Harmony Healthcare International (HHI) Blog

Respiratory Therapy: 1, 2, 3, 4



1. Reimbursement Respiratory Therapy

Over the past decade, the acuity levels in the SNF setting have been steadily increasing. As a colleague (and dear friend of mine) eloquently predicted back in 2013:

“They are coming into the nursing homes sicker and quicker!”
- Clint Maun of Maun-Lemke


And boy, was he dead on accurate!


Couple the “sicker and quicker” with the COVID-19 pandemic, and one must ponder the “Ruh Roh” decision to displace respiratory therapy from the ancillary reimbursable cost center back in 1998. Remember when PT, OT, ST and RT were reimbursed for total cost. That changed in 1998. PT, OT and ST were reimbursed under the PPS system, but RT became a non-reimbursable service.


This is more glaring when you Monday morning quarterback and research that hospital readmissions are the focus of the Value Based Purchasing initiative (meaning nursing homes are penalized for sending residents to the hospital) and the top 3 diagnoses for readmission to the hospital (Pneumonia, COPD and CHF) fall under the domain of respiratory therapy. Does this keep anyone else up at night?



Today, Respiratory Therapy is reimbursed under Medicare Part A benefit and this is the time the SNF’s need it most because:



1. The patient acuity (i.e., COVID-19…. attacks the lungs).
2. There is a nursing shortage…. maybe these extra sets of expert hands could help?
3. However, CMS needs to count Respiratory Therapy hours in the PBJ HPPD. (Please advocate and call your local representative.)


Examples of respiratory therapy treatments that can be provided in a Skilled Nursing Facility (SNF) setting include:


  • Oxygen Therapy: This treatment involves administering oxygen to a patient with a low oxygen level in the blood. Oxygen can be delivered through a nasal cannula, a mask, or a ventilator.


  • Bronchopulmonary Hygiene Therapy: This treatment involves using techniques such as coughing, deep breathing, and chest physical therapy to help clear mucus and other secretions from the lungs.


  • Postural Drainage Therapy: This treatment involves positioning the patient in specific positions to help drain mucus from the lungs and reduce the risk of infection.


  • Incentive Spirometry: This treatment involves using an incentive spirometer, a device that measures breathing capacity and encourages deep breathing exercises to improve lung function.


  • Nebulizer Treatment: This treatment involves administering medication through a nebulizer, which is a machine that turns liquid medication into a fine mist that can be inhaled.


  • Ventilator Management: This treatment involves the use of a mechanical ventilator to assist or replace the patient's spontaneous breathing.


  • Pulmonary Rehabilitation: This treatment involves a comprehensive program that helps to improve lung function, reduce symptoms, and increase the patient's ability to perform daily activities.


These are just a few examples of respiratory therapy treatments that can be provided in a SNF setting. The specific treatments provided will depend on the patient's individual needs and condition.


Respiratory Therapy reimbursement in a Skilled Nursing Facility (SNF) for Medicare Part A is determined by the patient's level of care and the specific services provided. For respiratory therapy services to be covered under Medicare Part A in a SNF, the patient must meet certain criteria. The patient must be a Medicare beneficiary, be in a SNF for a medically necessary stay, and have a medical condition that requires respiratory therapy services.


The specific respiratory therapy services provided, as well as the frequency and duration of those services, will determine the reimbursement rate for the SNF.


Reimbursement for respiratory therapy services in a SNF is determined by the Case Mix Group (CMG) level assigned to the patient. The CMG level is determined by the patient's assessment, and it's based on the patient's clinical status, functional status, and therapy needs.


The CMG level impacts aspects of the both the Medicare Part A and Medicaid Case Mix reimbursement system. This subject matter consistently generates questions from all over the country. The intent of this narrative is to distill and synthesize the framework for a better understanding.


2. MDS Coding: Respiratory Therapy


The coding of the Respiratory Therapy on the MDS requires:


  • Respiratory Therapy 7 Days Per Week.
  • At least 15 Minutes Per Day: Equivalent to 5 minutes per shift (105 minutes total/week).
  • Code and Count only time the Qualified Personnel is with the Resident:
    • Assessing,
    • Teaching,
    • Training,
    • Incentive Spirometry,
    • Bronchopulmonary Hygiene Therapy,
    • Oxygen therapy, and
    • Postural Drainage,
    • Delivering Nebulizer Therapy (with set up and clean up).
  • Do Not Count time away from the resident. 
  • Document Exact Minutes spent delivering the services and care planning for the intervention.


Definition of a “Day of Treatment.”


  • On page O-24 of the RAI User’s Manual, the following example is given to reinforce the need of 15 minutes or more of Respiratory Therapy in a 24-hour period.
  • To accurately code on the MDS, there must be a “Day” of Respiratory Therapy.


Example MDS Coding:


  • Respiratory Therapy services that were provided over the 7 days of the look back period.
  • Respiratory Therapy services provided Sunday through Thursday for 10 minutes each day.




  • O0400D1 would be coded 50,
  • O0400D2 would be coded 0.




  • Total minutes were 50 minutes over the 7-day look back period (10 × 5 = 50).
  • Although a total of 50 minutes of Respiratory Therapy services were provided over the 7-day look back period, there were not any days of Respiratory Therapy provided for 15 minutes or more.
  • Therefore, O0400D equals zero (0) days.


Harmony Healthcare International, Inc. (HHI) suggests documenting the Respiratory Clinical Assessments of the patient's respiratory status to accurately depict the 5 minutes rendered per shift.


  • This includes a focused physical assessment of the respiratory status (i.e., assessing and obtaining the patient’s oxygen saturation levels, usage of oxygen, and oxygen flow volume to maintain oxygen saturation levels).


3. Criteria Respiratory Therapy


According to the RAI User’s Manual (Page O-140)


For purposes of the MDS, providers should record services for Respiratory, psychological, and recreational therapies (Item O0400D, E, and F) when the following criteria are met:


  • The Physician Orders the therapy.
  • The Physician’s Order includes a Statement of:
    • Frequency,
    • Duration, and
    • Scope of
  • The services must be:
    • Directly and specifically related to an active written treatment plan.
    • Based on an Initial Evaluation.
    • Performed by Qualified Personnel.
  • The services are required and provided by Qualified Personnel.
  • The services must be Reasonable and Necessary for treatment of the resident’s condition.


4. Qualified Personnel Respiratory Therapy


In Appendix A (page Appendix A-18), the following definition is provided as to what is considered Respiratory Therapy:


“Services that are provided by a qualified professional (Respiratory Therapists, Respiratory Nurse).”


Respiratory Therapy services are for the:


  • Assessment,
  • Treatment,
  • Monitoring


of patients with deficiencies or abnormalities of pulmonary function.


Respiratory Therapy services include services provided by a Respiratory Therapist or Trained Respiratory Nurse:


  • Coughing,
  • Deep Breathing,
  • Heated Nebulizers,
  • Aerosol Treatments,
  • Assessing Breath Sounds, and
  • Mechanical Ventilation,,


  • Does not include hand-held medication dispensers.


Trained Nurses can provide Respiratory Therapy. However, the RAI User’s Manual does not specifically define a “Trained Respiratory Nurse,” hence, HHI recommends that the facility seek guidance from their respective State Practice Acts and review that Nurses are practicing:


  • According to scope of practice as defined by the State Specific Board for Nursing.
  • According to Facility Policy.


(For example, the State of New York does not allow MDS coding of the minutes provided by an LPN performing lung sounds. Per the NY state practice acts, LPNs cannot assess. This is not the case in every state.)


The RAI User’s Manual defines the Trained Respiratory Nurse as:


“One who received education in


respiratory services and assessment through formal training or during nursing education.”


Harmony Healthcare International, Inc. (HHI) recommends Respiratory Therapy Competencies. This is to demonstrate that the nurse is competent and received education on delivering Respiratory Therapy services.



Mark your calendars for February 6th - 8th!
We're hosting a 3 day intensive Respiratory Professional certification course featuring
Gary Y.G. Wong, RRT, MBA


Gary Wong is on a mission to help skilled nursing facilities develop a revenue generating post-acute care weaning and decannulation program in their medical communities to help their acute care hospitals free needed ICU beds and ventilators. As a healthcare administration industry leader and a Registered Respiratory Therapist, he has over 42 years of clinical operations and business development experience which helps his clients with unique advantages. He has helped two skilled nursing facilities in Hawaii develop post-acute care weaning and decannulation programs that are modeled after therapist- implemented patient specific protocols, post-acute care trained Respiratory Therapist staffing, and the use of continuous respiratory monitoring technology as found in a Long-Term Acute Care Hospital (LTACH).

Respiratory Professional CHHI-Respiratory (3-Day) - February 6 - 8, 2023




Topics: Respiratory Therapy

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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