Life Care Planning with Pulmonary · PDF fileLife Care Planning with Pulmonary Impairments ... – Minimum of 12 hours per week for 6 or more weeks ... 5 Durable Medical

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Life Care Planning with Pulmonary Impairments

• William R. Goodrich– Certified Rehabilitation Counselor– Certified Case Manager– Certified Life Care Planner

l A d f l E– Diplomat: American Board of Vocational Experts• Adjunct Faculty University of Florida• President: Board Certified Rehabilitation Consultants dba Life

Care Services• VP Operations: National Life Care Institute

Life Care Planning with Pulmonary Impairments

• The following items are meant for educational purposes only. They are not meant as a standard or template for treatment recommendations for specific pulmonary impairments.

• Replacement frequencies are generalized suggestions and are not meant for case specific usenot meant for case specific use.

• Case application must be adjusted to their unique demands with activity level and age appropriate recommendations and replacement frequencies supported by treatment team and/or specialist consultations.

• Additional consideration must be given to specific impairments and comorbid progressions as age and disability combine

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Allied Health Evaluations• Pulmonary nurse clinician• Respiratory therapy• Registered dietitian/nutrition therapy• Physical therapy• Occupational therapy• Exercise physiologist• Functional capacity evaluation (FCE)• Speech therapy

– Swallow– Communication

• Psychological/mental health• Recreation therapy• Driving training• Genetics counseling• Sexual counseling

Allied Health Therapeutic Modalities

• Pulmonary nurse clinician• Respiratory therapy• Registered dietitian/nutrition therapy• Physical therapy• Occupational therapy• Exercise physiologist• Speech therapySpeech therapy

– Swallow– Communication

• Psychological– Individual adjustment to disability counseling– Family adjustment to disability counseling– Marital adjustment to disability counseling

• Pharmacist• Recreation therapy• Driving

Allied Health Therapeutic Modalities

• Pulmonary Rehabilitation– A ʺmulti‐disciplinary program of care for patients with chronic

respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy.ʺ

– In‐patient– Out‐patient– Minimum of 12 hours per week for 6 or more weeks

• Source:– American Association for Respiratory Care (AARC). AARC clinical practice

guideline: pulmonary rehabilitation. Dallas (TX): American Association for Respiratory Care (AARC); 2002. 9 p.

• (Hyperbaric) Oxygen Therapy– The prescription should always include:

• the source of supplemental oxygen (gas or liquid)• the method of delivery• duration of use• the flow rate at rest, during exercise, and during sleep

– Typically in Stage IV very severe COPD patients

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Diagnostic and Educational Testing

• Developmental testing and monitoring• Neuropsychological evaluation for baseline • Educational testing for IDEA programming• Serial neuropsychological evaluations for cognitive

programming• Vocational evaluation

Wheelchair(s) / Mobility / Maintenance

• Manual wheelchair• Power wheelchair

– Manual back‐up• Powered cart• Shower/commode wheelchair• Maintenance of each @ 10% of purchase price beginning

second year after purchase• Referenced foundation for replacement frequencies

Wheelchair Accessories

• Replacement batteries for powered wheelchair/cart (stagger replacements)

• Oxygen tank attachments• Wheelchair cushions• Augmentative communication attachments• ECU attachments• Lap board• Gloves• Backpack

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Orthotics/Prosthetics

• Impaired mobility may require orthotic interventions for positional and/or mobility supports

• Inserts• AFO• KAFO• WHFO• HFO

Orthopedic Equipment

• Positioning– Electric hospital/specialty bed 1X/10 yrs

• Micro‐air • Annual maintenance @ 10% beginning year after warranty expires

1X/1‐2 yrs• Replacement components p p

– Filter– Overlay pad– Blower– Mattress– Alternating pressure mattress 1X/4‐6 yrs

– Lift recliner 1X/7‐10 yrs

Durable Medical Items• Home ventilators (monthly rental – Check inclusive accessories)

– Purchase replacement (1X/3‐4 yrs)• *6 ventilator circuits• Universal power supply battery (1X/4‐6 yrs) • Back up generator (include installation and maintenance agreement) (1X/15‐

20 years)• External ventilator battery kit (1X/4‐6 yrs)• External battery charger (1X/4‐6 yrs)y g ( / y )• * Back up portable ventilator with external rechargeable battery (1X/4‐6 yrs)• AC adapter for portable ventilator (1X/3‐4 yrs)• * 1 Concentrator (1X/4‐6 yrs)

– eliminates nitrogen from room air and provides the patient with over 90%‐proof oxygen

• Hand held oxygen concentrator analyzer (1X/3‐4 yrs)• * 1 Portable home concentrator• Compressor• Portable compressor• Oxygen cylinder (1X/3‐4 yrs)• Oxygen cylinder Rack (1X/10 yrs)

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Durable Medical Items• Oxygen cart system (1X/4‐6 yrs)

– Cylinder– Regulator– Gauge– Nasal Cannula– Wrench

• Two wheeled oxygen cart (1X/10 yrs)P l b k k (1X/5 7 )• Pulmonary vent back pack – transport (1X/5‐7 yrs)

• Stationary suction/aspirator machine (1X/3‐4 yrs)• Portable suction machine (1X/3 years)• Digital overnight pulse oximeter (1X/4‐6 yrs)• Nebulizer (1X/3‐4 yrs)

– Not recommended for aerosol therapy• Concha heater• IV Pole• Ambu‐bag/mask (1X/5 yrs)• Heated humidifier (1X/3‐4 yrs)

Durable Medical Items• Stopwatch• Digital blood pressure cuff (1X/2‐3 years)

– Sphygmomanometer • Stethoscope (1X/2 years)• Digital thermometer (1X/2‐3 years)• Metered dose inhaler (MDI)

– MDI spacerp• Dry powder inhaler (DPI)

– Synchronization of inhalation with actuation not necessary• Phrenic nerve stimulatorSources: * Initial Discharge supplies

Institute for Clinical Systems Improvement (ICSI). Chronic obstructive pulmonary disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2003 Dec. 67 p. [113 references]

Engleman, S. (2004). Life care planning for the child with asthma and other chronic respiratory conditions. Pediatric Life Care Planning and Case Management. CRC Press. 2004.

Winkler, T and Deming, L. (2004). Life care planning for the child with spinal cord injury. Pediatric Life Care Planning and Case Management. CRC Press. 2004.

Durable Medical Items

• Electric hospital/specialty bed– Micro‐air – Annual maintenance @ 10% beginning year after warranty

expires• Replacement components

– Filter– Overlay pad– Blower– Mattress

• Lift– Lift sling replacements– Lift maintenance @ 10% beginning year after warranty expires– Track system (requires construction support)– Back up external battery system

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Durable Medical Items• Phrenic nerve stimulator (PNS)

– DRGs:• 327.24 Idiopathic sleep related non‐obstructive alveolar

hypoventilation• 327.25 Congenital central alveolar hypoventilation syndrome• 344.01 C1‐C4 complete quadriplegia and quadriparesis• 344 02 C1‐C4 Incomplete quadriplegia and quadriparesis344.02 C1 C4 Incomplete quadriplegia and quadriparesis• 518.83 Chronic respiratory failure

– Equipment• PNS Implantable neurostimulator electrodes, each (HCPCS L8680)• PNS patient programmer (HCPCS L8681)• PNS Radiofrequency receiver (HCPCS L8682)• PNS Radiofrequency transmitter (HCPCS L8683)• PNS Rechargeable implantable single array pulse generator (HCPCS L8685)• PNS Non‐rechargeable implantable single array pulse generator (HCPCS

L8686)• PNS Rechargeable implantable dual array pulse generator (HCPCS L8687)• PNS Non‐rechargeable implantable dual array pulse generator (HCPCS

L8688)

Aids for Independent Function

• Adaptive clothing allowance– {AVAILABLE}‐On‐line:

http://www.vba.va.gov/bln/21/Rates/special1.htm• Adaptive equipment allowance• Environmental control unit

A t ti i ti t h l i– Augmentative communication technologies– Computers and Software

• Emergency response/medic alert• Land based/cell/satellite phone

– Offset for usual and customary expenditures

Supplies (Disposable)*Initial Supplies & Supply Replacement Schedule

• * 1 box alcohol wipes • Alcohol isopropyl 16 oz (3/mo)• * 24 sterile concha water (1 case – 1 liter bottles/month)• * 2 control III disinfectant germicide solution• * 2 boxes cotton tip applicators (100/month)• * 4 boxes split gauze sponges 2X2 or 4X4• * 4 boxes non‐latex gloves4 boxes non latex gloves• * 60 pairs thermovent heat/moisture exchanger• * 2 bottles hydrogen peroxide 16 oz (1/mo)• * 2 tubes water soluble lubricant• * 2 nebulizer filters• * 4 nebulizer kits (then 3/mo.)• * 4 nebulizer masks• * 8 bottles normal saline• * 2 boxes normal saline vial• * 4 suction canisters (then 2/mo.)

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Supplies • * 2 suction and connection tubing (then 6’ 2‐4X/mo.)• * 200 suction catheters (2/day)• * 4 Yankauer suction catheters (then 2/mo.)• Suction kits (120/mo) – What is included?• * 3 tracheostomy tubes (Cuffless) (14/yr.)

– 2 same size– 1 one size smaller

• Tracheostomy collars (2/month)• * 15 tracheostomy tube holders (1/day)• Tracheostomy ties (7‐8X/mo.)• * 30 tracheostomy care kits• * Tracheostomy sponges (2 boxes/month)• * 2 Passy‐Muir speaking valves (6/yr)• * 6 aerosol drain bags• * 4 tracheostomy masks• * 4 large volume aerosol nebulizers

Supplies (Disposable)• * 16 oxygen swivel adaptors/connectors • 15 and 22 mm adaptors (2/mo. each)• * 1 ‐ 100 feet corrugated oxygen tubing (1/week)• * 1 H system (Large Oxygen Cylinder)• * 4 H refills (Oxygen)• * 1 E system (Portable Oxygen Cylinder)• * 10 E refills (Oxygen)10 E refills (Oxygen)

– Portable Compressed Oxygen for transport• Entrainment for humidifier (1X/week)• Sterile cotton tip applicators (1 box/month)• Oral suction tips (1 box/month)• Saline bullets for suctioning (1 ‐ 100 count box/month)• Antibacterial/Alcohol foam hand soap (1/mo)• Back up portable ventilator battery (1X/2 years)• Disinfectant 8 oz. (1/mo)• Omni flex connectors (1/mo)

Supplies (Disposable)• Vent circuit, disposable with PEEP (1/mo)

– Power reboot system• Vent bacteria filter (1/mo)• Air inlet filters• Exhalation valve assembly (1/mo)• Enteral syringes 60 cc (30/mo.)

S di hl id 0 9% i h l i l i• Sodium chloride 0.9% inhalation solution• Gauze, sterile drain 4X4X6 (100/mo)• Tape, transparent clear (1‐2 rolls/mo)• Disposable bed pads (if incontinent and/or otherwise

impaired mobility)• Oximeter probes (1/mo)

NOTE: Consumption rates increase during periods of illness and/or exacerbations and as the patient matures

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Supplies (Disposable)• Nutritional Supplementation

– Off‐set cost of supplementation from the usual expenditures for nutrition

– Statistical Abstract of the US (2007). Section 13, Income, expenditures and wealth. US Bureau of the Census. Tables 667‐668 {AVAILABLE}‐On‐line: http://www.census.gov/prod/2006pubs/07statab/income.pdf

• Adaptive clothing allowance– Veterans administration {AVAILABLE}‐On‐line:– Veterans administration {AVAILABLE}‐On‐line:

http://www.vba.va.gov/bln/21/Rates/special1.htm• Continence supplies • Symptom diary

Medications• Bronchodilators

– Beta2‐agonists:• Short‐acting

– Fenoterol– Salbutamol (albuterol) ‐ preferred– Terbutaline

• L ti• Long‐acting – Formoterol– Salmeterol

– Anticholinergics• Short‐acting

– Ipratropium bromide (may supplement albuterol)– Second most preferred– Oxitropium bromide

• Long‐acting– Tiotropium

Medications

• Bronchodilators– Combination short‐acting Beta2‐agonists plus anticholinergic in

one inhaler• Fenoterol/Ipratropium• Salbutamol/Ipratropium

– Methylxanthines: Slow release preparationsy p p• Aminophylline • Theophylline

– Inhaled glucocorticosteroids• Beclomethasone• Budesonide• Fluticasone• Triamcinolone

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Medications

• Bronchodilators– Combination long‐acting Beta2‐agonists plus

glucocorticosteroids on one inhaler• Formoterol/Budesonide• Salmeterol/Fluticasone

– Systemic glucocorticosteroids (Severe COPD)y g ( )• Prednisone/prednisolone

– 30‐60 mg of per day for 10‐ 14 days

• Methyl‐prednisone

Medications• Other Pharmacologic Treatments

– Vaccines: • Influenza vaccines can reduce serious illness and death in COPD

patients by about 50%. Vaccines containing killed or live, inactivated viruses are recommended, and should be given once (in autumn) or twice (in autumn and winter) each year

– Antibiotics: • Only in treating infectious exacerbations of COPD and other

bacterial infections• First‐line agents

– Amoxicillin– Trimethoprim/sulfamethoxazole (TMP/SMX)– Doxycycline– Erythromycin

• Second‐line agents– second‐generation cephalosporins– Azithromycin– Clarithromycin– Amoxicillin/clavulanate.

Medications

– Mucolytic (Mucokinetic, Mucoregulator) Agents• Ambroxol• Erdosteine• Carbocysteine• Iodinated glycerol• Although a few patients with viscous sputum may benefit from mucolytics, these agents

are not recommended

– Antioxidant Agentsg• N –acetylcysteine• Used experimentally to reduce the frequency of exacerbations but requires

more trials– Immunoregulators (Immunostimulators, Immunomodulators)

• May decrease severity, but not the frequency of exacerbations• Not recommended as preliminary studies have not been replicated

– Antitussives• Coughing, while a troublesome symptom, has a significant

protective role. • Regular use of antitussives is contraindicated in stable patients

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Medications

– Vasodilators• Inhaled nitric oxide is contraindicated with risk of worsening gas exchange

with altered hypoxic regulation of ventilation‐perfusion balance– Respiratory Stimulants are not routinely recommended in

stable patients• Doxapram, a non‐specific respiratory stimulant available as an intravenous

formulationformulation• Almitrine bismesylate is not recommended for regular use

– Narcotics• The use of oral and parenteral opioids may be effective for treating dyspnea

in COPD patients with advanced disease• Nebulized opioids may have serious adverse effects with use limited to a

few sensitive subjects.– Others not recommended

• Alternative healing methods not adequately tested– Herbal medicine– Acupuncture– Homeopathy

Medications• Step‐Care ‐ Pharmacologic Approach for Managing Stable

COPD – Each step represents an intervention that should be considered

only if the previous course of action fails to improve symptoms of COPD.• Step 1 is an intervention that is generally associated with mild

COPD. O• Step 2 is associated with moderate COPD. • Steps 3 and 4 are associated with severe COPD. While the intensity

of pharmacological management generally increases with higher levels of severity, they are not necessarily directly correlated.

– Albuterol and ipratropium are bronchodilators, improving dyspnea and exercise tolerance.

– Salmeterol is a long‐acting bronchodilator which is a suitable agent for scheduled administration.

Medications– Step 1

• Inhaled short‐acting bronchodilator• Short‐acting beta agonist (albuterol is preferred)

– 2‐4 puffs, when necessary/as needed (PRN) (every 4‐6 hours)• Consider Step 2 if symptoms persist

– Step 2• Continue when necessary/as needed (PRN) inhaled short‐actingContinue when necessary/as needed (PRN) inhaled short acting

bronchodilator PLUS scheduled dosing of one of the following:– Salmeterol* (Serevent® Discus)– Formoterol* (Foradil®)– Albuterol (Proventil®, Ventolin®)– Ipratropium (Atrovent®)– Albuterol + Ipratropium (Combivent®)– Levalbuterol– 1 puff twice a day (BID)– 1 puff (12 mcg) BID– 2‐4 puffs, 4 times a day (QID)– 2‐4 puffs QID– 2‐4 puffs QID– 0.63‐1.25 mg every 6‐8 hours via nebulizer

• Consider Step 3 if symptoms persist

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Medications– Step 3

• Continue therapy in Step 2 and perform corticosteroid trial• Prednisone PO 30‐40 mg/day for 2‐4 weeks or inhaled

corticosteroid in a dose 1600 micrograms beclomethasone/day or dose equivalent of another inhaled steroid for 6‐12 weeks

• Consider Step 4 if symptoms persist– Step 4:

• Positive Response:• Positive Response: – greater than or equal to 15% improvement in post‐bronchodilator

FEV1, symptoms + improvement in 6‐minute walk.– Pharmaceutical Intervention: Taper off or discontinue oral

corticosteroids and prescribe or continue inhaled corticosteroids.• Negative Response:

– Less than 15 % improvement in post‐bronchodilator FEV1 or no improvement in symptoms +/‐ 6‐minute walk.

– Discontinue corticosteroids and consider theophylline as adjunctive therapy with inhaled bronchodilators.

» Dosing Information: Therapeutic range of theophylline at a steady state has conventionally been considered to be 10‐20 micrograms/mL, but lower serum concentrations of 5‐15 micrograms/mL provide similar efficacy with a lower incidence of adverse effects.

» Potentially significant adverse effects and drug interactions that must be carefully considered and closely monitored during therapy.

Home Care• Family: Willing and Able

– Composition– Stability– Location (EMS proximity)– Respite for family caregivers

• Medical social worker• Home health care agency

– AttendantAttendant– Skilled Nursing

• LPN• RN

• Case manager• DME Vendor

– Respiratory Therapist• Community notification (power and telephone companies, EMS)• Medical Foster Care

– Private Residence

Facility Care

• May be required as alternative to home care dependent on community resources available

• May be presented as an option to home care• Consider specialized facilities• Cystic Fibrosis Care Centers (CFCC)• Medical Foster Care

– Group Home

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Future Medical Care Routine• Pediatrician/Primary Care Physician for routine preventive

care and monitoring• Routine vaccinations

– Pneumococcal vaccination – Haemophilus influenza

• Pediatric pulmonologist/pulmonologist and/or intensivist– Follow up one week following exacerbationso o up o e ee o o i g e ace ba io s– Follow up four weeks after initiation of therapy– Follow up every two to four weeks until control is attained– Follow up every four to six months for persistent symptoms

• Pediatric otolaryngologist/otolaryngologist (if has a tracheostomy)

• Pediatric gastroenterologist/Gastroenterologist• Pediatric otorhinolaryngologist/ otorhinolaryngologist• Pediatric orthopedist/orthopedist

Future Medical Care Routine

• Diagnostics– Chest x‐ray– Diaphragm fluoroscopy– Bronchoscopy– Electrocardiogram

Echocardiogram– Echocardiogram– Holter monitor recording– Brain MRI– Brainstem MRI– Sleeping pediatric respiratory physiology lab studies

Future Medical Care Routine• Labs

– Serum carnitine levels– Urine carnitine levels– CBC (baseline, follow‐up as needed)– Electrolytes (baseline, follow‐up as needed)– Sputum culture and sensitivityp y– Blood glucose (especially if on steroids– Arterial blood gas (ABG as needed)

• Respiratory Synctial Virus (RSV) Prophylaxis: American Academy of Pediatrics Practice Guidelines– {AVAILABLE}‐On‐line:

http://aapgrandrounds.aappublications.org/cgi/content/extract/5/4/37‐a

– {AVAILABLE}‐On‐line: http://aappolicy.aappublications.org/

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Transportation

• Transport capacity with ventilator tray• Adapted van

– Minus average cost of a vehicle ($29,400 4th Qtr. 2006)• {AVAILABLE}‐On‐line:

http://www.nada.org/NR/rdonlyres/233DD641‐C551‐479A‐8669‐5D7E877A5B92/0/NADA_DATA_2007.pdf

– Minus vehicle trade‐in value (from economist)– Minus equipment trade‐in value (from economist)

Architectural Renovations• Considerations

– Proximity to EMS– Ingress/Egress– House:Family Size– Space and storage– Electrical systems/power source– Climate control

Plu bi– Plumbing– Communication (telephone)– Back up power source/generator– Mobility – Med‐Alert System/Community awareness– Comorbidities affecting independence in activities of daily living

(ADLs) and instrumental activities of daily living (IADLs)• Reference $50,000 if unable to obtain actual retrofit analysis, design

and bid– Source: {AVAILABLE}‐On‐line:

http://www.vba.va.gov/benefit_facts/Home_Loans/English/HomeModseg_0406.doc

Health and Strength Maintenance

• Patients are encouraged, when possible, to participate in an ongoing maintenance exercise program to sustain strength and endurance

• Free weights or elastic exercise bands• Health club membership

H i i• Home exercise equipment• Camps for Medically Fragile Kids

– {AVAILABLE} On‐Line: http://www.familyvillage.wisc.edu/Leisure/camps.html

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Acute Medical Intervention

• Genetic testing• Emergency Room Treatment

2007 Usual and Customary Fees50% 75% 90%

– 99281 ER Visit $ 69 $ 82 $ 9399282 ER Vi it $107 $126 $144– 99282 ER Visit $107 $126 $144

– 99283 ER Visit $180 $211 $241 – Plus hospital ER charges

Surgical Intervention• Medialization laryngoplasty• Implantation PNS neurostimulator electrodes (CPT: 64577)• Insertion or replacement of peripheral or gastric neurostimulator

pulse generator or receiver, direct or inductive coupling (CPT: 64590)

• Bullectomy – Lung Volume Reduction Surgery (LVRS)I f ll l t d ti t thi d i ff ti i– In carefully selected patients, this procedure is effective in reducing dyspnea and improving lung function

– Remove compressive effects of diseased lung tissue on the ventilation and perfusion of the surrounding lung

– Diagnostic Testing• Thoracic computed tomography scan• Arterial blood gas measurement• Comprehensive respiratory function test• Bronchoscopy

Surgical InterventionLung Volume Reduction Surgery (LVRS)

• An experimental palliative surgical lung resection to reduce hyperinflation

• Does not improve life expectancy• Does improve exercise capacity in patients with

predominant upper lobe emphysemaD i l h bili i i i• Does improve low post‐rehabilitation exercise capacity

• May improve global health status in patients with heterogeneous emphysema

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Surgical InterventionLung Volume Reduction Surgery (LVRS)

• CPT Codes (Medical Fees in the United States 2007)Usual and Customary Fees50% 75% 90%

– 32141 Remove/Treat Lung Lesions $2,744 $3,395 $4,249– 32491 Lung Volume Reduction $3,343 $4,137 $5,177– 32124 Explore Chest Free Adhesions $2,583 $3,196 $4,000

$ 1 $ 1 $6– 32440 – 32488 Remove Lung $4,189 $5,183 $6,487– 32540 Remove Lung Lesion $2,390 $2,957 $3,701– 32500 Partial Lung Removal $3,262 $4,037 $5,052– 32655 Thoracoscopy $2,696 $3,336 $4,175– G0302 Pre‐Op Minimum of 16 days pre‐surgery– G0303 Pre‐Op 10‐15 days preoperative services– G0304 Pre‐Op 1‐9 days preoperative services– G0305 Post‐Op Minimum of 6 days preoperative services

Surgical Intervention

• Transplantation– Lung Transplantation

• Criteria for referral for lung transplantation include FEV1 <35% predicted, PaO2 <7.3‐8.0 kPa (55‐60 mm Hg), PaCO2 >6.7 kPa (50mm Hg), and secondary pulmonary hypertension.

• Referred when 2 year survival rate is less than 50%• Bilateral sequential lung transplant• 81% survival @ 1 year• 59% survival @ 5 years• 38% survival @ 10 years

– Liver Transplantation– Milliman Studies

• {AVAILABLE} On‐line: http://www.transplantliving.org/beforethetransplant/finance/costs.aspx

Potential ComplicationsVentilator Dependence

• Monitoring– Occlusion or other airway obstruction– Misplaced airway– Erosion of soft tissues– Cuff over or under inflated

• Pulmonary– Tension pneumothorax– Subcutaneous emphysema– Pneumomediastinum– Pneumopericardium– Pneumoperitoneum

• Infection• Oxygen toxicity• Inadequate ventilation

– Atelectasis– Decreased functional residual capacity (FRC)– Decreased compliance– Decreased V/Q– Decreased PaO2

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• Cardiovascular– Diminished venous return– Hypotension– Diminished cardiac output– Diminished oxygenization

• Gastrointestinal– Fecal impaction– Ulcers

• Equipment– Tracheostomy tube

• Inadequate size• Faulty cuff

– Ventilator circuitry• Disconnection between patient and ventilator• Tubing obstruction• Tubing leaks• Improper assembly• Failed exhalation value


– Ventilator • Electrical failure• Mechanical failure• Pneumatic system failure• Faulty/inaccurate settings

– Humidification Device• Electrical failure• Improper temperature• System leaks

– Monitoring Device• Not activated• Improper adjustment• Mechanical malfunction

Vocational Rehabilitation

• Parental/Family Occupational Patterns• Educational attainment

(individual/parents/family)• Evaluation Results• Developmental AttainmentDevelopmental Attainment• Synthesis (Integration of PEED)• Rehabilitation Plan• Access to Labor Market• Placeability• Earning Capacity• Labor Force Participation

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Official Disability GuidelinesPulmonary ICD‐9 Codes

• Diseases of the Respiratory System– ICD‐9 460‐466 Acute Respiratory Infections– ICD‐9 470‐478 Other UR Tract Diseases– ICD‐9 480‐487 Pneumonia and Influenza– ICD‐9 490‐496 COPD and Related Conditions

ICD 9 500 508 Pneumonconiosis and Other Lung– ICD‐9 500‐508 Pneumonconiosis and Other Lung Diseases Due to External Agents

– ICD‐9 510‐519 Other Disease of the Respiratory System

Official Disability GuidelinesPulmonary ICD‐9/CPT Codes

• COPD and Allied Conditions– ICD‐9 490– ICD‐10 J40– Average length of hospital stay 3.4 days– Average cost of hospital stay $9,433– Average disabled work days 30.22– At risk work days 42– Typical CPT Usual and Customary Fees

50% 75% 90%50% 75% 90%– 71020 Chest x‐ray $ 80 $ 97 $112

• 71020‐26 Reading $ 33 $ 40 $ 47– 94010 Breathing Capacity Test $ 77 $102 $139

• 94010‐26 Reading $ 43 $ 57 $ 77– 94640 Airway Inhalation Tx $ 40 $ 53 $ 72– 94760 Measure Blood 02 $ 26 $ 34 $ 46 – 99281 ER Visit $ 69 $ 82 $ 93– 99282 ER Visit $107 $126 $144 – 99283 ER Visit $180 $211 $241


• Chronic Bronchitis– ICD‐9 491– ICD‐10 J41‐J42– Average length of hospital stay 3.3 days– Average cost of hospital stay $15,214– Average disabled work days 6.83– At risk work days 25– Typical CPT Usual and Customary Fees

50% 75% 90%• 36415 Collection Venous Blood $ 13 $ 18 $ 21• 36600 Withdrawal Art. Blood $ 61 $ 82 $ 97• 82375 Carbon Monoxide $ 74 $ 97 $126• 94640 Airway Inhalation Tx $ 40 $ 53 $ 72• 94760 Measure Blood 02 $ 26 $ 34 $ 46

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• Emphysema– ICD‐9 492– ICD‐10 J43– Average length of hospital stay 6 days– Average cost of hospital stay $26,720– Average disabled work days 105.71– At risk work days 365


• Other Diseases of the Lung– ICD‐9 518– ICD‐10 J81, J82, J95, J98– Average length of hospital stay 5.4 days– Average cost of hospital stay $45,680.00– Average disabled work days 19.95– At risk work days 28– Typical CPT Usual and Customary Fees

50% 75% 90%• 31500 Insert emergency airway $307 $376 $449• 36415 Collection Venous Blood $ 13 $ 18 $ 21• 36600 Withdrawal Art. Blood $ 61 $ 82 $ 97• 64550 Apply Neurostimulator $ 60 $ 79 $103• 71010 Chest x‐ray $ 80 $ 97 $112

– 71010‐26 Reading $ 33 $ 40 $ 47• 71020 Chest x‐ray $ 99 $120 $140

– 71020‐26 Reading $ 40 $ 49 $ 57


– Typical Lab CPT Usual and Customary Fees50% 75% 90%

• 80048 Basic Meta Panel $38 $49 $64• 81003 Urinalysis $15 $20 $24• 82150 Amylase $30 $39 $51• 82150 Amylase $30 $39 $51• 82550 Creatine Kinase (cpk) $26 $34 $45• 82565 Assay Creatinine; Blood $20 $26 $34

82947 Glucose, Qualitative $18 $24 $32• 83615 Lactate Dehydrogenase $29 $38 $50• 83690 Lipase $30 $39 $51• 83735 Magnesium $27 $35 $46• 84075 Phosphatase, Alkaline $20 $25 $32• 84100 Phosphorus, Inorganic $21 $25 $32

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– Typical Lab CPT Usual and Customary Fees50% 75% 90%

• 84132 Potassium; Serum $20 $25 $32• 84450 Transferase (Ast) (SGOT) $20 $28 $36• 84460 Tansferase; Alanine $21 $28 $37• 84460 Tansferase; Alanine $21 $28 $37• 84520 Urea Nitrogen, Qual. $18 $24 $32• 84550 Uric Acid; Blood $19 $26 $35• 85041 Blood Count: Hemato. $ 5 $ 6 $ 8• 85018 Blood Count: Hemog. $15 $18 $21• 85025 Blood Count: Complete $34 $39 $48• 85610 Prothombine Time $18 $26 $31


– Typical Diagnostic CPT Usual and Customary Fees50% 75% 90%

• 93000 EKG, Complete $69 $ 86 $103• 93005 EKG, Tracing $39 $ 48 $ 58

94010 B thi C it T t $77 $102 $139• 94010 Breathing Capacity Test $77 $102 $139– 94010‐26 Reading $43 $ 57 $ 77

• 94260 Thoracic Gas Volume $66 $ 87 $118– 94260‐26 Reading $15 $ 20 $ 28

• 94640 Airway Inhalation Tx $40 $ 53 $ 72• 94664 Aerosol or Vapor Inhal. $42 $ 56 $ 76• 94760 Measure Blood 02 $26 $ 34 $ 46


– Typical Treatment CPT Usual and Customary Fees50% 75% 90%

• 97001 PT Eval $115 $145 $177• 97002 PT Re‐Eval $ 65 $ 82 $100• 97010 Hot/Cold Pack Tx $ 25 $ 31 $ 38• 97035 Ultrasound Tx $ 32 $ 40 $ 49• 97110 Tx Exercise $ 48 $ 56 $ 65• 97140 Ma ual The apy $ 50 $ 59 $ 68• 97140 Manual Therapy $ 50 $ 59 $ 68• 97530 Therapeutic Activities $ 46 $ 54 $ 63• 99203 Office, New Out‐Pt $137 $158 $187• 99212 Office, Est. Out‐Pt $ 58 $ 66 $ 77• 99213 Office, Est. Out‐Pt $ 78 $ 89 $103• 99214 Office, Est. Out‐Pt $118 $135 $158• 99282 ER Visit $107 $126 $144 • 99283 ER Visit $180 $211 $241• 99284 ER Visit $269 $316 $360• 99285 ER Visit $391 $460 $ 52

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– Typical Treatment CPT Usual and Customary Fees50% 75% 90%

– Common Inpatient Treatment• 99222 Initial Hospital Care $198 $233 $272• 99223 Initial Hospital Care $260 $306 $357• 99231 Subsequent Hosp. Care $ 72 $ 85 $ 99• 99232 Subsequent Hosp. Care $101 $119 $139• 99233 Subsequent Hosp. Care $148 $174 $203• 99238 Hosp Discharge Day $116 $136 $159• 99239 Hosp Discharge Day $158 $185 $216• 99243 Office Consult $197 $232 $269• 99252 Initial In‐Pt Consult $152 $180 $209• 99253 Initial In‐Pt Consult $192 $227 $263• 99254 Initial In‐Pt Consult $251 $297 $344

Reference• Common Abbreviation of Terms

– A/C: Assist Control – voluntary breathing with machine assist

– AHA: Alveolar Hypoventilation Syndrome– BPD/CLDP Bronchopulmonary Dysplasia/Chronic Lung Disease of

Prematurity– CFCC Cystic Fibrosis Care Centers– CK, CPK: Creatine KinaseCK, CPK: Creatine Kinase– CLD Chronic Lung Disease– CMC Continuous Mandatory Ventilation – each breath

machine controlled– CON: Certificate of Need– COPD: Chronic Obstructive Pulmonary Disease– CPAP: Continuous Positive Airway Pressure ‐ elevated

baseline pressure during spontaneous breathing– CPT Current Procedural Terminology Codes©– CSA: Central sleep apnea– CSR: Cheyenne Stokes Respiration


– CSV: Continuous Spontaneous Ventilation (a.k.a. PSV) spontaneous pressure limiting patient breathing

– CT: Computed tomography – CWP: Coal Worker’s Pneumoconiosis – CX: Chest x‐ray/radiograph– DLCO: Diffusing capacity for carbon monoxide DLCO: Diffusing capacity for carbon monoxide– DPI Dry powder inhaler– ECS: Environmental control system– “E” Cylinder: Mobile oxygen tank– FRC: Functional residual capacity – FVC: Forced vital capacity – FEV1: Forced expiratory volume in 1 second – “H” Cylinder: Stationary oxygen tank– HCPCS Healthcare Common Procedure Coding System– LAI Lower airway injuries– LAS Lower airway system– LRTI Lower respiratory tract infections

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– LVRS Lung volume reduction surgery– LTOT Long‐term oxygen therapy – MDI Metered dose inhaler– OA: Occupational asthma– OSA: Obstructive sleep apnea– PEEP: Positive end‐expiratory pressure ‐ elevated

baseline pressure during mechanical ventilationbaseline pressure during mechanical ventilation– PEF Peak expiratory flow– PSG Polysomnography– RADS: Reactive airway dysfunction syndrome– RERAs Respiratory effort related arousals– SIMV: Synchronized Intermittent Mandatory Ventilation‐

machine synchronized support of patient breathing– SRBD Sleep related breathing disorders– UAI Upper airway injuries– UARS Upper airway resistance syndrome– UAS Upper airway system– VLBW Very low birth weight infants

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