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

Risk adjustment

J43.0 risk-adjusts. Under the CMS-HCC V28 model it maps to this category:

• HCC 280 Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, and Other Chronic Lung Disorders0.319 RAF

Coefficient shown for the Community Non-dual Aged segment. A higher HCC in the same hierarchy will suppress this one, so capturing it does not always add score.

Medicare coverage

J43.0 is named in 30 Medicare coverage policies — 28 listing it as supporting medical necessity, and 2 listing it as NOT covered. Which of them applies to you depends on your Medicare contractor, and coverage genuinely differs by state.

• A56566Billing and Coding: Outpatient Physical and Occupational Therapy Servicesnot covered
• A57067Billing and Coding: Outpatient Physical and Occupational Therapy Servicesnot covered
• A52466Nebulizers - Policy Article
• A52466Nebulizers - Policy Article