G71.036 — Limb girdle muscular dystrophy due to fukutin related protein dysfunction
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 97032 (attended/manual electrical stimulation) is covered when delivered with direct 1-on-1 contact by qualified personnel (examples: direct motor point stimulation; FES/NMES when performed with therapeutic exercise, neuromuscular reeducation, or functional activities).
- CPT 97032 may be billed for the application, instruction, and adjustment of a TENS unit or other probe-based stimulation (including determining trigger points) when provided as an attended/manual modality.
- Non-implantable pelvic floor electrical stimulation (97032 for probes; G0283 for electrode-based delivery) is covered for treatment of stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
20 Active Policies
L34594 — Nerve Conduction Studies and Electromyography
J05
A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography
J05
A57668 — Billing and Coding: Nerve Conduction Studies and Electromyography
J06
L35098 — Nerve Conduction Studies and Electromyography
J06
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