R05.4 — Cough syncope
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims for swallowing studies should include documentation consistent with LCD L33449; this billing guideline is a complement to that LCD and providers should retain medical records supporting the medical necessity of the dysphagia evaluation.
- A specific written order (referral/prescription) by the physician or appropriate NPP must be on file for all respiratory care services.
- Medical records must fully document that services were reasonable and medically necessary, with results and usage of the test documented in the record and available upon request.
- Each claim must be submitted with ICD-10-CM code(s) that reflect the patient's actual condition; listing a diagnosis code alone does not justify the test without supporting clinical context.
Key Coverage Criteria
- Swallowing studies (videofluoroscopic or radiologic studies described by CPT 70370, 70371, or 74230) performed for evaluation or diagnosis of dysphagia are the intended covered service per this billing guideline and LCD L33449.
- 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.
11 Active Policies
A57473 — Billing and Coding: Allergy Testing
J05
L36402 — Allergy Testing
J05
L33674 — Duplex Scanning
J09
A57636 — Billing and Coding: Duplex Scanning
J09
A56621 — Billing and Coding: Swallowing Studies for Dysphagia
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.