J95.3 — Chronic pulmonary insufficiency following surgery
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Each claim must be submitted with ICD-10-CM code(s) that accurately reflect the patient’s condition and indicate the reason(s) the service was performed.
- The medical record must include the ordering/referring provider’s name and NPI for services that require a referring/ordering physician.
- The patient’s medical record should include the assessment by the ordering provider related to the patient’s complaint, relevant medical history, results of pertinent tests/procedures, and signed and dated office visit or operative reports.
- For diagnostic tests, report the test result on the claim when known; otherwise report the symptoms that prompted performance of the test.
Key Coverage Criteria
- Cardiac catheterization and coronary angiography are covered when the medical record documents medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests that support the procedure.
- Follow-up or limited transthoracic echocardiography performed to evaluate a single specified cardiac problem or region must be billed with CPT 93308.
- Limited Doppler/follow-up echocardiographic studies (for targeted velocity or gradient assessment) should be billed with CPT 93321 (e.g., tricuspid regurgitant velocity to estimate pulmonary artery systolic pressure or sequential transmitral velocity in mitral stenosis).
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
- Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.
20 Active Policies
L33577 — Transthoracic Echocardiography (TTE)
J06
A56781 — Billing and Coding: Transthoracic Echocardiography (TTE)
J06
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
L35049 — Monitored Anesthesia Care
J12
L35434 — Oximetry Services
Related Codes
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