Local Coverage Determination (LCD)

Respiratory Therapy (Respiratory Care)

L34430

Expand All | Collapse All

Contractor Information

LCD Information

Document Information

LCD ID
L34430
LCD Title
Respiratory Therapy (Respiratory Care)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34430
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 07/22/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
08/18/2016
Notice Period End Date
10/02/2016
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 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 © 2022 American Dental Association. All rights reserved.

Copyright © 2022, 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

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1861(cc)(1) discusses Comprehensive Outpatient Rehabilitation Facility (CORF) services

Title XVIII of the Social Security Act, §1861(s)(2)(B) provides coverage of services incident to physicians services furnished to hospital patients

42 CFR §485.70 Comprehensive Outpatient Rehabilitation Facility (CORF) personnel qualifications- lists qualifications for respiratory therapists

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4 Outpatient Diagnostic Services and §20.4.1 Diagnostic Services Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 8, §50.8.2 Respiratory Therapy

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §10 Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare, §20 Required and Optional CORF Services, §20.1 Required Services, §20.2 Optional CORF Services, and §30 Rules for Provision of Services

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §240.7 Postural Drainage Procedures and Pulmonary Exercises and §240.8 Pulmonary Rehabilitation Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Respiratory therapy (respiratory care) is defined as those services prescribed by a physician or a non-physician practitioner (NPP) for the assessment and diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function.

Monitoring is defined as the periodic checking of the equipment in actual use to ascertain proper functioning, real time tracking of the individual's condition to assure that he/she is receiving effective respiratory therapy services, and periodic evaluation of the patient's progress in improvement of function.

Respiratory therapy (respiratory care) services may include but are not limited to the following:

  • application techniques to support oxygenation and ventilation in an acute illness (e.g., establish/maintain artificial airway, ventilatory therapy, precise delivery of oxygen concentrations, aid in removal of secretions from pulmonary tree)
  • therapeutic use/monitoring of medicinal gases, pharmacologically active mists and aerosols, and equipment (e.g., resuscitators, ventilators)
  • bronchial hygiene therapy (e.g., deep breathing, coughing exercises, intermittent positive pressure breathing (IPPB), postural drainage, chest percussion/vibration, and nasotracheal/endotracheal suctioning)
  • diagnostic tests for evaluation by a physician (e.g., pulmonary function test (PFT), spirometry, and blood gas analyses)
  • pulmonary rehabilitation techniques (e.g., exercise conditioning, breathing retraining, and patient education regarding management of patient's respiratory problems)
  • periodic assessment of the patient for the effectiveness of respiratory therapy services

The above services may be performed by respiratory therapists, physical therapists, nurses, and other qualified personnel as described by relevant State Practice Acts. Documentation in the medical record must clearly support the need for respiratory therapy services to be separately reimbursed.

Respiratory therapy (respiratory care) services can be considered reasonable and necessary for the diagnosis and treatment of a specific illness or injury. The service provided must be consistent with the severity of the patient's documented illness and must be reasonable in terms of modality, amount, frequency, and duration of treatment. The treatment must be generally accepted by the professional community as safe and effective for the purpose used, and recognized standards of care should not be violated.

There must be a specific written order by the physician for all respiratory therapy (respiratory care) services.

Medicare coverage of respiratory therapy (respiratory care) provided as outpatient hospital or extended care services depends on the determination by the attending physician (as part of his/her plan of treatment) that for the safe and effective administration of such services the procedures or exercises in question need to be performed by a respiratory therapist. In addition, Medicare may cover postural drainage and pulmonary exercises furnished by a respiratory therapist as incident to a physician's professional service. In order to be considered for reimbursement by Medicare, respiratory therapy services must be fully documented in the medical records. The documentation must clearly indicate that the services rendered were reasonable and medically necessary and required the skills of a licensed respiratory therapist.

Instructing a patient in the use of equipment, breathing exercises, etc. may be considered reasonable and necessary for the treatment of the patient's condition and can usually be given to a patient during the course of treatment by any of the health personnel involved, (e.g., physician, nurse, respiratory care practitioner or other qualified personnel). Separate payment is not made for educational instruction (i.e., use of equipment, breathing exercises, etc.) as they are grouped into the covered service. Separate billing for 1-on-1 education is rarely necessary and is usually only reasonable at the start of the treatment plan. Initially, for outpatient care where a series of visits provides "...an individualized physical conditioning and exercise program using proper breathing techniques..." separate billing for 1-on-1 intervention is both reasonable and necessary. Provision of more information than is ordinarily provided during the course of a treatment (e.g., extensive theoretical background in the pathology, etiology, and physiological effects of the disease) is not considered reasonable and necessary. Group sessions that only offer generalized (i.e., non-individualized) education and training are not covered.

Therapeutic procedures with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations. Breathing retraining, energy conservation, and relaxation techniques are often used. Ventilatory muscle training (VMT) may be considered reasonable and necessary in a very select population of pulmonary patients who demonstrate significantly decreased respiratory muscle strength and who remain symptomatic despite optimal therapy. Routine exercise, or any exercise, without a documented need for skilled care, is not covered.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

A physician order for all respiratory therapy intervention/service must be recorded in the patient's medical record. The order must clearly indicate the evaluation or treatment to be performed, the specific modality and duration of all aspects of the treatment, including frequency of monitoring.

Documentation by the physician must indicate the cardiopulmonary diagnosis supporting the medical necessity of the service.

Documentation must be present in the respiratory services records to show:

  • the plan of treatment and progress toward measurable goals.
  • that the care rendered was appropriately delivered by a qualified practitioner. As previously noted, the above services may be performed by respiratory therapists, physical therapists, nurses, and other qualified personnel.

Other qualified personnel may include occupational therapists. 

CORF social and/or psychological services do not include services for mental health diagnoses. Social and/or psychological services are covered only if the patient's physician or the CORF physician establishes that the services directly relate to the patient's rehabilitation plan of treatment and are needed to achieve the goals in the rehabilitation plan of treatment. Social and/or psychological services are those services that address the patient's response and adjustment to the rehabilitation treatment plan, rate of improvement and progress towards the rehabilitation goals, or other services as they directly relate to the respiratory therapy (respiratory care) plan of treatment being provided to the patient.

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

Sources of Information
N/A
Bibliography

American Association of Respiratory Care (AARC). Accredited Respiratory Care Programs and Online CRCE (continuing respiratory care education). Accessed 6/14/21.

Filart RA, Bach JR. Pulmonary physical medicine interventions for elderly patients with muscular dysfunction. Clin Geriatr Med. 2003;19(1):189-204.

International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization (WHO); 2001.

Mahler DA, Fierro-Carrion G, Baird JC. Evaluation of dyspnea in the elderly. Clin Geriatr Med. 2003;19(1):19-33.

Taiwo OA, Cain HC. Pulmonary impairment and disability. Clin Chest Med. 2002;23(4):841-851.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
07/22/2021 R16

Under CMS National Coverage Policy updated section headings for regulations. Typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/24/2019 R15

This LCD 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. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Respiratory Therapy (Respiratory Care) A56717 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
07/25/2019 R14

All coding located in the Coding Information section has been moved into the related Billing and Coding: Respiratory Therapy (Respiratory Care) A56717 article and removed from the LCD.

All verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Respiratory Therapy (Respiratory Care) A56717 article. Formatting was corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
07/04/2019 R13

Under Coverage Indications, Limitations and/or Medical Necessity removed quoted Internet Only Manual (IOM) text and changed verbiage to read “Separate payment is not made for educational instruction (i.e., use of equipment, breathing exercises, etc.) as they are grouped into the covered service”. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/01/2018 R12

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes E88.02, G71.00, G71.01, G71.02, and G71.09. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
07/12/2018 R11

Under Coverage Indications, Limitations and/or Medical Necessity added the verbiage “intermittent positive pressure breathing” and placed parentheses around the acronym (IPPB). Under Associated Information – Documentation Requirements added the words “HCPCS codes” in the first paragraph after the bullet points. Under Bibliography added the verbiage “Accessed July 3, 2018” at the end of the first citation and changed the reference pages from 841-845 to 841-851 in the fifth citation. Formatting and punctuation was corrected throughout the policy.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Typographical Error
01/29/2018 R10 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/01/2018 R9

Under CPT/HCPCS Codes Group 1 deleted CPT code 94620. Description was revised for CPT code 94621. This revision is due to the Annual CPT/HCPCS Code Update.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R8

Under ICD-10 Codes That Support Medical Necessity deleted ICD-10 codes E85.8 and I27.2 and added E85.81, E85.82, E85.89, G12.23, G12.24, G12.25, I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, and R06.03. The code description was revised for I50.1, M33.01 and M33.11. This revision is due to the 2017 Annual ICD-10 Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
12/05/2016 R7 Under ICD-10 Codes That Support Medical Necessity- Group 1: Codes added ICD-10 codes G47.31, G47.33, G47.34, G47.35, G47.36, G47.37, and G47.39.
  • Provider Education/Guidance
  • Reconsideration Request
10/03/2016 R6 Under ICD-10 Codes That Support Medical Necessity Group 1 added J95.860, J95.861, J95.862, J95.863, J98.51, J98.59, and Z53.32. Under ICD-10 Codes That Support Medical Necessity Group 1 deleted J98.5. This revision is due to the Annual ICD-10 Code Update that becomes effective October 1, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
10/03/2016 R5 Under ICD-10 Codes that Support Medical Necessity removed code D86.1 and code range D86.81-D86.89 as these codes are not specific to pulmonary sarcoidosis.
  • Provider Education/Guidance
  • Other
  • Revisions Due To ICD-10-CM Code Changes
05/19/2016 R4 Under Revenue Codes added revenue code 0460 for reporting pulmonary function tests.
  • Provider Education/Guidance
  • Reconsideration Request
03/24/2016 R3 Under CMS National Coverage Policy deleted the following manual reference as it relates to home health services: CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, §80.8 and deleted CMS Internet-Only Manual and revised the verbiage to now read CMS Manual System as cited on Change Request 6338. Under Coverage Indications, Limitations, and/or Medical Necessity added “of” to the second paragraph. Under ICD-10 Codes That Support Medical Necessity added ICD-10 code J84.9 as requested. Under Associated Information-Documentation Requirements deleted “the” from the last paragraph. Under Sources of Information and Basis for Decision corrected the page numbers for the following journal citation: Taiwo OA, Cain HC. Pulmonary impairment and disability. Clinics in Chest Medicine.
  • Provider Education/Guidance
  • Reconsideration Request
01/01/2016 R2 The description changed for CPT code 94640 under the CPT/HCPCS Codes section.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R1 Under CMS National Coverage Policy added 100-02, Chapter 7, Section 80.8.
Under Coverage Indications, Limitations and/or Medical Necessity made a few punctuation corrections.
Under Sources of Information and Basis for Decision corrected hyperlink to AARC, removed “describes that the prevalence of dyspnea in the elderly could be as high as 38% and raises the question of how much of this is related to obesity and deconditioning as opposed to actual pulmonary impairments” and “Describes the role of both PFTs and CPET in the evaluation of pulmonary impairments” as these descriptors are incorrectly the source citations.
  • Provider Education/Guidance
  • Other (Annual Validation)

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
07/16/2021 07/22/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Respiratory Therapy
  • Respiratory Care

Read the LCD Disclaimer