J17 — Pneumonia in diseases classified elsewhere
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
- 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.
- Supporting documentation must demonstrate that CPT 31720 was personally performed by the physician or qualified NPP when billing that code.
- For consecutive days of respiratory therapy, the medical record must document why the patient was not transferred to a higher level of care.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- CPT 94762 is medically necessary when intermittent arterial blood gas sampling is likely to miss important variations in the patient's respiratory status.
- CPT 94762 is medically necessary when the patient has hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic oxygen regimen.
- 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.
13 Active Policies
A57205 — Billing and Coding: Oximetry Services
J12
L35434 — Oximetry Services
J12
NOVITAS-L35434 — Oximetry Services
JL MAC Part B
A56730 — Billing and Coding: Respiratory Therapy and Oximetry Services
A57224 — Billing and Coding: Respiratory Care
Related Codes
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