J98.6 — Disorders of diaphragm
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes under Final Rule 1713 and must be obtained prior to delivery per the LCD-related Standard Documentation Requirements (Article A55426).
- The diagnosis code that justifies the need for the HFCWO item must be included on the claim.
- The beneficiary's medical record must describe the underlying medical condition(s) causing accumulation of pulmonary secretions, prior and current treatment interventions (e.g., chest physiotherapy, postural drainage, medications, mechanical modalities such as in-exsufflation devices), and the effectiveness of those treatments; this information must be available upon request.
- Suppliers must append modifier KX to HFCWO codes only when all LCD Coverage Indications/Limitations/Medical Necessity criteria are met; if not met, suppliers must append GA (if a valid ABN was obtained) or GZ (if no valid ABN was obtained); claim lines without KX, GA, or GZ will be rejected as missing information.
Key Coverage Criteria
- High Frequency Chest Wall Oscillation (HFCWO) devices (HCPCS E0483) are covered under the Durable Medical Equipment benefit when the device is reasonable and necessary for the beneficiary per the related Local Coverage Determination (LCD) and all applicable Medicare statutory and regulatory requirements are met.
- Mechanical in-exsufflation devices are covered under the Durable Medical Equipment (DME) benefit when the beneficiary meets the reasonable and necessary (R&N) requirements specified in the related Local Coverage Determination (LCD).
- Replacement reimbursement for HCPCS A7020 is allowed only if the beneficiary owns or is purchasing the mechanical in-exsufflation device and the claim includes the diagnosis code that justifies medical need.
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Therapeutic respiratory procedures (HCPCS G0237, G0238, G0239) using an individualized physical conditioning and exercise program with breathing techniques are covered for patients with documented activity limitations.
- Pulmonary function tests (PFTs) represented by CPT codes 94070, 94200, 94640, 94726, 94727, and 94729 are covered when reasonable and medically necessary with supporting clinical documentation and a written order by a physician or appropriate NPP.
17 Active Policies
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
A52494 — High Frequency Chest Wall Oscillation Devices - Policy Article
J19
A52510 — Mechanical In-exsufflation Devices - Policy Article
J19
AETNA-CPB-0339
Related Codes
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