Does J81.0 require prior authorization?

No, J81.0 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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`J81.0`, Acute pulmonary edema

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

Billing must be based on the patient's Plan of Care (POC) or other available medical records; dialysis sessions listed in the POC that were not furnished must not be billed.
Additional sessions billed with the KX modifier must be supported by medical documentation demonstrating reasonableness and necessity, such as recent hospital records, office visit notes, dialysis progress notes, or MCP visits.
Monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881 must follow the per-line billing approaches described and supporting documentation may be requested during reviews.
Refer to LCD L37475 for detailed documentation requirements and utilization guidelines when clinical conditions outside those listed in this article are asserted as reason for additional sessions.

Key Coverage Criteria

Each dialysis session performed for an ESRD patient must be reported on a separate line for dates of service on or after 2007-04-01.
When the hemodialysis prescription is three times per week and each session is furnished, bill each session as CPT 90999 with no modifier; these sessions will be paid as routine conventional dialysis.
Dialysis sessions furnished in addition to three per week that have medical documentation supporting reasonable and necessary need should be billed as CPT 90999 with the KX modifier for consideration of additional payment.
Report each hemodialysis session for ESRD patients on a separate line for claims with dates of service on or after April 1, 2007.
When hemodialysis prescription is 3 sessions per week and each session is furnished, bill each session as CPT 90999 with no modifier for routine conventional dialysis.
For dialysis sessions beyond 3 sessions per week that are reasonable and necessary and supported by medical documentation, bill each additional session as CPT 90999 with modifier KX to be considered for additional payment.

20 Active Policies

CGS-J15-L37575, Frequency of Hemodialysis

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

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J81.0, Acute pulmonary edema