Respiratory Therapy and Oximetry Services

LCD Information Document Information Source LCD ID N/A LCD ID L33446 Original ICD-9 LCD ID Not Applicable LCD Title Respiratory Therapy and Oximetry Services Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 06/24/2021 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. 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. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description Issue - Explanation of Change Between Proposed LCD and Final LCD 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 member42 CFR §410.32(b) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions42 CFR §411.15(k)(1) Particular services excluded from coverageCMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 1, §10.3 Supplementary Medical Insurance (Part B) - A Brief Description CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §10 Medical and Other Health Services Furnished to Inpatients of Participating Hospitals, §20 Outpatient Hospital Services, §20.2 Outpatient Defined, and §20.4.1 Diagnostic Services Defined CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §70 Sleep Disorder Clinics and §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §20 Services Not Reasonable and Necessary 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 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. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

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.