Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 22 - RESPIRATORY THERAPY SERVICES
Section 471-22-005 - BILLING AND PAYMENT FOR RESPIRATORY THERAPY SERVICES

Universal Citation: 471 NE Admin Rules and Regs ch 22 ยง 005

Current through September 17, 2024

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with ail applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this 471 NAC 22, the individual billing requirements in 471 NAC 22 will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i) PROCEDURE CODES. The provider must use the appropriate American Medical Association's Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure codes when billing Nebraska Medicaid.

005.01(B)(ii) REQUIRED CLAIMS. Depending on the place of service, the provider must bill as follows:
(1) If the service is provided in a hospital, the hospital makes payment to the respiratory therapist. The hospital submits claims to Nebraska Medicaid for respiratory therapy services provided in the hospital to inpatients and outpatients using the appropriate claim form or electronic format; or

(2) If the service is provided in a long term care facility, the facility must contract for services not readily available in the facility. Depending on the type of provider, reimbursement is claimed as follows:
(a) If services are provided by another licensed hospital or rehabilitation agency, the long term care facility makes payment to the provider. The long term care facility is reimbursed for the payment as an allowable cost under the long term care reimbursement plan; or

(b) If services are provided by a facility staff member or by an individual under contract to the facility, the long term care facility makes payment to the individual. The facility is reimbursed under the long term care reimbursement plan.

005.01(B)(iii) DOCUMENTATION. Respiratory therapy services are subject to pre-or post payment utilization reviews. To help determine medical necessity for the treatments provided fay the therapist, the following documentation must accompany each outpatient hospital claim:
(1) A copy of the respiratory therapist's progress notes and anticipated goals; and

(2) Information on the claim or as an attachment that includes:
(a) The location where the services were provided:

(b) The date of onset of the patient's condition: and

(c) The patient's diagnosis.

005.02 PAYMENT.

005.02(A). GENERAL PAYMENT REQUIREMENTS. The Department will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAG 3. in the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this 471 NAC 22, the individual payment regulations in 471 NAC 22 will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Nebraska Medicaid does not reimburse the respiratory therapist directly; payment is made to the hospital or nursing home. Nebraska Medicaid may make exceptions to this policy. Prior authorization by Nebraska Medicaid is required in order to make direct payment to the respiratory therapist.
005.02(B)(i) PAYMENT FOR HOSPITAL SERVICES. See 471 NAC 10.

005.02(B)(ii) PAYMENT FOR NURSING HOME SERVICES. See 471 NAC 12.

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