N52.9 — Male erectile dysfunction, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must document medical necessity and meet the reasonable and necessary requirements specified in Novitas LCD L35050.
- WatchPAT studies must be billed using CPT 95800 or 95801; actigraphy/CPAP documentation should be billed with CPT 95803 when used for NCD CPAP documentation or when accepted by the DME contractor.
- Providers must check NCCI edits and follow NCCI correct coding guidelines before billing; this policy does not override NCCI.
- All facility-based sleep studies must be under the direction of a physician licensed in the state and board certified or board eligible in sleep medicine (AASM/ABMS) and attended by trained technologists; non-hospital facilities must also be accredited by AASM, The Joint Commission, or ACHC.
Key Coverage Criteria
- Outpatient sleep studies that meet the reasonable and necessary clinical criteria in Novitas LCD L35050 are covered.
- Home sleep testing performed with a WatchPAT device should be billed with CPT code 95800 or 95801.
- Actigraphy may be reported with CPT code 95803 to document CPAP coverage under the applicable NCD or as follow-up CPAP administration when accepted by the DME contractor.
- Narcolepsy: facility-based overnight polysomnography followed by a facility-based MSLT is covered to confirm narcolepsy, including assessment of nighttime sleep, first REM latency, MSLT, and presence of REM-sleep episodes.
- Repeat polysomnography is covered when the initial study is technically inadequate (equipment failure), the patient could not sleep or slept insufficiently, results were inconclusive/ambiguous, or when initiation/confirmation of therapy is needed.
- Obstructive sleep apnea (OSA) diagnostic testing is covered when AHI/RDI ≥ 15 events/hour, or AHI 5–14 events/hour with documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorder, or insomnia) or documented hypertension, ischemic heart disease, or history of stroke.
8 Active Policies
A56923 — Billing and Coding: Outpatient Sleep Studies
J12
L35050 — Outpatient Sleep Studies
J12
AETNA-CPB-0262 — External Counterpulsation (ECP)
AETNA-CPB-0327 — Infertility
AETNA-CPB-0007 — Erectile Dysfunction
Related Codes
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