J96.12 — Chronic respiratory failure with hypercapnia
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.
- The medical record must contain relevant medical history, physical examination, and results of pertinent diagnostic tests that fully support the medical necessity of each non-invasive vascular study.
- Diagnostic tests must be ordered by the treating practitioner (or consulting physician) who will use the test results in managing the patient's specific medical problem; the ordering practitioner's name and NPI must be reported on the claim when required.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Non-invasive vascular studies (duplex scan, physiologic studies, plethysmography, transcranial Doppler) are covered when ordered by the treating or consulting practitioner and medically necessary to evaluate, diagnose, or manage vascular disease.
- Initial autogenous access vessel mapping should be billed with HCPCS codes 93985 or 93986 and is covered when medically necessary for surgical planning.
- Subsequent autogenous access mapping may be billed with CPT codes 93970 or 93971 when clinically indicated.
- Pre-surgical radial artery conduit mapping may be performed and accompanied by vein-mapping when either study shows insufficient conduits for multiple bypass procedures.
- Immediate post-operative studies of an access or bypass site are covered if pulses are lost, become equivocal, or the patient develops signs or symptoms of ischemia suggesting need for repeat intervention.
20 Active Policies
A56758 — Billing and Coding: Non-Invasive Vascular Studies
J06
L33627 — Non-Invasive Vascular Studies
J06
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
ANTHEM-CG-MED-79 — CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Related Codes
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