Proposed LCD - Respiratory Care (DL34149)

Evaluation of the type and degree of pulmonary dysfunction,Evaluation of dyspnea, cough, and other symptoms,Early detection of lung dysfunction,Follow-up and response to therapy,Preoperative evaluation,Track pulmonary disease progression,Assess the effectiveness of therapy for pulmonary conditions,Pre and post-op evaluations for Lung Volume Reduction Surgery (LVRS).Limitations to performing a lung volume test are:Functional Residual Capacity (FRC) may be artificially high if the measurement is taken at a higher lung volume secondary to pain or anxiety,Subject cooperation is necessary,A complete evaluation may require the use of inhaled gases,Repetitive testing of total lung volume is not usually clinically necessary.3. Diffusion CapacityDiffusion capacity is measured when a person breathes in a measured amount of carbon monoxide for a very short time (often just one breath). While breathing out, the concentration of carbon monoxide is measured. The difference in the amount of carbon monoxide inhaled and the amount exhaled allows estimation of how rapidly gases can travel from the lungs into the blood.Diffusion capacity tests are most useful for the assessment of how well the lung tissues transfer oxygen from the air inside the lungs, across thin membranes, into the blood.Indications for diffusion capacity (DLCO) are as follows, when consistent with community standards of reasonable clinical practice:Evaluate and follow up parenchymal lung diseases associated with dusts or drug reactions or Sarcoidosis,Evaluate and follow up emphysema and cystic fibrosis,Differentiate between chronic bronchitis, emphysema, and asthma in patient with obstructive patterns,Evaluate the pulmonary involvement in systemic diseases (e.g., rheumatoid arthritis, systemic lupus),Help in the evaluation of some types of cardiovascular disease (e.g., primary pulmonary hypertension, pulmonary edema, acute or recurrent thromboembolism),Predict arterial desaturation during exercise in chronic obstructive pulmonary disease,Evaluate and quantify the disability associated with interstitial lung disease,Evaluate the effects of chemotherapy agents or other drugs known to induce pulmonary dysfunction,Evaluate hemorrhagic disorders.Limitations to performing a diffusion capacity test are:Mental confusion or muscular incoordination preventing the subject from adequately performing the maneuver,Single breath DLCO requires breath holding at maximal inhalation. Some patients may be limited by syncopal symptoms triggered by an associated Valsalva or Muller maneuver which may slow the heart rate.4. Lung ComplianceLung compliance studies are performed only when all other PFTs give equivocal results or results which must be confirmed by additional lung compliance testing. Lung compliance measures the elastic recoil/stiffness of the lungs. It is more invasive than other PFTs, because the patient is required to swallow an esophageal balloon.5. Pulmonary Studies during Exercise Testing:Pulmonary stress testing is done in two (2) forms.The simple pulmonary stress testing is a test that allows quantification of workload and heart rate activity, while measuring the degree of oxygen desaturation. This test is undertaken to measure the degree of hypoxemia or desaturation that occurs with exertion. It is also used to optimize titration of supplemental oxygen for the correction of hypoxemia.A more complex protocol involves the measurements of oxygen uptake, CO2 production, and O2. Indications for this protocol include the following:To distinguish between cardiac and pulmonary causes for dyspnea;To determine the need for and dose of ambulatory oxygen;To assist in developing a safe exercise prescription for patients with cardiovascular or pulmonary disease;To predict the morbidity of lung resection; orTo titrate optimal settings in selected patients who have physiologic pacemakers.Qualifications of personnelPersonnel who perform all pulmonary function tests should have verifiable training in all aspects of spirometry, lung volume, diffusion capacity, lung compliance, and pulmonary exercise testing, including equipment operation, quality control, and test outcomes relative to diagnosis and medical history.This A/B MAC would anticipate that clinical practices with heavy emphasis on extensive batteries of complex pulmonary function tests and primary focus on treating severe pulmonary disease would often be managed by pulmonologists or by other physicians with specialized experience in respiratory disorders, and that such pulmonary testing centers would often have staff with specific training in respiratory therapy (for example, associate degree in respiratory therapy, licensure as a Respiratory Care Practitioner, or National Board of Respiratory Care (NBRC) certification).According to National Regulations, clinics which are (a) not physician owned and which are (b) billing Medicare primarily for diagnostic tests may be required to enroll as IDTFs. For example, a nonphysician owner who establishes a diagnostic PFT clinic by leasing office space, equipment, and hiring technicians, and hires a retired ophthalmologist to provide off-site (general) supervision of diagnostic testing without treatment would be more appropriately enrolled as an IDTF.General InformationAssociated InformationN/ASources of InformationAmerican Association of Respiratory Care (AARC) website  http://www.aarc.org- information about accredited respiratory care programs and online CRCE (continuing respiratory care education).Filart RA, Bach JR. Pulmonary physical medicine interventions for elderly patients with muscular dysfunction.Clinics in Geriatric Medicine.2003; 19(1):189-204.International Classification of Functioning, Disability and Health (ICF).Geneva: World Health Organization; 2001. http://www.who.int/classifications/icf/en/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.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.Commission of Accreditation of Allied Health Education Programs. Available at: www.caahep.org Accessed 03/13/2012.Cystic-L. PFTs Explained For You. Available at:www.cystic-l.org/handbook/html/pft_s_explained_for_you.htm Accessed 03/13/2012.Puritan Bennett. Reimbursement: Spirometry. Available at: http://www.puritanbennett.com/remb/spirometry.aspx Accessed 03/13/2012.Respiratory Care Board of California. Available at:www.rcb.ca.gov/applicants/education_regs.shtml Accessed 03/13/2012. www.rcb.ca.gov/licensees/scopeofprac.shtml Accessed 03/13/2013.University of Maryland Medical Center. Pulmonary Function Tests. Available at: www.umm.edu/ency/article/003853 Accessed 03/13/2013.WebMD Health. Lung Function Tests. Available at:www.webmd.com Accessed 3/13/2013.This contractors prior LCDs Pulmonary Function Tests, (L10375, L10412) which will be retired once this policy becomes effective.Other contractors LCDs including Healthnow (L3929, in particular for pulmonary exercise testing), BCBS Arkansas (L13428), and Trailblazer (L11908).Contractor Medical DirectorBibliographyNA