L28822-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Diagnostic Aerosol or Vapor Inhalation (L28822)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28822

LCD Title Diagnostic Aerosol or Vapor Inhalation

Contractor's Determination Number A94640

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:

N/A

Indications and Limitations of Coverage and/or Medical Necessity

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.

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. Any type of nebulizer may be used; however, ultrasonic nebulizers, which produce a concentrated mist, are preferred. The procedure is terminated when an adequate specimen is obtained, the nebulizer solution is exhausted, or after a maximum of 15-20 minutes. 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:

• For the induction/mobilization of sputum in a patient who presents with signs and symptoms of a respiratory infection (e.g., fever, dyspnea, chest congestion, cough) or suspected lung malignancy, and who is unable to produce an adequate sputum specimen for examination by conventional methods;

• For the induction/mobilization of sputum in a patient who continues to demonstrate signs and symptoms of a respiratory infection (e.g., fever, dyspnea, chest congestion, cough) despite antibiotic treatment, and who is unable to produce an adequate sputum specimen for follow-up examination by conventional methods; and/or

• 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.

013x Hospital Outpatient

021x Skilled Nursing - Inpatient (Including Medicare Part A)

022x Skilled Nursing - Inpatient (Medicare Part B only)

023x Skilled Nursing - Outpatient

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)

085x 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.

046X Pulmonary Function - General Classification

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 - 162.9 MALIGNANT NEOPLASM OF TRACHEA - 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 - 466.19 ACUTE BRONCHITIS - ACUTE BRONCIOLITIS DUE TO OTHER INFECTIOUS ORGANISMS

486 PNEUMONIA ORGANISM UNSPECIFIED

490 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC

491.0 - 491.9 SIMPLE CHRONIC BRONCHITIS - UNSPECIFIED CHRONIC BRONCHITIS

492.0 - 492.8 EMPHYSEMATOUS BLEB - OTHER EMPHYSEMA

493.00 - 493.92 EXTRINSIC ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 - 494.1 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - BRONCHIECTASIS WITH ACUTE EXACERBATION

495.0 - 495.9 FARMERS' LUNG - 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 - 517.8 RHEUMATIC PNEUMONIA - LUNG INVOLVEMENT IN OTHER DISEASES CLASSIFIED ELSEWHERE

518.0 - 518.89 PULMONARY COLLAPSE - OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

786.02 - 786.09 ORTHOPNEA - RESPIRATORY ABNORMALITY OTHER

786.2 COUGH

786.30 HEMOPTYSIS, UNSPECIFIED

786.39 OTHER HEMOPTYSIS

786.4 ABNORMAL SPUTUM

793.11 - 793.19 SOLITARY PULMONARY NODULE - 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.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

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

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

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.

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.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 3

Revision History Explanation Revision Number: 3 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 793.1 and replaced it with diagnosis code range 793.11-793.19. The effective date of this revision is based on date of service.

Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR A2010-050

September 2010 Bulletin

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted diagnosis code 786.3. Added new diagnosis codes 786.30 and 786.39 and descriptors. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Revised the descriptor for diagnosis code 793.1. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-034FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28822) replaces LCD L1059 as the policy in notice. This document (L28822) is effective on 02/16/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 8/1/2010 - The description for Bill Type Code 13 was changed

8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0460 was changed 8/1/2010 - The description for Revenue code 0469 was changed

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change