RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: Therapy and Rehabilitation Services

A57156

Expand All | Collapse All
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.
Retired

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57156
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Therapy and Rehabilitation Services
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
03/09/2022
Revision Ending Date
03/01/2023
Retirement Date
03/01/2023
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33413 (Therapy and Rehabilitation Services). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

CPT code 97022 is used for whirlpool bath or fluidized therapy for dry heat.

CPT code 97036 is used for Hubbard tank hydrotherapy.

CPT code 97026 is not payable per NCD 270.6 Infrared Therapy Devices (Effective October 24, 2006).

If a therapist or physician performs any of the therapeutic procedures with two or more individuals concurrently or during the same time period, then only CPT code 97150 is reported for each patient.

CPT code 97537 is not payable. Community reintegration training is performed in conjunction with other therapeutic procedures and is bundled into the payment for these other services. Therefore, the services are not separately reimbursable. Work reintegration training is not payable per the LCD.

CPT codes 97545 and 97546 are not payable per the LCD.

Complex Decongestive Physiotherapy: Although there is no means to allow payment of the total treatment via one treatment code, payment will be allowed for the therapy services associated with the treatment (i.e., CPT codes 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168). Other services such as skin care and the supplies associated with the compression wrapping are included in the therapy services performed during each session.

HCPCS/CPT codes G0283 and 97032 are not payable for the diagnosis of Bell’s Palsy (ICD-10 code G51.0) per NCD 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy).

CPT Codes 97024 and 97035 are not payable for diagnoses asthma, bronchitis, or any other pulmonary condition per the LCD.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. A complete discussion of the documentation requirements for therapy services can be found in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 and Section 230.
  5. The progress notes must contain necessary and sufficient information, which indicates the services were actually provided and were reasonable and necessary to treat the patient's condition. Progress notes must substantiate the medical necessity of the treatment and support that skilled intervention is required. The progress note should document any treatment variations with the associated rationale. The progress notes should be written using measurements and functional accomplishments.

Use statements which can be used to assess the patient’s response to therapy such as:

    • "able to perform exercises as prescribed for 15 reps"
    • "able to safely transfer from bed to wheelchair with standby assistance"
    • "can now abduct shoulder 120 degrees"
    • "can bridge now sufficiently to pull slacks up over hips"

Avoid terms such as:

    • doing well
    • improving
    • less pain
    • increased range of motion
    • increased strength
    • tolerated treatment well
  1. The name and dosage of the medication utilized during Phonopheresis (CPT code 97035) or Iontopheresis (CPT code 97033) should be maintained in the medical record. This information may be indicated in the plan of treatment or on a prescription signed by the health care provider responsible for certifying the plan of treatment.
  2. Documentation for therapeutic exercise (CPT code 97110) must show objective loss of joint motion, strength, mobility (e.g., degrees of motion, strength grades, levels of assistance).
  3. For Therapeutic Procedure(s), group (2 or more individuals) (CPT code 97150), documentation must be maintained in the patient's medical record identifying the specific treatment technique(s) used in the group, how the treatment technique will restore function and the treatment goal in the individualized plan. The number of persons in the group must also be furnished.
  4. When billing CPT code 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient.
  5. For Physical Performance Test or Measurement (CPT code 97750), the health care provider performs a test of physical performance evaluating function of one or more body areas and evaluates functional capacity. A written report is included. This is in addition to a routine evaluation or re-evaluation (97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168).
  6. For Assistive Technology Assessment (CPT code 97755), The medical record should document the goal of the assessment, the technology/component/system involved, a description of the process involved in assessing the patient's response, the outcome of the assessment, and how this information affects the treatment plan.
  7. The medical record should document the distinct treatments rendered when prosthetic(s) training (CPT code 97761) for a lower extremity is done during the same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535).
  8. Documentation Requirements for Complex Decongestive Physiotherapy:

The documentation for the initial evaluation and treatment must include the following:

    • a physician documented diagnosis of lymphedema and a specific order for CDP.
    • a statement as to the ability of the patient/patient caregiver to follow through with the continuation of treatment on a long term home treatment plan.
    • history and physical including: the cause of the lymphedema and any prior treatment, measurements of body part/extremity prior to treatment, specific areas of indurated tissue, hardness of edema, condition of nails and skin, infected sites, scars, distal pulses, pain, discomfort and the affects the lymphedema has on the patient's Activities of Daily Living (i.e, symptomatic for lymphedema, with limitation of function related to self care, mobility and/or safety).
    • treatment plan identifying specific short and long term goals; the type, amount, frequency and duration of the services.
    • the services/modalities performed including a response to treatment.

The documentation for any subsequent treatment must include:

    • a report showing the progress of the therapy including periodic measurements of the applicable extremity(ies).
    • the response of the patient /patient caregiver to the education and their understanding and ability to take on some of the responsibilities of the treatment.
    • the services/modalities performed including a response to treatment.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

The following codes are specific to speech-language therapy services.

The following CPT codes associated with the services outlined in this Billing and Coding Article will not have diagnosis code limitations applied at this time: 92507, 92508, 92521, 92522, 92523, 92524, 92607, 92608, 92609, 92626, 92627, 92630, 92633, 96105, 96125, 97129 and 97130.

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes

N/A

Group 2

(5 Codes)
Group 2 Paragraph

The following codes are specific to physical and/or occupational therapy services.

The following CPT/HCPCS codes associated with the services outlined in this Billing and Coding Article will not have diagnosis code limitations applied at this time: 96125, 97012, 97016, 97018, 97022, 97028, 97033, 97034, 97036, 97110, 97112, 97113, 97124, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97763, G0281, G0282, 97129 and 97130.

Please see ICD-10-CM diagnosis codes that do not support medical necessity below for CPT code 97116 (Group 1 Codes), CPT/HCPCS codes 97032/G0283 (Group 2 Codes), and CPT codes 97024/97035 (Group 3 Codes).

Group 2 Codes
Code Description
97024 Diathermy eg microwave
97032 Electrical stimulation
97035 Ultrasound therapy
97116 Gait training therapy
G0283 Elec stim other than wound
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

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

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

Group 1

(171 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes do not support medical necessity for CPT code 97116 when billed for neuromuscular electrical stimulation/functional electrical stimulation (NMES/FES) to enhance walking for spinal cord injury per NCD 160.12.

Group 1 Codes
Code Description
G90.4 Autonomic dysreflexia
M21.00 Valgus deformity, not elsewhere classified, unspecified site
M21.021 Valgus deformity, not elsewhere classified, right elbow
M21.022 Valgus deformity, not elsewhere classified, left elbow
M21.029 Valgus deformity, not elsewhere classified, unspecified elbow
M21.051 Valgus deformity, not elsewhere classified, right hip
M21.052 Valgus deformity, not elsewhere classified, left hip
M21.059 Valgus deformity, not elsewhere classified, unspecified hip
M21.071 Valgus deformity, not elsewhere classified, right ankle
M21.072 Valgus deformity, not elsewhere classified, left ankle
M21.079 Valgus deformity, not elsewhere classified, unspecified ankle
M21.10 Varus deformity, not elsewhere classified, unspecified site
M21.121 Varus deformity, not elsewhere classified, right elbow
M21.122 Varus deformity, not elsewhere classified, left elbow
M21.129 Varus deformity, not elsewhere classified, unspecified elbow
M21.151 Varus deformity, not elsewhere classified, right hip
M21.152 Varus deformity, not elsewhere classified, left hip
M21.159 Varus deformity, not elsewhere classified, unspecified
M21.171 Varus deformity, not elsewhere classified, right ankle
M21.172 Varus deformity, not elsewhere classified, left ankle
M21.179 Varus deformity, not elsewhere classified, unspecified ankle
M21.20 Flexion deformity, unspecified site
M21.211 Flexion deformity, right shoulder
M21.212 Flexion deformity, left shoulder
M21.219 Flexion deformity, unspecified shoulder
M21.221 Flexion deformity, right elbow
M21.222 Flexion deformity, left elbow
M21.229 Flexion deformity, unspecified elbow
M21.231 Flexion deformity, right wrist
M21.232 Flexion deformity, left wrist
M21.239 Flexion deformity, unspecified wrist
M21.241 Flexion deformity, right finger joints
M21.242 Flexion deformity, left finger joints
M21.249 Flexion deformity, unspecified finger joints
M21.251 Flexion deformity, right hip
M21.252 Flexion deformity, left hip
M21.259 Flexion deformity, unspecified hip
M21.261 Flexion deformity, right knee
M21.262 Flexion deformity, left knee
M21.269 Flexion deformity, unspecified knee
M21.271 Flexion deformity, right ankle and toes
M21.272 Flexion deformity, left ankle and toes
M21.279 Flexion deformity, unspecified ankle and toes
M21.331 Wrist drop, right wrist
M21.332 Wrist drop, left wrist
M21.339 Wrist drop, unspecified wrist
M21.371 Foot drop, right foot
M21.372 Foot drop, left foot
M21.379 Foot drop, unspecified foot
M21.511 Acquired clawhand, right hand
M21.512 Acquired clawhand, left hand
M21.519 Acquired clawhand, unspecified hand
M21.521 Acquired clubhand, right hand
M21.522 Acquired clubhand, left hand
M21.529 Acquired clubhand, unspecified hand
M21.531 Acquired clawfoot, right foot
M21.532 Acquired clawfoot, left foot
M21.539 Acquired clawfoot, unspecified foot
M21.541 Acquired clubfoot, right foot
M21.542 Acquired clubfoot, left foot
M21.549 Acquired clubfoot, unspecified foot
M21.611 Bunion of right foot
M21.612 Bunion of left foot
M21.619 Bunion of unspecified foot
M21.621 Bunionette of right foot
M21.622 Bunionette of left foot
M21.629 Bunionette of unspecified foot
M21.6X1 Other acquired deformities of right foot
M21.6X2 Other acquired deformities of left foot
M21.6X9 Other acquired deformities of unspecified foot
M21.70 Unequal limb length (acquired), unspecified site
M21.721 Unequal limb length (acquired), right humerus
M21.722 Unequal limb length (acquired), left humerus
M21.729 Unequal limb length (acquired), unspecified humerus
M21.731 Unequal limb length (acquired), right ulna
M21.732 Unequal limb length (acquired), left ulna
M21.733 Unequal limb length (acquired), right radius
M21.734 Unequal limb length (acquired), left radius
M21.739 Unequal limb length (acquired), unspecified ulna and radius
M21.751 Unequal limb length (acquired), right femur
M21.752 Unequal limb length (acquired), left femur
M21.759 Unequal limb length (acquired), unspecified femur
M21.761 Unequal limb length (acquired), right tibia
M21.762 Unequal limb length (acquired), left tibia
M21.763 Unequal limb length (acquired), right fibula
M21.764 Unequal limb length (acquired), left fibula
M21.769 Unequal limb length (acquired), unspecified tibia and fibula
M21.80 Other specified acquired deformities of unspecified limb
M21.821 Other specified acquired deformities of right upper arm
M21.822 Other specified acquired deformities of left upper arm
M21.829 Other specified acquired deformities of unspecified upper arm
M21.831 Other specified acquired deformities of right forearm
M21.832 Other specified acquired deformities of left forearm
M21.839 Other specified acquired deformities of unspecified forearm
M21.851 Other specified acquired deformities of right thigh
M21.852 Other specified acquired deformities of left thigh
M21.859 Other specified acquired deformities of unspecified thigh
M21.90 Unspecified acquired deformity of unspecified limb
M21.921 Unspecified acquired deformity of right upper arm
M21.922 Unspecified acquired deformity of left upper arm
M21.929 Unspecified acquired deformity of unspecified upper arm
M21.931 Unspecified acquired deformity of right forearm
M21.932 Unspecified acquired deformity of left forearm
M21.939 Unspecified acquired deformity of unspecified forearm
M21.941 Unspecified acquired deformity of hand, right hand
M21.942 Unspecified acquired deformity of hand, left hand
M21.949 Unspecified acquired deformity of hand, unspecified hand
M21.951 Unspecified acquired deformity of right thigh
M21.952 Unspecified acquired deformity of left thigh
M21.959 Unspecified acquired deformity of unspecified thigh
M21.961 Unspecified acquired deformity of right lower leg
M21.962 Unspecified acquired deformity of left lower leg
M21.969 Unspecified acquired deformity of unspecified lower leg
M41.40 Neuromuscular scoliosis, site unspecified
M41.41 Neuromuscular scoliosis, occipito-atlanto-axial region
M41.42 Neuromuscular scoliosis, cervical region
M41.43 Neuromuscular scoliosis, cervicothoracic region
M41.44 Neuromuscular scoliosis, thoracic region
M41.45 Neuromuscular scoliosis, thoracolumbar region
M41.46 Neuromuscular scoliosis, lumbar region
M41.47 Neuromuscular scoliosis, lumbosacral region
M41.50 Other secondary scoliosis, site unspecified
M41.52 Other secondary scoliosis, cervical region
M41.53 Other secondary scoliosis, cervicothoracic region
M41.54 Other secondary scoliosis, thoracic region
M41.55 Other secondary scoliosis, thoracolumbar region
M41.56 Other secondary scoliosis, lumbar region
M41.57 Other secondary scoliosis, lumbosacral region
M43.00 Spondylolysis, site unspecified
M43.01 Spondylolysis, occipito-atlanto-axial region
M43.02 Spondylolysis, cervical region
M43.03 Spondylolysis, cervicothoracic region
M43.04 Spondylolysis, thoracic region
M43.05 Spondylolysis, thoracolumbar region
M43.06 Spondylolysis, lumbar region
M43.07 Spondylolysis, lumbosacral region
M43.08 Spondylolysis, sacral and sacrococcygeal region
M43.09 Spondylolysis, multiple sites in spine
M43.10 Spondylolisthesis, site unspecified
M43.11 Spondylolisthesis, occipito-atlanto-axial region
M43.12 Spondylolisthesis, cervical region
M43.13 Spondylolisthesis, cervicothoracic region
M43.14 Spondylolisthesis, thoracic region
M43.15 Spondylolisthesis, thoracolumbar region
M43.16 Spondylolisthesis, lumbar region
M43.17 Spondylolisthesis, lumbosacral region
M43.18 Spondylolisthesis, sacral and sacrococcygeal region
M43.19 Spondylolisthesis, multiple sites in spine
M43.8X9 Other specified deforming dorsopathies, site unspecified
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture
M99.83 Other biomechanical lesions of lumbar region
M99.84 Other biomechanical lesions of sacral region
Q67.5 Congenital deformity of spine
Q76.3 Congenital scoliosis due to congenital bony malformation
Q76.425 Congenital lordosis, thoracolumbar region
Q76.426 Congenital lordosis, lumbar region
Q76.427 Congenital lordosis, lumbosacral region
Q76.428 Congenital lordosis, sacral and sacrococcygeal region
Q76.429 Congenital lordosis, unspecified region
Z45.010 Encounter for checking and testing of cardiac pacemaker pulse generator [battery]
Z45.018 Encounter for adjustment and management of other part of cardiac pacemaker
Z95.0 Presence of cardiac pacemaker
Z95.810 Presence of automatic (implantable) cardiac defibrillator
Z95.818 Presence of other cardiac implants and grafts
Z95.9 Presence of cardiac and vascular implant and graft, unspecified
Z97.8 Presence of other specified devices
Z98.3 Post therapeutic collapse of lung status
Z98.62 Peripheral vascular angioplasty status
Z98.890 Other specified postprocedural states

Group 2

(1 Code)
Group 2 Paragraph

The following ICD-10-CM codes do not support medical necessity for CPT/HCPCS codes 97032 and G0283.

Group 2 Codes
Code Description
G51.0 Bell's palsy

Group 3

(350 Codes)
Group 3 Paragraph

The following ICD-10-CM codes do not support medical necessity for CPT Codes 97024 and 97035.

Group 3 Codes
Code Description
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
B44.81 Allergic bronchopulmonary aspergillosis
B77.81 Ascariasis pneumonia
D57.01 Hb-SS disease with acute chest syndrome
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.411 Sickle-cell thalassemia, unspecified, with acute chest syndrome
D57.431 Sickle-cell thalassemia beta zero with acute chest syndrome
D57.451 Sickle-cell thalassemia beta plus with acute chest syndrome
D57.811 Other sickle-cell disorders with acute chest syndrome
J00 Acute nasopharyngitis [common cold]
J01.00 Acute maxillary sinusitis, unspecified
J01.01 Acute recurrent maxillary sinusitis
J01.10 Acute frontal sinusitis, unspecified
J01.11 Acute recurrent frontal sinusitis
J01.20 Acute ethmoidal sinusitis, unspecified
J01.21 Acute recurrent ethmoidal sinusitis
J01.30 Acute sphenoidal sinusitis, unspecified
J01.31 Acute recurrent sphenoidal sinusitis
J01.40 Acute pansinusitis, unspecified
J01.41 Acute recurrent pansinusitis
J01.80 Other acute sinusitis
J01.81 Other acute recurrent sinusitis
J01.90 Acute sinusitis, unspecified
J01.91 Acute recurrent sinusitis, unspecified
J02.8 Acute pharyngitis due to other specified organisms
J02.9 Acute pharyngitis, unspecified
J03.80 Acute tonsillitis due to other specified organisms
J03.81 Acute recurrent tonsillitis due to other specified organisms
J03.90 Acute tonsillitis, unspecified
J03.91 Acute recurrent tonsillitis, unspecified
J04.0 Acute laryngitis
J04.10 Acute tracheitis without obstruction
J04.11 Acute tracheitis with obstruction
J04.2 Acute laryngotracheitis
J04.30 Supraglottitis, unspecified, without obstruction
J04.31 Supraglottitis, unspecified, with obstruction
J05.0 Acute obstructive laryngitis [croup]
J05.10 Acute epiglottitis without obstruction
J05.11 Acute epiglottitis with obstruction
J06.0 Acute laryngopharyngitis
J06.9 Acute upper respiratory infection, unspecified
J09.X1 Influenza due to identified novel influenza A virus with pneumonia
J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations
J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations
J09.X9 Influenza due to identified novel influenza A virus with other manifestations
J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia
J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia
J10.08 Influenza due to other identified influenza virus with other specified pneumonia
J10.1 Influenza due to other identified influenza virus with other respiratory manifestations
J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations
J10.81 Influenza due to other identified influenza virus with encephalopathy
J10.82 Influenza due to other identified influenza virus with myocarditis
J10.83 Influenza due to other identified influenza virus with otitis media
J10.89 Influenza due to other identified influenza virus with other manifestations
J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia
J11.08 Influenza due to unidentified influenza virus with specified pneumonia
J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations
J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations
J11.81 Influenza due to unidentified influenza virus with encephalopathy
J11.82 Influenza due to unidentified influenza virus with myocarditis
J11.83 Influenza due to unidentified influenza virus with otitis media
J11.89 Influenza due to unidentified influenza virus with other manifestations
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
J12.89 Other viral pneumonia
J12.9 Viral pneumonia, unspecified
J13 Pneumonia due to Streptococcus pneumoniae
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
J15.6 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
J18.1 Lobar pneumonia, unspecified organism
J18.2 Hypostatic pneumonia, 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
J22 Unspecified acute lower respiratory infection
J30.0 Vasomotor rhinitis
J30.1 Allergic rhinitis due to pollen
J30.2 Other seasonal allergic rhinitis
J30.5 Allergic rhinitis due to food
J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
J30.89 Other allergic rhinitis
J30.9 Allergic rhinitis, unspecified
J31.0 Chronic rhinitis
J31.1 Chronic nasopharyngitis
J31.2 Chronic pharyngitis
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.3 Chronic sphenoidal sinusitis
J32.4 Chronic pansinusitis
J32.8 Other chronic sinusitis
J32.9 Chronic sinusitis, unspecified
J33.0 Polyp of nasal cavity
J33.1 Polypoid sinus degeneration
J33.8 Other polyp of sinus
J33.9 Nasal polyp, unspecified
J34.0 Abscess, furuncle and carbuncle of nose
J34.1 Cyst and mucocele of nose and nasal sinus
J34.2 Deviated nasal septum
J34.3 Hypertrophy of nasal turbinates
J34.81 Nasal mucositis (ulcerative)
J34.89 Other specified disorders of nose and nasal sinuses
J34.9 Unspecified disorder of nose and nasal sinuses
J35.01 Chronic tonsillitis
J35.02 Chronic adenoiditis
J35.03 Chronic tonsillitis and adenoiditis
J35.1 Hypertrophy of tonsils
J35.2 Hypertrophy of adenoids
J35.3 Hypertrophy of tonsils with hypertrophy of adenoids
J35.8 Other chronic diseases of tonsils and adenoids
J35.9 Chronic disease of tonsils and adenoids, unspecified
J36 Peritonsillar abscess
J37.0 Chronic laryngitis
J37.1 Chronic laryngotracheitis
J38.00 Paralysis of vocal cords and larynx, unspecified
J38.01 Paralysis of vocal cords and larynx, unilateral
J38.02 Paralysis of vocal cords and larynx, bilateral
J38.1 Polyp of vocal cord and larynx
J38.2 Nodules of vocal cords
J38.3 Other diseases of vocal cords
J38.4 Edema of larynx
J38.5 Laryngeal spasm
J38.6 Stenosis of larynx
J38.7 Other diseases of larynx
J39.0 Retropharyngeal and parapharyngeal abscess
J39.1 Other abscess of pharynx
J39.2 Other diseases of pharynx
J39.3 Upper respiratory tract hypersensitivity reaction, site unspecified
J39.8 Other specified diseases of upper respiratory tract
J39.9 Disease of upper respiratory tract, unspecified
J40 Bronchitis, not specified as acute or chronic
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
J68.1 Pulmonary edema due to chemicals, gases, fumes and vapors
J68.2 Upper respiratory inflammation due to chemicals, gases, fumes and vapors, not elsewhere classified
J68.3 Other acute and subacute respiratory conditions 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
J69.1 Pneumonitis due to inhalation of oils and essences
J69.8 Pneumonitis due to inhalation of other solids and liquids
J70.0 Acute pulmonary manifestations due to radiation
J70.1 Chronic and other pulmonary manifestations due to radiation
J70.2 Acute drug-induced interstitial lung disorders
J70.3 Chronic drug-induced interstitial lung disorders
J70.4 Drug-induced interstitial lung disorders, unspecified
J70.5 Respiratory conditions due to smoke inhalation
J70.8 Respiratory conditions due to other specified external agents
J70.9 Respiratory conditions due to unspecified external agent
J80 Acute respiratory distress syndrome
J81.0 Acute pulmonary edema
J81.1 Chronic pulmonary edema
J82.81 Chronic eosinophilic pneumonia
J82.82 Acute eosinophilic pneumonia
J82.83 Eosinophilic asthma
J82.89 Other pulmonary eosinophilia, not elsewhere classified
J84.01 Alveolar proteinosis
J84.02 Pulmonary alveolar microlithiasis
J84.03 Idiopathic pulmonary hemosiderosis
J84.09 Other alveolar and parieto-alveolar conditions
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
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.83 Surfactant mutations of the lung
J84.841 Neuroendocrine cell hyperplasia of infancy
J84.842 Pulmonary interstitial glycogenosis
J84.843 Alveolar capillary dysplasia with vein misalignment
J84.848 Other interstitial lung diseases of childhood
J84.89 Other specified interstitial pulmonary diseases
J84.9 Interstitial pulmonary disease, unspecified
J85.0 Gangrene and necrosis of lung
J85.1 Abscess of lung with pneumonia
J85.2 Abscess of lung without pneumonia
J85.3 Abscess of mediastinum
J86.0 Pyothorax with fistula
J86.9 Pyothorax without fistula
J90 Pleural effusion, not elsewhere classified
J91.0 Malignant pleural effusion
J91.8 Pleural effusion in other conditions classified elsewhere
J92.0 Pleural plaque with presence of asbestos
J92.9 Pleural plaque without asbestos
J93.0 Spontaneous tension pneumothorax
J93.11 Primary spontaneous pneumothorax
J93.12 Secondary spontaneous pneumothorax
J93.81 Chronic pneumothorax
J93.82 Other air leak
J93.83 Other pneumothorax
J93.9 Pneumothorax, unspecified
J94.0 Chylous effusion
J94.1 Fibrothorax
J94.2 Hemothorax
J94.8 Other specified pleural conditions
J94.9 Pleural condition, unspecified
J95.00 Unspecified tracheostomy complication
J95.01 Hemorrhage from tracheostomy stoma
J95.02 Infection of tracheostomy stoma
J95.03 Malfunction of tracheostomy stoma
J95.04 Tracheo-esophageal fistula following tracheostomy
J95.09 Other tracheostomy complication
J95.1 Acute pulmonary insufficiency following thoracic surgery
J95.2 Acute pulmonary insufficiency following nonthoracic surgery
J95.3 Chronic pulmonary insufficiency following surgery
J95.811 Postprocedural pneumothorax
J95.812 Postprocedural air leak
J95.821 Acute postprocedural respiratory failure
J95.822 Acute and chronic postprocedural respiratory failure
J95.84 Transfusion-related acute lung injury (TRALI)
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
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
J98.3 Compensatory emphysema
J98.4 Other disorders of lung
J98.51 Mediastinitis
J98.59 Other diseases of mediastinum, not elsewhere classified
J98.6 Disorders of diaphragm
J98.8 Other specified respiratory disorders
J98.9 Respiratory disorder, unspecified
J99 Respiratory disorders in diseases classified elsewhere
M32.13 Lung involvement in systemic lupus erythematosus
M33.01 Juvenile dermatomyositis with respiratory involvement
M33.11 Other dermatomyositis with respiratory involvement
M33.21 Polymyositis with respiratory involvement
M33.91 Dermatopolymyositis, unspecified with respiratory involvement
M34.81 Systemic sclerosis with lung involvement
M35.02 Sjogren syndrome with lung involvement
R09.1 Pleurisy
R09.81 Nasal congestion
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
999x Not Applicable
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
99999 Not Applicable
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
03/31/2023 R6

This article is being retired effective for dates of service on and after 03/01/2023 as the related LCD is being retired.

03/09/2022 R5

Article revised and published on 05/05/22 effective for dates of service on and after 03/09/22 to reflect changes related to an inquiry. The 'frequency and duration of the particular group setting' has been removed from #8 in the 'Documentation Requirements' section, as the language was inconsistent with the IOM instructions.  

10/01/2021 R4

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has undergone a descriptor change in the Group 3 ICD-10-CM codes that do not support medical necessity: M35.02.

10/01/2020 R3

Revision Number: 3
Publication: September 2020 Connection
LCR A/B2020-065

Explanation of revision: Based on CR 11895 and CR 11845 (Annual 2021 ICD-10-CM Update), the “ICD-10 Codes that DO NOT Support Medical Necessity/ Group 3 Codes:” section of this billing and coding article was revised to delete ICD-10-CM codes J82 and J84.17 and replace them with ICD-10-CM codes J82.81, J82.82, J82.83, J82.89, J84.170 and J84.178. The following ICD-10-CM codes have been added to the “ICD-10 Codes that DO NOT Support Medical Necessity/ Group 3 Codes:” section of this billing and coding article: D57.431 and D57.451. The following ICD-10-CM code, D57.411, in the “ICD-10 Codes that DO NOT Support Medical Necessity/ Group 3 Codes:” section of this billing and coding article has undergone a descriptor change. In addition, formatting changes have been made throughout the article. The effective date of this revision is based on date of service.

02/20/2020 R2

Revision Number: 2
Publication: February 2020 Connection
LCR A/B2020-008

Based on review of the Billing and Coding article, the “CPT/HCPCS Codes” section was revised. The "Group 2 Codes:" section was revised to add CPT/HCPCS codes 97116, 97032, G0283, 97024, and 97035. The effective date of this revision is based on process date.

01/01/2020 R1

Revision Number: 1
Publication: December 2019 Connection
LCR A/B2020-001

Explanation of Revision: Annual 2020 HCPCS Update. HCPCS code G0515 was deleted and replaced with CPT codes 97129 and 97130. The effective date of this revision is based on date of service.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33413 - Therapy and Rehabilitation Services
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
03/31/2023 03/09/2022 - 03/01/2023 Retired You are here
04/29/2022 03/09/2022 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A