Local Coverage Determination
CPT Code
94660
LMRP ID
L1626
LMRP Title
Respiratory Therapy
LMRP Description
Respiratory Therapy services, both diagnostic and therapeutic, are provided on the
order of the treating physician. They are medically necessary only when:
1. The diagnosis established by the physician supports the utilization of the
intervention.
2. The type, frequency and duration of services are reasonable and
medically necessary for the treatment of the patient's condition (signs and
symptoms) in accordance with generally accepted medical standards of care.
3. There is a specific written order by the attending physician for the
individual beneficiary in response to the physical findings from an
assessment and identification of a problem (an evaluation). The order must
specify any administration parameters such as dosage, frequency, etc. or
other defining conditions that are applicable to the diagnostic test or
treatment, (E.g. oxygen must specify the method of delivery, the flow rate,
the circumstances under which it should be administered, and the duration
of the service).
4. Respiratory services may be performed in the institutional environment
by qualified respiratory therapists (as defined by national and state
regulations), respiratory therapy technicians, or qualified nursing personnel.
A "qualified" individual is defined as a person who has completed an
educational or training program and has documented evidence of the ability
to perform respiratory care interventions/modalities in accordance with the
policies of the administering facility.
5. Respiratory therapy therapeutic services must require the unique skills of
a respiratory therapist or similarly trained professional. Services that are
typically taught to patients and caregivers (e.g. chest percussion, unassisted
aerosol by nebulizer) are not considered skilled services for chronic care in
the outpatient environment. These services may be considered skilled
services acutely.
6. Facility ancillary services may not be billed as respiratory therapy
therapeutic services. There can be overlaps of skills between respiratory and
nursing services (particularly in skilled nursing facilities and hospitals). In
these instances, there must be specific documentation to support the need
for interventions by a qualified respiratory therapist (i.e., what special skills
of the respiratory therapist is needed which could not be done by the nursing
personnel) to differentiate the respiratory therapy service from the ancillary
service. The presumptive determination is that services performed by nurses
are ancillary services and services performed by respiratory therapists are
specialized respiratory therapy services
7. Respiratory therapy interventions include (but are not limited to) the
following:
Pulmonary assessment*
Oxygen therapy, including ventilator management
Selection of aerosol delivery devices and delivery of aerosol to
upper airway*
Incentive spirometery **
Bronchial provocation
Chest physiotherapy (postural drainage, cupping, percussion) *
Positive airway pressure adjuncts to bronchial hygiene therapy
Nasotracheal, endotracheal suctioning **
Pulse oximetery **
Spirometery
Management of airway in acute/emergency situations (Intubation)
*These services may overlap services rendered by nurses. Documentation in
the beneficiary's medical record by the physician must clearly indicate why
the special skills of the respiratory therapist are needed. Typically these
services require the skills of the Respiratory Therapist only when the
intervention is first initiated.
**These services are typically provided by nurses as an ancillary service.
Documentation in the beneficiary's medical record by the physician must
clearly indicate why the special skills of the respiratory therapist are needed.
Indicators for Oxygen therapy include:
Oxygen therapy is administered utilizing many devices ranging from the simple
nasal cannula to progressively more complex techniques providing controlled
oxygen concentrations. These devices are usually applied maintained, and
monitored by the respiratory therapist and/or technicians. Documentation in the
medical record must support the need for the skills of a respiratory therapist or
technician.
The goal of oxygen therapy is to maintain adequate tissue and cell oxygenation (
while minimizing oxygen toxicity). Oxygen therapy must be indicated by
documentation of clinical signs and symptoms of hypoxemia (hypoxia).
These signs and symptoms may include:
a. PaO2 = 55 torr or SaO2 =88% (breathing room air)
b. SaO2 = 88% consistently during sleep, ambulation or exercise;
c. PaO2 56-59 torr or SaO2/SpO2 = 89% in association with Cor
Pulmonale,
d. CHF, Hematocrit > 56 ( erythrocythemia);
e. Changes in PaO2, PaCO2> 10-15 mm Hg from baseline; or
f. Restlessness, anxiety, confusion, hypotension, dysrythmias, somnolence,
or memory loss
g. A medical condition that renders the patient particularly susceptible to or
at risk for hypoxemia or hypercarbia.
Management of beneficiaries requiring long term /chronic ventilatory support:
The use of long term/chronic ventilatory support or management is common in
many settings such as home and long term care facilities. Long term (or chronic)
ventilator management addresses maintenance therapies such as the routine
monitoring of equipment, beneficiary's response to mechanical support, medicinal
gases, pulmonary assessment, and ongoing reinforcement of treatment modalities
and interventions. These patients are generally cardiopulmonarily stable and do not
require the skills of a respiratory therapist on a continuous basis. Interventions and
treatments by the respiratory therapist beyond the initial set up, periodic equipment
checks and beneficiary assessments specific to ventilatory support and management
must be clearly documented in the medical record. The skills of the respiratory
therapist are typically required during periods of rapidly changing pulmonary status
Requirements for specific services:
Special skills of a respiratory therapist may be required for the periodic
measurement of arterial oxygen levels(ABGs) in the clinically unstable beneficiary
or to document clinical changes. However this would not be routinely expected for
the beneficiary receiving chronic long term oxygen therapy.
Documentation in the beneficiary's medical record must include:
* the type of airway (tracheotomy, endotracheal tube), cuff pressures if
applicable, date tube was last changed, difficulties maintaining patency of
the tube
* type of ventilatory support and the ordered/maintained parameters
* the beneficiary's breath sounds, ventilatory pressures, and responses to
therapy and
* Therapeutic and educational interventions and the beneficiary/caregivers
response to the education.
Limitations
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)
Metered dose inhalers are self-administered treatments, and, as such, are not
covered. The clinical skills of a respiratory therapist are not required to administer
MDIs even in the acute situation; this is either an unskilled or ancillary service.
Nebulizers typically require the skills of the respiratory therapist in the acute
situation but do not require those skills in a chronic (outpatient) setting. A patient
who typically self-administers (or who has a caregiver administer) nebulizer
treatments does not require the skills of the respiratory therapist on an intermittent
basis except in an emergent situation or when the patient is specifically being
treated by a physician in order to assess the response during an acute episode of
bronchospasm. Routine, occasional and "drive by" treatments in an outpatient clinic
or CORF are therefore not medically necessary.
94664 DEMONSTRATION AND/OR EVALUATION OF PATIENT
UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED
DOSE INHALER OR IPPB DEVICE2.
CPT 94664 requires the evaluation of the patient's use of an aerosol generator,
nebulizer MDI or IPPB device, in addition to the demonstration of the device to be
deemed medically necessary. This is only medically necessary on one day of
service in a patient who has never self-administered the specified form of therapy
before; additional services will be denied as not medically necessary. Medical
necessity may rarely be determined on appeal if the patient is incapable of self
administration and a new caretaker needs instruction.
94642 AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS
CARINII PNEUMONIA TREATMENT OR PROPHYLAXIS
Although variation exists in the administration of this therapy, Riverbend will
consider it to require the skills of the therapist when administered in a facility
setting and will therefore consider the administration to be medically necessary
whenever the drug itself is medically necessary.
94667 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING,
AND VIBRATION TO FACILITATE LUNG FUNCTION; INITIAL
DEMONSTRATION AND/OR EVALUATION
Up to five demonstration sessions may be medically necessary to instruct the
caregiver of a patient who has never received this service before. Once the service
has been taught, the conditions of 94668 apply as additional instruction is not
medically necessary.
94668 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING,
AND VIBRATION TO FACILITATE LUNG FUNCTION; SUBSEQUENT
This service is only considered to require the skills of the respiratory therapist in the
acute situation; this is a self care (caregiver) service in the chronic outpatient
environment and an ancillary (nursing) service in the subacute or chronic inpatient
environment.
94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND
TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE
MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY
VENTILATION
94150 VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE)
Full spirometry and/or vital capacity are not medically necessary on a repetitive
basis unless:
There has been a sudden unexplained deterioration in pulmonary status, or
The patient has a chronic progressive pulmonary condition and repeat
values are likely to significantly impact management
The patient has a chronic progressive pulmonary condition and
demonstrates a significant clinical change since the last measurement.
Except in the case of the sudden deterioration, repeat spirometry is not
medically necessary more often than annually and then not on a routine
basis.
94200 MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY
VENTILATION
The routine use of this service for monitoring is not medically necessary.
Documentation should support a clinical change in status necessitating this
assessment.
94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN
SATURATION; SINGLE DETERMINATION
Pulse oximetry is an ancillary nursing function that does not require the skills of the
respiratory therapist.
94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN
SATURATION; MULTIPLE DETERMINATIONS (EG, DURING EXERCISE)
Repetitive or continuous pulse oximetry is an ancillary nursing monitoring function
that does not require the skills of the respiratory therapist.
94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN
SATURATION; BY CONTINUOUS OVERNIGHT MONITORING (SEPARATE
PROCEDURE)
Repetitive or continuous pulse oximetry is an ancillary nursing monitoring function
that does not require the skills of the respiratory therapist
Coverage Topic
Outpatient Hospital Services
Coding Information
Bill Type Codes
85x Special facility or ASC surgery-rural primary care hospital (eff 10/94)
Revenue Codes
041X
Respiratory services-general classification
046X
Pulmonary function-general classification
CPT/HCPCS Codes
31500
INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE
31502
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF
FISTULA TRACT
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
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
94760
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN
SATURATION; SINGLE DETERMINATION
94761
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN
SATURATION; MULTIPLE DETERMINATIONS (EG, DURING
EXERCISE)
94762
NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN
SATURATION; BY CONTINUOUS OVERNIGHT MONITORING
(SEPARATE PROCEDURE)
94772
CIRCADIAN RESPIRATORY PATTERN RECORDING (PEDIATRIC
PNEUMOGRAM), 12 TO 24 HOUR CONTINUOUS RECORDING,
INFANT
ICD-9 Codes that Support Medical Necessity
All ICD-9 codes must be carried out to their highest level of
specificity.
011.01 011.06
011.11 011.16
011.21 011.26
011.31 011.36
011.41 011.46
011.51 011.56
011.61 011.66
011.81 011.86
012.01 012.06
012.21 012.26
012.31 012.36
012.81 012.86
031.0
PULMONARY DISEASES DUE TO OTHER MYCOBACTERIA
039.1
PULMONARY ACTINOMYCOTIC INFECTION
042
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
162.0 162.8
231.0 231.8
276.2
ACIDOSIS
276.3
ALKALOSIS
398.91
RHEUMATIC HEART FAILURE (CONGESTIVE)
402.01
MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART
FAILURE
402.11
BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
402.91
UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART
FAILURE
404.11
HYPERTENSIVE HEART AND KIDNEY DISEASE, BENIGN, WITH
HEART FAILURE
404.13
HYPERTENSIVE HEART AND KIDNEY DISEASE, BENIGN, WITH
HEART FAILURE AND CHRONIC KIDNEY DISEASE
404.91
HYPERTENSIVE HEART AND KIDNEY DISEASE, UNSPECIFIED,
WITH HEART FAILURE
404.93
HYPERTENSIVE HEART AND KIDNEY DISEASE, UNSPECIFIED,
WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE
415.0
ACUTE COR PULMONALE
415.11
IATROGENIC PULMONARY EMBOLISM AND INFARCTION
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
CONGESTIVE HEART FAILURE UNSPECIFIED
428.1
LEFT HEART FAILURE
466.0 466.19
480.0 480.8
481
PNEUMOCOCCAL PNEUMONIA [STREPTOCOCCUS PNEUMONIAE
PNEUMONIA]
482.0 482.89
483.0
PNEUMONIA DUE TO MYCOPLASMA PNEUMONIAE
484.1 484.8
485
BRONCHOPNEUMONIA ORGANISM UNSPECIFIED
486
PNEUMONIA ORGANISM UNSPECIFIED
490
BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC
491.0 491.8
492.0 492.8
493.00 493.21
493.90 493.92
494.0
BRONCHIECTASIS WITHOUT ACUTE EXACERBATION
494.1
BRONCHIECTASIS WITH ACUTE EXACERBATION
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
ABSCESS OF LUNG
513.1
ABSCESS OF MEDIASTINUM
514
PULMONARY CONGESTION AND HYPOSTASIS
515
POSTINFLAMMATORY PULMONARY FIBROSIS
516.0 516.8
518.0 518.3
518.5 518.81
519.4
DISORDERS OF DIAPHRAGM
786.1
STRIDOR
786.3
HEMOPTYSIS
786.52
PAINFUL RESPIRATION
786.6
SWELLING MASS OR LUMP IN CHEST
786.7
ABNORMAL CHEST SOUNDS
793.1
NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND
OTHER EXAMINATION OF LUNG FIELD
794.2
NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF
PULMONARY SYSTEM
799.01
ASPHYXIA
799.02
HYPOXEMIA
799.1
RESPIRATORY ARREST
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
V58.69
LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS