Facility charges for daily respiratory therapy services will be prorated

Blue Cross Blue Shield of Michigan and Blue Care Network are prorating daily respiratory therapy services by hours used, not to exceed 24 hours in a single day. We communicated this in a January 2021 Record article titled “Facilities required to prorate respiratory therapy services.”

Providers have told us that they’re unable to bill respiratory therapy on an hourly basis. Therefore, we’ll manually prorate the service and won’t reimburse the full charge.

This reimbursement policy is effective Jan. 1, 2021, for Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ members. It applies to an inpatient setting only.

The following is a list of general respiratory therapy services applicable to this billing policy:

• All types of ventilators
• Continuous Positive Airway Pressure, or CPAP
• Bilevel Positive Airway Pressure, or BIPAP
• All types of oxygen

Billing guidance

If, on a single day of service, a patient is on the ventilator for five hours and then weaned to CPAP for the remaining 19 hours of the day, Blue Cross and BCN will only provide reimbursement for those hours used for each modality. Currently, services are billed at a daily rate, regardless of hours used.

Background

Respiratory therapy services are services prescribed by a physician or a non-physician practitioner for the assessment and diagnostic evaluation, treatment, management and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. This reimbursement policy isn’t intended to affect physician decision-making; providers are expected to apply medical judgment when caring for all members.