Does J96.01 require prior authorization?

No, J96.01 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`J96.01`, Acute respiratory failure with hypoxia

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

The medical record must contain relevant medical history, physical examination, and results of pertinent diagnostic tests that fully support the medical necessity of each non-invasive vascular study.
Diagnostic tests must be ordered by the treating practitioner (or consulting physician) who will use the test results in managing the patient's specific medical problem; the ordering practitioner's name and NPI must be reported on the claim when required.
Providers of interpretations and technical personnel must maintain documentation of training, licensure, certification, and proficiency for post-payment audit; IDTF supervising physicians must document proficiency in each diagnostic procedure performed.
For diagnostic tests, report the test result if known; if not known, report the symptoms prompting the test on the claim.

Key Coverage Criteria

Non-invasive vascular studies (duplex scan, physiologic studies, plethysmography, transcranial Doppler) are covered when ordered by the treating or consulting practitioner and medically necessary to evaluate, diagnose, or manage vascular disease.
Initial autogenous access vessel mapping should be billed with HCPCS codes 93985 or 93986 and is covered when medically necessary for surgical planning.
Subsequent autogenous access mapping may be billed with CPT codes 93970 or 93971 when clinically indicated.
Pre-surgical radial artery conduit mapping may be performed and accompanied by vein-mapping when either study shows insufficient conduits for multiple bypass procedures.
Immediate post-operative studies of an access or bypass site are covered if pulses are lost, become equivocal, or the patient develops signs or symptoms of ischemia suggesting need for repeat intervention.
Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J96.01 Sign up free

J96.01, Acute respiratory failure with hypoxia