Contractor Information. LCD Information. Local Coverage Determination (LCD): Respiratory Therapy and Oximetry Services (L33446) Document Information

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1 Local Coverage Determination (LCD): Respiratory Therapy and Oximetry Services (L33446) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Palmetto GBA A and B MAC MAC B J - J Alabama Palmetto GBA A and B MAC MAC B J - J Georgia Palmetto GBA A and B MAC MAC B J - J Tennessee Palmetto GBA A and B and HHH MAC MAC B J - M South Carolina Palmetto GBA A and B and HHH MAC MAC B J - M Virginia Palmetto GBA A and B and HHH MAC MAC B J - M West Virginia Palmetto GBA A and B and HHH MAC MAC B J - M North Carolina Back to Top LCD Information Document Information LCD ID L33446 Original ICD-9 LCD ID L31755 LCD Title Respiratory Therapy and Oximetry Services Proposed LCD in Comment Period Source Proposed LCD AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 02/26/2018 Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date Printed on 5/1/2018. Page 1 of 15

2 The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy 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. Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. 42 CFR (b) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 42 CFR (k)(1) Particular services excluded from coverage CMS Internet-Only Manual, Pub , Medicare General Information, Eligibility and Entitlement Manual, Chapter 1, 10.3 CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 6, 10, 20, 20.2, CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 15, 70 & 80 CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 16, 20 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Respiratory therapy services 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 respiratory services. Acute disease states are expected to either subside after a short period of treatment, or, if no response occurs, transfer the patient 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 (NPP) 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. Printed on 5/1/2018. Page 2 of 15

3 CPT code is payable only if it is personally performed by the physician (or qualified NPP). Medically necessary reasons for pulse oximetry include: The patient exhibits signs or symptoms of acute respiratory dysfunction such as: Tachypnea Dyspnea Cyanosis Respiratory distress Confusion Hypoxia The patient has chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons: Initial evaluation to determine the severity of respiratory impairment Evaluation of an acute change in condition Evaluation of exercise tolerance in a patient with respiratory disease Evaluation to establish medical necessity of an oxygen therapeutic regimen The patient has sustained severe multiple trauma or complains of acute severe chest pain. The patient is under treatment with a medication with known pulmonary toxicity and oximetry is medically necessary to monitor for potential adverse effects of therapy. Note: Codes and are bundled by the Correct Coding Initiative (CCI) with critical care services. Therefore, codes and cannot be paid separately when billed with critical care codes (99291 and 99292). CPT code is considered medically necessary when performed for any of the following reasons: The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations. The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen. *The results of tests performed by a durable medical equipment supplier or his employees to qualify patients for home oxygen service are not covered. Summary of Evidence Analysis of Evidence (Rationale for Determination) Printed on 5/1/2018. Page 3 of 15

4 Back to Top Coding Information 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. 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 Not Applicable CPT/HCPCS Codes Group 1 Paragraph: Group 1 Codes: Clearance of airways Airway inhalation treatment Evaluate pt use of inhaler Measure blood oxygen level Measure blood oxygen level Measure blood oxygen level ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The CPT/HCPCS codes included in this policy will be subjected to "procedure to diagnosis" editing. The following list includes 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, 94664, and 94761: Group 1 Codes: ICD-10 Codes A15.0 Tuberculosis of lung A22.1 Pulmonary anthrax A37.01 Whooping cough due to Bordetella pertussis with pneumonia A37.11 Whooping cough due to Bordetella parapertussis with pneumonia A37.81 Whooping cough due to other Bordetella species with pneumonia A37.91 Whooping cough, unspecified species with pneumonia A48.1 Legionnaires' disease B25.0 Cytomegaloviral pneumonitis Printed on 5/1/2018. Page 4 of 15

5 ICD-10 Codes B44.0 Invasive pulmonary aspergillosis B77.81 Ascariasis pneumonia C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung C34.91 Malignant neoplasm of unspecified part of right bronchus or lung C34.92 Malignant neoplasm of unspecified part of left bronchus or lung C38.4 Malignant neoplasm of pleura C45.0 Mesothelioma of pleura C78.01 Secondary malignant neoplasm of right lung C78.02 Secondary malignant neoplasm of left lung C78.2 Secondary malignant neoplasm of pleura C78.39 Secondary malignant neoplasm of other respiratory organs E84.0 Cystic fibrosis with pulmonary manifestations E84.8 Cystic fibrosis with other manifestations E84.9 Cystic fibrosis, unspecified F51.19 Other hypersomnia not due to a substance or known physiological condition G47.01 Insomnia due to medical condition G47.09 Other insomnia G47.10 Hypersomnia, unspecified G47.11 Idiopathic hypersomnia with long sleep time G47.12 Idiopathic hypersomnia without long sleep time G47.13 Recurrent hypersomnia G47.14 Hypersomnia due to medical condition G47.19 Other hypersomnia G47.20 Circadian rhythm sleep disorder, unspecified type G47.21 Circadian rhythm sleep disorder, delayed sleep phase type G47.22 Circadian rhythm sleep disorder, advanced sleep phase type G47.23 Circadian rhythm sleep disorder, irregular sleep wake type G47.24 Circadian rhythm sleep disorder, free running type G47.25 Circadian rhythm sleep disorder, jet lag type G47.26 Circadian rhythm sleep disorder, shift work type G47.27 Circadian rhythm sleep disorder in conditions classified elsewhere G47.29 Other circadian rhythm sleep disorder G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.32 High altitude periodic breathing G47.33 Obstructive sleep apnea (adult) (pediatric) G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation G47.35 Congenital central alveolar hypoventilation syndrome G47.36 Sleep related hypoventilation in conditions classified elsewhere G47.37 Central sleep apnea in conditions classified elsewhere G47.39 Other sleep apnea G47.50 Parasomnia, unspecified G47.51 Confusional arousals G47.52 REM sleep behavior disorder G47.53 Recurrent isolated sleep paralysis G47.54 Parasomnia in conditions classified elsewhere G47.59 Other parasomnia G47.69 Other sleep related movement disorders G47.8 Other sleep disorders I09.81 Rheumatic heart failure I11.0 Hypertensive heart disease with heart failure Printed on 5/1/2018. Page 5 of 15

6 ICD-10 Codes I26.01 Septic pulmonary embolism with acute cor pulmonale I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale I26.09 Other pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I27.81 Cor pulmonale (chronic) I27.9 Pulmonary heart disease, unspecified I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I Right heart failure, unspecified I Acute right heart failure I Chronic right heart failure I Acute on chronic right heart failure I Right heart failure due to left heart failure I50.82 Biventricular heart failure I50.83 High output heart failure I50.84 End stage heart failure I50.89 Other heart failure I50.9 Heart failure, unspecified J04.10 Acute tracheitis without obstruction J04.11 Acute tracheitis with obstruction J04.2 Acute laryngotracheitis J05.0 Acute obstructive laryngitis [croup] J05.10 Acute epiglottitis without obstruction J05.11 Acute epiglottitis with obstruction J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.08 Influenza due to other identified influenza virus with other specified pneumonia J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J12.0 Adenoviral pneumonia J12.1 Respiratory syncytial virus pneumonia J12.2 Parainfluenza virus pneumonia J12.3 Human metapneumovirus pneumonia J12.81 Pneumonia due to SARS-associated coronavirus J12.89 Other viral pneumonia J12.9 Viral pneumonia, unspecified J14 Pneumonia due to Hemophilus influenzae J15.0 Pneumonia due to Klebsiella pneumoniae J15.1 Pneumonia due to Pseudomonas J15.20 Pneumonia due to staphylococcus, unspecified J Pneumonia due to Methicillin susceptible Staphylococcus aureus J Pneumonia due to Methicillin resistant Staphylococcus aureus J15.29 Pneumonia due to other staphylococcus J15.3 Pneumonia due to streptococcus, group B J15.4 Pneumonia due to other streptococci J15.5 Pneumonia due to Escherichia coli Printed on 5/1/2018. Page 6 of 15

7 ICD-10 Codes J15.6 Pneumonia due to other Gram-negative bacteria J15.7 Pneumonia due to Mycoplasma pneumoniae J15.8 Pneumonia due to other specified bacteria J15.9 Unspecified bacterial pneumonia J16.0 Chlamydial pneumonia J16.8 Pneumonia due to other specified infectious organisms J17 Pneumonia in diseases classified elsewhere J18.0 Bronchopneumonia, unspecified organism J18.8 Other pneumonia, unspecified organism J18.9 Pneumonia, unspecified organism J20.0 Acute bronchitis due to Mycoplasma pneumoniae J20.1 Acute bronchitis due to Hemophilus influenzae J20.2 Acute bronchitis due to streptococcus J20.3 Acute bronchitis due to coxsackievirus J20.4 Acute bronchitis due to parainfluenza virus J20.5 Acute bronchitis due to respiratory syncytial virus J20.6 Acute bronchitis due to rhinovirus J20.7 Acute bronchitis due to echovirus J20.8 Acute bronchitis due to other specified organisms J20.9 Acute bronchitis, unspecified J21.0 Acute bronchiolitis due to respiratory syncytial virus J21.1 Acute bronchiolitis due to human metapneumovirus J21.8 Acute bronchiolitis due to other specified organisms J21.9 Acute bronchiolitis, unspecified J39.8 Other specified diseases of upper respiratory tract J41.0 Simple chronic bronchitis J41.1 Mucopurulent chronic bronchitis J41.8 Mixed simple and mucopurulent chronic bronchitis J42 Unspecified chronic bronchitis J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome] J43.1 Panlobular emphysema J43.2 Centrilobular emphysema J43.8 Other emphysema J43.9 Emphysema, unspecified J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J Unspecified asthma with (acute) exacerbation J Unspecified asthma with status asthmaticus J Unspecified asthma, uncomplicated J Exercise induced bronchospasm J Cough variant asthma J Other asthma J47.0 Bronchiectasis with acute lower respiratory infection J47.1 Bronchiectasis with (acute) exacerbation J47.9 Bronchiectasis, uncomplicated Printed on 5/1/2018. Page 7 of 15

8 ICD-10 Codes J60 Coalworker's pneumoconiosis J61 Pneumoconiosis due to asbestos and other mineral fibers J62.0 Pneumoconiosis due to talc dust J62.8 Pneumoconiosis due to other dust containing silica J63.0 Aluminosis (of lung) J63.1 Bauxite fibrosis (of lung) J63.2 Berylliosis J63.3 Graphite fibrosis (of lung) J63.4 Siderosis J63.5 Stannosis J63.6 Pneumoconiosis due to other specified inorganic dusts J64 Unspecified pneumoconiosis J65 Pneumoconiosis associated with tuberculosis J66.0 Byssinosis J66.1 Flax-dressers' disease J66.2 Cannabinosis J66.8 Airway disease due to other specific organic dusts J67.0 Farmer's lung J67.1 Bagassosis J67.2 Bird fancier's lung J67.3 Suberosis J67.4 Maltworker's lung J67.5 Mushroom-worker's lung J67.6 Maple-bark-stripper's lung J67.7 Air conditioner and humidifier lung J67.8 Hypersensitivity pneumonitis due to other organic dusts J67.9 Hypersensitivity pneumonitis due to unspecified organic dust J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors J68.4 Chronic respiratory conditions due to chemicals, gases, fumes and vapors J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors J68.9 Unspecified respiratory condition due to chemicals, gases, fumes and vapors J69.0 Pneumonitis due to inhalation of food and vomit J70.1 Chronic and other pulmonary manifestations due to radiation J70.5 Respiratory conditions due to smoke inhalation J80 Acute respiratory distress syndrome J84.10 Pulmonary fibrosis, unspecified J Idiopathic interstitial pneumonia, not otherwise specified J Idiopathic pulmonary fibrosis J Idiopathic non-specific interstitial pneumonitis J Acute interstitial pneumonitis J Respiratory bronchiolitis interstitial lung disease J Cryptogenic organizing pneumonia J Desquamative interstitial pneumonia J84.17 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere J84.2 Lymphoid interstitial pneumonia J84.89 Other specified interstitial pulmonary diseases J90 Pleural effusion, not elsewhere classified J91.0 Malignant pleural effusion J91.8 Pleural effusion in other conditions classified elsewhere J94.0 Chylous effusion J94.2 Hemothorax J94.8 Other specified pleural conditions J95.84 Transfusion-related acute lung injury (TRALI) J Postprocedural hematoma of a respiratory system organ or structure following a respiratory system procedure J Postprocedural hematoma of a respiratory system organ or structure following other procedure J Postprocedural seroma of a respiratory system organ or structure following a respiratory system procedure Printed on 5/1/2018. Page 8 of 15

9 ICD-10 Codes J Postprocedural seroma of a respiratory system organ or structure following other procedure J98.01 Acute bronchospasm J98.09 Other diseases of bronchus, not elsewhere classified J98.11 Atelectasis J98.19 Other pulmonary collapse J98.2 Interstitial emphysema J98.4* Other disorders of lung J98.51 Mediastinitis J98.59 Other diseases of mediastinum, not elsewhere classified M05.10 Rheumatoid lung disease with rheumatoid arthritis of unspecified site M Rheumatoid lung disease with rheumatoid arthritis of right shoulder M Rheumatoid lung disease with rheumatoid arthritis of left shoulder M Rheumatoid lung disease with rheumatoid arthritis of right elbow M Rheumatoid lung disease with rheumatoid arthritis of left elbow M Rheumatoid lung disease with rheumatoid arthritis of right wrist M Rheumatoid lung disease with rheumatoid arthritis of left wrist M Rheumatoid lung disease with rheumatoid arthritis of right hand M Rheumatoid lung disease with rheumatoid arthritis of left hand M Rheumatoid lung disease with rheumatoid arthritis of right hip M Rheumatoid lung disease with rheumatoid arthritis of left hip M Rheumatoid lung disease with rheumatoid arthritis of right knee M Rheumatoid lung disease with rheumatoid arthritis of left knee M Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot M Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot M05.19 Rheumatoid lung disease with rheumatoid arthritis of multiple sites Q33.4 Congenital bronchiectasis R06.00 Dyspnea, unspecified R06.03 Acute respiratory distress R06.09 Other forms of dyspnea R06.89 Other abnormalities of breathing R09.01 Asphyxia R09.02 Hypoxemia R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems R23.0 Cyanosis R40.0 Somnolence R40.1 Stupor R41.0 Disorientation, unspecified R41.82 Altered mental status, unspecified T78.2XXA Anaphylactic shock, unspecified, initial encounter T78.2XXD Anaphylactic shock, unspecified, subsequent encounter T78.2XXS Anaphylactic shock, unspecified, sequela T88.6XXA Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial encounter T88.6XXD Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, subsequent encounter T88.6XXS Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, sequela Z Personal history of other malignant neoplasm of bronchus and lung Z85.12 Personal history of malignant neoplasm of trachea Z86.74 Personal history of sudden cardiac arrest Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *Note: Use J98.4 for patients who have become oxygen dependent following an illness. Group 2 Paragraph: Medicare is establishing the following limited coverage for CPT/HCPCS code Printed on 5/1/2018. Page 9 of 15

10 Group 2 Codes: ICD-10 Codes G47.10* Hypersomnia, unspecified G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.32 High altitude periodic breathing G47.33 Obstructive sleep apnea (adult) (pediatric) G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation G47.35 Congenital central alveolar hypoventilation syndrome G47.36 Sleep related hypoventilation in conditions classified elsewhere G47.37* Central sleep apnea in conditions classified elsewhere I26.01 Septic pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale I27.0 Primary pulmonary hypertension I27.20 Pulmonary hypertension, unspecified I27.21 Secondary pulmonary arterial hypertension I27.22 Pulmonary hypertension due to left heart disease I27.23 Pulmonary hypertension due to lung diseases and hypoxia I27.24 Chronic thromboembolic pulmonary hypertension I27.29 Other secondary pulmonary hypertension I27.81* Cor pulmonale (chronic) I27.82 Chronic pulmonary embolism I27.83 Eisenmenger's syndrome I27.89 Other specified pulmonary heart diseases I27.9* Pulmonary heart disease, unspecified I50.1 Left ventricular failure, unspecified I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23* Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33* Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43* Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I Right heart failure, unspecified I Acute right heart failure I Chronic right heart failure I Acute on chronic right heart failure I Right heart failure due to left heart failure I50.82 Biventricular heart failure I50.83 High output heart failure I50.84 End stage heart failure I50.89 Other heart failure I50.9* Heart failure, unspecified J43.0* Unilateral pulmonary emphysema [MacLeod's syndrome] J43.1* Panlobular emphysema J43.2* Centrilobular emphysema J43.8* Other emphysema J43.9* Emphysema, unspecified J44.9* Chronic obstructive pulmonary disease, unspecified R06.03 Acute respiratory distress R09.01* Asphyxia R09.02* Hypoxemia R40.0 Somnolence R40.1 Stupor Printed on 5/1/2018. Page 10 of 15

11 ICD-10 Codes R68.13 Apparent life threatening event in infant (ALTE) Z86.74 Personal history of sudden cardiac arrest Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation: *Note: These codes are to be used only for those patients who exhibit signs and symptoms of oxygen deprivation (supported by the patients medical record). ICD-10 Codes that DO NOT Support Medical Necessity ICD-10 Additional Information Back to Top General Information Associated Information Documentation Requirements Documentation that supports the medical necessity of the respiratory therapy services and shows it is 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 A/B MAC 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 record must be documented to explain the medical necessity for the separate administrations. Payment can be allowed for code only if supporting documentation demonstrates the service was personally performed by the physician or NPP when this service falls within his scope of practice. Continuous Overnight Oximetry (94762) The patient's record must document that the oximeter is preset and self sealed and cannot be adjusted by the patient. In addition, the device must provide a printout that documents an adequate number of sampling hours, percent of oxygen saturation and an aggregate of the results. This information must be available if requested. In all instances, there must be a request documented in the medical record from the treating physician for these services. Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request. Utilization Guidelines Payment for code may be allowed, on an individual consideration basis, for respiratory treatments for three consecutive days or three identical services within a 30-day time frame. Additional payment may be allowed for respiratory therapy treatments exceeding these parameters only if medical necessity can be established by medical documentation. In the case of consecutive days of care, the medical record should indicate why the patient was not transferred to a higher level of care. In outpatient or home management for patients with chronic cardiopulmonary problems, oximetric determinations once or twice a year are considered reasonable. In all instances, there must be a documented request by a physician/npp in the medical record for these services. Regular or routine testing will not be allowed for reimbursement. In all circumstances, testing would be expected to be useful in the continued management of a patient particularly in acute exacerbations or unstable conditions (e.g., acute bronchitis in a patient with Chronic Obstructive Pulmonary Disease (COPD)) where increased frequency of testing would be considered, on an Printed on 5/1/2018. Page 11 of 15

12 individual consideration basis, for coverage purposes. Only one service (oximetry determination) per day will be allowed for testing at a reasonable frequency and if medically necessary regardless of whether the patient is sitting, standing or lying, with or without exercise or oxygen use, unless medical necessity can be demonstrated for additional needs on an individual consideration basis. More frequent testing may be allowed, on an individual consideration basis, when there is documentation of an acute exacerbation of a chronic pulmonary disease or other acute illnesses with signs indicating or suggesting increased hypoxemia. Sources of Information Bibliography Bafadhel M, McKenna S, Terry S, et al. Blood Eosinophils to Direct Corticosteroid Treatment of Exacerbations of Chronic Obstructive Pulmonary Disease a Randomized Placebo-Controlled Trial. Am J Respir Crit Care Med. 2012;186(1): Braunwald E., Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson LJ. Harrison s Principles of Internal Medicine. 15th ed. McGraw-Hill Professional Publishing; Filart RA, Bach JR. Pulmonary physical medicine interventions for elderly patients with muscular dysfunction. Clinics in Geriatric Medicine. 2003;19(1): Garcha DS, Thurston SJ, Patel AR, et al. Changes in prevalence and load of airway bacteria using quantitative PCR in stable and exacerbated COPD. Thorax. 2012;67(12): International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization, Miravitlles M. Long-term antibiotics in COPD: more benefit than harm? Prim Care Respire Jour. 2013;22(3): Mahler DA, Fierro-Carrion G, Baird JC. Evaluation of dyspnea in the elderly. Clinics in Geriatric Medicine. 2003;19(1): Schermer T, Leenders J, in't Veen H, et al. Pulse oximetry in family practice: indications and clinical observations in patients with COPD. Fam Pract. 2009;26(6): Seemungal TA, Wilkinson TM, Hurst JR, Perera WR, Sapsford RJ, Wedzicha JA. Long-term Erythromycin Therapy is Associated with Decreased Chronic Obstructive Pulmonary Disease Exacerbations. Am J Respir Crit Care Med. 2008;178(11): Serisier DJ. Risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases. Lancet Respir Med. 2013;1(3): Taiwo OA, Cain HC. Pulmonary impairment and disability. Clinics in Chest Medicine. 2002; 23(4): Back to Top Revision History Information Revision History Date 02/26/2018 R8 Revision History Revision History Explanation Number The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision. 10/01/2017 R7 Printed on 5/1/2018. Page 12 of 15 Reason(s) for Change Change in Affiliated Contract Numbers

13 Revision History Date Revision History Number Revision History Explanation Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 codes I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89 and R06.03 and the code description was revised for J15.6. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes deleted ICD- 10 code I27.2, added I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89 and R06.03 and the code description was revised for I50.1. These revisions are due to the 2017 Annual ICD-10 Updates. Reason(s) for Change Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes 06/05/2017 R6 10/01/2016 R5 06/23/2016 R4 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. Under ICD-10 Codes that Support Medical Necessity - created Group 2 Paragraph with verbiage Medicare is establishing the following limited coverage for CPT/HCPCS code 94762: Under ICD- 10 Codes that Support Medical Necessity Group 2: Codes added codes G47.10, G47.30, G47.31, G47.32, G47.33, G47.34, G47.35, G47.36, G47.37, I26.01, I26.90, I27.0, I27.2, I27.81, I27.82, I27.89, I27.9, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.9, R09.01, R09.02, R40.0, R40.1, R68.13, Z Under Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation: *Note: - added These codes are to be used only for those patients who exhibit signs and symptoms of oxygen deprivation (supported by the patients medical record). Under ICD-10 Codes That Support Medical Necessity added J95.860, J95.861, J95.862, J95.863, J98.51 and J This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16. Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes Provider Education/Guidance Typographical Error Printed on 5/1/2018. Page 13 of 15

14 Revision History Date 01/01/2016 R3 10/01/2015 R2 10/01/2015 R1 Revision History Revision History Explanation Number Under CMS National Coverage Policy for 42 CFR (b) the title diagnostic x-ray and other diagnostic tests was removed and replaced with the full title Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions and for 42 CFR (k)(1) the title diagnosis or treatment of illness was removed and replaced with the title Particular services excluded from coverage. Under Coverage Indications, Limitations and/or Medical Necessity revised the sentence in the second paragraph from Nevertheless, selected chronic stable conditions could require the services. to now read Nevertheless, selected chronic stable conditions could require respiratory services. The word The was added to the beginning of the sentences Patient exhibits signs or symptoms of acute respiratory dysfunction such as: and Patient has chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons:. The word an was added to the verbiage Evaluation to establish medical necessity of oxygen therapeutic regimen to read Evaluation to establish medical necessity of an oxygen therapeutic regimen. The word The was added to the beginning of the sentences Patient has sustained severe multiple trauma or complains of acute severe chest pain. and Patient is under treatment with a medication with known pulmonary toxicity and oximetry is medically necessary to monitor for potential adverse effects of therapy. Under CPT/HCPCS Codes-Group 1: Paragraph removed the verbiage 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. Under ICD-10 Codes that Support Medical Necessity removed the verbiage Note: Providers should continue to submit ICD-10-CM diagnosis codes without decimals on their claim forms and electronic claims.. Under Associated Information Documentation Requirements the word carrier was deleted in the first paragraph and replaced with the verbiage A/B MAC.The letter s was removed from the word records in the second paragraph and the word the was removed from the verbiage in the fifth paragraph. Under Sources of Information and Basis for Decision supplement numbers, page numbers and author s names were added throughout this section. Punctuation and capitalization were corrected throughout the policy. Printed on 5/1/2018. Page 14 of 15 The description changed for CPT code under the CPT/HCPCS Codes section. Under CMS National Coverage Policy for citation CMS IOM Pub Chapter 1 removed reference to 10.1 and 10.2; for citation CMS IOM Pub Chapter 6 removed 70. Under Sources of Information and Basis for Decision corrected citations to meet 508 compliance and corrected the spelling of exacerbations. In CMS National Coverage Policy added CMS to all Internet- Only Manual citations. Added citations for Internet-Only Manuals Pub Sections 10.1, 10.2, and 10.3 as well as Pub Chapter 6 Sections 10, 20, 20.2, , and 70. Removed sleep disorder clinics and diagnostic tests. In Sources of Information and Basis for Decision removed 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 and Describes the role of both PFTs and CPET in the evaluation of pulmonary impairments. Also added source Miravitlles M. Long-term antibiotics in COPD: more benefit than harm? Prim care Respir Jour. 2013;22. Formatted all citations to comply with AMA formatting. Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes Provider Education/Guidance Typographical Error Other (Annual Validation) Other (Annual Validation)

15 Back to Top Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 12/07/2017 with effective dates 02/26/ Updated on 09/01/2017 with effective dates 10/01/ /25/2018 Updated on 05/05/2017 with effective dates 06/05/ /30/2017 Updated on 09/12/2016 with effective dates 10/01/ /04/2017 Some older versions have been archived. Please visit the MCD Archive Site to retrieve them. Back to Top Keywords Read the LCD Disclaimer Back to Top Printed on 5/1/2018. Page 15 of 15