Does J43.0 require prior authorization?

No, J43.0 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`J43.0`, Unilateral pulmonary emphysema [MacLeod's syndrome]

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
Diagnosis code(s) must best describe the patient’s condition for which the service was performed and a valid ICD-10-CM code is required on the claim.
For an evaluation-only episode, the evaluation serves as the plan of care if it contains a diagnosis or a description from which a referring physician/NPP may determine a diagnosis, and the referral/order certifies the evaluation is needed.

When a qualified professional allows a student to participate, the qualified professional must be present in the room, direct the service and make skilled judgments, not be treating another patient or performing other tasks, and must sign all documentation appropriately.

When PTA/OTA services are furnished in a private practice office or physician/NPP office, documentation must reflect required direct supervision by a PT (for PTAs) or OT (for OTAs) in the private practice setting and compliance with enrollment rules if billed by a physician group under the therapist’s PIN/NPI.

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.

Key Coverage Criteria

Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.
Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
CPT 94762 is medically necessary when intermittent arterial blood gas sampling is likely to miss important variations in the patient's respiratory status.

20 Active Policies

A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services

FIRST_COAST-L38918, Respiratory Pathogen Panel Testing

FIRST_COAST-L33923, Noninvasive Ear or Pulse Oximetry For Oxygen Saturation

NOVITAS-JH-L38916, Respiratory Pathogen Panel Testing

NOVITAS-JH-L35049, Monitored Anesthesia Care

NOVITAS-JH-L35434, Oximetry Services

NGS-L39027, Respiratory Pathogen Panel Testing

NOVITAS-JL-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

A57361, Billing and Coding: Monitored Anesthesia Care

NOVITAS-JL-L38916, Respiratory Pathogen Panel Testing

NOVITAS-JL-L35049, Monitored Anesthesia Care

A56717, Billing and Coding: Respiratory Therapy (Respiratory Care)

A56730, Billing and Coding: Respiratory Therapy and Oximetry Services

A56784, Billing and Coding: Pulmonary Stress Testing

A56852, Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity

A57067, Billing and Coding: Outpatient Physical and Occupational Therapy Services

A57115, Billing and Coding: Noninvasive Ear or Pulse Oximetry For Oxygen Saturation

A57224, Billing and Coding: Respiratory Care

A57326, Billing and Coding: Electrocardiograms

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J43.0, Unilateral pulmonary emphysema [MacLeod's syndrome]