Pulmonology Coding Alert

The coding most often used for postural drainage and other related chest physical therapies is relatively straightforward: 94667 (manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation), among others. Reimbursement questions arise, however, in regard to a number of factors, including where the therapy takes place and the qualifications of the individual who performs the procedure.

According to the Health Care Financing Administration (HCFA), Chest physical therapies can be carried out safely and effectively by nursing personnel. However, in some cases, patients may have acute or severe pulmonary conditions involving complex situations in which these procedures or therapies require the knowledge and skills of a physical therapist or a respiratory therapist.

The reimbursement rules differ slightly depending on whether a physical therapist or a respiratory therapist performs the procedure, and this is where things can get tricky. The services of ... a [physical] therapist, states national HCFA policy, constitute covered physical therapy when provided as an inpatient hospital service, extended care service, home health service, or outpatient physical therapy service ... Physical therapy furnished in the outpatient department of a hospital is covered under the outpatient physical therapy benefit.

What Happens If a Respiratory Therapist Performs the Therapy

Payments for respiratory therapists services are covered under all the same circumstances except the home health service. Because respiratory therapists are specifically mentioned in the HCFA guidelines, explains Walter ODonahue, MD, FCCP, representative to the American Medical Associations CPT advisory committee of the American College of Chest Physicians, they should not have problems billing for code 94667, or even 94664 (aerosol or vapor inhalations for sputum mobilization, brochodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) or 94640 (nonpressurized inhalation treatment for acute airway obstruction).

Respiratory therapy does not have its own reimbursement numbers, and this could lead to problems, cautions ODonahue, if respiratory therapists, whether operating independently or as an employee of a pulmonologist or hospital, try to use physical therapy codes for such procedures.

Some local carriers specifically list postural drainage and related chest therapies under code 97140 (manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes), 97110 (therapeutic procedure, one or more areas, each 15 minutes;) or 97124 (massage, including effleurage, ptrissage and/or tapotement [stroking, compression, percussion]); those codes make no mention of respiratory therapists in the explanations. Therefore, pulmonologists should check with the local carrier before billing the services of a respiratory therapist.

The medical-record documentation must include reasons supporting the intervention of a respiratory therapist. Some local carriers require, before they pay for the services of a respiratory therapist, written documentation explaining exactly what the respiratory therapist did that the unskilled nurse could not do.

The General Rules Always Apply

If the services are reimbursable, keep in mind that most of the services within the set of physical medicine and rehabilitation/therapeutic procedures (97110-97546) come in 15-minute time blocks and require that the physician or therapist have direct (one-on-one) patient contact.

Be aware that, regardless of who performs the procedure, claims for reimbursement for respiratory therapy services in general (and postural drainage in particular) may be subject to denial if the following information is found in your reimbursement documentation:

you are checking solely to determine if the patient is using oxygen;

using a qualified respiratory therapist is deemed not
medically necessary;

the screening is part of a routine exam; or

services are provided on a mass or group basis (without
specific individualized written orders by a physician).

An additional consideration is justifying the therapy, which is not always as straightforward as it may seem. HCFA national policy states, A cardiac or pulmonary diagnosis will not automatically ensure coverage of respiratory services by Medicare. The policy of Riverbend Government Benefits Administrator, a division of BlueCross BlueShield of Tennessee that serves as a Part A Intermediary under the Medicare program, describes this consideration in detail: It is not the diagnosis alone which justifies the therapy, states local medical review policy. Clear documentation of the clinical problems has significant impact to justify the reasonable and necessary requirement for reimbursement. The documentation of need for a bronchodilator does not automatically indicate the need for the respiratory therapist. Documentation of the beneficiarys response [to the procedure] must be considered necessary documentation in the record.