Z87.01 — Personal history of pneumonia (recurrent)
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Treating physician must clearly document medical necessity to initiate IVIg therapy and the continued need for ongoing therapy in the medical record.
- Include a History and Physical (H&P) in the medical record supporting IVIg therapy.
- Include office and/or progress notes that document clinical status, response, and ongoing need for IVIg.
- Provide relevant test results with written interpretation supporting the indication for IVIg.
Key Coverage Criteria
- IVIg (intravenous immune globulin) is covered when medically necessary as determined and documented by the treating physician, consistent with the associated Local Coverage Determination (LCD).
- 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.
10 Active Policies
AMBETTER-CP.MP.242 — Pulmonary Function Testing
A57225 — Billing and Coding: Respiratory Care
AETNA-CPB-0572 — Home/Ambulatory Spirometry
A57187 — Billing and Coding: Immune Globulin Intravenous (IVIg)
A57194 — Billing and Coding: Immune Globulin Intravenous (IVIg)
Related Codes
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