Respiratory Therapy Services by Independent Practitioner Provider
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Coverage rules for respiratory therapy services provided by licensed Respiratory Care Practitioners (Independent Practitioner Providers) to NC Medicaid beneficiaries, with EPSDT provisions for beneficiaries under 21; includes eligibility, documentation, prior authorization, telehealth and billing rules.
No material clinical or coverage changes in this revision.
Coverage Criteria
General Coverage Criteria
Covered when ALL of the following are met:
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Asthma / Unspecified Respiratory Disease Coverage Criteria
Medicaid shall cover medically necessary respiratory therapy services by an IPP for beneficiaries with asthma or unspecified chronic respiratory disease when ALL of the following are satisfied:
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Chronic Respiratory Condition Coverage Criteria
Medicaid shall cover respiratory therapy services by an IPP for chronic respiratory conditions other than asthma when the severity classification (based on AARC guidance) is met and ALL of the following components are satisfied:
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Telehealth Delivery
Select respiratory therapy interventions may be provided via telehealth for established patients when clinically appropriate and per telehealth policy.
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Medicaid-covered respiratory therapy services (IPP)
Covered when ALL of the following are met
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Coverage conditions
Covered when documentation, coding, and billing requirements are met and services are furnished by eligible providers under NC Medicaid rules:
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Administrative Coverage Rules
Coverage and billing rules for respiratory therapy visits
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EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) requires covering medically necessary services for beneficiaries under 21 to correct or ameliorate health problems, but it does not obligate coverage for services that are unsafe, ineffective, experimental or investigational, or not medical in nature. EPSDT can allow exceeding usual policy limits when documented as medically necessary, but it does not remove prior approval requirements.
Respiratory therapy treatment is covered only when provided on an individual basis. Services provided to two or more beneficiaries at the same time in the same location (group sessions) are explicitly not covered; only direct face-to-face time with a single beneficiary is billable.
Services are not covered when the beneficiary fails to meet eligibility or the policy's clinical criteria, when the service duplicates another provider's billed service, or when the procedure/product is experimental, investigational, or part of a clinical trial. Specific non-covered items include separate payment for assessment activities such as interpretive conferences, educational placement meetings, care planning meetings, group or selection screenings; and administrative or overhead time—preparation, report writing, claims processing, billing documentation, travel time/expenses—and certain administrative treatment activities (consultation activities, ESL-specific objectives, or POC maintenance/monitoring) which are considered included in the unit rate.
CPT and HCPCS codes marked in the attachment as 'Telehealth Eligible Services = No' are not eligible for telehealth delivery under this policy. Refer to Attachment A (code list) for the telehealth eligibility flag for each code and to policy instructions for billing telehealth-eligible codes.
Reinforcing EPSDT limits: even for beneficiaries under 21, services that are unsafe, ineffective, experimental, investigational, or not generally recognized as accepted medical practice remain excluded from coverage under EPSDT.
Group delivery of respiratory therapy (two or more beneficiaries concurrently in the same location) is explicitly excluded from coverage and therefore should not be provided or billed as covered respiratory therapy services.
Administrative and non-direct treatment activities—including preparation, report writing, claims processing, documentation for billing, and travel time—are not separately reimbursable. These activities are considered part of the unit rate and must be included in the provider's usual billing rather than billed as separate services.
Post-payment and program integrity reviews are used to validate utilization, quality, and documentation. Findings from these reviews may result in tentative overpayment determinations and recovery; providers receive written notice of findings, basis for determinations, and information on appeal rights.
Coding, Billing Units, and Limits
| No codes listed |
| 94799 | Respiratory therapy assessment (unlisted) — Telehealth eligible: No |
| 31502 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 31720 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94010 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94060 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94150 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94200 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94375 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94664 | Respiratory Therapy Treatment — Telehealth Eligible: Yes |
| 94667 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| 94668 | Respiratory Therapy Treatment — Telehealth Eligible: No |
| POS 12 | Primary Private Residence (Place of Service code 12) |
| POS 99 | Other (Place of Service code 99) |
| POS 03 | School (Place of Service code 03) |
| POS 11 | Office (Place of Service code 11) |
Provider Actions, Authorization, and Documentation
EPSDT does not waive prior approval
EPSDT does not remove prior approval obligations; if a service requires prior approval, beneficiaries under 21 still must meet the PA requirement before services are provided.
General prior approval requirement
Obtain prior approval whenever the service, product, or procedure requires prior approval; the beneficiary's age (<21) does not exempt the service from PA requirements.
Submit PA via DHHS Utilization Review Contractor
Request prior authorization for Respiratory Therapy Services by an IPP through the DHHS Utilization Review Contractor (Choice PA website); for asthma/unspecified chronic respiratory disease, request up to 15 visits per six consecutive months under the billing NPI and include required documentation and POC with anticipated discharge date for reauthorization.
- Submit PA requests via the Choice PA website as directed in Subsection 5.2.2.
- Prior authorization must be requested under the billing NPI.
- Reauthorization must include PCP-MD justification and the POC with anticipated discharge date.
Bill CPT 94799 for initial/reassessment prior to PA
Bill CPT 94799 for the IPP's initial assessment before submitting the initial prior authorization, for reassessment prior to reauthorization, or when a significant measurable change in respiratory status occurs.
- Each 94799 assessment must produce a written assessment report meeting Subsections 1.1.1 and relevant assessment requirements.
Place of Service considerations for PA and claims
File telehealth claims with the provider's usual place-of-service code(s); treatment visits are allowed at POS 12, 99, 03, or 11 per policy and refer to Subsection 5.3 for school/daycare allowances.
- Telehealth claims must be submitted with the provider's usual POS code(s).
- Up to two of the allowed 15 visits may occur in school or day care for staff training (see Subsection 5.3).
EPSDT may allow exceptions but PA still required
For beneficiaries under 21, EPSDT may allow exceeding policy limits when provider documentation shows the service is medically necessary to correct or ameliorate a condition, but EPSDT does not remove prior approval requirements.
- Document how the requested service meets EPSDT criteria to justify exceeding limits.
Meet general medical necessity criteria
Ensure services are medically necessary: individualized, consistent with diagnosis/symptoms, safely furnishable, and no equally effective, more conservative or less costly statewide alternative is available.
- Services must not be primarily for convenience of beneficiary, caregiver, or provider.
Avoid concurrent same-date services with other Medicaid providers
Do not provide IPP respiratory therapy services on the same date of service as another Medicaid provider who can provide the same services; concurrent same-day services by another provider (e.g., CAP/C nurses or PDN) prevent IPP delivery.
Provide written assessment and action plan documentation
Produce a written assessment report that includes the assessment results, current diagnosis, specific measurable and quantified functional limitations, and identifies all education needed to transfer care and promote discharge.
- Assessment components may include ABG collection, pulmonary function studies, spirometry, breath sounds, and respiratory status (per Subsection 1.1.1).
Include required assessment content in the written report
Document assessment results, current diagnosis, and specific measurable/quantified functional limitations; for chronic conditions, document secretion clearance ability, PFT deficits over 2 consecutive weeks if applicable, tracheostomy care ability, O2 saturation maintenance (92–97%), activity tolerance, breathing technique ability, and ventilator weaning ability if applicable.
- Include oxygen saturation targets (92–97%) where applicable.
Develop POC with required elements and signatures
Develop the Plan of Care (POC) with the IPP, beneficiary/caregiver and PCP-MD (or Pulmonologist for chronic conditions); POC must document PCP-MD severity determination, pharmacologic treatment, goals/objectives, anticipated discharge date, IPP signature/credentials/date, and record AP development within the first three visits.
- POC must specify respiratory tools provided within the first three visits if applicable.
Maintain required beneficiary and POC/order documentation
Maintain beneficiary name and Medicaid ID; keep a copy of the POC signed by the PCP-MD; retain the PCP-MD written order or countersigned verbal order; document service descriptions, dates, duration (time in/out), provider signature and credentials for each date of service; and keep test results and the written assessment report.
- Document dates of communication with the PCP-MD, education/training provided, educational materials given, and caregiver skill/competence.
Keep signed POC and orders with per-date signatures
Retain beneficiary identifiers and a signed POC/orders with PCP-MD signature or countersignature; ensure each date of service note contains the provider's signature and credentials and duration of service.
Bill usual/customary charges; reference Medicaid rate schedule
Bill usual and customary charges and refer to the North Carolina Medicaid schedule of rates for reimbursement specifics.
- Providers should consult the Medicaid rate schedule at medicaid.ncdhhs.gov for rates.
Verify Medicaid eligibility for every service
Verify NC Medicaid enrollment and eligibility for each service; services may be denied if the beneficiary is not enrolled, eligibility is not verified at each visit, or the beneficiary's eligibility category restricts the service.
- Providers shall verify eligibility each time a service is rendered.
Group treatment is not covered
Do not provide group therapy; Medicaid does not cover services provided to two or more beneficiaries at the same time in the same location and such services risk denial.
Obtain PCP-MD assessment before IPP assessment if <365 days post-discharge
If less than 365 days have elapsed since discharge, a PCP-MD assessment is required before an IPP assessment; failure to obtain the PCP-MD assessment may result in denial of subsequent IPP services.
- After 365 consecutive days from discharge, an IPP assessment may be administered without a new PCP-MD assessment.
Denial triggers: eligibility, criteria, duplication, investigational services
Services are not covered if the beneficiary fails to meet eligibility in Section 2.0, does not meet clinical criteria in Section 3.0, duplicates another provider's service, or the service is experimental/part of a clinical trial.
Risk of tentative overpayment from post-payment reviews
Noncompliance identified during post-payment or program integrity reviews can lead to tentative overpayment determinations and recovery; findings and appeal rights will be provided in writing.
- Reviews use statistically valid random samples and findings include description, basis, tentative overpayment amount, and appeal information.
Claims must be filed within 365 days of first DOS
Submit claims within 365 consecutive days of the first date of service; claims received later may not be accepted for processing and payment and may be denied.
Use correct Place of Service codes for claims (telehealth = usual POS)
File claims with the correct place-of-service code; telehealth claims must be filed with the provider's usual POS code(s). Incorrect POS coding may jeopardize claim payment.
- Allowed POS values include POS 12, 99, 03, and 11 for respiratory therapy treatment visits.
Background
Respiratory therapy services are provided by licensed respiratory care practitioners (licensed respiratory therapists) and include a collaborative assessment, individualized face-to-face treatment, education, and development of a written Action Plan to enable beneficiaries and caregivers to manage pulmonary dysfunction. Providers must meet state licensing and regulatory requirements for respiratory therapists.
Definitions
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