P36.9 — Bacterial sepsis of newborn, unspecified
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.
- A specific written order by the physician is required for all respiratory therapy services.
- Medical records must fully document services rendered, clearly indicate that services were reasonable and medically necessary, and demonstrate that the skills of a licensed respiratory therapist were required for reimbursement.
- For outpatient or extended care, Medicare coverage depends on the attending physician's determination, documented in the plan of treatment, that the procedures/exercises need to be performed by a respiratory therapist.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Respiratory therapy services prescribed by a physician or non-physician practitioner for assessment, diagnostic evaluation, treatment, management, or monitoring of deficiencies or abnormalities of cardiopulmonary function are covered.
- Application techniques to support oxygenation and ventilation in acute illness (e.g., establishing/maintaining artificial airway, ventilatory therapy, precise oxygen delivery, and aiding removal of secretions) are covered when prescribed and documented as medically necessary.
- Therapeutic use and monitoring of medicinal gases, pharmacologically active mists/aerosols, and related equipment (e.g., resuscitators, ventilators) are covered when medically necessary and prescribed.
- Bronchial hygiene therapies (deep breathing, coughing exercises, IPPB, postural drainage, chest percussion/vibration, nasotracheal/endotracheal suctioning) are covered when individually prescribed and medically necessary.
- Diagnostic tests for physician evaluation—pulmonary function tests (PFT), spirometry, and blood gas analyses—are covered when ordered and documented as medically necessary for respiratory assessment.
6 Active Policies
AETNA-CPB-0518 — Nitric Oxide, Inhalational (INO)
AETNA-CPB-0618 — Brain Natriuretic Peptide Testing
ANTHEM-CG-LAB-24 — CG-LAB-24 Outpatient Urine Culture
ANTHEM-CG-MED-49 — CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
A56717 — Billing and Coding: Respiratory Therapy (Respiratory Care)
Related Codes
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