L29268-LCD

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Local Coverage Determination (LCD) for Respiratory Therapeutic Services (L29268)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29268

LCD Title

Respiratory Therapeutic Services

Contractor's Determination Number G0237

Primary Geographic Jurisdiction opens in new window 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 02/02/2009 Original Determination Ending Date

Revision Effective Date

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

CMS National Coverage Policy

• Section 1862(a)(1)(A) of Title XVIII of the Social Security Act.

• Section 1833(e) of Title XVIII of the Social Security Act

• 42 CFR 485.70, Personnel Qualifications

• CMS Transmittal No. AB-00-39, May 1, 2000, consolidates CMS Program Memoranda for outpatient rehabilitation therapy services.

• CMS Transmittal No. AB-98-14 (April 1998) addresses The National Institute of Health’s National Emphysema Treatment Trial (NETT).

• Pub. 100-03, Medicare National Coverage Determination Manual, Sections 170.1 and 240.7

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:

1. 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:

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

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

• A blanket respiratory therapy or pulmonary rehabilitation order is not acceptable;

2. 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);

3. 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;

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

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

6. 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. For respiratory therapeutic services, it is expected that no more than six (6) modalities per day would be performed per patient. 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. Medical record documentation must support the need for the additional respiratory therapy sessions.

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:

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

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

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

Unless the patient will be able to conduct ongoing self-care at home, there will only be a temporary benefit. 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. Treatment is individualized and supervised by the patient’s attending physician (referring physician or facility medical director). Medicare does not cover services of a maintenance exercise program where a skilled therapist's services are not medically necessary.

Respiratory Therapeutic Codes:

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

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.

G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one-on-one, face

-to-face, per 15 minutes (includes monitoring)

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. 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).

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

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.

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.

99999 Not Applicable

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 - 491.9 opens in new

window SIMPLE CHRONIC BRONCHITIS - UNSPECIFIED CHRONIC BRONCHITIS

492.8 OTHER EMPHYSEMA

493.00 - 493.92 opens in new EXTRINSIC ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE)

window

494.0 - 494.1 opens in new window

EXACERBATION

BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - 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 - 516.37 opens in new IDIOPATHIC INTERSTITIAL PNEUMONIA, NOT OTHERWISE SPECIFIED -

window

DESQUAMATIVE INTERSTITIAL PNEUMONIA

516.8 OTHER SPECIFIED ALVEOLAR AND PARIETOALVEOLAR PNEUMONOPATHIES

518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

519.00 - 519.9 opens in new window

TRACHEOSTOMY COMPLICATION UNSPECIFIED - UNSPECIFIED DISEASE OF RESPIRATORY SYSTEM

V42.6 LUNG REPLACED BY TRANSPLANT

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

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

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations 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”). 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. 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. 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.

Appendices

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).

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

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.

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.

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 12/04/2008

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

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

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 516.3 and replaced it with diagnosis code range 516.30-516.37. 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:02/02/2009

LCR B2009-

December 2008 Bulletin

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

For Florida (00590) this LCD (L29268) replaces LCD L15075 as the policy in notice. This document (L29268) is effective on 02/02/2009.

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

Reason for Change