J98.8 — Other specified respiratory disorders
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- Billing and coding for pulmonary stress testing must follow Local Coverage Determination (LCD) L33444; consult LCD L33444 for specific medical necessity, coding, and billing criteria.
- This article provides billing, coding, or other guidelines that complement LCD L33444 rather than standalone coverage criteria.
- A specific written order (referral/prescription) by the physician or appropriate NPP must be on file for all respiratory care services.
Key Coverage Criteria
- 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.
- Spirometry (CPT 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726, 94727) is covered when clinically indicated and documented in the medical record.
- Lung volume determination (CPT 94013, 94726, 94727, 94728) and diffusion capacity testing (CPT 94729) are covered when medically necessary and documented.
- Pulmonary stress testing (CPT 94617, 94618, 94619, 94621) is covered when clinically indicated and supported by the medical record.
9 Active Policies
AMBETTER-CP.MP.242 — Pulmonary Function Testing
A57225 — Billing and Coding: Respiratory Care
A56717 — Billing and Coding: Respiratory Therapy (Respiratory Care)
A56784 — Billing and Coding: Pulmonary Stress Testing
A57224 — Billing and Coding: Respiratory Care
Related Codes
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