J95.851 — Ventilator associated pneumonia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
- Report overnight oximetry using CPT code 94762 on claims.
- Medical records must document the signs, symptoms, diagnosis, or clinical rationale that meet one of the covered indications (e.g., acute respiratory symptoms, chronic respiratory/cardiopulmonary/neuromuscular disease and the specific reason for oximetry).
- Providers should retain records and be prepared for post-payment data analysis and subsequent medical review audits related to oximetry services.
Key Coverage Criteria
- Oximetry is medically necessary for patients exhibiting acute respiratory dysfunction signs or symptoms (tachypnea, dyspnea, cyanosis, respiratory distress, confusion, or hypoxia).
- Oximetry is medically necessary for patients with chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease affecting respiratory muscles when used for initial evaluation to determine the severity of respiratory impairment.
- Oximetry is medically necessary for patients with chronic lung disease, severe cardiopulmonary disease, or neuromuscular respiratory muscle disease to evaluate an acute change in condition.
- Oximetry is medically necessary to evaluate exercise tolerance in a patient with respiratory disease.
- Oximetry is medically necessary to establish the medical necessity of an oxygen therapeutic regimen in patients with chronic respiratory, cardiopulmonary, or neuromuscular disease affecting respiration.
- Oximetry is medically necessary for patients with sustained severe multiple trauma or who present with acute severe chest pain.
3 Active Policies
A57205 — Billing and Coding: Oximetry Services
J12
L35434 — Oximetry Services
J12
AETNA-CPB-0572 — Home/Ambulatory Spirometry
Related Codes
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