J86.0 — Pyothorax with fistula
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
- All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
- 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.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- If billing just the pulmonary function testing CPT® codes 94070 and 94617-94619 and 94621 together, the following diagnosis codes are allowed: J12.82, J45.990, and Z86.16.
- Therapeutic procedures (G0237 through G0239) with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations.
- CPT codes relative to Medicare’s standards of reasonable and necessary care are: 94070, 94200, 94640, 94726, 94727 and 94729.
- Pulmonary Function Testing codes – Spirometry: CPT codes include 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726 and 94727.
20 Active Policies
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L35434 — Oximetry Services
J12
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A57361
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.