Does J43.1 require prior authorization?

No, J43.1 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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`J43.1`, Panlobular emphysema

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.

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.
Billing and coding guidance applies to laparoscopic sleeve gastrectomy (sleeve gastrectomy) performed for severe obesity and is intended to complement LCD L34576.
Use this policy's billing/coding rules when submitting claims for laparoscopic sleeve gastrectomy; follow the clinical indication criteria in LCD L34576 for medical necessity determinations.

20 Active Policies

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

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

FIRST_COAST-L38918, Respiratory Pathogen Panel Testing

NOVITAS-JH-L38916, Respiratory Pathogen Panel Testing

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J43.1, Panlobular emphysema