Respiratory Therapy CPT code 31720, 94640, 94664

Respiratory therapy services that are provided in a facility are usually the responsibility of the facility’s nursing staff and/or respiratory therapy department.

Payment to a physician may be allowed for respiratory services only when the services are rendered as an integral although incidental part of the physician’s professional services in the course of diagnosis or treatment of an injury or illness. It is expected that respiratory therapy services will most often be used in cases of acute respiratory disease or acute exacerbation of chronic disease. Nevertheless, selected chronic stable conditions could require the services. Acute disease states are expected to either subside after a short period of treatment or, if no response occurs, the patient is transferred to a higher level of care.

• Respiratory therapy services performed in a nursing facility or office setting may be eligible for payment to a physician if one of the following conditions is met:
  • The service is personally performed by the physician or qualified non-physician practitioner if provision of the service is within the scope of his license.

Or,

• The service is performed by ancillary personnel employed by the physician, under the direct personal supervision of the physician, and is furnished during a course of treatment in which the physician performs an initial service and subsequent service(s) which reflect his active participation in and management of the course of treatment.
• CPT code 31720 is payable only if it is personally performed by the physician (or qualified non-physician practitioner).

LCD Individual Consideration

Additional payment may be allowed for respiratory therapy treatments and oximetric determinations exceeding the parameters described in the Utilization Guidelines section below on an individual consideration basis. The LCD Individual Consideration procedure is described in the related article.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

13X, 18X, 21X, 22X, 23X, 73X, 74X, 75X, 77X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

041X, 046X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
31720©	Clearance of airways
94640©	Airway inhalation treatment
94664©	Aerosol or vapor inhalations

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to "procedure to diagnosis" editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 31720, 94640 and 94664:

Covered for:

011.50–011.56	Tuberculous bronchiectasis
162.0–162.5	Malignant neoplasm of trachea, bronchus or lung
162.8–162.9	Malignant neoplasm of trachea, bronchus or lung
163.0–163.1	Malignant neoplasm of pleura
163.8–163.9	Malignant neoplasm of pleura
197.0	Secondary malignant neoplasm, lung
197.2 –197.3	Secondary malignant neoplasm of respiratory system
276.7*	Hyperpotassemia Note: Use this code with a diagnosis of hyperkalemia.
277.00–277.03	Cystic fibrosis
277.09	Cystic fibrosis, with other manifestations
327.00–327.02	Organic disorders of initiating and maintaining sleep [Organic insomonia]
327.09	Other organic insomnia
327.10–327.15	Organic disorders of excessive somnolence [Organic hypersomnia]
327.19	Other organic hypersomnia
327.20–327.27	Organic sleep apnea
327.29	Other organic sleep apnea
327.30–327.37	Circadian rhythum sleep disorder
327.39	Other circadian rhythum sleep disorder
327.40–327.44	Organic parasomnia
327.49	Other organic parasomnia
327.51–327.53	Organic sleep related movement disorders
327.59	Other organic sleep related movement disorders
327.8	Other organic sleep related disorders
398.91	Rheumatic heart failure (congestive)
402.01	Malignant hypertensive heart disease with heart failure
415.12	Septic pulmonary embolism
415.19	Other pulmonary embolism and infarction
416.2	Chronic pulmonary embolism
416.8-416.9	Chronic pulmonary heart disease
428.0	Congestive heart failure
464.10–464.11	Acute tracheitis
464.20–464.21	Acute laryngotracheitis
464.30–464.31	Acute epiglottitis
466.0	Acute bronchitis
466.11	Acute bronchiolitis due to Respiratory Syncytial Virus (RSV)
466.19	Acute bronchiolitis due to other infectious organisms
480.0-480.3	Viral pneumonia
480.8-480.9	Viral pneumonia
481	Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
482.0–482.2	Other bacterial pneumonia
482.30–482.32	Pneumonia due to streptococcus
482.39	Pneumonia due to other streptococcus
482.40–482.42	Pneumonia due to staphylococcus
482.49	Pneumonia due to other staphylococcus
482.81–482.84	Pneumonia due to other specified bacteria
482.89	Pneumonia due to other specified bacteria
482.9	Bacterial pneumonia unspecified
483.0–483.1	Pneumonia due to other specified organism
483.8	Pneumonia due to other specified organism
484.1	Pneumonia in cytomegalic inclusion disease
484.3	Pneumonia in whooping cough
484.5–484.8	Pneumonia in other infectious diseases classified elsewhere
485	Bronchopneumonia, organism unspecified
486	Pneumonia, organism unspecified
487.0	Influenza with pneumonia
491.0–491.1	Chronic bronchitis
491.20–491.22	Obstructive chronic bronchitis
491.8–491.9	Chronic bronchitis
492.0	Emphysematous bleb
492.8	Other emphysema
493.00–493.02	Extrinsic asthma
493.10–493.12	Intrinsic asthma
493.20–493.22	Chronic obstructive asthma
493.81–493.82	Other forms of asthma
493.90–493.92	Asthma, unspecified
494.0–494.1	Bronchiectasis
495.0–495.9	Extrinsic allergic alveolitis
496	Chronic airway obstruction, not elsewhere classified
500-505	Pneumoconioses and other lung diseases due to external agents
506.0–506.4	Respiratory conditions due to chemical fumes and vapors
506.9	Unspecified respiratory conditions due to fumes and vapors
507.0–507.1	Pneumonitis due to solids and liquids
507.8	Pneumonitis due to other solids and liquids
508.1	Chronic and other pulmonary
511.81	Malignant pleural effusion
511.89	Other specified forms of effusion, except tuberculous
511.9	Unspecified pleural effusion
513.0–513.1	Abscess of lung and mediastinum
514	Pulmonary congestion and hypostasis
515	Post-inflammatory pulmonary fibrosis
516.0–516.3	Other alveolar and parietoalveolar pneumonopathy
516.8–516.9	Other alveolar and parietoalveolar pneumonopathy
517.1-517.8
518.0-518.7	Other diseases of lung
518.81–518.84	Other pulmonary insufficiency, not elsewhere classified
518.89*	Other diseases of lung, not elsewhere classified
	*Note: Use this code for patients who have become oxygen dependent following an illness.
519.11	Acute bronchospasm
519.19	Other diseases of trachea and bronchus
714.81	Rheumatoid lung
748.61	Congenital bronchiectasis
780.09	Other alteration of consciousness
780.51	Insomnia with sleep apnea
780.53	Hypersomnia with sleep apnea
780.57	Other and unspecified sleep apnea
780.97	Altered mental status
782.5	Cyanosis
786.01–786.07	Dyspnea and respiratory abnormalities
786.09	Other dyspnea and respiratory abnormality
786.1–786.2	Dyspnea and respiratory abnormalities
786.4	Abnormal sputum
786.7	Abnormal chest sounds
799.01-799.02	Other ill-defined and unknown causes of morbidity and mortality, asphyxia (hypoxemia)
995.0	Other anaphylactic shock
V10.11-V10.12	Personal history of malignant neoplasm, trachea, bronchus, lung

* Note: 276.7 – Use this code with a diagnosis of hyperkalemia.

* Note: 518.89 – Use this code for patients who have become oxygen dependent following an illness.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation that supports the medical necessity of the respiratory therapy services and that indicates the services are an integral although incidental part of the physician’s professional services must be included in the patient’s medical records and be available to the carrier upon request. In addition to the physician’s initial assessment (history and physical examination), the documentation might include:

• Physician’s orders.
• Plan of treatment.
• The patient’s response to treatment.
• An ongoing assessment for the patient’s continued need for treatment.
• In case of consecutive days of care, the medical record should indicate why the patient was not transferred to a higher level of care.
• Documentation of frequency must be consistent with the patient plan of care.

When multiple medications are administered and the medications cannot be mixed and administered at one time, the patient’s records must be documented to explain the medical necessity for the separate administrations.

Payment can be allowed for code 31720 only if supporting documentation demonstrates the service was personally performed by the physician or non-physician practitioner when this service falls within his scope of practice.

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.