Reimbursement of Respiratory Therapy Services for Facilities

Policy No: 108
Originally Created: 11/01/2016
Section: Facility
Last Reviewed: 01/01/2024
Last Revised: 10/01/2021
Approved: 01/11/2024
Effective: 02/01/2024
Policy Applies To: Group and Individual & Medicare Advantage

The policy applies to inpatient hospital facilities.

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, and 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 settings, as a result of, changes in the patient’s condition.

Our health plan will limit reimbursement of ventilator management to one charge, per date of service, for respiratory therapy performed by a respiratory therapist, regardless of the number of times a respiratory therapist reviews the equipment settings.

Our health plan will limit reimbursement of administration of intermittent inhaled medications to five charges, per date of service, performed by respiratory therapists.

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 be allowed to retain reimbursement for services considered to be non-reimbursable. The following are general categories and 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 a RN.
• Ventilator system set up and/or checks by respiratory therapists.
• Ventilator circuit change (in addition to the ventilator maintenance charge).
• 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 *unless managed by the facility and clearly documented.
• Respiratory assessment when performed during treatment sessions.
• Oximetry trending when done by routine monitoring *including but not limited to continuous respiratory therapy, as well as checks done with a pulse oximeter.
• 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.
• Oxygen while on a ventilator.
• Carbon dioxide end tidal system setup and/or monitoring while on the ventilator.
• Transcutaneous monitoring system setup and/or monitoring.
• Tracheostomy, tracheostomy tube and/or trach collar care.
• Patient transport by a respiratory therapist.

American Association for Respiratory Care (AARC) Coding Guidelines for Certain Respiratory Care Services - May 2020

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 Care (Respiratory Therapy) (L37293) effective 10/1/2019

Local Coverage Article: Billing and Coding: Respiratory Care (Respiratory Therapy) A57225 eff 10/1/2022

Noridian Correct Coding and Coverage of Ventilators - Revised July 2020; Joint DME MAC Publication

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

Discarded Drugs and Biologicals

Reimbursement of Facility Room and Board