S21.319A — Laceration without foreign body of unspecified front wall of thorax with penetration into thoracic cavity, initial encounter
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.
- Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
- Report overnight oximetry using CPT code 94762 on claims.
- An interpretation and report must be a complete, separately identifiable written report addressing findings, relevant clinical issues, comparative data (when available), and must be included in the medical record.
Key Coverage Criteria
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
- A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).
- Rhythm ECGs are covered when used to evaluate signs or symptoms suggesting a cardiac rhythm disorder.
- Home-based ECG services (including additional payment above the base ECG amount for transportation) are covered when there is a documented medical need to perform the ECG in the patient's home, typically for homebound or bed-confined patients.
- A second professional component (PC) interpretation may be paid when a second physician’s substantially greater expertise is necessary and reasonable to clarify a questionable or confusing ECG finding and contributes substantially to diagnosis or treatment.
7 Active Policies
A57205 — Billing and Coding: Oximetry Services
J12
L35434 — Oximetry Services
J12
A57327 — Billing and Coding: Electrocardiograms
L34315 — Electrocardiograms
L34430 — Respiratory Therapy (Respiratory Care)
Related Codes
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