Billing and Coding: Respiratory Care

The following coding and billing guidance is to be used with its associated
Local Coverage Determination.

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

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.

Therapeutic procedures (G0237 through G0239) with an individualized physical
conditioning and exercise program using proper breathing techniques can be
considered for a patient with activity limitations. Please refer to the JE
A56152 Local Coverage Article (LCA) Billing and Coding: Pulmonary
Rehabilitation Services.

**Pulmonary Function Testing codes:**

CPT codes relative to Medicare's standards of reasonable and necessary care
are: 94070, 94200, 94640, 94726, 94727 and 94729.

  1. Spirometry - CPT codes for Spirometry include 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726 and 94727. Routine and/or repetitive billing for unnecessary batteries of tests is not clinically reasonable.
  2. Lung Volume - CPT codes for lung volume determination are 94013, 94726, 94727 and 94728.
  3. Diffusion Capacity - CPT codes for diffusion capacity include 94729.
  4. Pulmonary stress testing - CPT codes for pulmonary stress testing include 96417, 96418, 94619 and 96421.

CPT 94664 is intended for device "demonstration and/or evaluation" and will be
usually paid for once per beneficiary for the same provider or group.
(Occasional extenuating circumstances, new equipment, etc, may merit two
sessions or other repeat training or evaluation. Simple follow-up observation
during an E/M exam for pulmonary disease is not a stand-alone procedure,
unless the E/M session is not billed).

**Documentation Requirements**

Supportive documentation evidencing the condition and treatment is expected to
be documented in the medical record and be available upon request.  
  
Contractors are explicitly authorized to request additional documentation from
third parties (e.g. ordering physician) when needed to evaluate the medical
necessity of the service and may consider care prior to or subsequent to the
service in question.  
  
Each claim must be submitted with ICD-10-CM codes that reflect the actual
condition of the patient. The mere listing of an ICD-10-CM code alone does not
justify the test if the overall context and condition of the patient do not
support necessity of the test.  
  
All providers of pulmonary function tests should have on file a referral (an
order, a prescription) with clinical diagnoses and requested tests.
Indications in the primary medical record must be available for review.  
  
All equipment and studies should meet minimum standards as outlined by the
American Thoracic Society.  
  
Spirometry studies, in particular, require 3 attempts to be clinically
acceptable.  
  
All studies require an interpretation with a written report. Computerized
reports must have a physician's signature attesting to review and accuracy.  
  
Documentation must be available to Medicare upon request and must be legible.
The medical record must document the test results and usage in treatment.  
  
American Thoracic Society and the American Lung Association and the American
College of Chest Physicians have published guidelines for typical usage of
pulmonary function tests which represent typical community norms.  
  
Follow up testing which is weekly or monthly is appropriate only when
clinically required, such as in periods of acute exacerbation of interstitial
lung disease.  
  
PFTs are diagnostic, not therapeutic. PFTs are not used to demonstrate
breathing exercises.  
  
Demonstration/observation of a nebulizer (94664) is usually used once or at
rare intervals as a stand-alone procedure code. See Indications and
Limitations.