Respiratory Therapy (Respiratory Care)

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1861(cc)(1) discusses Comprehensive Outpatient Rehabilitation Facility (CORF) services

Title XVIII of the Social Security Act, §1861(s)(2)(B) provides coverage of services incident to physicians services furnished to hospital patients

42 CFR §485.70 Comprehensive Outpatient Rehabilitation Facility (CORF) personnel qualifications- lists qualifications for respiratory therapists

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4 Outpatient Diagnostic Services and §20.4.1 Diagnostic Services Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 8, §50.8.2 Respiratory Therapy

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §10 Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare, §20 Required and Optional CORF Services, §20.1 Required Services, §20.2 Optional CORF Services, and §30 Rules for Provision of Services

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §240.7 Postural Drainage Procedures and Pulmonary Exercises and §240.8 Pulmonary Rehabilitation Services

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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Documentation Requirements

A physician order for all respiratory therapy intervention/service must be recorded in the patient's medical record. The order must clearly indicate the evaluation or treatment to be performed, the specific modality and duration of all aspects of the treatment, including frequency of monitoring.

Documentation by the physician must indicate the cardiopulmonary diagnosis supporting the medical necessity of the service.

Documentation must be present in the respiratory services records to show:

• the plan of treatment and progress toward measurable goals.
• that the care rendered was appropriately delivered by a qualified practitioner. As previously noted, the above services may be performed by respiratory therapists, physical therapists, nurses, and other qualified personnel.

Other qualified personnel may include occupational therapists. 

CORF social and/or psychological services do not include services for mental health diagnoses. Social and/or psychological services are covered only if the patient's physician or the CORF physician establishes that the services directly relate to the patient's rehabilitation plan of treatment and are needed to achieve the goals in the rehabilitation plan of treatment. Social and/or psychological services are those services that address the patient's response and adjustment to the rehabilitation treatment plan, rate of improvement and progress towards the rehabilitation goals, or other services as they directly relate to the respiratory therapy (respiratory care) plan of treatment being provided to the patient.

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

American Association of Respiratory Care (AARC). Accredited Respiratory Care Programs and Online CRCE (continuing respiratory care education). Accessed 6/14/21.

Filart RA, Bach JR. Pulmonary physical medicine interventions for elderly patients with muscular dysfunction. Clin Geriatr Med. 2003;19(1):189-204.

International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization (WHO); 2001.

Mahler DA, Fierro-Carrion G, Baird JC. Evaluation of dyspnea in the elderly. Clin Geriatr Med. 2003;19(1):19-33.

Taiwo OA, Cain HC. Pulmonary impairment and disability. Clin Chest Med. 2002;23(4):841-851.

• Respiratory Therapy
• Respiratory Care