Harmony Healthcare Blog

Respiratory Therapy: MDS Coding, Criteria and Qualified Professional

Posted by Kris Mastrangelo on Tue, Mar 06, 2018

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Photo of elderly patient having professional care at hospital.jpegRespiratory Therapy rendered in a Skilled Nursing Facility Nurse is a common area of discussion related to the coding the MDS.  Accuracy 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 blog is to distill and synthesize the framework for a better understanding. 

MDS Coding


Qualified Professional

  1. MDS Coding
    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 only the time the Nurse is with the Resident:

      • Assessing
      • Teaching
      • Training
      • Incentive Spirometry
      • 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 plan for the intervention. 

Harmony Healthcare International (HHI) reiterates the importance of what constitutes 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 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 that respiratory therapy was provided for 15 minutes or more. Therefore, O0400D equals zero days.

Harmony Healthcare International (HHI) suggests documenting the nurse 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 which includes assessing and obtaining patients oxygen saturation, assessing any use of oxygen and flow volume to maintain oxygen saturations.  

Download the Respiratory Therapy Flowsheet

  1. Criteria 

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 treatment;
  • The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by qualified personnel (See Glossary in Appendix A for definitions of respiratory, psychological and recreational therapies);
  • The services are required and provided by qualified personnel (See Glossary in Appendix A for definitions of respiratory, psychological and recreational therapies);
  • The services must be reasonable and necessary for treatment of the resident’s condition. 
  1. Qualified Professional

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, 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. Does not include hand-held medication dispensers." 

Because the RAI User’s Manual does not specifically define a “Respiratory Nurse,” Harmony Healthcare International (HHI) recommends that the facility seek guidance from the State Practice Act in their respective state and review that nurses are practicing: 

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

The RAI User’s Manual defines the trained nurse as one who received education in delivering respiratory services and assessment.  This may be through formal training or during nursing education. 

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

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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7th Annual LTPAC Symposium
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