Respiratory Therapy Services

40.5 - Respiratory Therapy Services (Rev. 111, Issued: 09-25-09; Effective Date: 07-07-08; Implementation Date: 10-26- 09) A respiratory therapy plan of treatment is wholly established and signed by the referring physician before the respiratory therapist initiates the actual treatment. A. Definition Respiratory therapy services include only those services that can be appropriately provided to CORF patients by a qualified respiratory therapist, as defined at 42CFR485.70(j), under a physician-established respiratory therapy plan of treatment. The facility physician must be present in the facility for a sufficient time to provide, in accordance with accepted principles of medical practice, medical direction, medical care services and consultation. Respiratory therapy services include the physiological monitoring necessary to furnish these services. Payment for these services is bundled into the payment for respiratory therapy services and is not payable separately. Diagnostic and other medical services provided in the CORF setting are not considered CORF services, and therefore may not be included in a respiratory therapy plan of treatment because these are covered under separate benefit categories. The respiratory therapist assesses the patient to determine the appropriateness of pursed lip breathing activity and may check the patient’s oxygen saturation level (via pulse oximetry). If appropriate, the respiratory therapist then provides the initial training in order to ensure that the patient can accurately perform the activity. The respiratory therapist may again check the patient’s oxygen saturation level, or perform peak respiratory flow, or check other respiratory parameters. These types of services are considered “physiological monitoring” and are bundled into the payment for HCPCS codes G0237, G0238 and G0239. Physiological monitoring also includes the provision of a 6-minute walk test that is typically conducted before the start of the patient’s respiratory therapy activities. The time to provide this walk “test” assessment is included as part of the HCPCS code G0238. When provided as part of a CORF respiratory therapy plan of treatment, payment for these monitoring activities is bundled into the payment for other services provided by the respiratory therapist, such as the three respiratory therapy specific G-codes. B. Guidelines for Applying Coverage Criteria There are some conditions for which respiratory therapy services may be indicated. However, respiratory therapy performed as part of a standard protocol without regard to the individual patient's actual condition, capacity for improving, and the need for such services as established, is not reasonable and medically necessary. All respiratory therapy services must meet the test of being “reasonable and medically necessary” pursuant to §1862(a)(1)(A) of the Act. Determinations of medical necessity are made based on local contractor decisions on a claim-by-claim basis. The three HCPCS codes G0237, G0238, and G0239 are specific to services provided under the respiratory therapy plan of treatment and, as such, are not designated as subject to the therapy caps. C. Patient Education Programs Instructing a patient in the use of equipment, breathing exercises, etc. may be considered reasonable and necessary to the patient's respiratory therapy plan of treatment and can usually be given to a patient during the course of treatment by the respiratory therapist. These educational instructions are bundled into the covered service and separate payment is not made.