J45.998 — Other asthma
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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.
- Allergy testing is covered when the medical record documents a history indicating the possible presence of allergy and the clinician selected a minimal number of tests/antigens based on patient-specific history and physician examination.
- Allergy testing is covered when the medical record documents the test(s) used, the interpretation(s), and objective measurement of reaction size (wheal and erythema in mm) or a standardized in vivo grading system.
- Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
20 Active Policies
L36408 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
J05
A57473 — Billing and Coding: Allergy Testing
J05
L40195 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
J05
L36402 — Allergy Testing
J05
A57472
Related Codes
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