J90 — Pleural effusion, not elsewhere classified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- Diagnostic test claims should include the test result if known; if result is not available, report the symptoms that prompted the test.
- The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- When using an Advance Beneficiary Notice of Non‑coverage (ABN) with modifier GA, the ABN Form CMS‑R‑131 must be signed by the beneficiary (or properly witnessed if refused) and Part A MAC claims require occurrence code 32 plus the ABN date.
Key Coverage Criteria
- CPT 88182 reports the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometry.
- CPT 88184 (first marker) and CPT 88185 (each additional marker) report the facility technical component of flow cytometric immunophenotyping for assessment of potential hematolymphoid neoplasia.
- Flow cytometry interpretation is reported using CPT codes 88187–88189 (one interpretation code per specimen).
- Quantitative cell counts by flow cytometry are billed using CPT codes 86355, 86356, 86357, 86359, 86360, 86361, and 86367.
- Flow cytometry services are payable under Medicare Part B at specified places of service according to CPT: groups of CPTs have defined allowable POS (see mapping in policy).
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
20 Active Policies
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
L35049 — Monitored Anesthesia Care
J12
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
AETNA-CPB-0259 — Transjugular Intrahepatic Portosystemic Shunt (TIPSS)
Related Codes
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