U09.9 — Post COVID-19 condition, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for the HCPCS codes specified under Final Rule 1713; claims lacking these per the LCD-related Standard Documentation Requirements Article will be denied.
- For add-on ensifentrine (J7601) therapy, the treating practitioner must document continuation of dual or triple maintenance therapy and either (a) history of continued COPD exacerbations within 12 months evidenced by hospitalization, ER visit, or new prescription for systemic glucocorticoids or antibiotics, or (b) during one exacerbation a combination of at least three clinical parameters (dyspnea VAS >5, respiratory rate >24 bpm, heart rate >95 bpm, oxygen saturation decline >=3% from baseline, or CRP >10 mg/L); also document persistent COPD-related dyspnea by persistent breathlessness or exercise limitation.
- A diagnosis code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.
Key Coverage Criteria
- Nebulizers are covered under the Durable Medical Equipment (DME) benefit when the reasonable and necessary (R&N) requirements in the related Local Coverage Determination (LCD) are met.
- Unfilled nebulizers (HCPCS A7007, A7017, E0585) filled with water or saline (A4217 or A7018) by the beneficiary or caregiver are an acceptable covered alternative.
- Add-on ensifentrine (J7601) therapy to dual LABA+LAMA maintenance therapy or LABA+LAMA+ICS triple maintenance therapy for COPD is covered when the treating practitioner documents continuation of maintenance therapy and the required exacerbation or dyspnea criteria in the medical record.
- Individual pulmonary rehabilitation components are covered when tailored to the individual patient based on a thorough evaluation, require a qualified clinician due to complexity, and are medically reasonable and necessary for treatment of an acute or exacerbated pulmonary condition.
- Medicare covers Pulmonary Rehabilitation Program services for patients with moderate to very severe COPD (GOLD II-IV) when referred by the physician treating the chronic respiratory disease and when all program requirements are met.
- Medicare covers pulmonary rehabilitation program services for confirmed or suspected COVID-19 patients who experience persistent respiratory symptoms for at least four weeks (effective Jan 1, 2022) when all program requirements are met.
8 Active Policies
A52466 — Nebulizers - Policy Article
J19
A52770 — Billing and Coding: Pulmonary Rehabilitation Services
A56152 — Billing and Coding: Pulmonary Rehabilitation Services
A56717 — Billing and Coding: Respiratory Therapy (Respiratory Care)
A56730 — Billing and Coding: Respiratory Therapy and Oximetry Services
Related Codes
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