J4A.0 — Restrictive allograft syndrome
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include patient identification (e.g., name, dates of service), and be made available to the contractor upon request.
- Medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The ordering/referring physician's medical record (e.g., office/progress notes) must indicate the medical necessity/clinical indication for the oximetry study and the order for the test must state the clinical indication.
Key Coverage Criteria
- Noninvasive ear or pulse oximetry (CPT 94760, 94761) is covered when ordered by a physician or non-physician practitioner and determined medically necessary per LCD L33923.
- Single or multiple determinations of oxygen saturation (ear or pulse oximetry) are medically necessary when the patient has a condition resulting in hypoxemia and there is a need to assess the status of a chronic respiratory condition, supplemental oxygen requirements, or a therapeutic regimen.
- Continuous overnight ear or pulse oximetry is medically necessary when the patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations and the patient has a condition resulting in hypoxemia with a need to assess supplemental oxygen requirements or a therapeutic regimen.
2 Active Policies
A57115 — Billing and Coding: Noninvasive Ear or Pulse Oximetry For Oxygen Saturation
L33923 — Noninvasive Ear or Pulse Oximetry For Oxygen Saturation
Related Codes
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