Does 94004 require prior authorization?

No, 94004 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 94004?

Medicare facility rate: $43.76. Non-facility rate: $43.76. Work RVU: 1.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.00

Facility

$43.76

Non-Facility

$43.76

Claims must follow the complementary Local Coverage Determination (LCD L34430) and, when CPT 97000–97799 are used by PT/OT, must include documentation that the services meet the coverage and documentation requirements for physical or occupational therapy.
A specific written order (referral/prescription) by the physician or appropriate NPP must be on file for all respiratory care services.
Medical records must fully document that services were reasonable and medically necessary, with results and usage of the test documented in the record and available upon request.
Each claim must be submitted with ICD-10-CM code(s) that reflect the patient's actual condition; listing a diagnosis code alone does not justify the test without supporting clinical context.

Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
Therapeutic respiratory procedures (HCPCS G0237, G0238, G0239) using an individualized physical conditioning and exercise program with breathing techniques are covered for patients with documented activity limitations.
Pulmonary function tests (PFTs) represented by CPT codes 94070, 94200, 94640, 94726, 94727, and 94729 are covered when reasonable and medically necessary with supporting clinical documentation and a written order by a physician or appropriate NPP.
Spirometry (CPT 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726, 94727) is covered when clinically indicated and documented in the medical record.
Lung volume determination (CPT 94013, 94726, 94727, 94728) and diffusion capacity testing (CPT 94729) are covered when medically necessary and documented.
Pulmonary stress testing (CPT 94617, 94618, 94619, 94621) is covered when clinically indicated and supported by the medical record.

AMBETTER-CP.MP.71 — Long Term Care Placement

A56717 — Billing and Coding: Respiratory Therapy (Respiratory Care)

A57224 — Billing and Coding: Respiratory Care

L34430 — Respiratory Therapy (Respiratory Care)

L34149 — Respiratory Care

Ask Verity about documentation requirements, denial risks, or coverage in your state.