J94.9 — Pleural condition, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
- Report overnight oximetry using CPT code 94762 on claims.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
- CT thorax is covered for diagnosis and/or staging of neoplastic and hematologic processes arising in or involving the thorax.
12 Active Policies
A57205 — Billing and Coding: Oximetry Services
J12
L35049 — Monitored Anesthesia Care
J12
L35434 — Oximetry Services
J12
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
A56580 — Billing and Coding: Computerized Axial Tomography (CT), Thorax
Related Codes
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