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SUPERSEDED Local Coverage Determination (LCD)

Respiratory Care (Respiratory Therapy)

L37293

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L37293
Original ICD-9 LCD ID
Not Applicable
LCD Title
Respiratory Care (Respiratory Therapy)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL37293
Original Effective Date
For services performed on or after 07/09/2018
Revision Effective Date
For services performed on or after 10/01/2019
Revision Ending Date
11/04/2023
Retirement Date
N/A
Notice Period Start Date
05/22/2018
Notice Period End Date
07/08/2018
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.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

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

Title XVIII of the Social Security Act, §1861(cc)(1) discusses CORF facility services.

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

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.

42 CFR 485.70-CORF personnel qualifications- lists qualifications for respiratory therapists.

Federal Register: December 31, 2002 (Volume 67, Number 251) p 79999-80000 Final rule revisions to payment policies specific to G0237-G0239

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 6, §§20.4-20.4.1

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, §50.8.2

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 12, §§10, 20, 20.1, 20.2, 30, 30.1, and 40.5

CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §240.7 and §240.8

CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Respiratory care (respiratory therapy) is defined as those services prescribed by a physician or a non-physician practitioner 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 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 care (respiratory therapy) 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, IPPB, postural drainage, chest percussion/vibration, and nasotracheal/endotracheal suctioning)
  • diagnostic tests ordered by and for the evaluation by a physician or NPP (e.g., pulmonary function test, spirometry, and blood gas analyses etc.)
  • pulmonary rehabilitation techniques (e.g., exercise conditioning, breathing retraining, and patient education regarding management of patient’s respiratory problems) and
  • 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 care (respiratory therapy) 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.

Medicare coverage of respiratory care (respiratory therapy) 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, physical therapists, nurses, and other qualified personnel as described by relevant state practice acts as listed above. In addition, Medicare may cover postural drainage and pulmonary exercises furnished by a respiratory therapist as incident to a physician's professional service.


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). These educational instructions are bundled into the covered service and separate payment is not made. Separate billing for one-on-one 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 one-on-one 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

NA
Analysis of Evidence (Rationale for Determination)

NA

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

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

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information
  1. American Association of Respiratory Care (AARC) website – http://www.aarc.org- information about accredited respiratory care programs and online CRCE (continuing respiratory care education).
  2. Filart RA, Bach JR. Pulmonary physical medicine interventions for elderly patients with muscular dysfunction. Clinics in Geriatric Medicine. 2003; 19(1):189-204.
  3. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization; 2001. http://www.who.int/classifications/icf/en/
  4. Mahler DA, Fierro-Carrion G, Baird JC. Evaluation of dyspnea in the elderly. Clinics in Geriatric Medicine. 2003;19(1):19-33. 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.
  5. Taiwo OA, Cain HC. Pulmonary impairment and disability. Clinics in Chest Medicine. 2002;23(4):841-851. Describes the role of both PFTs and CPET in the evaluation of pulmonary impairments.
Bibliography

NA

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2019 R5

The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of 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.
  • Other (The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD.
    )
10/01/2019 R4

As required by CR 10901, all billing and coding information has been moved to the companion article, this article is linked to the LCD.

09/18/2019: 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 Code Removal
10/01/2019 R3

Effective date of service 7/9/18 added:

  • Z48.290 – Encounter for Aftercare Following Bone Marrow Transplant
  • Z76.82 – Awaiting Organ Transplant Status
  • Z94.81 – Bone Marrow Transplant Status
  • Z94.84 – Stem Cell Transplant Status

Effective 10/01/2019, added and revised the following ICD-10 codes per the 2019 ICD-10-CM updates:Additions:

  • I26.93 - Single subsegmental pulmonary embolism without acute cor pulmonale
  • I26.94 - Multiple subsegmental pulmonary emboli without acute cor pulmonale

Code Revision:

  • From J44.0 - Chronic obstructive pulmonary disease with acute lower respiratory infection to J44.0 - Chronic obstructive pulmonary disease with (acute) lower respiratory infection.

9/16/18 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.
  • Request for Coverage by a Practitioner (Part B)
  • Creation of Uniform LCDs Within a MAC Jurisdiction
  • Revisions Due To ICD-10-CM Code Changes
10/01/2018 R2

9/4/18 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.

Effective date of service 7/9/2018 added: I-10 code G47.33 and corrected R85.59 to E85.59in Associated Documents above. This ICD-10-CM code is correct in the ICD-10 Codes that Support Medical Necessity section above.

Effective date of service 10/01/2018 added E88.02 per the 2018 ICD-10-CM annual update.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
  • Revisions Due To ICD-10-CM Code Changes
  • Typographical Error
07/09/2018 R1

06/27/18 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.

Corrected ICD-10 code I27.9 noted in the Associated Information section above to  I27.29.
  • Typographical Error
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/09/2023 11/05/2023 - N/A Currently in Effect View
09/15/2023 11/05/2023 - N/A Superseded View
01/29/2020 10/01/2019 - 11/04/2023 Superseded You are here
09/20/2019 10/01/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Respiratory care
  • Respiratory therapy
  • RT

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