Isn’t All Ventilator Care ‘Clinical'?

HQAA fields quite a few questions about ventilator care and whether or not the care is “clinical” in nature or non-clinical.  It may be helpful to clarify some points about ventilator care and review the definition of clinical respiratory services. 

Medicare and most insurances pay for ventilator care by renting a ventilator for a given patient.  Often, the supplies associated with the ventilator, such as tubing, humidifiers, and filters are expected to be included in that rental fee.  Ancillary equipment and supplies, such as suction machines and catheters may be paid for separately.  Oxygen, often used in conjunction with ventilators is typically a separate piece of equipment and a separate billing code.  Note that “care” –for our discussion, the service associated with this equipment and these supplies—is typically not covered. 

Depending on factors such as local traditions, the requests (or demands) of the referral source, and whether or not a home health agency is involved in the patient’s care, the durable medical equipment company providing the rental equipment and supplies may or may not be expected to provide clinical care in conjunction with the ventilator. 

HQAA defines clinical respiratory services (CRS) as hands on care, assessment, or treatment, governed by state regulations including Respiratory Practice Acts and Licensure Laws.  It is usually physician-prescribed in conjunction with medical equipment services.  And it typically isn’t covered, so it’s usually a free service offered by the DME.  

With ventilators, there are a wide range of services including therapy, assessment, and diagnostic testing that are considered CRS.  They include (but are not limited to):

• Obtaining weaning parameters and measurement of spontaneous breathing effort
• Titrating settings on the ventilator based on blood gases, oxygen saturation, and even comfort/subjective feeling
• Measuring oxygen saturation (pulse oximetry) and CO2 levels (end tidal CO2)
• Physical assessment, such as measuring pulse, blood pressure, or respiratory rate
• Chest auscultation with stethoscope
• Tracheal tube changes

Sounds pretty straightforward, right?  Turns out that there are many gray areas.  For instance, RT’s doing follow up that only considers equipment settings or ventilator maintenance issues are NOT doing CRS.  But if they document anything about how the patient is tolerating the ventilator care, they may slide down that slippery slope toward CRS.  For instance, charting on a follow up visit that the patient “seems to be tolerating the new settings well” could imply or be construed to be using clinical knowledge and their RT skills. 

The good news is that providing CRS is not difficult and the standards of providing that care and not particularly onerous.  These requirements include:

• For any clinical care, you need a physician order, which typically takes the form of a “treatment plan”.
• To provide the prescribed care, you’ll need trained, competent, and appropriately licensed RT’s. Check the licensure laws in your state carefully.  Be careful if you provide this care across state lines—in that case you may need multiple state licenses. 
• Follow the American Association for Respiratory Care (AARC) Clinical Practice Guidelines (CPG’s). This set of guidelines are a roadmap for what best practices are out there in the clinical community.  They aren’t law, but they are strong set of suggestions by a professional body of RT peers, who are quite expert at what they do.
• RT’s should be on call and available 24/7 within your organization.
• RT’s should document their clinical follow up in progress notes or updates to the care plan. Make sure your policy & procedure spells out how the RT should conduct the visit and how to document the visit as well. 
• Finally, list the services you provide in a scope of service document. This serves as a vehicle to tell your referral sources what services you offer and also helps keep your staff on the same page.  If you have multiple RT’s, you want them all adhering to the same set of rules, standards, and policies. 

Clinical care, despite the fact that it is typically not covered or reimbursed, can be a useful adjunct to equipment rental services.  Furthermore, it can set you apart from your competition and establish a good reputation for you in your local community. If you decide to provide it, market the clinical program to referral sources, who may be looking for just such a service.