|
General Guidelines
Respiratory Therapy services, both diagnostic and therapeutic, are provided
on the order of the treating physician. They are medically necessary only
when:
1. The diagnosis
established by the physician supports the utilization of the intervention.
2. The type, frequency and duration of services are reasonable and
medically necessary for the treatment of the patient's condition (signs and
symptoms) in accordance with generally accepted medical standards of care.
3. There is a specific written order by the attending physician for the
individual beneficiary in response to the physical findings from an
assessment and identification of a problem (an evaluation). The order must
specify any administration parameters such as dosage, frequency, etc. or
other defining conditions that are applicable to the diagnostic test or
treatment, (E.g. oxygen must specify the method of delivery, the flow rate,
the circumstances under which it should be administered, and the duration
of the service).
4. Respiratory services may be performed in the institutional environment
by qualified respiratory therapists (as defined by national and state
regulations), respiratory therapy technicians, or qualified nursing
personnel. A "qualified" individual is defined as a person who
has completed an educational or training program and has documented evidence
of the ability to perform respiratory care interventions/modalities in
accordance with the policies of the administering facility.
5. Respiratory therapy therapeutic services must require the unique skills
of a respiratory therapist or similarly trained professional. Services that
are typically taught to patients and caregivers (e.g. chest percussion,
unassisted aerosol by nebulizer) are not
considered skilled services for chronic care in the outpatient environment.
These services may be considered skilled services acutely.
6. Facility ancillary services may not be billed as respiratory therapy
therapeutic services. There can be overlaps of skills between respiratory
and nursing services (particularly in skilled nursing facilities and
hospitals). In these instances, there must be specific documentation to
support the need for interventions by a qualified respiratory therapist
(i.e., what special skills of the respiratory therapist is needed which
could not be done by the nursing personnel) to differentiate the respiratory
therapy service from the ancillary service. The presumptive determination
is that services performed by nurses are ancillary services and services
performed by respiratory therapists are specialized respiratory therapy
services
7. Respiratory therapy interventions include (but are not limited to) the
following:
Pulmonary
assessment*
Oxygen therapy, including ventilator management
Selection of aerosol delivery devices and delivery of aerosol to upper
airway*
Incentive spirometery **
Bronchial provocation
Chest physiotherapy (postural drainage, cupping, percussion) *
Positive airway pressure adjuncts to bronchial hygiene therapy
Nasotracheal, endotracheal
suctioning **
Pulse oximetery **
Spirometery
Management of airway in acute/emergency situations (Intubation)
*These services may overlap services rendered by nurses. Documentation in
the beneficiary's medical record by the physician must clearly indicate why
the special skills of the respiratory therapist are needed. Typically these
services require the skills of the Respiratory Therapist only when the
intervention is first initiated.
**These services are typically provided by nurses as an ancillary service.
Documentation in the beneficiary's medical record by the physician must
clearly indicate why the special skills of the respiratory therapist are
needed.
Indicators for Oxygen therapy include:
Oxygen therapy is administered utilizing many devices ranging from the
simple nasal cannula to progressively more
complex techniques providing controlled oxygen concentrations. These
devices are usually applied maintained, and monitored by the respiratory
therapist and/or technicians. Documentation in the medical record must
support the need for the skills of a respiratory therapist or technician.
The goal of oxygen therapy is to maintain adequate tissue and cell
oxygenation ( while minimizing oxygen toxicity).
Oxygen therapy must be indicated by documentation of clinical signs and
symptoms of hypoxemia (hypoxia).
These signs and symptoms may include:
a.
PaO2 = 55 torr or SaO2 =88% (breathing room air)
b. SaO2 = 88% consistently during sleep, ambulation or exercise;
c. PaO2 56-59 torr or SaO2/SpO2 = 89% in
association with Cor Pulmonale,
d. CHF, Hematocrit > 56 ( erythrocythemia);
e. Changes in PaO2, PaCO2> 10-15 mm Hg from baseline; or
f. Restlessness, anxiety, confusion, hypotension, dysrythmias,
somnolence, or memory loss
g. A medical condition that renders the patient particularly susceptible to
or at risk for hypoxemia or hypercarbia.
Management of beneficiaries requiring long term /chronic ventilatory support:
The use of long term/chronic ventilatory support
or management is common in many settings such as home and long term care
facilities. Long term (or chronic) ventilator management addresses
maintenance therapies such as the routine monitoring of equipment,
beneficiary's response to mechanical support, medicinal gases, pulmonary
assessment, and ongoing reinforcement of treatment modalities and
interventions. These patients are generally cardiopulmonarily
stable and do not require the skills of a respiratory therapist on a
continuous basis. Interventions and treatments by the respiratory therapist
beyond the initial set up, periodic equipment checks and beneficiary
assessments specific to ventilatory support and
management must be clearly documented in the medical record. The skills of
the respiratory therapist are typically required during periods of rapidly
changing pulmonary status
Requirements for specific services:
Special skills of a respiratory therapist may be required for the periodic
measurement of arterial oxygen levels(ABGs) in the clinically unstable beneficiary or to
document clinical changes. However this would not be routinely expected for
the beneficiary receiving chronic long term oxygen therapy.
Documentation in the beneficiary's medical record must include:
*
the type of airway (tracheotomy, endotracheal tube), cuff pressures if applicable, date
tube was last changed, difficulties maintaining patency of the tube
* type of ventilatory support and the
ordered/maintained parameters
* the beneficiary's breath sounds, ventilatory
pressures, and responses to therapy and
* Therapeutic and educational interventions and the beneficiary/caregivers
response to the education.
Limitations
94640 PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE
AIRWAY OBSTRUCTION OR FOR SPUTUM INDUCTION FOR DIAGNOSTIC PURPOSES (EG,
WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT
POSITIVE PRESSURE BREATHING (IPPB) DEVICE)
Metered dose inhalers are self-administered treatments, and, as such, are
not covered. The clinical skills of a respiratory therapist are not
required to administer MDIs even in the acute
situation; this is either an unskilled or ancillary service.
Nebulizers typically require the skills of the
respiratory therapist in the acute situation but do not require those
skills in a chronic (outpatient) setting. A patient who typically self-administers
(or who has a caregiver administer) nebulizer
treatments does not require the skills of the respiratory therapist on an
intermittent basis except in an emergent situation or when the patient is
specifically being treated by a physician in order to assess the response
during an acute episode of bronchospasm. Routine,
occasional and "drive by" treatments in an outpatient clinic or
CORF are therefore not medically necessary.
94664 DEMONSTRATION AND/OR EVALUATION OF
PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE
INHALER OR IPPB DEVICE2.
CPT 94664 requires the evaluation of the patient's use of an aerosol
generator, nebulizer MDI or IPPB device, in
addition to the demonstration of the device to be deemed medically
necessary. This is only medically necessary on one day of service in a
patient who has never self-administered the specified form of therapy
before; additional services will be denied as not medically necessary.
Medical necessity may rarely be determined on appeal if the patient is
incapable of self administration and a new caretaker needs instruction.
94642 AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS CARINII
PNEUMONIA TREATMENT OR PROPHYLAXIS
Although variation exists in the administration of this therapy, Riverbend
will consider it to require the skills of the therapist when administered
in a facility setting and will therefore consider the administration to be
medically necessary whenever the drug itself is medically necessary.
94667 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND
VIBRATION TO FACILITATE LUNG FUNCTION; INITIAL DEMONSTRATION AND/OR
EVALUATION
Up to five demonstration sessions may be medically necessary to instruct
the caregiver of a patient who has never received this service before. Once
the service has been taught, the conditions of 94668 apply as additional
instruction is not medically necessary.
94668 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND
VIBRATION TO FACILITATE LUNG FUNCTION; SUBSEQUENT
This service is only considered to require the skills of the respiratory
therapist in the acute situation; this is a self care (caregiver) service
in the chronic outpatient environment and an ancillary (nursing) service in
the subacute or chronic inpatient environment.
94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL
CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL
VOLUNTARY VENTILATION
94150 VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE)
Full spirometry and/or vital capacity are not medically
necessary on a repetitive basis unless:
There
has been a sudden unexplained deterioration in pulmonary status, or
The patient has a chronic progressive pulmonary condition and repeat values
are likely to significantly impact management
The patient has a chronic progressive pulmonary condition and demonstrates
a significant clinical change since the last measurement.
Except in the case of the sudden deterioration, repeat spirometry
is not medically necessary more often than annually and then not on a
routine basis.
94200 MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION
The routine use of this service for monitoring is not medically necessary.
Documentation should support a clinical change in status necessitating this
assessment.
94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE
DETERMINATION
Pulse oximetry is an ancillary nursing function
that does not require the skills of the respiratory therapist.
94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; MULTIPLE
DETERMINATIONS (EG, DURING EXERCISE)
Repetitive or continuous pulse oximetry is an
ancillary nursing monitoring function that does not require the skills of
the respiratory therapist.
94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; BY
CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE)
Repetitive or continuous pulse oximetry is an
ancillary nursing monitoring function that does not require the skills of
the respiratory therapist
|