Section 51316 - Respiratory Care Services(a) Respiratory care services provided by respiratory care practitioners acting within their scope of practice, upon the written prescription of a physician or surgeon, are covered as Medi-Cal benefits subject to the following: (1) The respiratory care service is within accepted respiratory treatment modalities and considered to be specific and effective treatment for the beneficiary's condition; and(2) The respiratory care service is shown to be medically necessary for the treatment of the beneficiary's condition pursuant to Section 51303.(b) Reimbursement will not be made for: (1) respiratory care procedures which are included within other procedure codes;(2) training in the use of durable medical equipment or devices related to respiratory care reimbursed to any other provider; or(3) teaching or training of patients or care givers to administer intermittent positive pressure breathing (IPPB).(c) Except as otherwise noted, respiratory care services are subject to prior authorization.(d) One respiratory care evaluation (code number X4700) of a patient with an acute respiratory illness, or respiratory problem in a six (6) month period, is covered without prior authorization unless reimbursement for a comparable examination has been made to the patient's physician within six months. Additional evaluations within a six (6) month period require medical justification and are subject to prior authorization. A respiratory care evaluation or reevaluation includes but is not limited to:(1) review of the effectiveness of current and past medical treatment including services, items, or equipment related to the patient's respiratory condition;(2) development, in conjunction with a physician, of a treatment plan to address the patient's respiratory condition, or to prevent or substantially shorten an anticipated hospital stay; and(3) any other appropriate assessments or measurements of the patient's respiratory system not already covered under other service codes which are within the respiratory care practitioner's scope of practice and are related to the patient's current treatment plan.(e) Participation in an organized respiratory care case conference (code number X4702) with other health team members immediately involved in the care or recovery of the patient is reimbursable only when the following criteria are met:(1) The respiratory care case conference must be documented as medically necessary pursuant to Section 51303.(2) Documentation in the patient's medical record must include the status or progress of the patient as well as the proposed treatment plan agreed upon in the respiratory care case conference.Cal. Code Regs. Tit. 22, § 51316
1. New section filed 6-23-97; operative 7-23-97 (Register 97, No. 26). Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14509 and 14132, Welfare and Institutions Code.
1. New section filed 6-23-97; operative 7-23-97 (Register 97, No. 26).