The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

Documenting Respiratory Care Services Provided Under a Transfer Agreement: An Auditor's Perspective

J. Michael Thompson, BS, RRT, RPFT Wednesday, November 6, 1996

As more acute care hospitals establish "transfer agreements" with Skilled Nursing Facilities (SNFs) the volume of respiratory therapy services provided in SNFs has increased dramatically. With increased utilization of our services has come a mandate to Medicare Fiscal Intermediaries (FIs), such as Blue Cross of California, to increase their review of these services to insure that the services provided meet Medicare requirements.

The documentation required by Medicare for respiratory care services provided in SNFs has two major components -- technical and medical.

The technical documentation required includes the following items:

1. An itemized financial ledger or bill from the SNF to Medicare which shows the dates, the type and number or procedures and the charge for each procedure.

2. A complete physician's order for each respiratory care service billed.

3. Documentation that the patient received each respiratory care service billed.

The required medical documentation must show that the respiratory care service was medically necessary and that the skills of a respiratory care practitioner (RCP) were required to provide the service. To be considered medically necessary by Medicare, the documentation must show that respiratory care services meet the following criteria:

1. "Consistent with the nature and severity of the patient's symptoms and diagnosis."

2. "Reasonable in terms of modality, amount, frequency and duration."

3. Generally accepted by the professional community as being safe and effective treatment for the purpose used."

The documentation must also establish that the skills of a RCP were required to provide the service. The RT records should make it obvious why the presence of the RCP was necessary to insure the outcome. For example, if the documentation gives the appearance that the RCP is simply observing a patient self-administer a MDI treatment, the medical necessity for the presence of the RCP is likely to be questioned.

Although essentially the entire medical record is reviewed to establish the medical basis for the therapy, the daily respiratory care documentation is the primary source of data that is used to perform the claim review. The quality of the RCPs documentation of the patient's condition and response to therapy is often the key in the final determination of the appropriateness of therapy.

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