Respiratory Therapy CPT code 31720, 94640, 94664 (2024)

94640 – Pressurized or non-pressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device).

94664 Administration of bronchodilator – Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device $18

Inhaler Techniques

The following code is appropriate for inhaler techniques and can include demonstration of flow-operated inhaled devices such as flutter valves. The code may only be used once per day. This cannot be billed at the same time/ same visit as 94640. These can be billed on the same day, but must be a separate patient visit.

* 94664 – Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device can be used demonstrating (teaching) patients to use an aerosol generating device property.

Inhalation Treatment for Acute Airway Obstruction

When providing inhalation treatment for acute airway obstruction, Medicare will not pay for both 94640 and 94644 or 94645 if they are billed on the same day for the same patient. The coder must decide which of the two codes to submit for payment. Generally, it would be the code that has the greatest volume/quantity. The following information applies to inhalation treatments administered to Part B patients. This includes Emergency Room patients who are not admitted to the hospital. CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered at that time. However, if there are multiple separate patient encounters for inhalation therapy on the same date of service, the additional encounters for inhalation therapy may be reported with modifier 76. Medicare defines a hospital outpatient encounter as “a direct personal contact between a patient and a physician, or other person who is authorized by State licensure law and, if applicable, by hospital or CAH staff bylaws, to order or furnish hospital services for diagnosis or treatment of the patient.”

* 94640 – Pressurized or non-pressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device).

(For more than 1 inhalation treatment performed on the same date (separate single encounter), append modifier 76) (Do not report 94640 in conjunction with 94060, 94070 or 94400)

* 94644 – Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour (For services of less than 1 hour, use 94640)

* 94645 – each additional hour (List separately in addition to code for primary procedure) (Use 94645 in conjunction with 94644)

Several commenters expressed concern about our proposal to reject the Panel’s recommendation that we designate HCPCS code 94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device), as a non-surgical extended duration therapeutic service (extended duration service).

Extended duration services require an initial period of direct supervision, but the patient may be transitioned to general supervision once he or she is stable at the discretion of the supervising practitioner. One commenter believed that the physician’s presence should not be required for HCPCS code 94640 in the hospital, since this service can be performed by a patient at home.

Others commented that since the Panel’s charter does not prohibit the Panel from recommending extended duration services, it should be permitted to do so.

In the CY 2012 final rule, we indicated that the Panel may recommend only general, direct or personal supervision. HCPCS code 94640 is not performed over an extended period of time, and hospital patients receiving this service may require the supervising practitioner’s presence depending on their condition. At a future Panel meeting the Panel may reevaluate the supervision level for this service. Therefore, we continue to require direct supervision for HCPCS code 94640.

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.

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.

CPT/HCPCS Codes

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:

* 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.

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.