Indications and Limitations of Coverage and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered.
Services for Respiratory Therapy Rehabilitation (RTR) must be medically reasonable and necessary and prescribed by a physician for the assessment, diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. RTR should only be provided in the Outpatient (OP) departments of acute hospitals or in a Comprehensive Outpatient Rehabilitation Facility (CORF). Patients who require RTR will meet all of the following criteria:
- A respiratory therapy rehabilitation plan of care prepared by a physician.
- A medical diagnosis of a chronic, but stable respiratory condition that is under optimal medical management (See the “ICD-9-CM Codes That Support Medical Necessity” section below).
- Within three months prior to initiation of RTR, Pulmonary Function Tests (PFTs) revealing Forced Volume Capacity (FVC) or Forced Expiratory Volume in one second (FEV1) must be less than 60
- percent of predicted or Carbon Monoxide Diffusing Capacity (Dco) less than 60 percent of predicted.
- Exhibits disabling symptoms that impede the patient’s level of function in performing activities of daily living (ADL).
- Demonstrated physical ability to participate be motivated and committed to the prescribed pulmonary rehabilitation program.
- Expectation of a measurable improvement (respiratory and physically) within a reasonable time frame.
The goal of RTR is not to achieve a maximum exercise tolerance, but to ultimately transfer the responsibility of care from the clinic, hospital or doctor to home care by the patient, the patient’s family or the patient’s caregiver. Unless the patient will be able to continue an ongoing self-continuation program at home, there may be only a temporary benefit from the treatment. The endpoint of treatment is not when the patient achieves maximal exercise tolerance or stabilizes, but when the patient or his attendant is able to continue the RTR at home. Medicare does not cover maintenance care.
As described in this policy, RTR services may use a multidisciplinary team approach with RTs, RNs, PTs and OTs, or any combination of these services/disciplines. A duplication of services occurs when there is a direct overlap of services or when a single service can provide the care. When there is an order for the same treatment modality or procedure for multiple clinicians (e.g., therapeutic exercise, breathing retraining), each clinician is expected to provide skilled treatment that reflects his unique skills and knowledge without exceeding the patient’s skilled care needs. The treatment is directed toward each clinician’s patient-specific goals. This is critical to establish that the services provided by various disciplines are reasonable, necessary and distinct from each other.
Note: Respiratory therapists perform and bill for these modalities when they are performed within their scope of practice in the state in which they are licensed and the services are performed by them.
This policy does not apply to those individuals in the National Institute of Health National Emphysema Treatment Trial (NETT). Those individuals are covered under NETT. This policy also does not apply to programs that are performing pulmonary rehabilitation as described in 42CFR 410.47. For programs that are performing pulmonary rehabilitation, refer to the “Pulmonary Rehabilitation – 4Y-27AB” LCD (when available). Services described in 42 CFR 410.47 pertain to HCPCS code G0424 (pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day), which is not allowed in a CORF setting. This policy pertains to HCPCS codes G0237, G0238 and G0329, which are described below.
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, 22X, 23X, 74X, 75X, 85X
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, 042X, 043X, 046X
CPT/HCPCS Codes
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Note:
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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.
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G0237
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Therapeutic procd strg endur
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G0238
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Oth resp proc, indiv
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G0239
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Oth resp proc, group
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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 G0237, G0238 and G0239:
Covered for:
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135
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Sarcoidosis
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277.00
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Cystic Fibrosis without meconium ileus
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340
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Multiple Sclerosis
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357.0
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Acute infective polyneuritis
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358.00-358.01
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Myasthenia gravis
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491.0–491.1
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Chronic bronchitis
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491.20
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Obstructive chronic bronchitis, without exacerbation
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491.8
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Other chronic bronchitis
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492.8
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Other emphysema
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493.20
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Chronic obstructive asthma, unspecified
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493.81–493.82
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Other forms of asthma
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494.0–494.1
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Bronchiectasis
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496
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Chronic airway obstruction, not elsewhere classified
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500-504
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Pneumoconioses and other lung diseases due to external agents
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506.0
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Bronchitis and pneumonitis due to fumes and vapors
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506.4
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Chronic respiratory conditions due to fumes and vapors
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506.9
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Unspecified respiratory conditions due to fumes and vapors
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508.1
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Chronic and other pulmonary manifestations due to radiation
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515
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Postinflammatory pulmonary fibrosis
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516.0
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Pulmonary alveolar proteinosis
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516.2–516.3
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Other alveolar and parietoalveolar pneumonopathy
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516.8
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Other specified alveolar and parietoalveolar pneumonopathy
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518.1
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Interstitial emphysema
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518.7
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Transfusion related acute lung injury (TRALI)
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518.89*
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Other diseases of lung, not elsewhere classified
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Note: Use 518.89* for patients who have become oxygen dependent following an illness.
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737.30
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Scoliosis (and kyphoscoliosis) idiopathic
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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 supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
All documentation must demonstrate clinical rationale for skilled intervention. Clinicians are required to document all activities, tasks, instruction and treatment provided. This documentation must be done each time the patient receives any RTR service.
The patient’s medical record must contain documentation that fully supports the medical necessity for RTR services as covered by Medicare (see “Indications for and Limitations of Coverage” section). This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.
The patient’s medical record must contain documentation that fully supports the medical necessity for RTR services as covered by Medicare (see “Indications for and Limitations of Coverage” section). This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.
It may be reasonable and necessary for multiple clinicians, ordered by the physician, to address a patient’s particular needs. Each clinician must then perform an individualized skilled evaluation within his scope of practice and his specific area of expertise. Each of the individualized evaluations will identify the problems leading to the development of a specific plan of treatment and the setting of specific goals.
Physician Orders
The supervising RTR physician or the referring physician must provide orders to initiate RTR treatment. All treatment orders for RTR therapies must include the following:
Physician Orders
The supervising RTR physician or the referring physician must provide orders to initiate RTR treatment. All treatment orders for RTR therapies must include the following:
- Specification of the discipline, type, frequency and duration of the procedure, modality or activity.
- Verbal and telephone orders that are cosigned and dated by the physician prior to billing the claim.
A blanket RTR order is not acceptable.
Discharge Criteria
A patient should be discharged from RTR services when the documentation shows the following:
- The patient, his family, or the patient’s caregiver can assume responsibility for continuing the RTR at home.
- There is minimal or no potential for material gains or significant progress.
- The patient is non-compliant with the established plan of care.
The total number of timed minutes must be documented in the medical record.
