Cal. Code Regs. Tit. 22, § 51316 - Respiratory Care Services
(a)
Respiratory care services provided by respiratory care practitioners acting
within their scope of practice, upon the written prescription of a physician or
surgeon, are covered as Medi-Cal benefits subject to the following:
(1) The respiratory care service is within
accepted respiratory treatment modalities and considered to be specific and
effective treatment for the beneficiary's condition; and
(2) The respiratory care service is shown to
be medically necessary for the treatment of the beneficiary's condition
pursuant to Section
51303.
(b) Reimbursement will not be made for:
(1) respiratory care procedures which are
included within other procedure codes;
(2) training in the use of durable medical
equipment or devices related to respiratory care reimbursed to any other
provider; or
(3) teaching or
training of patients or care givers to administer intermittent positive
pressure breathing (IPPB).
(c) Except as otherwise noted, respiratory
care services are subject to prior authorization.
(d) One respiratory care evaluation (code
number X4700) of a patient with an acute respiratory illness, or respiratory
problem in a six (6) month period, is covered without prior authorization
unless reimbursement for a comparable examination has been made to the
patient's physician within six months. Additional evaluations within a six (6)
month period require medical justification and are subject to prior
authorization. A respiratory care evaluation or reevaluation includes but is
not limited to:
(1) review of the
effectiveness of current and past medical treatment including services, items,
or equipment related to the patient's respiratory condition;
(2) development, in conjunction with a
physician, of a treatment plan to address the patient's respiratory condition,
or to prevent or substantially shorten an anticipated hospital stay;
and
(3) any other appropriate
assessments or measurements of the patient's respiratory system not already
covered under other service codes which are within the respiratory care
practitioner's scope of practice and are related to the patient's current
treatment plan.
(e)
Participation in an organized respiratory care case conference (code number
X4702) with other health team members immediately involved in the care or
recovery of the patient is reimbursable only when the following criteria are
met:
(1) The respiratory care case conference
must be documented as medically necessary pursuant to Section
51303.
(2) Documentation in the patient's medical
record must include the status or progress of the patient as well as the
proposed treatment plan agreed upon in the respiratory care case
conference.
Notes
Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14509 and 14132, Welfare and Institutions Code.
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