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Date Printed: August 23, 2017: 01:40 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-94010-09

Original Effective Date: 07/15/12

Reviewed: 01/26/17

Revised: 02/15/17

Subject: Total Body Plethysmography

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Total body plethysmography, also referred to as whole-body plethysmography, is a pulmonary function study for determining thoracic gas volume (VTG) and airways resistance (Raw).

During body plethysmography, the individual is enclosed in a chamber equipped to measure pressure, flow, or volume changes. The most common measurements made using body plethysmography are VTG and Raw. Airways conductance (Gaw) is also commonly calculated as the reciprocal of Raw. Specific airways conductance (i.e., conductance/unit of lung volume) is routinely reported as sGaw. Other tests that can be administered in body plethysmography include spirometry, bronchial challenge, diffusing capacity (DLCO), single-breath nitrogen (N2), multiple-breath N2 washout, pulmonary compliance, and occlusion pressure. These are not discussed as part of this guideline.

Body plethysmography can be performed in pulmonary function laboratories, cardiopulmonary laboratories, or clinics and physician's offices.

POSITION STATEMENT:

Total body plethysmography meets the definition of medical necessity when performed for determining thoracic gas volume (VTG), airways resistance (Raw), and Specific airways conductance (sGaw) for any of the following indications:

Total body plethysmography, using any method, is considered experimental or investigational for all other indications including, but not limited to the following:

BILLING/CODING INFORMATION:

The following code(s) may be used to describe total body plethysmography.

CPT Coding

94726

Plethysmography for determination of lung volumes and, when performed, airway resistance

94750

Pulmonary compliance study (e.g., plethysmography, volume and pressure measurements)

ICD-10 Diagnoses Codes That Support Medical Necessity

D86.0, D86.2, D86.9

Sarcoidosis (of lung)

E84.0

Cystic fibrosis with pulmonary manifestations

E84.11

Meconium ileus in cystic fibrosis

E84.19

Cystic fibrosis with gastrointestinal manifestations

E84.8

Cystic fibrosis with other manifestations

E84.9

Cystic fibrosis, unspecified

G12.21

Amyotrophic lateral sclerosis

J40

Bronchitis, not specified as acute or chronic

J41.8

Mixed simple and mucopurulent chronic bronchitis

J42

Unspecified chronic bronchitis

J43.0 – J43.9

Emphysema

J44.0 – J44.1

Chronic obstructive pulmonary disease

J44.9

Chronic obstructive pulmonary disease, unspecified

J45.20 – J45.998

Asthma

J47.0 – J47.9

Bronchiectasis

J60

Coal worker’s pneumoconiosis

J61

Pneumoconiosis due to asbestos and other mineral fibers

J62.0,

J62.8

Pneumoconiosis due to other dust containing silica

J63.0

Aluminosis (of lung)

J63.1

Bauxite fibrosis (of lung)

J63.2

Berylliosis

J63.3

Graphite fibrosis (of lung)

J63.4

Siderosis

J63.5

Stannosis

J63.6

Pneumoconiosis due to other specified inorganic dusts

J64

Unspecified pneumoconiosis

J65

Pneumoconiosis associated with tuberculosis

J66.0

Byssinosis

J66.1

Flax-dresser’s disease

J66.2

Cannabinosis

J66.8

Airway disease due to other specific organic dusts

J67.0

Farmer’s lung

J67.1

Bagassosis

J67.2

Bird fancier’s lung

J67.3

Suberosis

J67.4

Malt worker’s lung

J67.5

Mushroom worker’s lung

J67.6

Maple bark-stripper’s lung

J67.7

Air conditioner and humidifier lung (ventilation pneumonitis)

J67.8

Hypersensitivity pneumonitis due to other organic dusts

J67.9

Hypersensitivity pneumonitis due to unspecified organic dust

J68.0 – J68.9

Respiratory conditions due to inhalation of chemicals, gases, fumes and vapors

J70.1

Chronic and other pulmonary manifestations due to radiation

J84.10

Pulmonary fibrosis, unspecified

J84.111 – J84.117

Idiopathic pulmonary fibrosis

J84.2

Lymphoid interstitial pneumonia

J84.81 – J84.848, J84.89

Other specified interstitial pulmonary diseases

M34.0 – M34.9

Systemic sclerosis (scleroderma)

M35.5

Multifocal fibrosclerosis

R06.00-R06.09

Dyspnea

Z01.811

Encounter for preprocedural respiratory examination

LOINC Codes

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Clinical notes and chart section (i.e., nursing home records, home health agency records, and other health care professional

28650-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Plethysmography (20.14) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Pulmonary Diagnostic Services (L33707) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Association for Respiratory Care. Clinical practice guideline for body plethysmography. 2001 Revision and update. Accessed 04/16/13 at AARC website.
  2. Bar-Yishay E. Whole-body plethysmography. The human factor. Chest. 2009;135(6):1412-4.
  3. Borg BM, Thompson BR. The measurement of lung volumes using body plethysmography: a comparison of methodologies. Respir Care. 2012;57(7):1076-83.
  4. Broekhuizen BD, Sachs AP, Hoes AW, Verheij TJ, Moons KG. Diagnostic management of chronic obstructive pulmonary disease. Neth J Med. 2012 Jan;70(1):6-11.
  5. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) for Plethysmography 20.14, 11/15/80.
  6. Chandrasoma B, Balfe D, Naik T et al. Pulmonary function in patients with amyotrophic lateral sclerosis at disease onset. Monaldi Archives for Chest Disease 2012; 77 (314): 129-133.
  7. Criee CP, Sorichter S, Smith HJ et al. Body plethysmography-Its principles and clinical use. Respiratory Medicine 2011; 105: 959-971.
  8. First Coast Service Options (FCSO). Local Coverage Determination (LCD) for Pulmonary Diagnostic Services L33707, 10/01/15.
  9. Garfield JL, Marchetti N, Gaughan JP, Steiner RM, Criner GJ. Total lung capacity by plethysmography and high-resolution computed tomography in COPD. Int J Chron Obstruct Pulmon Dis. 2012;7:119-26.
  10. Glaab T, Vogelmeier C, Hellmann A, Buhl R. Guideline-based survey of outpatient COPD management by pulmonary specialists in Germany. Int J Chron Obstruct Pulmon Dis. 2012;7:101-8.
  11. Javad Mousavi SA, Zamani B, Shahabi Shahmiri S et al. Pulmonary function tests in patients with amyotrophic lateral sclerosis and the association between these tests and survival. Iranian Journal of Neurology 2014; 13(3): 131-137.
  12. O'Donnell CR, Bankier AA, Stiebellehner L, Reilly JJ, Brown R, Loring SH.Comparison of plethysmographic and helium dilution lung volumes: which is best for COPD? Chest. 2010 ;137(5):1108-15.
  13. Miller RG, Brooks BR, Swain-Eng RJ et al. Quality improvement in neurology: Amyotrophic lateral sclerosis quality measures. Report of the quality measurement and reporting subcommittee of the American Academy of Neurology, 2013; 2136-2140.
  14. Miller RG, Jackson CE, Kasarski EJ et al. Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review). Report of the quality standards subcommittee of the American Academy of Neurology, 2009; 1218-1226.
  15. National Institutes of Health/U.S. National Library of Medicine: Pulmonary function tests, 2016.
  16. Poorisrisak P, Vrang C, Henriksen JM, Klug B, Hanel B, Bisgaard H. Accuracy of whole-body plethysmography requires biological calibration. Chest. 2009;135(6):1476-80.
  17. Ruppel GL. Respir Care. What is the clinical value of lung volumes? 2012 Jan;57(1):26-35; discussion 35-8. doi: 10.4187/respcare.01374.Schneider A, Gindner L, Tilemann L, Schermer T, Dinant GJ, Meyer FJ, Szecsenyi J. Diagnostic accuracy of spirometry in primary care. BMC Pulm Med. 2009 ;9:31.
  18. Wanger J, Clausen JL, Coates A, et al. Standardization of the measurement of lung volumes. Eur Respir J. 2005;26(3):511-22.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/26/17.

GUIDELINE UPDATE INFORMATION:

07/15/12

New Medical Coverage Guideline.

06/15/13

Annual review; position statement unchanged; Program Exceptions section updated.

06/15/14

Scheduled review; position statement unchanged; references updated.

10/01/15

Revision; updated ICD10 coding section.

11/01/15

Revision; ICD-9 Codes deleted.

08/15/16

Revision; added J41.8, J44.9 and J65. Updated references.

02/15/17

Revision; added G12.21, R06.00-R06.09 and Z01.811. Updated references.

Date Printed: August 23, 2017: 01:40 PM