LCD L34430: Respiratory Therapy (Respiratory Care)

Respiratory therapy (respiratory care) is defined as those services prescribed by a physician or a non-physician practitioner (NPP) for the assessment and diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function.

Monitoring is defined as the periodic checking of the equipment in actual use to ascertain proper functioning, real time tracking of the individual's condition to assure that he/she is receiving effective respiratory therapy services, and periodic evaluation of the patient's progress in improvement of function.

Respiratory therapy (respiratory care) 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, intermittent positive pressure breathing (IPPB), postural drainage, chest percussion/vibration, and nasotracheal/endotracheal suctioning)

• diagnostic tests for evaluation by a physician (e.g., pulmonary function test (PFT), spirometry, and blood gas analyses)

• pulmonary rehabilitation techniques (e.g., exercise conditioning, breathing retraining, and patient education regarding management of patient's respiratory problems)

• periodic assessment of the patient for the effectiveness of respiratory therapy services

The above services may be performed by respiratory therapists, physical therapists, nurses, and other qualified personnel as described by relevant State Practice Acts. Documentation in the medical record must clearly support the need for respiratory therapy services to be separately reimbursed.

Respiratory therapy (respiratory care) services can be considered reasonable and necessary for the diagnosis and treatment of a specific illness or injury. The service provided must be consistent with the severity of the patient's documented illness and must be reasonable in terms of modality, amount, frequency, and duration of treatment. The treatment must be generally accepted by the professional community as safe and effective for the purpose used, and recognized standards of care should not be violated.

There must be a specific written order by the physician for all respiratory therapy (respiratory care) services.

Medicare coverage of respiratory therapy (respiratory care) provided as outpatient hospital or extended care services depends on the determination by the attending physician (as part of his/her plan of treatment) that for the safe and effective administration of such services the procedures or exercises in question need to be performed by a respiratory therapist. In addition, Medicare may cover postural drainage and pulmonary exercises furnished by a respiratory therapist as incident to a physician's professional service. In order to be considered for reimbursement by Medicare, respiratory therapy services must be fully documented in the medical records. The documentation must clearly indicate that the services rendered were reasonable and medically necessary and required the skills of a licensed respiratory therapist.

Instructing a patient in the use of equipment, breathing exercises, etc. may be considered reasonable and necessary for the treatment of the patient's condition and can usually be given to a patient during the course of treatment by any of the health personnel involved, (e.g., physician, nurse, respiratory care practitioner or other qualified personnel). Separate payment is not made for educational instruction (i.e., use of equipment, breathing exercises, etc.) as they are grouped into the covered service. Separate billing for 1-on-1 education is rarely necessary and is usually only reasonable at the start of the treatment plan. Initially, for outpatient care where a series of visits provides "...an individualized physical conditioning and exercise program using proper breathing techniques..." separate billing for 1-on-1 intervention is both reasonable and necessary. Provision of more information than is ordinarily provided during the course of a treatment (e.g., extensive theoretical background in the pathology, etiology, and physiological effects of the disease) is not considered reasonable and necessary. Group sessions that only offer generalized (i.e., non-individualized) education and training are not covered.

Therapeutic procedures with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations. Breathing retraining, energy conservation, and relaxation techniques are often used. Ventilatory muscle training (VMT) may be considered reasonable and necessary in a very select population of pulmonary patients who demonstrate significantly decreased respiratory muscle strength and who remain symptomatic despite optimal therapy. Routine exercise, or any exercise, without a documented need for skilled care, is not covered.

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