R05.9 — Cough, unspecified
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.
- Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
- ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
- High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
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.
- Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
- Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
- Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
- Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
- 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.
15 Active Policies
A57636 — Billing and Coding: Duplex Scanning
J09
L33674 — Duplex Scanning
J09
AETNA-CPB-0581 — Lung Imaging: Selected Techniques
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0667 — Esophageal and Airway pH Monitoring
Related Codes
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