J64, Unspecified pneumoconiosis
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.
- Dispensing fees (G0333, Q0513, Q0514) must be billed on the same claim as the inhalation drug(s); initial dispensing fee G0333 applies only once-in-a-lifetime for first 30-day inhalation drug use as a Medicare beneficiary on or after 01/01/2006, and subsequent dispensing fees must follow the policy coding rules.
- Modifiers JW (unused/discarded drug amount) and JZ (no unused/discarded amount) are required when billing for single-dose container drugs administered by the supplier, effective JW from 01/01/2017 and JZ from 07/01/2023.
- When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
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.
- 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.
- Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
- Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
14 Active Policies
A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services
J6
NOVITAS-JH-L35434, Oximetry Services
JH
NOVITAS-JH-L35049, Monitored Anesthesia Care
JH
NOVITAS-JL-L35049, Monitored Anesthesia Care
JL
Related Codes
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