CMS National Coverage Policy

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1 LCD ID Number L32748 LCD Title Respiratory Therapy Rehabilitation Contractor s Determination Number L32748 AMA CPT/ADA CDT 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. 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-2010 are trademarks of the American Dental Association. Primary Geographic Jurisdiction Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma, New Mexico Oversight Region Central Office Original Determination Effective Date For services performed on or after 08/13/2012 Original Determination Ending Date Revision Effective Date For services performed on or after 11/19/2012 Revision Ending Date CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for respiratory therapy rehabilitation. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for respiratory therapy rehabilitation and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding respiratory therapy rehabilitation are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: Medicare Benefit Policy Manual Pub ; Chapter 12 Comprehensive Outpatient Rehabilitation Facility Coverage. Medicare National Coverage Determinations Manual Pub , Section and Correct Coding Initiative Medicare Contractor Beneficiary and Provider Communications Manual Pub , Chapter 5. Social Security Act (Title XVIII) Standard References, Sections: 1862 (a)(1)(a) Medically Reasonable & Necessary (a)(1)(d) Investigational or Experimental (e) Incomplete Claim. 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. When billing for non-covered services, use the appropriate modifier.

2 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 Services described in 42 CFR 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.

3 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 , Section , in order 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, that 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 needs. - At least as beneficial as an existing and available medically appropriate alternative. 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. 013x Hospital Outpatient 022x 023x 074x 075x 085x Skilled Nursing - Inpatient (Medicare Part B only) Skilled Nursing - Outpatient Clinic - Outpatient Rehabilitation Facility (ORF) Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) Critical Access Hospital 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.

4 Note: The contractor 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/or Revenue 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 (IOM) Publication , Claims Processing Manual, for further guidance. 041X Respiratory Services - General Classification 042X 043X 046X Physical Therapy - General Classification Occupational Therapy - General Classification Pulmonary Function - General Classification 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. G0237 Therapeutic procd strg endur G0238 G0239 Oth resp proc, indiv Oth resp proc, group ICD-9 Codes that Support Medical Necessity Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. 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: 135 SARCOIDOSIS CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS 340 MULTIPLE SCLEROSIS ACUTE INFECTIVE POLYNEURITIS MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION LAMBERT-EATON SYNDROME, UNSPECIFIED - LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASE LAMBERT-EATON SYNDROME IN OTHER DISEASES CLASSIFIED ELSEWHERE SIMPLE CHRONIC BRONCHITIS - MUCOPURULENT CHRONIC BRONCHITIS

5 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION OTHER CHRONIC BRONCHITIS OTHER EMPHYSEMA CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED EXERCISE-INDUCED BRONCHOSPASM - COUGH VARIANT ASTHMA BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - BRONCHIECTASIS WITH ACUTE EXACERBATION 496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED COAL WORKERS' PNEUMOCONIOSIS - PNEUMONOPATHY DUE TO INHALATION OF OTHER DUST BRONCHITIS AND PNEUMONITIS DUE TO FUMES AND VAPORS CHRONIC RESPIRATORY CONDITIONS DUE TO FUMES AND VAPORS UNSPECIFIED RESPIRATORY CONDITIONS DUE TO FUMES AND VAPORS CHRONIC AND OTHER PULMONARY MANIFESTATIONS DUE TO RADIATION - RESPIRATORY CONDITIONS DUE TO SMOKE INHALATION 515 POSTINFLAMMATORY PULMONARY FIBROSIS PULMONARY ALVEOLAR PROTEINOSIS PULMONARY ALVEOLAR MICROLITHIASIS IDIOPATHIC INTERSTITIAL PNEUMONIA, NOT OTHERWISE SPECIFIED - DESQUAMATIVE INTERSTITIAL PNEUMONIA LYMPHANGIOLEIOMYOMATOSIS - ADULT PULMONARY LANGERHANS CELL HISTIOCYTOSIS OTHER SPECIFIED ALVEOLAR AND PARIETOALVEOLAR PNEUMONOPATHIES INTERSTITIAL EMPHYSEMA TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) * OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED SCOLIOSIS (AND KYPHOSCOLIOSIS) IDIOPATHIC Note: Use * for patients who have become oxygen dependent following an illness. Diagnoses that Support Medical Necessity ICD-9 Codes that DO NOT Support Medical Necessity ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 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. Other Information

6 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. 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: 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. Utilization Guidelines Sources of Information and Basis for Decision Other Contractor Local Coverage Determinations Outpatient Pulmonary Rehabilitation, TrailBlazer LCD, (00400) L1929. Outpatient Pulmonary Rehabilitation, Chisholm Administrative Services, LCD, (OK) L5363. Novitas Solutions, Inc. JH Local Coverage Determination (LCD) Consolidation Narrative Justification Most Clinically Appropriate LCD LCDs Compared: L26724, Respiratory Therapy Rehabilitation, TrailBlazer, CO, NM, TX, OK A/B CMD Rationale:

7 This is the only LCD that addresses respiratory therapy rehab G codes G0237, G0238, and G0239. The Indications/Limitations sections are well written. The LCD clearly indicates this therapy is not the same as pulmonary rehabilitation (see TrailBlazer LCD L31221). CPT and ICD-9 codes appear appropriate. Documentation Requirements including Discharge Criteria are present. Sources of Information and Basis for Decision are not available as TrailBlazer adopted the LCD from another TrailBlazer LCD during the J4 transition. L26724 is the most clinically appropriate LCD. Start Date of Comment Period End Date of Comment Period: Start Date of Notice Period 06/28/2012

CMS National Coverage Policy

CMS National Coverage Policy LCD ID Number L32764 LCD Title Pulmonary Rehabilitation (PR) Programs Contractor s Determination Number L32764 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association.

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