J18.2 — Hypostatic pneumonia, unspecified organism
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.
- Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
- Report overnight oximetry using CPT code 94762 on claims.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
- Beneficiary is under the care of a physician.
- Beneficiary is receiving services under a plan of care that is established and periodically reviewed by a physician.
- Beneficiary needs skilled nursing care on an intermittent basis, or physical therapy, or speech-language pathology, or has a continued need for occupational therapy.
- Physical therapy services ordered by a physician and provided by a qualified physical therapist or under the general supervision of a qualified physical therapist are covered when reasonable and necessary to treat illness/injury or to restore or maintain function.
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
A57205 — Billing and Coding: Oximetry Services
J12
L35434 — Oximetry Services
J12
Related Codes
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