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Policy No:  108

Originally Created: 11/01/2016

Section: Facility

Last Reviewed: 09/01/2018

Last Revised: 09/01/2018

Approved: 09/20/2018

Effective:  11/01/2018

The policy applies to inpatient hospital facilities.

Definitions

Respiratory Care or Respiratory Therapy

Services prescribed by a physician or a non-physician practitioner for the assessment and diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function.

The Medication Administration Record (MAR or eMAR for electronic version)

The report that serves as a record of the drugs administered to a patient at a facility by a health care professional.

In the inpatient hospital setting, Respiratory Therapy may be eligible for reimbursement when supported by a treating physician's signed written order and documentation of respiratory service rendered in the patient's medical record by a Respiratory Therapist.

If respiratory services are performed by a registered nurse (RN), these services will be considered part of room and board.

Respiratory care (respiratory therapy) services may include, but are not limited to the following:

  • Application techniques to support oxygenation and ventilation in an acute illness (e.g., establish/maintain artificial airway, ventilatory therapy, precise delivery of oxygen concentrations, aid in removal of secretions from pulmonary tree)
  • Therapeutic use/monitoring of medicinal gases, pharmacologically active mists and aerosols, and equipment (e.g., resuscitators, ventilators)
  • Bronchial hygiene therapy (e.g., deep breathing, coughing exercises, IPPB, postural drainage, chest percussion/vibration and other chest physiotherapy treatments, and nasotracheal/endotracheal suctioning)
  • Periodic assessment of the patient for the effectiveness of respiratory therapy services when not performed during a treatment session

Ventilator management by a respiratory therapist includes, but is not limited to, the following:

  • Evaluation and assessment for changes in the patient's condition, particularly in situations where the patient's respiratory status is unstable and may change suddenly and unpredictably, and require medical treatment
  • Changes in ventilator setting as a result of change in patient condition

Policy Statement

In an inpatient setting our health plan will limit reimbursement of ventilator management, regardless of the number of times a Respiratory Therapist(s) reviews the equipment settings to one charge, per date of service, for respiratory therapy performed by a Respiratory Therapist(s).

Our health plan will limit reimbursement of administration of inhaled medication(s) to five charges, per date of service, for respiratory therapy performed by a Respiratory Therapist(s).

The patient's medical record must support a treating physician's signed written order and be documented in the MAR/eMAR as well as any medication waste.

Inpatient hospitals will not be reimbursed, nor allowed to retain reimbursement for services considered to be non-reimbursable. The following are general categories and lists of examples of inpatient facility Respiratory Therapy charges that are not separately billable or reimbursable, as they are an integral part of the therapy.  These services include, but are not limited to:

  • Ventilator adjustments if performed by RN
  • Ventilator System checks by respiratory therapist
  • More than one type of respiratory support (for example: mechanical ventilation and CPAP) at the same time, unless there is clinical documentation to support that the member requires different levels of respiratory support.
  • Ventilator weaning and extubation
  • Patient's own CPAP/BiPAP/Ventilator machine services
  • Respiratory Assessment when performed during treatment sessions
  • Oximetry Trending when done by routine monitor
  • Endotracheal Suctioning when done with treatments or on ventilator
  • Surfactant administration when done by the physician
  • Ventilator maintenance and calibration
  • Cleaning of internal or external components of ventilator
  • Respiratory therapy consultations for instruction on the use of equipment, such as incentive spirometers, or other such breathing apparatuses or techniques. Such patient education is included during the treatment and thus not separately reimbursable.

References

American Association for Respiratory Care (AARC) Coding Guidelines for Certain Respiratory Care Services - January 2018 

Centers for Medicare & Medicaid Services - CMS Medically Unlikely Edits (MUEs).  Note: In the absence of inpatient guidelines, outpatient guidance is followed.

Local Coverage Determination (LCD): Respiratory Therapy (Respiratory Care) (L37293)

Noridian Administrative Services (NAS). Routine Hospital Supplies and Services (Not Separately Billable). Noridian - Part A Open Door Coverage Meeting Minutes October 29, 2009 Geographic Jurisdiction-Idaho/Oregon

Noridian Correct Coding and Coverage of Ventilators - Revised May 2016; Joint DME MAC Publication

Washington State Legislature, WACs, Title 182, Chapter 182-550-1050 Hospital Services Definition - Room and Board, Bedside Nursing Services

Cross References

Reimbursement of Medications for Facilities

Reimbursement of Multi-Dose Inhaled Medications for Facilities

Discarded Drugs and Biologicals

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.