Question:
Can you provide any basic guidelines regarding the required documentation for separately reporting inpatient RT?
Answer:
In general, the guideline for inpatient services states that separately reportable services must be supported by documentation in the medical record indicating the need (medical necessity) and the frequency that the service is provided. An auditor’s expectation would be that a patient’s condition would improve resulting in a change in therapy and a decrease in services provided and therefore billed. Respiratory therapy services must be consistent with the severity of the patient’s documented illness and must be reasonable in terms of modality, amount, frequency, and duration or treatment.
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