J96.91 — Respiratory failure, unspecified with hypoxia
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical necessity for oxygen and oxygen equipment must be documented in the medical record according to the requirements of the related Local Coverage Determination (LCD).
- A treating practitioner's order is required to justify a change in equipment modality, and a beneficiary must sign an Advance Beneficiary Notice (ABN) when electing an upgrade that may not be covered.
- For a break-in-need that could restart a rental period, new medical necessity must be established and documented in the medical record.
- Suppliers must retain documentation of the initial date of service and rental history to calculate the RUL and rental-period eligibility.
Key Coverage Criteria
- Oxygen and oxygen equipment are covered under the Durable Medical Equipment (DME) benefit when reasonable and necessary as documented per the related Local Coverage Determination (LCD) and all Medicare statutory and regulatory requirements are met.
- When the reasonable useful lifetime (RUL) end date of stationary oxygen equipment occurs, the beneficiary may elect simultaneous replacement of both stationary and portable oxygen equipment, which starts a new 36-month rental period and a new RUL for both items.
- If portable oxygen use begins after stationary equipment use began, payment for the portable equipment may continue beyond the end of stationary equipment payments until 36 monthly rental payments have been made for the portable equipment.
- 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.
- 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.
14 Active Policies
L35049 — Monitored Anesthesia Care
J12
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
A52514 — Oxygen and Oxygen Equipment - Policy Article
Related Codes
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