Automated World Health
L28822 DIAGNOSTIC AEROSOL OR VAPOR INHALATION
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.
• Chest congestion.
Suspected lung malignancy.
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:
• Chest congestion.
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.
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
• 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
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
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
495.2 BIRD-FANCIERS' LUNG
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
786.04 CHEYNE-STOKES RESPIRATION
786.05 SHORTNESS OF BREATH
786.09 RESPIRATORY ABNORMALITY OTHER
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.
• 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.
• 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.