Article - Billing and Coding: Respiratory Care (A57224)

CMS National Coverage PolicyLanguage 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 physicians 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-G0239CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 6, 20.4-20.4.1CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 8, 50.8.2CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 12, 10, 20, 20.1, 20.2, 30, 30.1, and 40.5CMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.7 and 240.8CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338Title XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not 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, 1862(a)(7) and 42 Code of Federal Regulations (CFR), 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.42 CFR 410.32 and 410.33, indicate that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.2.3.3, Third-party Additional Documentation Request.CMS Manual System, Publication 100-08 ,Medicare Program Integrity Manual,Chapter 15, Enrollment, 15.5.19 - 15.5.19.7 Independent Diagnostic Testing Facilities Standards. See also 42 CFR 410.33.CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, 60 and 80, indicate that the technical component of diagnostic tests are not covered as "incident-to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database. See also 42 CFR 410.32 and 410.33.Ruling of the Administrator 95-1 (HCFA Ruling 95-1), binding on providers, contractors, and Administrative Law Judges, states that by virtue of their licensure and practice, providers are responsible for knowing norms of community practice.CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3., Diagnosis Code Requirement.Article TextThe 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 Medicares standards of reasonable and necessary care are: 94070, 94200, 94640, 94726, 94727 and 94729.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.Lung Volume - CPT codes for lung volume determination are 94013, 94726, 94727 and 94728.Diffusion Capacity - CPT codes for diffusion capacity include 94729.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 RequirementsSupportive 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 physicians 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.