Section O - Respiratory Therapy

Talino · Jan 13, 2014

Respiratory Therapy defined, RAI A-19

Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws.

Nurses providing respiratory medications alone won't.

mds2011 · Jan 13, 2014

So, Nebulizer treatment is also not included?

Talino · Jan 14, 2014

Handheld nebulizers are usually excluded. However, meds and treatments are not the determining factor. The person who provided the treatment is the clincher -- a respiratory therapist or a "trained" respiratory nurse.

mds2011 · Jan 14, 2014

Oh no!!!Our residents receive neb treatment for Pneumonia or Bronchitis administered by the floor RN given for 15 minutes and I have been counting it. I was WRONG............

MarggoRita · Jan 19, 2014

What exactly constitutes as "trained" respiratory nurse? Aren't all nurses "trained" to assess lung sounds? Only asking because we are to document HR/LS/minutes to claim for neb tx's, but I have not been "trained" beyond nursing school, is that enough?

TraumaSurfer · Jan 19, 2014

What exactly constitutes as "trained" respiratory nurse? Aren't all nurses "trained" to assess lung sounds? Only asking because we are to document HR/LS/minutes to claim for neb tx's, but I have not been "trained" beyond nursing school, is that enough?

From the CMS website:

Respiratory Therapy

Respiratory therapy can add up to $6 per day of reimbursement, and

the definition is very broad. Respiratory therapy can be provided by

a qualified respiratory therapist or a “trained nurse.” A trained nurse

has specific training over and above the nurse training program.
However, if your facility provides documented in-service training to

your staff by a Registered Respiratory Therapist, they are considered

trained nurses. Respiratory therapy is coded when nurses are

providing or supervising coughing, deep breathing, heated hand-held

nebulizer treatments, aerosol treatments, and mechanical ventilation.

Assessing breathe sounds is included. It does not include hand-held

medications, e.g., Albuteral or Spiriva.

Encourage your staff to be specific when transcribing nebulizer

orders and to specify that the nebulizer treatment is to be provided

over 15 minutes. The nurse should also document respiratory status

before and after the treatment.

The respiratory system is probably the weakest of all of the nursing education. But, according to the CMS requirements, all you need is a breath inservice which is no clearly defined and you are a "Respiratory Nurse". This is probably one of the reasons there are some scary bad things happening in long term care where RTs have been eliminated. Giving an MDI or nebulizers in not difficult. The difficult part is knowing when and why or why not. But, again, the requirements to be a Respiratory Nurse are not that specific.

The 15 minute thing is also confusing. For the definition here it just means the treatment lasts 15 minutes. For RTs to get reimbursement they must PROVIDE therapy for 15 minutes which means staying the one patient for 15 minutes assessing, doing the therapy and educating for 15 minutes. If they provide therapy to more than one patient at the same time or leave the room they must document concurrent therapy which gets very messy for billing in fractions and they may lose all reimbursement if it violates policy. The RT and department can also lose their license and accreditation. For this reason it is almost easier to have nurses to do the treatments since the guidelines or documentation requirements are not near as strict although the reimbursement code is also different.

MarggoRita · Jan 20, 2014

Thank you for the info, next question, the tx must be over 15 minutes, but do I have to stay with the resident for those minutes? Given that my resident in question received his Nebs through a face mask and we know he receives the entire tx because he does not remove the mask, we do leave him during that time, but doc 15 minutes for the time it took for the tx? And assess before and after the tx, but would be very poor utilization of time to sit with him during tx's since he has five separate Nebs each day.

TraumaSurfer · Jan 21, 2014

Thank you for the info, next question, the tx must be over 15 minutes, but do I have to stay with the resident for those minutes? Given that my resident in question received his Nebs through a face mask and we know he receives the entire tx because he does not remove the mask, we do leave him during that time, but doc 15 minutes for the time it took for the tx? And assess before and after the tx, but would be very poor utilization of time to sit with him during tx's since he has five separate Nebs each day.

I can not answer this for LTC. When we took over the treatments in acute care, it was clear nurses were not therapists with their expectations and were merely being reimbursed for the meds only. This question would need to be asked directly to CMS.

But, what we have unfortunately noticed is patients who can not defend themselves coming up with eye injuries and infections from the mask slipping. That used to be common when RTs were also allowed to do concurrent therapy at one time. So be careful "hangin' or slingin' nebs" as it is called in the ERs and floors among RTs and RNs.

Talino · Jan 21, 2014

...the tx must be over 15 minutes, but do I have to stay with the resident for those minutes?

No, but you can not include the minutes while you were not present or does not have the resident within line-of-sight.

...assess before and after the tx, but would be very poor utilization of time to sit with him during tx's since he has five separate Nebs each day.

The therapy mins involve time preparing the resident/equipment/med, assessing lung sounds before and after, observing, instructing (breathing/coughing exercises), tapping chest/back, etc. If staff took 3 mins to assess X 5 tx = 15 mins plus the time prepping for tx, requirements met.

MarggoRita · Jan 21, 2014

Thanks again, very helpful the way you explain it.

rcolon12 · Oct 30, 2015

Hello,

I am a nursing student currently in my fourth semester. I have always seen in lots of orders about "SAN treatment" and have always inquired about what is specifically. Is it an acronym for something? I know I usually see Duoneb and Atrovent in the orders.

Any help would be appreciated. Thanks :)