Local Coverage Determination CPT Code/Search Topic 94660 LMRP/LCD ID L15794 LMRP/LCD Title Respiratory Therapy Indications and Limitations of Coverage and/or Medical Necessity Respiratory therapy (respiratory care) is defined as those services prescribed by a physician or a non physician practitioner for the assessment and diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. Monitoring is defined as the periodic checking of the equipment in actual use to ascertain proper functioning; real time tracking the individual’s condition to assure that he/she is receiving effective respiratory therapy services; and periodic evaluation of the patient’s progress in improvement of function. Respiratory therapy (respiratory care) services may include but are not limited to the following: o application techniques to support oxygenation and ventilation in an acute illness (e.g. establish/maintain artificial airway, ventilatory therapy, precise delivery of oxygen concentrations, aid in removal of secretions from pulmonary tree) o therapeutic use/monitoring of medicinal gases, pharmacologically active mists and aerosols, and equipment (e.g., resuscitators, ventilators) o bronchial hygiene therapy (e.g. deep breathing, coughing exercises, IPPB, postural drainage, chest percussion/vibration, and nasotracheal/endotracheal suctioning) o diagnostic tests for evaluation by a physician (e.g. pulmonary function test, spirometry, and blood gas analyses) o pulmonary rehabilitation techniques (e.g. exercise conditioning, breathing retraining, and patient education regarding management of patient’s respiratory problems) o periodic assessment of the patient for the effectiveness of respiratory therapy services The above services may be performed by respiratory therapists, nurses, and other qualified personnel as described by relevant State practice acts. Documentation in the medical record must clearly support the need for respiratory therapy services to be separately reimbursed. Respiratory therapy (respiratory care) services can be considered reasonable and necessary for the diagnosis and treatment of a specific illness or injury. The service provided must be consistent with the severity of the patient’s documented illness and must be reasonable in terms of modality, amount, frequency, and duration of treatment. The treatment must be generally accepted by the professional community as safe and effective for the purpose used, and recognized standards of care should not be violated. There must be a specific written order by the physician for all respiratory therapy (respiratory care) services. Medicare coverage of respiratory therapy (respiratory care) provided as outpatient hospital or extended care services depends on the determination by the attending physician (as part of his/her plan of treatment) that for the safe and effective administration of such services the procedures or exercises in question need to be performed by a respiratory therapist. In addition Medicare may cover postural drainage and pulmonary exercises furnished by a respiratory therapist as incident to a physician's professional service. In order to be considered for reimbursement by Medicare, respiratory therapy services must be fully documented in the medical records. The documentation must clearly indicate that the services rendered were reasonable and medically necessary and required the skills of a licensed respiratory therapist. Instructing a patient in the use of equipment, breathing exercises, etc. may be considered reasonable and necessary to the treatment of the patient’s condition and can usually be given to a patient during the course of treatment by any of the health personnel involved, (e.g., physician, nurse, respiratory care practitioner or other qualified personnel). Separate billing for one-on-one education is rarely necessary and is usually only reasonable at the start of the treatment plan. Provision of more information than is ordinarily provided during the course of a treatment (e.g., extensive theoretical background in the pathology, etiology, and physiological effects of the disease) is not considered reasonable and necessary. Group sessions that only offer generalized (i.e., non-individualized) education and training are not covered. Therapeutic procedures (G0237 through G0239) with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations. Breathing retraining, energy conservation, and relaxation techniques are often used. Ventilatory muscle training (VMT) may be considered reasonable and necessary in a very select population of pulmonary patients who demonstrate significantly decreased respiratory muscle strength and who remain symptomatic despite optimal therapy. Routine exercise, or any exercise, without a documented need for skilled care, is not covered. Coverage Topic Outpatient Hospital Services CPT/HCPCS Codes 31500 INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE 31502 TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT 31720 CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRACHEAL 92950 CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST) 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION 94060 BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION 94070 BRONCHOSPASM PROVOCATION EVALUATION, MULTIPLE SPIROMETRIC DETERMINATIONS AS IN 94010, WITH ADMINISTERED AGENTS (EG, ANTIGEN(S), COLD AIR, METHACHOLINE) 94150 VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE) 94200 MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION 94240 FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME: HELIUM METHOD, NITROGEN OPEN CIRCUIT METHOD, OR OTHER METHOD 94250 EXPIRED GAS COLLECTION, QUANTITATIVE, SINGLE PROCEDURE (SEPARATE PROCEDURE) 94260 THORACIC GAS VOLUME 94350 DETERMINATION OF MALDISTRIBUTION OF INSPIRED GAS: MULTIPLE BREATH NITROGEN WASHOUT CURVE INCLUDING ALVEOLAR NITROGEN OR HELIUM EQUILIBRATION TIME 94360 DETERMINATION OF RESISTANCE TO AIRFLOW, OSCILLATORY OR PLETHYSMOGRAPHIC METHODS 94370 DETERMINATION OF AIRWAY CLOSING VOLUME, SINGLE BREATH TESTS 94375 RESPIRATORY FLOW VOLUME LOOP 94400 BREATHING RESPONSE TO CO2 (CO2 RESPONSE CURVE) 94450 BREATHING RESPONSE TO HYPOXIA (HYPOXIA RESPONSE CURVE) 94620 PULMONARY STRESS TESTING; SIMPLE (EG, PROLONGED EXERCISE TEST FOR BRONCHOSPASM WITH PRE- AND POST- SPIROMETRY) 94621 PULMONARY STRESS TESTING; COMPLEX (INCLUDING MEASUREMENTS OF CO2 PRODUCTION, O2 UPTAKE, AND ELECTROCARDIOGRAPHIC RECORDINGS) 94640 PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION OR FOR SPUTUM INDUCTION FOR DIAGNOSTIC PURPOSES (EG, WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE) 94642 AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS CARINII PNEUMONIA TREATMENT OR PROPHYLAXIS 94656 VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; FIRST DAY 94657 VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; SUBSEQUENT DAYS 94660 CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), INITIATION AND MANAGEMENT 94662 CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), INITIATION AND MANAGEMENT 94664 DEMONSTRATION AND/OR EVALUATION OF PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR IPPB DEVICE 94667 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; INITIAL DEMONSTRATION AND/OR EVALUATION 94668 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; SUBSEQUENT 94720 CARBON MONOXIDE DIFFUSING CAPACITY (EG, SINGLE BREATH, STEADY STATE) 94725 MEMBRANE DIFFUSION CAPACITY 94750 PULMONARY COMPLIANCE STUDY (EG, PLETHYSMOGRAPHY, VOLUME AND PRESSURE MEASUREMENTS) 94772 CIRCADIAN RESPIRATORY PATTERN RECORDING (PEDIATRIC PNEUMOGRAM), 12 TO 24 HOUR CONTINUOUS RECORDING, INFANT G0237 THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, FACE TO FACE, ONE ON ONE, EACH 15 MINUTES (INCLUDES MONITORING) G0238 THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BY G0237, ONE ON ONE, FACE TO FACE, PER 15 MINUTES (INCLUDES MONITORING) G0239 THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION OR INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, TWO OR MORE INDIVIDUALS (INCLUDES MONITORING) ICD-9 Codes that Support Medical Necessity 010.01 - 010.06 010.11 - 010.16 010.80 - 010.86 011.00 - 011.96 012.01 - 012.06 012.21 - 012.26 012.31 - 012.36 012.81 - 012.86 020.2 - 020.5 022.1 PULMONARY ANTHRAX 031.0 PULMONARY DISEASES DUE TO OTHER MYCOBACTERIA 032.3 LARYNGEAL DIPHTHERIA 033.0 - 033.9 039.1 PULMONARY ACTINOMYCOTIC INFECTION 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 052.1 VARICELLA (HEMORRHAGIC) PNEUMONITIS 055.1 POSTMEASLES PNEUMONIA 073.0 ORNITHOSIS WITH PNEUMONIA 081.2 SCRUB TYPHUS 083.0 Q FEVER 095.1 SYPHILIS OF LUNG 112.4 CANDIDIASIS OF LUNG 114.0 PRIMARY COCCIDIOIDOMYCOSIS (PULMONARY) 114.4 - 114.5 115.05 HISTOPLASMA CAPSULATUM PNEUMONIA 115.15 HISTOPLASMA DUBOISII PNEUMONIA 115.95 HISTOPLASMOSIS PNEUMONIA UNSPECIFIED 117.3 ASPERGILLOSIS 117.5 CRYPTOCOCCOSIS 130.4 PNEUMONITIS DUE TO TOXOPLASMOSIS 135 SARCOIDOSIS 136.3 PNEUMOCYSTOSIS 162.0 - 162.8 163.0 - 163.9 165.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS 176.4 KAPOSI'S SARCOMA LUNG 195.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 197.0 - 197.3 212.0 - 212.5 231.0 - 231.8 235.7 - 235.8 273.4 ALPHA-1-ANTITRYPSIN DEFICIENCY 276.2 ACIDOSIS 276.3 ALKALOSIS 277.00 - 277.01 277.02 CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS 277.03 CYSTIC FIBROSIS WITH GASTROINTESTINAL MANIFESTATIONS 277.09 CYSTIC FIBROSIS WITH OTHER MANIFESTATIONS 277.6 OTHER DEFICIENCIES OF CIRCULATING ENZYMES 335.20 AMYOTROPHIC LATERAL SCLEROSIS 415.0 ACUTE COR PULMONALE 415.11 - 415.19 416.0 - 416.8 417.0 ARTERIOVENOUS FISTULA OF PULMONARY VESSELS 417.8 OTHER SPECIFIED DISEASES OF PULMONARY CIRCULATION 424.3 PULMONARY VALVE DISORDERS 427.5 CARDIAC ARREST 428.0 - 428.9 464.10 - 464.4 465.0 ACUTE LARYNGOPHARYNGITIS 466.0 - 466.19 476.1 CHRONIC LARYNGOTRACHEITIS 478.30 - 478.34 478.6 EDEMA OF LARYNX 478.70 - 478.75 478.79 OTHER DISEASES OF LARYNX 478.8 UPPER RESPIRATORY TRACT HYPERSENSITIVITY REACTION SITE UNSPECIFIED 478.9 OTHER AND UNSPECIFIED DISEASES OF UPPER RESPIRATORY TRACT 480.0 - 480.8 481 PNEUMOCOCCAL PNEUMONIA [STREPTOCOCCUS PNEUMONIAE PNEUMONIA] 482.0 - 482.89 483.0 - 483.1 484.1 - 484.8 485 BRONCHOPNEUMONIA ORGANISM UNSPECIFIED 486 PNEUMONIA ORGANISM UNSPECIFIED 487.0 INFLUENZA WITH PNEUMONIA 487.1 INFLUENZA WITH OTHER RESPIRATORY MANIFESTATIONS 490 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC 491.0 - 491.8 492.0 - 492.8 493.00 - 493.92 494.0 - 494.1 496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED 500 COAL WORKERS' PNEUMOCONIOSIS 501 ASBESTOSIS 502 PNEUMOCONIOSIS DUE TO OTHER SILICA OR SILICATES 503 PNEUMOCONIOSIS DUE TO OTHER INORGANIC DUST 504 PNEUMONOPATHY DUE TO INHALATION OF OTHER DUST 505 PNEUMOCONIOSIS UNSPECIFIED 506.0 - 506.4 507.0 - 507.8 508.0 - 508.9 510.0 - 510.9 511.0 - 511.8 512.0 - 512.8 513.0 - 513.1 514 PULMONARY CONGESTION AND HYPOSTASIS 515 POSTINFLAMMATORY PULMONARY FIBROSIS 516.0 - 516.8 517.1 - 517.8 518.0 - 518.89 519.00 - 519.8 639.6 EMBOLISM FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES 668.00 - 668.04 771.81 - 771.89 780.50 - 780.59 786.00 - 786.09 786.1 STRIDOR 786.2 COUGH 786.3 HEMOPTYSIS 786.52 PAINFUL RESPIRATION 786.6 SWELLING MASS OR LUMP IN CHEST 786.7 ABNORMAL CHEST SOUNDS 790.91 ABNORMAL ARTERIAL BLOOD GASES 793.1 NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD 794.2 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM 799.0 ASPHYXIA 799.1 RESPIRATORY ARREST 860.0 - 862.9 987.0 - 987.9 V42.6 LUNG REPLACED BY TRANSPLANT V44.0 TRACHEOSTOMY STATUS V46.11 DEPENDENCE ON RESPIRATOR, STATUS V46.12 ENCOUNTER FOR RESPIRATOR DEPENDENCE DURING POWER FAILURE V55.0 ATTENTION TO TRACHEOSTOMY A physician order for all respiratory therapy intervention/service must be recorded in the patient’s medical record. The order must clearly indicate the evaluation or treatment to be performed, the specific modality and duration of all aspects of the treatment, including frequency of monitoring. Documentation by the physician must indicate the cardiopulmonary diagnosis supporting the medical necessity of the service. Documentation must be present in the respiratory services records to show: o The plan of treatment and progress toward measurable goals. o That the care rendered was appropriately delivered by a qualified practitioner. As previously noted, the above services may be performed by respiratory therapists, nurses, and other qualified personnel. Other qualified personnel may include physical therapists and occupational therapists. Therapeutic procedures whose principal aim is to treat a respiratory impairment should be identified using the G0237 - G0239 series of codes. CPT codes 97000 to 97799 are not to be billed by professionals involved in treating respiratory conditions, unless these services are delivered by physical or occupational therapists and meet the other requirements for physical and occupational therapy services. Please see Palmetto GBA physical and occupational therapy LCDs at http://www.PalmettoGBA.com.