471 Neb. Admin. Code, ch. 22, § 004

Current through September 17, 2024

Section 471-22-004 - SERVICE REQUIREMENTS

004.01GENERAL SERVICE REQUIREMENTS.

004.01(A)MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity from 471 NAC 1. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered. In addition to meeting these requirements, respiratory therapy services are considered to be reasonable and necessary for the diagnosis or treatment of an individual's illness or injury only if they also satisfy additional conditions.

004.01(B)CONDITIONS IN ADDITION TO MEDICAL NECESSITY.

004.01(B)(i)CONSISTENT WITH THE NATURE AND SEVERITY OF THE INDIVIDUAL'S COMPLAINTS AND DIAGNOSIS. A patient's primary diagnosis alone must justify the need for respiratory therapy, if the primary diagnosis alone is insufficient, the need for respiratory therapy must be justified by medical evidence documenting the need based on:

(1) The combination of secondary and primary diagnoses: or

(2) The severity of the secondary diagnosis alone.

004.01(B)(ii)REASONABLE IN TERMS OF MODALITY AMOUNT FREQUENCY AND DURATION OF THE TREATMENTS. In addition to being considered reasonable and necessary based on the nature and severity of the patient's condition, respiratory therapy must also be reasonable and necessary with respect to modality, amount, frequency, and duration of treatments.

004.01(B)(ii)(1)DISCHARGE. It is expected that the level and intensity of the care is modified as discharge nears, if the amount and frequency of respiratory therapy provided throughout the hospital stay remains constant and the primary or secondary diagnosis indicates that under normal circumstances, a decline in amount and frequency could be anticipated, the provider must submit an explanation to Nebraska Medicaid.

004.01(B)(iii)GENERALLY ACCEPTED BY THE PROFESSIONAL COMMUNITY AS BEING SAFE AND EFFECTIVE TREATMENT FOR THE PURPOSE USED. In the absence of evidence to the contrary, it may be presumed that respiratory therapy is an accepted treatment and may be covered.

004.01(C)PHYSICIAN CERTIFICATION. Respiratory therapy services must be provided only on written orders by a licensed Nebraska physician, or, if provided out of state, a licensed physician of that state. Services must be recertified by a physician every 30 days, or more frequently if the patient's condition necessitates.

004.01(D)ADDITIONAL GUIDELINES FOR COVERAGE CRITERIA. Medicaid covers respiratory therapy services only when there is a distinction, or decision, made with respect to the individual patient's condition and the need for the services.

004.02COVERED SERVICES.

004.02(A)PLACE OF SERVICE. Nebraska Medicaid covers respiratory therapy in hospitals and long-term care facilities.

004.02(A)(i)HOSPITAL. When provided by a respiratory therapist or technician, the services are covered as ancillary services. When provided by a nurse, the services are covered as nursing services. If the services are reasonable and necessary, they are covered regardless of where in the hospital they are provided, such as an emergency room or intensive Care Unit (ICU).

004.02(A)(ii)LONG TERM CARE FACILITIES. See 471 NAC 12.

004.02(B)RESPIRATORY THERAPY SERVICES. Respiratory care services include:

(i) The application of techniques for support of oxygenation and ventilation in the acutely ill patient.

(ii) The therapeutic use and monitoring of medical gases (especially oxygen), bland and pharmacologically active mists and aerosols and equipment as resuscitators and ventilators:

(iii) Bronchial hygiene therapy, including deep breathing and coughing exercises, intermittent positive pressure breathing (IPPB), postural drainage, chest percussion and vibration, and nasotracheal suctioning;

(iv) Diagnostic tests for evaluation by a physician, such as pulmonary function tests, spirometry, and blood gas analyses;

(v) Pulmonary rehabilitation techniques that include:

(1) Exercise conditioning;

(2) Breathing retraining; and

(3) Patient education regarding the management of the patient's respiratory problems; and

(vi) Periodic assessment and monitoring of the acute and chronically ill patients for indications for, and the effectiveness of, respiratory therapy services.

004.02(C)INTENSIVE CARE AND RECOVERY ROOM PATIENTS, intensive care and recovery room patients that require respiratory monitoring, support, and therapy qualify for coverage if the treatment is reasonable and necessary.

004.02(D)PREOPERATIVE BRONCHIAL HYGIENE THERAPY. Preoperative bronchial hygiene therapy may be reasonable and necessary when the patient has a presumptive condition that by itself requires respiratory therapy. In the absence of a presumptive condition, preoperative respiratory therapy is reasonable and necessary if the prescribing physician adequately documents the medical necessity for it.

004.02(E)POSTOPERATIVE BRONCHIAL HYGIENE THERAPY. Respiratory therapy services aiding bronchial hygiene are reasonable and necessary in the postoperative patient with identifiable pulmonary complications or in patients with underlying pulmonary diseases. The provider must document the medical necessity for the therapy when billing Nebraska Medicaid. Routine procedures when provided on a routine basis to most postoperative patients are not considered necessary and are not covered under Nebraska Medicaid.

004.02(F)SETTING UP EQUIPMENT AND INSTRUCTING PATIENTS IN ITS USE. Setting up respiratory equipment and instructing patients in the use of equipment, or on postural drainage and breathing exercises, is considered reasonable and necessary. Once patients have been instructed, services of a respiratory therapist or nurse are not reasonable and necessary, and are not covered by Nebraska Medicaid. Any monitoring of the equipment or of the effects of the treatment is expected to be carried out by a staff nurse as part of the regular nursing activities. Use of a respiratory therapist for these activities is considered a duplication of services and is not covered. Payment may be made for use of the equipment and covered gases or drugs used in connection with the equipment.

004.02(G)OXYGEN THERAPY. Oxygen therapy is covered if the need and the effectiveness is documented. Use of continuous oxygen without periodic assessment of arterial PO₂ or oxygen saturation must be medically necessary, and supported by sufficient documentation. The physician's order must state the oxygen device and the specific flow rate or concentration of oxygen desired. A prescription for "oxygen as needed" does not meet these requirements. An intermittent or pro re nata (PRN) oxygen therapy order must include time limits and specific indications for initiating and terminating therapy.

004.02(H)STRUCTURED PATIENT EDUCATION PROGRAM. Instructing a patient on the use of equipment or breathing exercises is considered reasonable and necessary to the treatment of the patient's condition and can be given to a patient during the course of their treatment by the health personnel involved, unless these activities are of a complexity that warrants a structured patient education program. A structured program generally is not considered reasonable and necessary and is not covered by Nebraska Medicaid.

471 Neb. Admin. Code, ch. 22, § 004

Amended effective 12/26/2021