G71.0340 — Limb girdle muscular dystrophy due to sarcoglycan dysfunction, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes under Final Rule 1713 and must be obtained prior to delivery per the LCD-related Standard Documentation Requirements (Article A55426).
- The diagnosis code that justifies the need for the HFCWO item must be included on the claim.
- The beneficiary's medical record must describe the underlying medical condition(s) causing accumulation of pulmonary secretions, prior and current treatment interventions (e.g., chest physiotherapy, postural drainage, medications, mechanical modalities such as in-exsufflation devices), and the effectiveness of those treatments; this information must be available upon request.
- Suppliers must append modifier KX to HFCWO codes only when all LCD Coverage Indications/Limitations/Medical Necessity criteria are met; if not met, suppliers must append GA (if a valid ABN was obtained) or GZ (if no valid ABN was obtained); claim lines without KX, GA, or GZ will be rejected as missing information.
Key Coverage Criteria
- High Frequency Chest Wall Oscillation (HFCWO) devices (HCPCS E0483) are covered under the Durable Medical Equipment benefit when the device is reasonable and necessary for the beneficiary per the related Local Coverage Determination (LCD) and all applicable Medicare statutory and regulatory requirements are met.
- Mechanical in-exsufflation devices are covered under the Durable Medical Equipment (DME) benefit when the beneficiary meets the reasonable and necessary (R&N) requirements specified in the related Local Coverage Determination (LCD).
- Replacement reimbursement for HCPCS A7020 is allowed only if the beneficiary owns or is purchasing the mechanical in-exsufflation device and the claim includes the diagnosis code that justifies medical need.
- CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
- CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
- Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
20 Active Policies
A52494 — High Frequency Chest Wall Oscillation Devices - Policy Article
J19
A52510 — Mechanical In-exsufflation Devices - Policy Article
J19
A53058 — Billing and Coding: Home Health Physical Therapy
A53064 — Billing and Coding: Outpatient Occupational Therapy
A53065 — Billing and Coding: Outpatient Physical Therapy
Related Codes
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