LCD L33446: Respiratory Therapy and Oximetry Services

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 1 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/her 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/her active participation in and management of the course of treatment.

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 1 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:

*The results of tests performed by a durable medical equipment (DME) supplier or their employees to qualify patients for home oxygen service are not covered.

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