J16.8 — Pneumonia due to other specified infectious organisms
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 the HCPCS codes specified under Final Rule 1713; claims lacking these per the LCD-related Standard Documentation Requirements Article will be denied.
- For add-on ensifentrine (J7601) therapy, the treating practitioner must document continuation of dual or triple maintenance therapy and either (a) history of continued COPD exacerbations within 12 months evidenced by hospitalization, ER visit, or new prescription for systemic glucocorticoids or antibiotics, or (b) during one exacerbation a combination of at least three clinical parameters (dyspnea VAS >5, respiratory rate >24 bpm, heart rate >95 bpm, oxygen saturation decline >=3% from baseline, or CRP >10 mg/L); also document persistent COPD-related dyspnea by persistent breathlessness or exercise limitation.
- A diagnosis code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.
Key Coverage Criteria
- Nebulizers are covered under the Durable Medical Equipment (DME) benefit when the reasonable and necessary (R&N) requirements in the related Local Coverage Determination (LCD) are met.
- Unfilled nebulizers (HCPCS A7007, A7017, E0585) filled with water or saline (A4217 or A7018) by the beneficiary or caregiver are an acceptable covered alternative.
- Add-on ensifentrine (J7601) therapy to dual LABA+LAMA maintenance therapy or LABA+LAMA+ICS triple maintenance therapy for COPD is covered when the treating practitioner documents continuation of maintenance therapy and the required exacerbation or dyspnea criteria in the medical record.
- Respiratory pathogen panel testing is covered when performed as a single service from a single biologic specimen in the outpatient setting on a single date of service and is reasonable and necessary per LCD L38918.
- The test is covered when performed in a Medicare Part B setting that is equipped to deliver timely results and when the results can reasonably be expected to lead to a change in clinical management that improves health outcomes.
- Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT®/PLA code (or CPT® 87999 if no specific code exists) and accompanied by ICD-10-CM diagnosis codes that support medical necessity documented in the patient record.
20 Active Policies
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
Related Codes
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