LCD/NCD Portal

L28978

 

RESPIRATORY THERAPEUTIC SERVICES

 

10/01/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• Medicare will consider respiratory therapeutic services medically necessary when all of the following criteria are met:

 

• There must be a specific written order by a licensed physician, who has training and/or experience in the treatment of patients with pulmonary disease (i.e., the physician who is treating the patient for the pulmonary disease). The physician orders, supervises, guides, and directs each patient’s plan of care.

• All treatment orders for respiratory therapies must include the following:

o Be specific as to the type, frequency, and duration of the procedure, modality, or activity and individualized for the patient

o Verbal and telephone orders must be co-signed and dated by the physician prior to billing the claim

o A blanket respiratory therapy or pulmonary rehabilitation order is not acceptable.

o The diagnosis must indicate a specific illness/injury or chronic pulmonary disease (See "ICD-9 Codes That Support Medical Necessity") and the patient is not actively involved in aggravating the existing disease state (i.e., patient may not be smoking or will participate in smoking cessation activities).

o The service(s) provided must be consistent with the severity of the patient’s documented illness and be reasonable in terms of modality, amount, frequency, and duration of treatment.

o Expectation of measurable improvement in a reasonable and predictable timeframe must be indicated.

o The patient must be physically able, motivated and willing to participate in the respiratory therapy; as well as, be a candidate for self-care.

o Pulmonary Function Tests (PFT’s) within twelve months of initiating respiratory services with the most recent values demonstrating DLCO, FVC or FEV1 <60% of predicted or consistently symptomatic COPD with FEV1 < 2 liters.

• The services must be reasonable and individualized for each patient’s condition.

o For respiratory therapeutic services, it is expected that no more than six (6) modalities per day would be performed per patient.

o Respiratory therapy procedures are usually provided 2-3 days per week for a period of 3-4 weeks, for no more than a total of ten (10) sessions.

o Medical record documentation must support the need for the additional respiratory therapy sessions.

• Unless the patient will be able to conduct ongoing self-care at home, there will only be a temporary benefit.

o The endpoint of treatment, therefore, is not when the patient achieves maximal exercise tolerance or stabilizes, but when the patient or his or her caregiver is able to continue the treatment modalities at home.

o Treatment is individualized and supervised by the patient’s attending physician (referring physician or facility medical director).

o Medicare does not cover services of a maintenance exercise program where a skilled therapist's services are not medically necessary.

• Respiratory Therapeutic Codes:

o G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring)

o G0237 should be used for therapy services to strengthen respiratory muscles.

 Examples are pursed-lip breathing, diaphragmatic breathing, and paced breathing (strengthening the diaphragm by breathing through tubes of progressively increasing resistance to flow).

 The service includes associated monitoring such as pulse oximetry, EKG, etc.

o G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one-on-one, face-to-face, per 15 minutes (includes monitoring)

o G0238 should be used for therapy services that involve a variety of activities including teaching the patient strategies for performing tasks with less respiratory effort and the performance of graded activity programs to increase endurance and strength of upper and lower extremities.

o G0238 does not include demonstration of the use of a nebulizer and/or inhaler, or chest percussions, since these services are represented by other CPT codes (see 94664 and 94667).

o G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)

o G0239 represents situations in which two or more patients are receiving services simultaneously (such as those described above by G0237 and G0238) during the same time period.

 The practitioners must be in constant attendance, but need not be providing one-on-one contact.

 For example, a therapist provides medically necessary therapeutic procedures to two patients in the same gym, for a 30-minute period.

 Both are performing different graded activities (described by G0238) to increase endurance of their upper and lower extremities while the therapist divides his/her time, in intermittent, brief episodes, between both patients.

 In this scenario the therapist would bill each patient for group therapy (G0239) because the treatment was provided simultaneously to two patients, and not one-on-one, as required by G0238.

• Monitoring provides physiologic or other data (pulse oximetry readings, electrocardiography data, measurements of strength or endurance, etc.) about the patient during the period before, during, and after the activities.

• An example would be pursed-lip breathing, which involves nasal inspiration followed by slow exhalations through partially closed pursed-lips to create positive pressure in upper respiratory tract, and improve respiratory muscles action.

• If after this training, the practitioner were to check the patient’s oxygen saturation level (by pulse oximetry), peak respiratory flow, or other respiratory parameters, then this would be considered “monitoring,” and would be included in the therapeutic procedure codes (G0237, G0238, G0239).

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.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

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.

 

 

0410 Respiratory Services - General Classification

0412 Respiratory Services - Inhalation Services

0419 Respiratory Services - Other Respiratory Services

 

 

CPT/HCPCS Codes

 

 

* G0239 is to be billed only once per day.

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

 

135 SARCOIDOSIS

277.00 CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS

277.02 CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS

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

492.8 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

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

506.4 CHRONIC RESPIRATORY CONDITIONS DUE TO FUMES AND VAPORS

508.1 CHRONIC AND OTHER PULMONARY MANIFESTATIONS DUE TO RADIATION

515 POSTINFLAMMATORY PULMONARY FIBROSIS

516.0 PULMONARY ALVEOLAR PROTEINOSIS

516.2 PULMONARY ALVEOLAR MICROLITHIASIS

516.30 IDIOPATHIC INTERSTITIAL PNEUMONIA, NOT OTHERWISE SPECIFIED

516.31 IDIOPATHIC PULMONARY FIBROSIS

516.32 IDIOPATHIC NON-SPECIFIC INTERSTITIAL PNEUMONITIS

516.33 ACUTE INTERSTITIAL PNEUMONITIS

516.34 RESPIRATORY BRONCHIOLITIS INTERSTITIAL LUNG DISEASE

516.35 IDIOPATHIC LYMPHOID INTERSTITIAL PNEUMONIA

516.36 CRYPTOGENIC ORGANIZING PNEUMONIA

516.37 DESQUAMATIVE INTERSTITIAL PNEUMONIA

516.8 OTHER SPECIFIED ALVEOLAR AND PARIETOALVEOLAR PNEUMONOPATHIES

518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

519.00 TRACHEOSTOMY COMPLICATION UNSPECIFIED

519.01 INFECTION OF TRACHEOSTOMY

519.02 MECHANICAL COMPLICATION OF TRACHEOSTOMY

519.09 OTHER TRACHEOSTOMY COMPLICATIONS

519.11 ACUTE BRONCHOSPASM

519.19 OTHER DISEASES OF TRACHEA AND BRONCHUS

519.2 MEDIASTINITIS

519.3 OTHER DISEASES OF MEDIASTINUM NOT ELSEWHERE CLASSIFIED

519.4 DISORDERS OF DIAPHRAGM

519.8 OTHER DISEASES OF RESPIRATORY SYSTEM NOT ELSEWHERE CLASSIFIED

519.9 UNSPECIFIED DISEASE OF RESPIRATORY SYSTEM

V42.6 LUNG REPLACED BY TRANSPLANT

 

 

Documentation Requirements

• The patient’s medical record must contain documentation that fully supports the medical necessity for respiratory therapeutic services as covered by Medicare (see “Indications and Limitations of Coverage and/or Medical Necessity”).

o This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

• The 30-day certification and re-certification of the plan of care requirement applies to the services of physical therapists, occupational therapists, and speech language pathologists as described in section 1861(p) of the Social Security Act.

o Since it is expected that codes G0237, G0238, and G0239 will typically be provided by respiratory therapists, the 30-day certification and re-certification of the plan of care requirement does not generally apply.

o If the services are performed by either a physical or occupational therapist (or by a therapy assistant under his or her direction), the requirement for the 30-day certification and re-certification applies.

 

Utilization Guidelines

• It is expected that no more than six (6) modalities of respiratory therapeutic services would be performed per patient, per day.

• Therapeutic procedures are usually provided 2-3 days per week for a period of 3-4 weeks, for no more than a total of ten (10) sessions.

• The medical record must document the medical necessity for additional respiratory therapy sessions (i.e., new condition, change in clinical status).

Treatment Logic

• The goal of these services is not to achieve a maximum exercise tolerance, but to ultimately transfer the responsibility of treatment from the clinic, hospital, or doctor to self-care in the home by the patient by:

o Controlling, reducing, and alleviating the symptoms and complications of chronic pulmonary diseases.

o Training the patient in how to reach and maintain the highest possible level of function in activities of daily living (ADL).

o Training the patient to self-manage his/her daily living consistent with the pulmonary disease process.

Sources of Information and Basis for Decision

 

American Association of Respiratory Care (AARC), AARC clinical practice guidelines. Retrieved June 17, 2003, from the World Wide Web: www.aarc.org. This reference was used for descriptions and definitions of respiratory therapy procedures.

 

American Thoracic Society (ATS), Pulmonary Rehabilitation. (1999). American Journal of Respiratory Critical Care Medicine, 159, 1666-1682. Eligibility criteria in our policy have been drawn from this ATS Position Statement.

 

FCSO LCD 28268, Respiratory Therapeutic Services, 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/  . The LCD data hosted on this site is an exact match of what appears on the MCD.

 

Federal Register, December 31, 2002, (Volume 67, Number 251), pgs. 79965-80184. This reference was used to clarify coverage for pulmonary rehabilitation and respiratory therapy services.

 

 

AMA CPT / ADA CDT 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. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

© Automated Clinical Guidelines, LLC 2011-2014

 

CMS LCD L28978 Respiratory Therapeutic Services