J98.9 — Respiratory disorder, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of lung transplant status or complications in the medical record (e.g., ICD-10 Z94.2 or T86.810-T86.819) to support medical necessity for home spirometry/telespirometry.
- Documentation that home spirometry/telespirometry is being used specifically for monitoring lung function in a lung transplant recipient (clinical notes indicating purpose: early detection of infection/rejection or routine monitoring).
- When billing CPT 94014 / 94015: documentation of program components described in the CPT code descriptors (reinforced education provided to the patient, transmission of spirometric tracings, data capture, analysis/trend analysis of transmitted data, periodic recalibration of device, and physician review and interpretation of the transmitted data).
- When billing CPT 94016: documentation of physician review and interpretation of spirometric data (notes of review, interpretation and any resulting clinical actions).
Key Coverage Criteria
- Home spirometry and telespirometry are considered medically necessary for lung transplant recipients (for monitoring lung function at home).
- ICD-10 T86.810 - T86.819 (Complications of lung transplant) — covered when used for monitoring of lung function at home.
- ICD-10 Z94.2 (Lung transplant status) — covered when used for monitoring of lung function at home.
- CPT codes covered if selection criteria are met: 94014 (patient-initiated spirometric recording per 30-day period; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and physician review and interpretation), 94015 (recording: hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration), 94016 (physician review and interpretation only).
- HCPCS code covered if selection criteria are met: E0487 (Spirometer, electronic, includes all accessories).
1 Active Policy
AETNA-CPB-0572 — Home/Ambulatory Spirometry
Related Codes
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