RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: Pulmonary Function Testing

A57320

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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General Information

Source Article ID
N/A
Article ID
A57320
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Pulmonary Function Testing
Article Type
Billing and Coding
Original Effective Date
10/01/2019
Revision Effective Date
10/01/2022
Revision Ending Date
06/08/2023
Retirement Date
06/08/2023
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35360, Pulmonary Function Testing. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Utilization Parameters:

Treatment for the following ICD-10 codes may require treatments up to four times per year: J84.10, J84.170, J84.178, J84.89 or J84.112. Refer to the related LCD for information regarding services for these diagnoses.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0410 Respiratory Services - General Classification
0412 Respiratory Services - Inhalation Services
0419 Respiratory Services - Other Respiratory Services
046X Pulmonary Function - General Classification
N/A

CPT/HCPCS Codes

Group 1

(13 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
94010 Breathing capacity test
94060 Evaluation of wheezing
94070 Evaluation of wheezing
94200 Lung function test (mbc/mvv)
94375 Respiratory flow volume loop
94450 Hypoxia response curve
94680 Exhaled air analysis o2
94681 Exhaled air analysis o2/co2
94690 Exhaled air analysis
94726 Pulm funct tst plethysmograp
94727 Pulm function test by gas
94728 Airwy resist by oscillometry
94729 Co/membane diffuse capacity
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(854 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 94010, 94060, 94200, 94375, 94450, 94680, 94681, 94690, 94726, 94727, 94728 and 94729.

Group 1 Codes
Code Description
A15.0 Tuberculosis of lung
A15.4 Tuberculosis of intrathoracic lymph nodes
A15.5 Tuberculosis of larynx, trachea and bronchus
A15.6 Tuberculous pleurisy
A15.7 Primary respiratory tuberculosis
A15.8 Other respiratory tuberculosis
A15.9 Respiratory tuberculosis unspecified
A31.0 Pulmonary mycobacterial infection
A42.0 Pulmonary actinomycosis
A43.0 Pulmonary nocardiosis
A80.39 Other acute paralytic poliomyelitis
B38.0 Acute pulmonary coccidioidomycosis
B38.1 Chronic pulmonary coccidioidomycosis
B40.0 Acute pulmonary blastomycosis
B40.1 Chronic pulmonary blastomycosis
B40.2 Pulmonary blastomycosis, unspecified
B40.7 Disseminated blastomycosis
B40.89 Other forms of blastomycosis
B42.0 Pulmonary sporotrichosis
B42.7 Disseminated sporotrichosis
B42.89 Other forms of sporotrichosis
B45.0 Pulmonary cryptococcosis
B45.7 Disseminated cryptococcosis
B45.8 Other forms of cryptococcosis
B46.0 Pulmonary mucormycosis
B46.4 Disseminated mucormycosis
B47.1 Actinomycetoma
B58.3 Pulmonary toxoplasmosis
B59 Pneumocystosis
B67.1 Echinococcus granulosus infection of lung
B77.81 Ascariasis pneumonia
B90.9 Sequelae of respiratory and unspecified tuberculosis
B91 Sequelae of poliomyelitis
B95.3 Streptococcus pneumoniae as the cause of diseases classified elsewhere
B96.0 Mycoplasma pneumoniae [M. pneumoniae] as the cause of diseases classified elsewhere
C33 Malignant neoplasm of trachea
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C37 Malignant neoplasm of thymus
C38.0 Malignant neoplasm of heart
C38.1 Malignant neoplasm of anterior mediastinum
C38.2 Malignant neoplasm of posterior mediastinum
C38.3 Malignant neoplasm of mediastinum, part unspecified
C38.4 Malignant neoplasm of pleura
C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
C39.0 Malignant neoplasm of upper respiratory tract, part unspecified
C39.9 Malignant neoplasm of lower respiratory tract, part unspecified
C45.0 Mesothelioma of pleura
C45.2 Mesothelioma of pericardium
C46.51 Kaposi's sarcoma of right lung
C46.52 Kaposi's sarcoma of left lung
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C78.00 Secondary malignant neoplasm of unspecified lung
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.39 Secondary malignant neoplasm of other respiratory organs
C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes
C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes
C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes
C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes
C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes
C81.92 Hodgkin lymphoma, unspecified, intrathoracic lymph nodes
C82.02 Follicular lymphoma grade I, intrathoracic lymph nodes
C82.12 Follicular lymphoma grade II, intrathoracic lymph nodes
C82.22 Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes
C82.32 Follicular lymphoma grade IIIa, intrathoracic lymph nodes
C82.42 Follicular lymphoma grade IIIb, intrathoracic lymph nodes
C82.52 Diffuse follicle center lymphoma, intrathoracic lymph nodes
C82.62 Cutaneous follicle center lymphoma, intrathoracic lymph nodes
C82.82 Other types of follicular lymphoma, intrathoracic lymph nodes
C82.92 Follicular lymphoma, unspecified, intrathoracic lymph nodes
C83.02 Small cell B-cell lymphoma, intrathoracic lymph nodes
C83.12 Mantle cell lymphoma, intrathoracic lymph nodes
C83.32 Diffuse large B-cell lymphoma, intrathoracic lymph nodes
C83.52 Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes
C83.82 Other non-follicular lymphoma, intrathoracic lymph nodes
C83.92 Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes
C84.02 Mycosis fungoides, intrathoracic lymph nodes
C84.12 Sezary disease, intrathoracic lymph nodes
C84.42 Peripheral T-cell lymphoma, not elsewhere classified, intrathoracic lymph nodes
C84.62 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes
C84.72 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes
C84.A2 Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes
C84.Z2 Other mature T/NK-cell lymphomas, intrathoracic lymph nodes
C85.12 Unspecified B-cell lymphoma, intrathoracic lymph nodes
C85.22 Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes
C85.82 Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes
C85.92 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes
C88.0 Waldenstrom macroglobulinemia
C96.5 Multifocal and unisystemic Langerhans-cell histiocytosis
C96.6 Unifocal Langerhans-cell histiocytosis
D02.20 Carcinoma in situ of unspecified bronchus and lung
D02.21 Carcinoma in situ of right bronchus and lung
D02.22 Carcinoma in situ of left bronchus and lung
D14.2 Benign neoplasm of trachea
D14.30 Benign neoplasm of unspecified bronchus and lung
D14.31 Benign neoplasm of right bronchus and lung
D14.32 Benign neoplasm of left bronchus and lung
D15.0 Benign neoplasm of thymus
D15.2 Benign neoplasm of mediastinum
D18.1 Lymphangioma, any site
D19.0 Benign neoplasm of mesothelial tissue of pleura
D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung
D38.2 Neoplasm of uncertain behavior of pleura
D38.3 Neoplasm of uncertain behavior of mediastinum
D38.4 Neoplasm of uncertain behavior of thymus
D38.5 Neoplasm of uncertain behavior of other respiratory organs
D49.1 Neoplasm of unspecified behavior of respiratory system
D75.1 Secondary polycythemia
D86.0 Sarcoidosis of lung
D86.1 Sarcoidosis of lymph nodes
D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.3 Sarcoidosis of skin
D86.82 Multiple cranial nerve palsies in sarcoidosis
D86.85 Sarcoid myocarditis
D86.87 Sarcoid myositis
D86.89 Sarcoidosis of other sites
D86.9 Sarcoidosis, unspecified
E66.01* Morbid (severe) obesity due to excess calories
E66.2 Morbid (severe) obesity with alveolar hypoventilation
E84.0 Cystic fibrosis with pulmonary manifestations
E88.89 Other specified metabolic disorders
F51.8 Other sleep disorders not due to a substance or known physiological condition
G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20 Motor neuron disease, unspecified
G12.21 Amyotrophic lateral sclerosis
G12.22 Progressive bulbar palsy
G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
G12.29 Other motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G14 Postpolio syndrome
G61.0 Guillain-Barre syndrome
G65.0 Sequelae of Guillain-Barre syndrome
G70.00 Myasthenia gravis without (acute) exacerbation
G70.01 Myasthenia gravis with (acute) exacerbation
G70.80 Lambert-Eaton syndrome, unspecified
G70.81 Lambert-Eaton syndrome in disease classified elsewhere
G71.01 Duchenne or Becker muscular dystrophy
G71.02 Facioscapulohumeral muscular dystrophy
G71.09 Other specified muscular dystrophies
G71.11 Myotonic muscular dystrophy
G73.1 Lambert-Eaton syndrome in neoplastic disease
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G83.81 Brown-Sequard syndrome
G83.82 Anterior cord syndrome
G83.83 Posterior cord syndrome
G83.84 Todd's paralysis (postepileptic)
G83.89 Other specified paralytic syndromes
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I27.0 Primary pulmonary hypertension
I27.1 Kyphoscoliotic heart disease
I27.20 Pulmonary hypertension, unspecified
I27.21 Secondary pulmonary arterial hypertension
I27.22 Pulmonary hypertension due to left heart disease
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.81 Cor pulmonale (chronic)
I27.82 Chronic pulmonary embolism
I27.83 Eisenmenger's syndrome
I27.89 Other specified pulmonary heart diseases
I27.9 Pulmonary heart disease, unspecified
I34.0 Nonrheumatic mitral (valve) insufficiency
I34.2 Nonrheumatic mitral (valve) stenosis
I35.0 Nonrheumatic aortic (valve) stenosis
I35.1 Nonrheumatic aortic (valve) insufficiency
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
J12.81 Pneumonia due to SARS-associated coronavirus
J12.82 Pneumonia due to coronavirus disease 2019
J20.0 Acute bronchitis due to Mycoplasma pneumoniae
J20.1 Acute bronchitis due to Hemophilus influenzae
J20.2 Acute bronchitis due to streptococcus
J20.3 Acute bronchitis due to coxsackievirus
J20.4 Acute bronchitis due to parainfluenza virus
J20.5 Acute bronchitis due to respiratory syncytial virus
J20.6 Acute bronchitis due to rhinovirus
J20.7 Acute bronchitis due to echovirus
J20.8 Acute bronchitis due to other specified organisms
J20.9 Acute bronchitis, unspecified
J21.0 Acute bronchiolitis due to respiratory syncytial virus
J21.1 Acute bronchiolitis due to human metapneumovirus
J21.8 Acute bronchiolitis due to other specified organisms
J21.9 Acute bronchiolitis, unspecified
J22 Unspecified acute lower respiratory infection
J39.8 Other specified diseases of upper respiratory tract
J40 Bronchitis, not specified as acute or chronic
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0 Pneumoconiosis due to talc dust
J62.8 Pneumoconiosis due to other dust containing silica
J63.0 Aluminosis (of lung)
J63.1 Bauxite fibrosis (of lung)
J63.2 Berylliosis
J63.3 Graphite fibrosis (of lung)
J63.4 Siderosis
J63.5 Stannosis
J63.6 Pneumoconiosis due to other specified inorganic dusts
J64 Unspecified pneumoconiosis
J65 Pneumoconiosis associated with tuberculosis
J66.0 Byssinosis
J66.1 Flax-dressers' disease
J66.2 Cannabinosis
J66.8 Airway disease due to other specific organic dusts
J67.0 Farmer's lung
J67.1 Bagassosis
J67.2 Bird fancier's lung
J67.3 Suberosis
J67.4 Maltworker's lung
J67.5 Mushroom-worker's lung
J67.6 Maple-bark-stripper's lung
J67.7 Air conditioner and humidifier lung
J67.8 Hypersensitivity pneumonitis due to other organic dusts
J67.9 Hypersensitivity pneumonitis due to unspecified organic dust
J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors
J68.1 Pulmonary edema due to chemicals, gases, fumes and vapors
J68.2 Upper respiratory inflammation due to chemicals, gases, fumes and vapors, not elsewhere classified
J68.3 Other acute and subacute respiratory conditions due to chemicals, gases, fumes and vapors
J68.4 Chronic respiratory conditions due to chemicals, gases, fumes and vapors
J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors
J68.9 Unspecified respiratory condition due to chemicals, gases, fumes and vapors
J69.0 Pneumonitis due to inhalation of food and vomit
J69.1 Pneumonitis due to inhalation of oils and essences
J69.8 Pneumonitis due to inhalation of other solids and liquids
J70.1 Chronic and other pulmonary manifestations due to radiation
J70.2 Acute drug-induced interstitial lung disorders
J70.3 Chronic drug-induced interstitial lung disorders
J70.4 Drug-induced interstitial lung disorders, unspecified
J70.5 Respiratory conditions due to smoke inhalation
J70.8 Respiratory conditions due to other specified external agents
J70.9 Respiratory conditions due to unspecified external agent
J80 Acute respiratory distress syndrome
J81.0 Acute pulmonary edema
J81.1 Chronic pulmonary edema
J82.81 Chronic eosinophilic pneumonia
J82.82 Acute eosinophilic pneumonia
J82.83 Eosinophilic asthma
J82.89 Other pulmonary eosinophilia, not elsewhere classified
J84.01 Alveolar proteinosis
J84.02 Pulmonary alveolar microlithiasis
J84.03 Idiopathic pulmonary hemosiderosis
J84.09 Other alveolar and parieto-alveolar conditions
J84.10 Pulmonary fibrosis, unspecified
J84.111 Idiopathic interstitial pneumonia, not otherwise specified
J84.112 Idiopathic pulmonary fibrosis
J84.113 Idiopathic non-specific interstitial pneumonitis
J84.114 Acute interstitial pneumonitis
J84.115 Respiratory bronchiolitis interstitial lung disease
J84.116 Cryptogenic organizing pneumonia
J84.117 Desquamative interstitial pneumonia
J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere
J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.2 Lymphoid interstitial pneumonia
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.83 Surfactant mutations of the lung
J84.89 Other specified interstitial pulmonary diseases
J84.9 Interstitial pulmonary disease, unspecified
J85.0 Gangrene and necrosis of lung
J85.1 Abscess of lung with pneumonia
J85.2 Abscess of lung without pneumonia
J85.3 Abscess of mediastinum
J86.0 Pyothorax with fistula
J86.9 Pyothorax without fistula
J90 Pleural effusion, not elsewhere classified
J91.0 Malignant pleural effusion
J91.8 Pleural effusion in other conditions classified elsewhere
J92.0 Pleural plaque with presence of asbestos
J92.9 Pleural plaque without asbestos
J94.0 Chylous effusion
J94.1 Fibrothorax
J94.2 Hemothorax
J94.8 Other specified pleural conditions
J94.9 Pleural condition, unspecified
J95.02 Infection of tracheostomy stoma
J95.1 Acute pulmonary insufficiency following thoracic surgery
J95.2 Acute pulmonary insufficiency following nonthoracic surgery
J95.3 Chronic pulmonary insufficiency following surgery
J95.4 Chemical pneumonitis due to anesthesia
J95.5 Postprocedural subglottic stenosis
J95.84 Transfusion-related acute lung injury (TRALI)
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
J98.01 Acute bronchospasm
J98.09 Other diseases of bronchus, not elsewhere classified
J98.11 Atelectasis
J98.19 Other pulmonary collapse
J98.2 Interstitial emphysema
J98.3 Compensatory emphysema
J98.4 Other disorders of lung
J98.59 Other diseases of mediastinum, not elsewhere classified
J98.6 Disorders of diaphragm
J98.8 Other specified respiratory disorders
J99 Respiratory disorders in diseases classified elsewhere
M05.10 Rheumatoid lung disease with rheumatoid arthritis of unspecified site
M05.111 Rheumatoid lung disease with rheumatoid arthritis of right shoulder
M05.112 Rheumatoid lung disease with rheumatoid arthritis of left shoulder
M05.121 Rheumatoid lung disease with rheumatoid arthritis of right elbow
M05.122 Rheumatoid lung disease with rheumatoid arthritis of left elbow
M05.131 Rheumatoid lung disease with rheumatoid arthritis of right wrist
M05.132 Rheumatoid lung disease with rheumatoid arthritis of left wrist
M05.141 Rheumatoid lung disease with rheumatoid arthritis of right hand
M05.142 Rheumatoid lung disease with rheumatoid arthritis of left hand
M05.151 Rheumatoid lung disease with rheumatoid arthritis of right hip
M05.152 Rheumatoid lung disease with rheumatoid arthritis of left hip
M05.161 Rheumatoid lung disease with rheumatoid arthritis of right knee
M05.162 Rheumatoid lung disease with rheumatoid arthritis of left knee
M05.171 Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot
M05.172 Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot
M05.19 Rheumatoid lung disease with rheumatoid arthritis of multiple sites
M06.1 Adult-onset Still's disease
M06.39 Rheumatoid nodule, multiple sites
M08.1 Juvenile ankylosing spondylitis
M30.0 Polyarteritis nodosa
M30.1 Polyarteritis with lung involvement [Churg-Strauss]
M31.0 Hypersensitivity angiitis
M31.2 Lethal midline granuloma
M31.30 Wegener's granulomatosis without renal involvement
M31.31 Wegener's granulomatosis with renal involvement
M31.8 Other specified necrotizing vasculopathies
M31.9 Necrotizing vasculopathy, unspecified
M32.0 Drug-induced systemic lupus erythematosus
M32.13 Lung involvement in systemic lupus erythematosus
M33.01 Juvenile dermatomyositis with respiratory involvement
M33.11 Other dermatomyositis with respiratory involvement
M33.21 Polymyositis with respiratory involvement
M33.91 Dermatopolymyositis, unspecified with respiratory involvement
M34.81 Systemic sclerosis with lung involvement
M34.9 Systemic sclerosis, unspecified
M35.00 Sjogren syndrome, unspecified
M35.02 Sjogren syndrome with lung involvement
M35.1 Other overlap syndromes
M35.89 Other specified systemic involvement of connective tissue
M36.0 Dermato(poly)myositis in neoplastic disease
M40.03 Postural kyphosis, cervicothoracic region
M40.04 Postural kyphosis, thoracic region
M40.05 Postural kyphosis, thoracolumbar region
M40.292 Other kyphosis, cervical region
M40.293 Other kyphosis, cervicothoracic region
M40.294 Other kyphosis, thoracic region
M40.295 Other kyphosis, thoracolumbar region
M40.30 Flatback syndrome, site unspecified
M40.35 Flatback syndrome, thoracolumbar region
M40.45 Postural lordosis, thoracolumbar region
M41.112 Juvenile idiopathic scoliosis, cervical region
M41.113 Juvenile idiopathic scoliosis, cervicothoracic region
M41.114 Juvenile idiopathic scoliosis, thoracic region
M41.115 Juvenile idiopathic scoliosis, thoracolumbar region
M41.122 Adolescent idiopathic scoliosis, cervical region
M41.123 Adolescent idiopathic scoliosis, cervicothoracic region
M41.124 Adolescent idiopathic scoliosis, thoracic region
M41.125 Adolescent idiopathic scoliosis, thoracolumbar region
M41.22 Other idiopathic scoliosis, cervical region
M41.23 Other idiopathic scoliosis, cervicothoracic region
M41.24 Other idiopathic scoliosis, thoracic region
M41.25 Other idiopathic scoliosis, thoracolumbar region
M41.34 Thoracogenic scoliosis, thoracic region
M41.35 Thoracogenic scoliosis, thoracolumbar region
M45.0 Ankylosing spondylitis of multiple sites in spine
M45.2 Ankylosing spondylitis of cervical region
M45.3 Ankylosing spondylitis of cervicothoracic region
M45.4 Ankylosing spondylitis of thoracic region
M45.5 Ankylosing spondylitis of thoracolumbar region
Q22.1 Congenital pulmonary valve stenosis
Q22.2 Congenital pulmonary valve insufficiency
Q22.3 Other congenital malformations of pulmonary valve
Q25.71 Coarctation of pulmonary artery
Q25.72 Congenital pulmonary arteriovenous malformation
Q25.79 Other congenital malformations of pulmonary artery
Q32.0 Congenital tracheomalacia
Q32.1 Other congenital malformations of trachea
Q32.2 Congenital bronchomalacia
Q32.3 Congenital stenosis of bronchus
Q32.4 Other congenital malformations of bronchus
Q33.0 Congenital cystic lung
Q33.1 Accessory lobe of lung
Q33.3 Agenesis of lung
Q33.4 Congenital bronchiectasis
Q33.5 Ectopic tissue in lung
Q33.6 Congenital hypoplasia and dysplasia of lung
Q33.8 Other congenital malformations of lung
Q33.9 Congenital malformation of lung, unspecified
Q34.0 Anomaly of pleura
Q34.1 Congenital cyst of mediastinum
Q34.8 Other specified congenital malformations of respiratory system
Q67.5 Congenital deformity of spine
Q67.6 Pectus excavatum
Q67.8 Other congenital deformities of chest
Q76.3 Congenital scoliosis due to congenital bony malformation
Q76.412 Congenital kyphosis, cervical region
Q76.413 Congenital kyphosis, cervicothoracic region
Q76.414 Congenital kyphosis, thoracic region
Q76.415 Congenital kyphosis, thoracolumbar region
Q76.425 Congenital lordosis, thoracolumbar region
Q76.8 Other congenital malformations of bony thorax
Q76.9 Congenital malformation of bony thorax, unspecified
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough syncope
R05.8 Other specified cough
R06.00 Dyspnea, unspecified
R06.01 Orthopnea
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.1 Stridor
R06.2 Wheezing
R06.3 Periodic breathing
R06.4 Hyperventilation
R06.82 Tachypnea, not elsewhere classified
R06.89 Other abnormalities of breathing
R06.9 Unspecified abnormalities of breathing
R09.01 Asphyxia
R09.02 Hypoxemia
R09.1 Pleurisy
R23.0 Cyanosis
R79.81 Abnormal blood-gas level
R91.1 Solitary pulmonary nodule
R91.8 Other nonspecific abnormal finding of lung field
R94.2 Abnormal results of pulmonary function studies
T50.0X1A - T50.0X5S Poisoning by mineralocorticoids and their antagonists, accidental (unintentional), initial encounter - Adverse effect of mineralocorticoids and their antagonists, sequela
T50.1X1A - T50.1X5S Poisoning by loop [high-ceiling] diuretics, accidental (unintentional), initial encounter - Adverse effect of loop [high-ceiling] diuretics, sequela
T50.2X1A - T50.2X5S Poisoning by carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, accidental (unintentional), initial encounter - Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, sequela
T50.3X1A - T50.3X5S Poisoning by electrolytic, caloric and water-balance agents, accidental (unintentional), initial encounter - Adverse effect of electrolytic, caloric and water-balance agents, sequela
T50.905A - T50.905S Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter - Adverse effect of unspecified drugs, medicaments and biological substances, sequela
T53.0X1A - T53.7X4S Toxic effect of carbon tetrachloride, accidental (unintentional), initial encounter - Toxic effect of other halogen derivatives of aromatic hydrocarbons, undetermined, sequela
T57.3X1A - T57.3X4S Toxic effect of hydrogen cyanide, accidental (unintentional), initial encounter - Toxic effect of hydrogen cyanide, undetermined, sequela
T58.01XA - T58.2X4S Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional), initial encounter - Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined, sequela
T59.0X1A - T59.94XS Toxic effect of nitrogen oxides, accidental (unintentional), initial encounter - Toxic effect of unspecified gases, fumes and vapors, undetermined, sequela
Z79.3 Long term (current) use of hormonal contraceptives
Z79.51 Long term (current) use of inhaled steroids
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z87.01 Personal history of pneumonia (recurrent)
Z87.09 Personal history of other diseases of the respiratory system
Z94.1 Heart transplant status
Z94.2 Lung transplant status
Z94.3 Heart and lungs transplant status
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Morbid Obesity diagnosis E66.01 is only available for CPT code 94690 every two years. This diagnosis is not allowable otherwise for other CPT codes listed in this group.

Group 2

(31 Codes)
Group 2 Paragraph

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 94070:

Group 2 Codes
Code Description
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J95.84 Transfusion-related acute lung injury (TRALI)
J98.4 Other disorders of lung
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough syncope
R05.8 Other specified cough
R06.02 Shortness of breath
R06.1 Stridor
R06.2 Wheezing
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(7 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
Z00.6 Encounter for examination for normal comparison and control in clinical research program
Z00.8 Encounter for other general examination
Z01.811 Encounter for preprocedural respiratory examination
Z12.2 Encounter for screening for malignant neoplasm of respiratory organs
Z13.83 Encounter for screening for respiratory disorder NEC
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description
0410 Respiratory Services - General Classification
0412 Respiratory Services - Inhalation Services
0419 Respiratory Services - Other Respiratory Services
046X Pulmonary Function - General Classification
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
06/08/2023 R7

This article is being retired effective for dates of service on and after 06/08/2023 in response to the related LCD being retired.

10/01/2022 R6

Article revised and published on 10/20/2022 effective for dates of service on and after 10/01/2022 to reflect the Annual ICD-10-CM Code Updates. For the following ICD-10-CM code the code description has changed: C84.42 in Group 1. Minor formatting changes made throughout the article.

10/01/2021 R5

Article revised and published on 10/14/2021 effective for dates of service on and after 5/20/2021 is a result of an inquiry. The following ICD-10-CM codes that support medical necessity has been added to Group 1 Codes: J12.82

Article revised and published on 10/14/2021 effective for dates of service on and after 10/1/2021 to reflect the Annual ICD-10-CM Code Updates.

The following Group 1 ICD-10-CM code(s) have undergone descriptor change: M35.00 and M35.02.

The following ICD-10-CM code(s) have been added the Group 1 & 2 Codes: R05.1, RO5.2, R05.3, R05.4, R05.8

The following ICD-10-CM code(s) have been deleted from the Group 1 Codes: M31.1 and R05.

The following ICD-10-CM code has been deleted from the Group 2 Codes: R05

01/01/2021 R4

Article revised and published on 02/11/2021 effective for dates of service on and after 01/01/2021 to reflect the Annual 2021 HCPCS/CPT Code Updates.

The following CPT codes 94250, 94400, 94750 and 94770 have been deleted and therefore have been removed from the “CPT/HCPCS Codes/ Group 1 Codes:” and the “ICD-10 Codes that Support Medical Necessity/Group 1 Paragraph:” sections of the article. In addition, for the following CPT code 94375 the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays in the “CPT/HCPCS Codes/ Group 1 Codes:” in this article.

In addition, based on the Quarterly 2021 ICD-10 Update the following ICD-10-CM code M35.8 has been deleted and the ICD-10-CM code M35.89 has been added in the“ICD-10 Codes that Support Medical Necessity /Group 1 codes:” section of the article. Also, minor formatting changes were made throughout the coding section.

10/01/2020 R3

Article revised and published on 10/01/2020 effective for dates of service on and after 10/01/2020 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been added to the Article Group 1 codes: J82.81, J82.82, J82.83, J82.89, J84.170, and J84.178. The following ICD-10-CM code(s) have been deleted and therefore removed from the article Group 1 codes: J82 and J84.17. The following code has been deleted from the frequency limitations section: J84.17. The following ICD-10-CM code(s) have been added to the frequency limitations: J84.170 and J84.178. Minor formatting revisions made throughout the Article.

07/01/2020 R2

Article revised and published on 06/25/2020 effective for dates of service on and after 07/01/2020, as a non-discretionary update to remove the CPT Code Group 2 paragraph and codes 94014, 94015 and 94016. Minor formatting revisions were made.

01/01/2020 R1

Article revised and published on 01/16/2020 effective for dates of service on and after 01/01/2020 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS code(s) have either a short description and/or long description change. Depending on which description is used in this article, there may not be any change in how the code displays in the document: 94728.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
06/08/2023 10/01/2022 - 06/08/2023 Retired You are here
10/14/2022 10/01/2022 - N/A Superseded View
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Keywords

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