Medicare Respiratory Therapy Initiative Frequently Asked Questions

February 17, 2009

What is Medicare Part B?
The Medicare program is divided into Parts A-D. Part A includes hospital inpatient services, Part C deals with managed care, and Part D is the new prescription drug benefit. Part B includes medical services generally delivered in the outpatient setting by physicians’, physician assistants, nurse practitioners, clinical nurse specialists, and physical therapists, to name a few. Although Medicare Part B recognizes a number of non-physician practitioners and the services they provide, it does not include respiratory therapists and the services they furnish.

To fully understand this complex subject, we suggest you review the AARC’s Reimbursement College.

What is the AARC’s Medicare RT Initiative?
We are asking Congress to recognize qualified respiratory therapists and the services they furnish by amending the statute to include a new and separate benefit category for respiratory therapy services under the Medicare Part B “medical and other health services” provision.

How would this be done?
Congress has to pass legislation in order to revise any portion of the Medicare statute. Although our legislation was introduced during the last Congress, we will need to get Congress to re-introduce and pass our changes into law, working with new Congressional leaders and staff.  Therefore this Initiative will be a key element of our legislative agenda.

How does this relate to the other issues AARC has pushed in its legislative agenda?
We are not abandoning our previous Congressional legislative agenda by any means. This is a more expansive and comprehensive strategy than our previous efforts. We will continue our work on other key health issues, including [working with our Tobacco Prevention Partners on pushing for legislation to exert greater regulation over tobacco products, and other as yet undetermined issues that will no doubt come up.

What exactly is AARC proposing?
Briefly, we are proposing to revise the Medicare statute to add recognition of respiratory therapy services as a separate Medicare Part B benefit and to permit qualified respiratory therapists to provide respiratory therapy services under the general supervision of a physician.

But, respiratory therapy services are provided in a number of settings now. Why change the law?
Under the law today, there are limited Medicare benefits that permit respiratory therapy services to be furnished outside of the institutional setting.  Generally, RT services are permitted if they are “incident to” a physician’s professional service or they are part of another benefit category such as the Comprehensive Outpatient Rehabilitation Facility (CORF) benefit.   We want to make sure that RT services are a stand alone benefit and that qualified RTs working in physician’s offices have the flexibility to treat patients when the physician is absent.

Can’t RTs do that now?
No. In Medicare terms, the provision of the law known as “incident to” a physician’s professional service requires that RTs must work under the direct supervision of a physician. “Direct supervision” means that the physician must be physically present in the office suite and be immediately available to provide assistance to the RT performing the services. Under “general” supervision, our change would allow the physician to see patients outside of the office setting because the qualified RT would be able to furnish RT services without the physician being there, although the physician would still need to be available for consultation by phone.

In simple terms, when the qualified RT furnishes the service without the physician being present, it would be as though the physician provided that respiratory therapy service.

Why is that such a big issue?
By changing the law, physicians will have much more flexibility to treat their patients with qualified personnel so they don’t have to be in the office for extended periods of time.  And, this new benefit category will provide an avenue for qualified respiratory therapists to provide RT services in ways they couldn’t before.

Most important, in setting Medicare coverage and payment rules, the Centers for Medicare and Medicaid Services (CMS), the agency that administers the Medicare program, can no longer point to the statute and say that there is no benefit category that recognizes respiratory therapy services.

The delivery of health care services has changed a lot over the years since the Medicare statute was first enacted. This is especially true for pulmonary medicine and the delivery of respiratory therapy services. Medical evidence supports the efficacy of services such as disease management, smoking cessation, proper education on aerosol device delivery systems, and office-based spirometry. Services that once could only be provided in an acute hospital setting are being delivered in alternate care sites.  For example, 25 years ago it would have been hard to imagine ventilator patients being cared for in the home setting.

You keep referring to “qualified respiratory therapists.” What do you mean?
In order for an RT to furnish services under the change we are proposing to Congress, the RT would not only have to be credentialed and legally authorized to perform RT services in the State in which the service is furnished, but they would also have to be a “registered” respiratory therapist (RRT) and hold a bachelor’s degree. This is an important distinction because it will effectively give respiratory therapists recognition under Medicare Part B's program similar to other non-physician practitioners such as nurse practitioners, physician assistants, and clinical nurse specialists, all of whom have a minimum of a bachelor’s degree or master’s degree and advanced professional credentials.

Why are you limiting the benefit to only Registered RTs with a bachelor’s degree?
We want to make sure that any request we make to Congress to change the Medicare law is credible. In order to do that, we need to make sure that the credentials of the RT are comparable to the credentials of other professionals who can provide services under Medicare Part B. For example, the services of a clinical nurse practitioner, clinical nurse specialist, and clinical registered nurse anesthetist are just some of the medical services recognized as separate Medicare Part B benefits, and in many cases these benefits require the health professional to have an advanced degree to become qualified. Therefore, we feel that at a minimum the RT must have the title of “registered” and hold a bachelor’s degree in order to qualify for this new benefit.

Can the qualified RT start his or her own independent practice?
No. Current Medicare law doesn’t permit it and neither will our proposed legislative change. The qualified RT still has to work for a physician and be under some type of physician supervision.

So, under the proposed change, can the qualified RT bill Medicare directly?
No.  The services of a qualified RT still have to be billed by the physician.  What would change is that the physician and/or RT would have to have some type of identifier or modifier so that when the physician submits the bill, Medicare has some way of knowing that the RT furnished the service instead of the physician. The difference between what happens now and what would happen if new legislation were enacted revolves around the level of physician supervision and payment to the physician.

For example, under current law, if the physician provided an RT service directly or had an RT furnish the service as “incident to” the physician’s professional service, Medicare would pay the physician based on 100% of the physician fee schedule amount for that service. Under the new legislation, if the qualified RT furnishes an RT service and the physician is not in the office when the service is performed, the physician would still be paid as though he or she furnished the service, but the payment amount would be based on 85% of the allowable amount under the physician fee schedule because the physician wasn’t directly involved when the service was provided.

If the physician would get less money when a qualified RT performs an RT service under the “general” supervision rule, what is the incentive to hire the qualified RT in the first place?
Under our Initiative, the big incentive for the physician is that it allows more flexibility and frees up his/her time to see other patients outside of the office setting. And, the qualified RT would now be recognized by Medicare as a non-physician practitioner who can furnish services without the need for the physician to be physically present when the service is being furnished. Using the example mentioned above, the physician could be doing rounds outside of the office and the RT could be providing the RT services the physician might otherwise be providing.  And that makes a huge difference.

Can the qualified RT be an independent contractor and work for more than one physician?
Yes, the qualified RT could be an independent contractor to the physician. In other words the RT wouldn’t have to be a full-time employee of one physician’s office. The RT could work for several physicians. For example, the RT could contract with one doctor’s office to provide asthma education to a physician practice on Tuesdays and Thursdays and work with another practice on Friday providing the same or different service.

I already work in a physician’s office.  How will this affect me?
If you work in a physician’s office now under Medicare’s “incident to” a physician’s professional service benefit, our legislative initiative will not affect your current status. In other words, CRTs or RRTs without a bachelor’s degree who currently work in a physician’s office in which the physician is required to provide “direct” supervision would continue to do so. This benefit does not change with our Initiative.

If I work in a physician office practice and don’t’ meet the criteria for a qualified RT, will I lose my job?
No. You will not lose your job if you don’t have the credentials we are proposing in our Initiative. Nothing in our Initiative mandates that the physician employ a registered respiratory therapist (RRT) with a bachelor’s degree. We are simply advocating it is an option for the physician to permit more flexibility in how the practice is run.  It is up to the physician to decide the circumstances under which he/she chooses to invoke the “direct” versus “general” supervision rules and the qualifications of the staff that meet the individual supervision criteria.

If Congress enacts this Medicare RT Initiative, what services do you see the qualified respiratory therapist providing?
Respiratory therapists are rapidly moving into areas such as disease management, patient education on the selection of appropriate aerosol devices, education on the devices and use of medications and patient compliance with the aerosol meds, office spirometry, smoking cessation and asthma management.  In  order for qualified RTs to provide smoking cessation under the “general’ supervision of a physician, CMS will need to amend the coverage criteria under its separate Medicare Part B smoking cessation benefit to include the new respiratory services benefit category if Congress enacts our Initiative. We will work with CMS to make sure this change takes place.

I’m a respiratory therapist who doesn’t meet the criteria. Why should I work and lobby for this since you are leaving me out of the provisions?
It is important for you to support this Initiative because Medicare recognition of RT services under Part B enhances both the profession and the respiratory therapist. It expands what the profession can do and it gives visibility to the respiratory therapist that does not exist under the current law.

The change could also enable us to track and collect data on the services that qualified RTs may provide, because Medicare will be able to identify such services for the first time. One of the challenges the respiratory profession has had over the years is having hard data on how the profession has clinically impacted patients’ health, their quality of care and their clinical outcomes. The new benefit could help us collect data that will provide further irrefutable evidence of the efficacy of respiratory therapy services and the benefits that result from such services being provided by all respiratory therapists.

I’m a respiratory therapist who works in the hospital. This Initiative impacts respiratory therapists who work primarily in a physician office practice. Why should I care and work for this?
We see the Initiative as opening up new employment opportunities and career advancement for the respiratory therapist. It enhances the profession and raises the stature of the respiratory therapist. And, that will benefit you. You may one day want to work outside the hospital and as a qualified RT a new door would be opened. Even if you always choose to be employed in the hospital, your colleagues might want to move on and be employed in a physician office practice with greater independence. If enacted, this Initiative will do just that.

The Medicare Durable Medical Equipment (DME) benefit is a Part B benefit. Will home care equipment companies be required to hire the qualified RT if they are employing RTs right now?
No. The DME benefit is a separate benefit with its own rules and regulations and our Initiative has no impact on it. The DME benefit primarily covers medically necessary equipment, such as oxygen and ventilators, and the services and supplies needed to make the equipment work. DME companies can choose, as they do now, whether to employ personnel such as respiratory therapists to assist with the set up, training and maintenance of the equipment, but clinical services are not covered under this benefit, regardless of whether they are provided by an RT, nurse or other clinical professional.

I am employed by a hospital outpatient department, skilled nursing facility, comprehensive outpatient rehabilitation facility, etc. How is this Initiative going to impact my job?
It’s not. Services provided by RTs in these settings now will continue unchanged because they are covered by rules and regulations that govern those sites of care. In accordance with existing Medicare rules, it is up to those agencies or facilities to determine the types of professionals they want to hire and the qualifications of those personnel in accordance with existing Medicare rules. Our Initiative does not impact those choices in any way.

I am a Registered RT with a Bachelor’s Degree. If the law changes and I can provide services in lieu of the physician providing them without the physician being present, just what services can I provide?
You will able to provide those respiratory therapy services that are defined under your state practice act or those in which you are legally authorized to perform by the state and are covered by Medicare.