LCD Reference Article Billing and Coding Article

Billing and Coding: Respiratory Therapy and Oximetry Services

A56730

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A56730
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Respiratory Therapy and Oximetry Services
Article Type
Billing and Coding
Original Effective Date
07/25/2019
Revision Effective Date
10/01/2023
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Respiratory Therapy and Oximetry Services L33446.

CPT® code 31720 is payable only if it is personally performed by the physician (or qualified Non-Physician Practitioner (NPP)).

Note:

CPT® codes 94760, 94761 and 94762 are bundled by the Correct Coding Initiative (CCI) with critical care services. Therefore, CPT® codes 94760, 94761 and 94762 cannot be paid separately when billed with critical care CPT® codes (99291 and 99292).

CPT® code 94762 is considered medically necessary when performed for any of the following reasons:

  • The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.
  • The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.

Payment can be allowed for CPT® code 31720 only if supporting documentation demonstrates the service was personally performed by the physician or NPP when this service falls within his scope of practice.

Payment for CPT® code 31720 may be allowed, on an individual consideration basis, for respiratory treatments for 3 consecutive days or 3 identical services within a 30-day time frame. Additional payment may be allowed for respiratory therapy treatments exceeding these parameters only if medical necessity can be established by medical documentation. In the case of consecutive days of care, the medical record should indicate why the patient was not transferred to a higher level of care.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

CPT® codes 94760, 94761, and 94762 are included in the critical care services listed in Group 2: Codes. These codes will not be paid separately when billed with a critical care code.

Group 1 Codes
Code Description
31720 CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRACHEAL
94640 PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE
94664 DEMONSTRATION AND/OR EVALUATION OF PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR IPPB DEVICE
94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION
94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; MULTIPLE DETERMINATIONS (EG, DURING EXERCISE)
94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; BY CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE)

Group 2

(2 Codes)
Group 2 Paragraph

Critical Care Codes

Group 2 Codes
Code Description
99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES
99292 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(298 Codes)
Group 1 Paragraph

The CPT/HCPCS codes included in this article will be subjected to "procedure to diagnosis" editing. The following list includes only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 31720, 94640, 94664, 94760 and 94761:

Group 1 Codes
Code Description
A15.0 Tuberculosis of lung
A22.1 Pulmonary anthrax
A37.01 Whooping cough due to Bordetella pertussis with pneumonia
A37.11 Whooping cough due to Bordetella parapertussis with pneumonia
A37.81 Whooping cough due to other Bordetella species with pneumonia
A37.91 Whooping cough, unspecified species with pneumonia
A48.1 Legionnaires' disease
B25.0 Cytomegaloviral pneumonitis
B44.0 Invasive pulmonary aspergillosis
B77.81 Ascariasis pneumonia
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C38.4 Malignant neoplasm of pleura
C45.0 Mesothelioma of pleura
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.2 Secondary malignant neoplasm of pleura
C78.39 Secondary malignant neoplasm of other respiratory organs
E84.0 Cystic fibrosis with pulmonary manifestations
E84.8 Cystic fibrosis with other manifestations
E84.9 Cystic fibrosis, unspecified
F51.19 Other hypersomnia not due to a substance or known physiological condition
G47.01 Insomnia due to medical condition
G47.09 Other insomnia
G47.10 Hypersomnia, unspecified
G47.11 Idiopathic hypersomnia with long sleep time
G47.12 Idiopathic hypersomnia without long sleep time
G47.13 Recurrent hypersomnia
G47.14 Hypersomnia due to medical condition
G47.19 Other hypersomnia
G47.20 Circadian rhythm sleep disorder, unspecified type
G47.21 Circadian rhythm sleep disorder, delayed sleep phase type
G47.22 Circadian rhythm sleep disorder, advanced sleep phase type
G47.23 Circadian rhythm sleep disorder, irregular sleep wake type
G47.24 Circadian rhythm sleep disorder, free running type
G47.25 Circadian rhythm sleep disorder, jet lag type
G47.26 Circadian rhythm sleep disorder, shift work type
G47.27 Circadian rhythm sleep disorder in conditions classified elsewhere
G47.29 Other circadian rhythm sleep disorder
G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
G47.32 High altitude periodic breathing
G47.33 Obstructive sleep apnea (adult) (pediatric)
G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation
G47.35 Congenital central alveolar hypoventilation syndrome
G47.36 Sleep related hypoventilation in conditions classified elsewhere
G47.37 Central sleep apnea in conditions classified elsewhere
G47.39 Other sleep apnea
G47.50 Parasomnia, unspecified
G47.51 Confusional arousals
G47.52 REM sleep behavior disorder
G47.53 Recurrent isolated sleep paralysis
G47.54 Parasomnia in conditions classified elsewhere
G47.59 Other parasomnia
G47.69 Other sleep related movement disorders
G47.8 Other sleep disorders
I09.81 Rheumatic heart failure
I11.0 Hypertensive heart disease with heart failure
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale
I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I27.81 Cor pulmonale (chronic)
I27.9 Pulmonary heart disease, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
I78.0 Hereditary hemorrhagic telangiectasia
J04.10 Acute tracheitis without obstruction
J04.11 Acute tracheitis with obstruction
J04.2 Acute laryngotracheitis
J05.0 Acute obstructive laryngitis [croup]
J05.10 Acute epiglottitis without obstruction
J05.11 Acute epiglottitis with obstruction
J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia
J10.08 Influenza due to other identified influenza virus with other specified pneumonia
J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia
J11.08 Influenza due to unidentified influenza virus with specified pneumonia
J12.0 Adenoviral pneumonia
J12.1 Respiratory syncytial virus pneumonia
J12.2 Parainfluenza virus pneumonia
J12.3 Human metapneumovirus pneumonia
J12.81 Pneumonia due to SARS-associated coronavirus
J12.82 Pneumonia due to coronavirus disease 2019
J12.89 Other viral pneumonia
J12.9 Viral pneumonia, unspecified
J14 Pneumonia due to Hemophilus influenzae
J15.0 Pneumonia due to Klebsiella pneumoniae
J15.1 Pneumonia due to Pseudomonas
J15.20 Pneumonia due to staphylococcus, unspecified
J15.211 Pneumonia due to Methicillin susceptible Staphylococcus aureus
J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
J15.29 Pneumonia due to other staphylococcus
J15.3 Pneumonia due to streptococcus, group B
J15.4 Pneumonia due to other streptococci
J15.5 Pneumonia due to Escherichia coli
J15.69 Pneumonia due to other Gram-negative bacteria
J15.7 Pneumonia due to Mycoplasma pneumoniae
J15.8 Pneumonia due to other specified bacteria
J15.9 Unspecified bacterial pneumonia
J16.0 Chlamydial pneumonia
J16.8 Pneumonia due to other specified infectious organisms
J17 Pneumonia in diseases classified elsewhere
J18.0 Bronchopneumonia, unspecified organism
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
J20.0 Acute bronchitis due to Mycoplasma pneumoniae
J20.1 Acute bronchitis due to Hemophilus influenzae
J20.2 Acute bronchitis due to streptococcus
J20.3 Acute bronchitis due to coxsackievirus
J20.4 Acute bronchitis due to parainfluenza virus
J20.5 Acute bronchitis due to respiratory syncytial virus
J20.6 Acute bronchitis due to rhinovirus
J20.7 Acute bronchitis due to echovirus
J20.8 Acute bronchitis due to other specified organisms
J20.9 Acute bronchitis, unspecified
J21.0 Acute bronchiolitis due to respiratory syncytial virus
J21.1 Acute bronchiolitis due to human metapneumovirus
J21.8 Acute bronchiolitis due to other specified organisms
J21.9 Acute bronchiolitis, unspecified
J39.8 Other specified diseases of upper respiratory tract
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0 Pneumoconiosis due to talc dust
J62.8 Pneumoconiosis due to other dust containing silica
J63.0 Aluminosis (of lung)
J63.1 Bauxite fibrosis (of lung)
J63.2 Berylliosis
J63.3 Graphite fibrosis (of lung)
J63.4 Siderosis
J63.5 Stannosis
J63.6 Pneumoconiosis due to other specified inorganic dusts
J64 Unspecified pneumoconiosis
J65 Pneumoconiosis associated with tuberculosis
J66.0 Byssinosis
J66.1 Flax-dressers' disease
J66.2 Cannabinosis
J66.8 Airway disease due to other specific organic dusts
J67.0 Farmer's lung
J67.1 Bagassosis
J67.2 Bird fancier's lung
J67.3 Suberosis
J67.4 Maltworker's lung
J67.5 Mushroom-worker's lung
J67.6 Maple-bark-stripper's lung
J67.7 Air conditioner and humidifier lung
J67.8 Hypersensitivity pneumonitis due to other organic dusts
J67.9 Hypersensitivity pneumonitis due to unspecified organic dust
J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors
J68.4 Chronic respiratory conditions due to chemicals, gases, fumes and vapors
J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors
J68.9 Unspecified respiratory condition due to chemicals, gases, fumes and vapors
J69.0 Pneumonitis due to inhalation of food and vomit
J70.1 Chronic and other pulmonary manifestations due to radiation
J70.5 Respiratory conditions due to smoke inhalation
J80 Acute respiratory distress syndrome
J82.81 Chronic eosinophilic pneumonia
J82.82 Acute eosinophilic pneumonia
J82.83 Eosinophilic asthma
J84.10 Pulmonary fibrosis, unspecified
J84.111 Idiopathic interstitial pneumonia, not otherwise specified
J84.112 Idiopathic pulmonary fibrosis
J84.113 Idiopathic non-specific interstitial pneumonitis
J84.114 Acute interstitial pneumonitis
J84.115 Respiratory bronchiolitis interstitial lung disease
J84.116 Cryptogenic organizing pneumonia
J84.117 Desquamative interstitial pneumonia
J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere
J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.2 Lymphoid interstitial pneumonia
J84.89 Other specified interstitial pulmonary diseases
J90 Pleural effusion, not elsewhere classified
J91.0 Malignant pleural effusion
J91.8 Pleural effusion in other conditions classified elsewhere
J94.0 Chylous effusion
J94.2 Hemothorax
J94.8 Other specified pleural conditions
J95.84 Transfusion-related acute lung injury (TRALI)
J95.860 Postprocedural hematoma of a respiratory system organ or structure following a respiratory system procedure
J95.861 Postprocedural hematoma of a respiratory system organ or structure following other procedure
J95.862 Postprocedural seroma of a respiratory system organ or structure following a respiratory system procedure
J95.863 Postprocedural seroma of a respiratory system organ or structure following other procedure
J95.87 Transfusion-associated dyspnea (TAD)
J98.01 Acute bronchospasm
J98.09 Other diseases of bronchus, not elsewhere classified
J98.11 Atelectasis
J98.19 Other pulmonary collapse
J98.2 Interstitial emphysema
J98.4* Other disorders of lung
J98.51 Mediastinitis
J98.59 Other diseases of mediastinum, not elsewhere classified
M05.10 Rheumatoid lung disease with rheumatoid arthritis of unspecified site
M05.111 Rheumatoid lung disease with rheumatoid arthritis of right shoulder
M05.112 Rheumatoid lung disease with rheumatoid arthritis of left shoulder
M05.121 Rheumatoid lung disease with rheumatoid arthritis of right elbow
M05.122 Rheumatoid lung disease with rheumatoid arthritis of left elbow
M05.131 Rheumatoid lung disease with rheumatoid arthritis of right wrist
M05.132 Rheumatoid lung disease with rheumatoid arthritis of left wrist
M05.141 Rheumatoid lung disease with rheumatoid arthritis of right hand
M05.142 Rheumatoid lung disease with rheumatoid arthritis of left hand
M05.151 Rheumatoid lung disease with rheumatoid arthritis of right hip
M05.152 Rheumatoid lung disease with rheumatoid arthritis of left hip
M05.161 Rheumatoid lung disease with rheumatoid arthritis of right knee
M05.162 Rheumatoid lung disease with rheumatoid arthritis of left knee
M05.171 Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot
M05.172 Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot
M05.19 Rheumatoid lung disease with rheumatoid arthritis of multiple sites
Q25.72 Congenital pulmonary arteriovenous malformation
Q33.4 Congenital bronchiectasis
R05.1 Acute cough
R05.2 Subacute cough
R06.00 Dyspnea, unspecified
R06.03 Acute respiratory distress
R06.09 Other forms of dyspnea
R06.2 Wheezing
R06.89 Other abnormalities of breathing
R09.01 Asphyxia
R09.02 Hypoxemia
R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems
R23.0 Cyanosis
R40.0 Somnolence
R40.1 Stupor
R41.0 Disorientation, unspecified
R41.82 Altered mental status, unspecified
T78.2XXA Anaphylactic shock, unspecified, initial encounter
T78.2XXD Anaphylactic shock, unspecified, subsequent encounter
T78.2XXS Anaphylactic shock, unspecified, sequela
T88.6XXA Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial encounter
T88.6XXD Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, subsequent encounter
T88.6XXS Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, sequela
Z85.118 Personal history of other malignant neoplasm of bronchus and lung
Z85.12 Personal history of malignant neoplasm of trachea
Z86.74 Personal history of sudden cardiac arrest
U09.9 Post COVID-19 condition, unspecified
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Use J98.4 for patients who have become oxygen dependent following an illness.

Group 2

(65 Codes)
Group 2 Paragraph

Medicare is establishing the following limited coverage for CPT/HCPCS code 94762.

Group 2 Codes
Code Description
G47.10* Hypersomnia, unspecified
G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
G47.32 High altitude periodic breathing
G47.33 Obstructive sleep apnea (adult) (pediatric)
G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation
G47.35 Congenital central alveolar hypoventilation syndrome
G47.36 Sleep related hypoventilation in conditions classified elsewhere
G47.37* Central sleep apnea in conditions classified elsewhere
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale
I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale
I27.0 Primary pulmonary hypertension
I27.20 Pulmonary hypertension, unspecified
I27.21 Secondary pulmonary arterial hypertension
I27.22 Pulmonary hypertension due to left heart disease
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.81* Cor pulmonale (chronic)
I27.82 Chronic pulmonary embolism
I27.83 Eisenmenger's syndrome
I27.89 Other specified pulmonary heart diseases
I27.9* Pulmonary heart disease, unspecified
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23* Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33* Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43* Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9* Heart failure, unspecified
J12.82 Pneumonia due to coronavirus disease 2019
J43.0* Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1* Panlobular emphysema
J43.2* Centrilobular emphysema
J43.8* Other emphysema
J43.9* Emphysema, unspecified
J44.9* Chronic obstructive pulmonary disease, unspecified
R05.1* Acute cough
R05.2* Subacute cough
R06.03 Acute respiratory distress
R09.01* Asphyxia
R09.02* Hypoxemia
R40.0 Somnolence
R40.1 Stupor
R68.13 Apparent life threatening event in infant (ALTE)
Z86.74 Personal history of sudden cardiac arrest
U09.9* Post COVID-19 condition, unspecified
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: The codes G47.10, G47.37, I27.81, I27.9, I50.23, I50.33, I50.43, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.9, R05.1, R05.2, R09.01, R09.02, and U09.9 are to be used only for those patients who exhibit signs and symptoms of oxygen deprivation (supported by the patient’s medical record).

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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

Code Description
N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2023 R9

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes added J15.69 and deleted J15.6. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/23.

10/01/2022 R8

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes added J95.87. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/22.

10/01/2021 R7

Under ICD-10-CM Codes that Support Medical Necessity Group 1 and 2: Codes added R05.1, R05.2, and U09.9. Under ICD-10-CM Codes that Support Medical Necessity Group 2: Medical Necessity ICD-10-CM Codes Asterisk Explanation revised the verbiage to state “*Note: The codes G47.10, G47.37, I27.81, I27.9, I50.23, I50.33, I50.43, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.9, R05.1, R05.2, R09.01, R09.02, and U09.9 are to be used only for those patients who exhibit signs and symptoms of oxygen deprivation (supported by the patient’s medical record).” This revision is due to the Annual ICD-10 Update and will become effective on 10/1/21.

01/01/2021 R6

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted U07.1. This revision is retroactive effective for dates of service on or after 1/1/2021.

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes and Group 2: Codes added J12.82. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/01/2020 R5

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted J84.17 and added J82.81, J82.82, J82.83, J84.170 and J84.178. This revision is due to the Annual ICD-10 Code Update and is effective on 10/1/20.

04/01/2020 R4

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added U07.1. This revision is due to the Q2 2020 Code Update and is effective for dates of service on or after 4/1/2020.

10/17/2019 R3

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Respiratory Therapy and Oximetry Services L33446 LCD and placed in this article. Under Article Text removed subheadings Documentation Requirements and Utilization Guidelines. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph removed Group 1: Asterisk subheading and corresponding paragraph. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes placed an asterisk on ICD-10 code J98.4. Under ICD-10 Codes that Support Medical Necessity Group 1: Medical Necessity ICD-10 Codes Asterisk Explanation added verbiage. Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph removed Group 2: Asterisk subheading and corresponding paragraph. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes placed an asterisk on ICD-10 codes G47.10, G47.37, I27.81, I27.9, I50.23, I50.33, I50.43, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.9, R09.01, and R09.02. Under ICD-10 Codes that Support Medical Necessity Group 2: Medical Necessity ICD-10 Codes Asterisk Explanation added verbiage.

10/01/2019 R2

Under Covered ICD-10 Codes Group 1: Codes the description changed for ICD-10 code J44.0 and ICD-10 codes I26.93 and I26.94 were added. Under Covered ICD-10 Codes Group 2: Codes ICD-10 codes I26.93 and I26.94 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

07/25/2019 R1

All coding located in the Coding Information section has been removed from the related Respiratory Therapy and Oximetry Services L33446 LCD and added to this article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33446 - Respiratory Therapy and Oximetry Services
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/23/2023 10/01/2023 - N/A Currently in Effect You are here
08/18/2022 10/01/2022 - 09/30/2023 Superseded View
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Keywords

  • Therapy
  • Respiratory
  • Oximetry