non-pressure chronic ulcer of right thigh with oth severity
L97.122 Non-pressure chronic ulcer of left thigh w fat layer exposed
L97.123 Non-prs chronic ulcer of left thigh w necrosis of muscle
L97.124 Non-pressure chronic ulcer of left thigh w necrosis of bone
L97.125 Non-prs chr ulc of left thigh with msl invl w/o evd of necr
L97.126 Non-prs chr ulc of left thigh with bone invl w/o evd of necr
L97.128 Non-pressure chronic ulcer of left thigh with oth severity
L97.212 Non-pressure chronic ulcer of right calf w fat layer exposed
L97.213 Non-prs chronic ulcer of right calf w necrosis of muscle
L97.214 Non-pressure chronic ulcer of right calf w necrosis of bone
L97.215 Non-prs chr ulcer of r calf with msl invl w/o evd of necr
L97.216 Non-prs chr ulcer of r calf with bone invl w/o evd of necr
L97.218 Non-pressure chronic ulcer of right calf with oth severity
L97.222 Non-pressure chronic ulcer of left calf w fat layer exposed
L97.223 Non-pressure chronic ulcer of left calf w necrosis of muscle
L97.224 Non-pressure chronic ulcer of left calf w necrosis of bone
L97.225 Non-prs chr ulcer of left calf with msl invl w/o evd of necr
L97.226 Non-prs chr ulc of left calf with bone invl w/o evd of necr
L97.228 Non-pressure chronic ulcer of left calf with oth severity
L97.312 Non-prs chronic ulcer of right ankle w fat layer exposed
L97.313 Non-prs chronic ulcer of right ankle w necrosis of muscle
L97.314 Non-pressure chronic ulcer of right ankle w necrosis of bone
L97.315 Non-prs chr ulcer of r ankle with msl invl w/o evd of necr
L97.316 Non-prs chr ulcer of r ankle with bone invl w/o evd of necr
L97.318 Non-pressure chronic ulcer of right ankle with oth severity
L97.322 Non-pressure chronic ulcer of left ankle w fat layer exposed
L97.323 Non-prs chronic ulcer of left ankle w necrosis of muscle
L97.324 Non-pressure chronic ulcer of left ankle w necrosis of bone
L97.325 Non-prs chr ulcer of l ankle with msl invl w/o evd of necr
L97.326 Non-prs chr ulcer of l ankle with bone invl w/o evd of necr
L97.328 Non-pressure chronic ulcer of left ankle with oth severity
L97.412 Non-prs chr ulcer of right heel and midft w fat layer expos
L97.413 Non-prs chr ulcer of right heel and midfoot w necros muscle
L97.414 Non-prs chr ulcer of right heel and midfoot w necros bone
L97.415 Non-prs chr ulc of r heel/midft w msl invl w/o evd of necr
L97.416 Non-prs chr ulc of r heel/midft w bne invl w/o evd of necr
L97.418 Non-prs chronic ulcer of right heel/midft with oth severity
L97.422 Non-prs chr ulcer of left heel and midfoot w fat layer expos
L97.423 Non-prs chr ulcer of left heel and midfoot w necros muscle
L97.424 Non-prs chronic ulcer of left heel and midfoot w necros bone
L97.425 Non-prs chr ulc of l heel/midft w msl invl w/o evd of necr
L97.426 Non-prs chr ulc of l heel/midft w bne invl w/o evd of necr
L97.428 Non-prs chronic ulcer of left heel/midft with oth severity
L97.512 Non-prs chronic ulcer oth prt right foot w fat layer exposed
L97.513 Non-prs chronic ulcer oth prt right foot w necros muscle
L97.514 Non-prs chronic ulcer oth prt right foot w necrosis of bone
L97.515 Non-prs chr ulc oth prt r foot with msl invl w/o evd of necr
L97.516 Non-prs chr ulc oth prt r foot with bne invl w/o evd of necr
L97.518 Non-prs chronic ulcer oth prt right foot with oth severity
L97.522 Non-prs chronic ulcer oth prt left foot w fat layer exposed
L97.523 Non-prs chronic ulcer oth prt left foot w necrosis of muscle
L97.524 Non-prs chronic ulcer oth prt left foot w necrosis of bone
L97.525 Non-prs chr ulc oth prt l foot with msl invl w/o evd of necr
L97.526 Non-prs chr ulc oth prt l foot with bne invl w/o evd of necr
L97.528 Non-prs chronic ulcer oth prt left foot with oth severity
L97.812 Non-prs chronic ulcer oth prt r low leg w fat layer exposed
L97.813 Non-prs chronic ulcer oth prt r low leg w necrosis of muscle
L97.814 Non-prs chronic ulcer oth prt r low leg w necrosis of bone
L97.815 Non-prs chr ulc oth prt r low leg w msl invl w/o evd of necr
L97.816 Non-prs chr ulc oth prt r low leg w bne invl w/o evd of necr
L97.818 Non-prs chronic ulcer oth prt r low leg with oth severity
L97.822 Non-prs chronic ulcer oth prt l low leg w fat layer exposed
L97.823 Non-prs chronic ulcer oth prt l low leg w necrosis of muscle
L97.824 Non-prs chronic ulcer oth prt l low leg w necrosis of bone
L97.825 Non-prs chr ulc oth prt l low leg w msl invl w/o evd of necr
L97.826 Non-prs chr ulc oth prt l low leg w bne invl w/o evd of necr
L97.828 Non-prs chronic ulcer oth prt l low leg with oth severity
L98.412 Non-pressure chronic ulcer of buttock with fat layer exposed
L98.413 Non-pressure chronic ulcer of buttock w necrosis of muscle
L98.414 Non-pressure chronic ulcer of buttock with necrosis of bone
L98.415 Non-prs chr ulcer of buttock with msl invl w/o evd of necr
L98.416 Non-prs chr ulcer of buttock with bone invl w/o evd of necr
L98.418 Non-pressure chronic ulcer of buttock with oth severity
L98.422 Non-pressure chronic ulcer of back with fat layer exposed
L98.423 Non-pressure chronic ulcer of back with necrosis of muscle
L98.424 Non-pressure chronic ulcer of back with necrosis of bone
L98.425 Non-prs chr ulcer of back with muscle invl w/o evd of necr
L98.426 Non-prs chr ulcer of back with bone invl without evd of necr
L98.428 Non-pressure chronic ulcer of back with oth severity
L98.492 Non-prs chronic ulcer of skin of sites w fat layer exposed
L98.493 Non-prs chronic ulcer of skin of sites w necrosis of muscle
L98.494 Non-prs chronic ulcer of skin of sites w necrosis of bone
L98.495 Non-prs chr ulc skin/ oth site with msl invl w/o evd of necr
L98.496 Non-prs chr ulc skin/ oth site with bne invl w/o evd of necr
L98.498 Non-prs chronic ulcer skin/ other sites with oth severity

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