LCD/NCD Portal

L28822 DIAGNOSTIC AEROSOL OR VAPOR INHALATION

 

 

10/01/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• This policy addresses the use of aerosol or vapor inhalation for sputum mobilization, bronchodilation, and sputum induction for diagnostic purposes.

• If a patient is unable to produce sputum, inhalation of a nebulized solution of 3 or 4 ml of distilled water or hypertonic sodium chloride results in the induction of an adequate specimen for examination.

o Any type of nebulizer may be used; however, ultrasonic nebulizers, which produce a concentrated mist, are preferred.

o The procedure is terminated when an adequate specimen is obtained, the nebulizer solution is exhausted, or after a maximum of 15-20 minutes.

o The procedure is most often used for patients suspected of having tuberculosis or a lung malignancy, and to search for Pneumocystis carinii infection in patients with the acquired immunodeficiency syndrome (AIDS).

• Medicare will consider the use of an aerosol or vapor inhalation for diagnostic purposes medically reasonable and necessary for the following indications:

o For the induction/mobilization of sputum in a patient who presents with:

 Signs and symptoms of a respiratory infection.

• Fever.

• Dyspnea.

• Chest congestion.

• Cough.

Or

 Suspected lung malignancy.

And

 Who is unable to produce an adequate sputum specimen for examination by conventional methods.

o For the induction/mobilization of sputum in a patient

 Who continues to demonstrate signs and symptoms of a respiratory infection:

• Fever.

• Dyspnea.

• Chest congestion.

• Cough.

And

 Despite antibiotic treatment, who is unable to produce an adequate sputum specimen for follow-up examination by conventional methods.

o To produce bronchodilation prior to a pulmonary function test (PFT), when the patient’s functional ability to perform the test is decreased and would otherwise result in an inconclusive finding.

 

 

Coding Information

 

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 policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

13x Hospital Outpatient

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

75x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)

85x Critical Access Hospital

 

 

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

 

0460 Pulmonary Function - General Classification

0469 Pulmonary Function - Other Pulmonary

 

 

CPT/HCPCS Codes

 

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)

 

 

ICD-9 Codes that Support Medical Necessity

 

135 SARCOIDOSIS

162.0 MALIGNANT NEOPLASM OF TRACHEA

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG

197.3 SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORY ORGANS

212.2 BENIGN NEOPLASM OF TRACHEA

212.3 BENIGN NEOPLASM OF BRONCHUS AND LUNG

231.2 CARCINOMA IN SITU OF BRONCHUS AND LUNG

446.20 HYPERSENSITIVITY ANGIITIS UNSPECIFIED

466.0 ACUTE BRONCHITIS

466.11 ACUTE BRONCHIOLITIS DUE TO RESPIRATORY SYNCYTIAL VIRUS (RSV)

466.19 ACUTE BRONCIOLITIS DUE TO OTHER INFECTIOUS ORGANISMS

486 PNEUMONIA ORGANISM UNSPECIFIED

490 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC

491.0 SIMPLE CHRONIC BRONCHITIS

491.1 MUCOPURULENT CHRONIC BRONCHITIS

491.20 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION

491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION

491.22 OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE BRONCHITIS

491.8 OTHER CHRONIC BRONCHITIS

491.9 UNSPECIFIED CHRONIC BRONCHITIS

492.0 EMPHYSEMATOUS BLEB

492.8 OTHER EMPHYSEMA

493.00 EXTRINSIC ASTHMA UNSPECIFIED

493.01 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.02 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.10 INTRINSIC ASTHMA UNSPECIFIED

493.11 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.12 INTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED

493.21 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS

493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION

493.81 EXERCISE-INDUCED BRONCHOSPASM

493.82 COUGH VARIANT ASTHMA

493.90 ASTHMA UNSPECIFIED

493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS

493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.1 BRONCHIECTASIS WITH ACUTE EXACERBATION

495.0 FARMERS' LUNG

495.1 BAGASSOSIS

495.2 BIRD-FANCIERS' LUNG

495.3 SUBEROSIS

495.4 MALT WORKERS' LUNG

495.5 MUSHROOM WORKERS' LUNG

495.6 MAPLE BARK-STRIPPERS' LUNG

495.7 'VENTILATION' PNEUMONITIS

495.8 OTHER SPECIFIED ALLERGIC ALVEOLITIS AND PNEUMONITIS

495.9 UNSPECIFIED ALLERGIC ALVEOLITIS AND PNEUMONITIS

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

508.0 ACUTE PULMONARY MANIFESTATIONS DUE TO RADIATION

515 POSTINFLAMMATORY PULMONARY FIBROSIS

517.1 RHEUMATIC PNEUMONIA

517.2 LUNG INVOLVEMENT IN SYSTEMIC SCLEROSIS

517.3 ACUTE CHEST SYNDROME

517.8 LUNG INVOLVEMENT IN OTHER DISEASES CLASSIFIED ELSEWHERE

518.0 PULMONARY COLLAPSE

518.1 INTERSTITIAL EMPHYSEMA

518.2 COMPENSATORY EMPHYSEMA

518.3 PULMONARY EOSINOPHILIA

518.4 ACUTE EDEMA OF LUNG UNSPECIFIED

518.51 ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.52 OTHER PULMONARY INSUFFICIENCY, NOT ELSEWHERE CLASSIFIED, FOLLOWING TRAUMA AND SURGERY

518.53 ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.6 ALLERGIC BRONCHOPULMONARY ASPERGILLIOSIS

518.7 TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)

518.81 ACUTE RESPIRATORY FAILURE

518.82 OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED

518.83 CHRONIC RESPIRATORY FAILURE

518.84 ACUTE AND CHRONIC RESPIRATORY FAILURE

518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

786.02 ORTHOPNEA

786.03 APNEA

786.04 CHEYNE-STOKES RESPIRATION

786.05 SHORTNESS OF BREATH

786.06 TACHYPNEA

786.07 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

786.2 COUGH

786.30 HEMOPTYSIS, UNSPECIFIED

786.39 OTHER HEMOPTYSIS

786.4 ABNORMAL SPUTUM

793.11 SOLITARY PULMONARY NODULE

793.19 OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD

E945.8* OTHER AND UNSPECIFIED RESPIRATORY DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

* According to the ICD-9-CM book, diagnosis code E945.8 is a secondary diagnosis code and should not be billed as the primary diagnosis.

 

 

Documentation Requirements

 

• Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed.

o In addition, documentation that the service was performed for sputum induction/mobilization or bronchodilation for diagnostic purposes must be included in the patient’s medical record.

o This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

• Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

 

 

Treatment Logic

 

• Aerosol or vapor inhalation involves the administration of drugs or solution of drugs by the nasal or oral respiratory route for local or systemic effect.

• The drugs or solution of drugs commonly administered via a nebulizer or aerosol include distilled water, hypertonic saline, and bronchodilators such as anticholinergics and B-Agonists.

• Inhalation therapy is used in the therapeutic treatment of patients with known lung disease, as well as for producing bronchodilation, mobilizing sputum, and inducing sputum production for diagnostic purposes.

 

 

Sources of Information and Basis for Decision

 

Fauci, A., Braunwald, E., Isselbacher, K., Wilson, J., Martin, J., Kasper, D., Hauser, S., & Longo, D. (Eds.). (1998). Harrison’s principles of internal medicine (14th ed.). New York: McGraw-Hill.

 

FCSO LCD 28822, Diagnostic Aerosol or Vapor Inhalation, 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Van den Berg, J et al (2003). Sputum Induction in Research: Beware of the Beast. American Journal of Respiratory and Critical Care, 168, pp. 1253. Retrieved from http://ajrccm.atsjournals.org/cgi/content/full/168/10/1253 on September 28, 2005.

 

 

AMA CPT / ADA Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

CMS LCD DIAGNOSTIC AEROSOL OR VAPOR INHALATION