Tenn. Comp. R. & Regs. 1200-13-02-.04 - CONDITIONS FOR REIMBURSEMENT OF ENHANCED RESPIRATORY CARE

(1) The NF must enter into a provider agreement with one (1) or more TennCare MCOs for the provision and reimbursement of Enhanced Respiratory Care (ERC) in a dual certified and licensed SNF/NF.
(a) A TennCare MCO shall, pursuant to T.C.A. § 71-5-1412, contract with any NF for the provision of Medicaid NF services, but shall not be obligated to reimburse any NF for ERC.
(b) Unless an exception is granted, a TennCare MCO shall not reimburse any NF for ERC unless such NF was contracted by the MCO for ERC Reimbursement as of July 1, 2016. An MCO may request an exception from TennCare to the moratorium on reimbursement for ERC upon the MCO's demonstration of the need for additional capacity or improved quality in the geographic area in which the NF is located, and the NF's compliance with all applicable conditions of ERC Reimbursement specified in this rule.
(2) The SNF/NF providing ERC services must be dual certified for the provision of Medicare SNF and Medicaid NF services, showing it has met the federal certification standards. Any NF providing ERC services in the TennCare Program shall be terminated by all TennCare MCOs as a TennCare provider if certification or licensure is canceled by CMS or the State.
(3) NFs providing ventilator weaning or chronic ventilator services and NFs receiving short-term reimbursement at the Sub-Acute Tracheal Suctioning Rate for a person who has just been weaned from the ventilator, but who still requires short-term intensive respiratory intervention, shall also meet or exceed the following minimum standards:
(a) The NF shall ensure that medical direction of all Ventilator Weaning, Chronic Ventilator Care, and Sub-Acute Tracheal Suctioning services is provided by a physician licensed to practice in the State of Tennessee and board certified in pulmonary disease or critical care medicine as recognized by either the American Board of Medical Specialties or American Osteopathic Association, as applicable.
(b) A licensed respiratory care practitioner, as defined by T.C.A. § 63-27-102, shall be on site in the ventilator care unit twenty-four (24) hours per day, seven (7) days per week to provide:
1. Ventilator care;
2. Administration of medical gases;
3. Administration of aerosol medications; and
4. Diagnostic testing and monitoring of life support systems.
(c) The NF shall ensure that an appropriate individualized Plan of Care (POC) is prepared for each resident receiving Ventilator Weaning, Chronic Ventilator Care, or Sub-Acute Tracheal Suctioning. The POC shall be developed with input and participation from the medical director of the NF's ERC program as described in Subparagraph (a).
(d) The NF shall establish admissions criteria to ensure the medical stability of ventilator-dependent residents prior to transfer from an acute care setting. The NF shall maintain documentation regarding the clinical evaluation of each resident who will receive ERC for appropriateness of placement in the facility prior to admission.
(e) End tidal carbon dioxide (etCO2) or transcutaneous monitoring of carbon dioxide and oxygen (tcCO2) and continuous pulse oximetry measurements shall be available for all residents receiving Chronic Ventilator Care and provided based on the needs of each resident. For residents receiving Ventilator Weaning or Sub-Acute Tracheal Suctioning, continuous pulse oximetry shall be provided, and end tidal Carbon Dioxide (etCO2) measurements shall be provided no less than every four (4) hours, and within one (1) hour following all vent parameter changes, or for residents receiving Sub-Acute Tracheal Suctioning, after all tracheostomy tube changes, tracheostomy capping trials, or the use of speaking devices.
(f) An audible, redundant external alarm system shall be connected to emergency power and/or battery back-up and located outside the room of each resident who is ventilator-dependent for the purpose of alerting staff of resident ventilator disconnection or ventilator failure.
(g) Ventilator equipment (and ideally physiologic monitoring equipment) shall be connected to back-up generator power via clearly marked wall outlets.
(h) Ventilators shall be equipped with adequate back-up provisions, including:
1. Internal and/or external battery back-up systems to provide a minimum of eight (8) hours of power;
2. Sufficient emergency oxygen delivery devices (i.e., compressed gas or battery operated concentrators);
3. At least one (1) battery operated suction device available per every eight (8) residents on mechanical ventilator or with a tracheostomy; and
4. A minimum of one (1) patient-ready back-up ventilator which shall be available in the facility at all times.
(i) The NF shall be equipped with current ventilator technology to encourage and enable maximum mobility and comfort, ideally weighing less than fifteen (15) pounds with various mounting options for portability (e.g., wheelchair, bedside table, or backpack).
(j) The facility shall have an emergency preparedness plan specific to residents receiving ERC (i.e., Ventilator Weaning, Chronic Ventilator Care, or Sub-Acute Tracheal Suctioning) which shall specifically address total power failures (loss of power and generator), as well as other emergency circumstances.
(k) The facility shall have a written training program, including an annual demonstration of competencies, for all staff caring for residents receiving ERC (i.e., Ventilator Weaning, Chronic Ventilator Care, or Sub-Acute Tracheal Suctioning), which shall include alarm response, positioning and transfers, care within licensure scope, and rescue breathing.
(4) A NF must be operating in compliance with all of the conditions specified in Paragraph (3) in order to be eligible for ventilator Weaning, Chronic Ventilator Care, or Sub-Acute Tracheal Suctioning Reimbursement.
(5) The standards set forth in Paragraph (3) are not applicable for Secretion Management Tracheal Suctioning Reimbursement; however, the NF must meet standards specified in Paragraph (6) below for Secretion Management Tracheal Suctioning Reimbursement.
(6) A NF contracted with one or more TennCare MCOs to receive only Secretion Management Tracheal Suctioning Reimbursement shall meet or exceed the following minimum standards:
(a) A licensed respiratory care practitioner as defined by T.C.A. § 63-27-102, shall be on site a minimum of weekly to provide:
1. Clinical Assessment of each resident receiving Secretion Management Tracheal Suctioning (including Pulse Oximetry measurements);
2. Evaluation of appropriate humidification;
3. Tracheostomy site and neck skin assessment;
4. Care plan updates; and
5. Ongoing education and training on patient assessment, equipment and treatment.
(b) The NF shall ensure that an appropriate individualized POC is prepared for each resident receiving Secretion Management Tracheal Suctioning. The POC shall be developed with input and participation from a licensed respiratory care practitioner as defined by T.C.A. § 63-27-102. Medical direction, including POC development and oversight for persons receiving Sub-Acute Tracheal Suctioning shall be conducted according to Paragraph (3).
(c) The NF shall establish admissions criteria which meet the standard of care to ensure the medical stability of residents who will receive Secretion Management Tracheal Suctioning prior to transfer from an acute care setting. The NF shall maintain preadmission documentation regarding the clinical evaluation of each resident who will receive Secretion Management Tracheal Suctioning for appropriateness of placement in the facility.
(d) Pulse oximetry measurements shall be provided at least daily with continuous monitoring available, based on the needs of each resident. For any resident being weaned from the tracheostomy, the following shall be provided:
1. Continuous pulse oximetry monitoring; and
2. End tidal Carbon Dioxide (etCO2) measurements at least every four (4) hours and within one (1) hour following tracheostomy tube changes, tracheostomy capping trials, or the use of speaking devices. Transcutaneous (tcCO2) shall not be appropriate for intermittent monitoring.
(e) Mechanical airway clearance devices and/or heated high flow molecular humidification via the tracheostomy shall also be available for secretion management, as appropriate for the needs of each resident.
(f) Oxygen equipment shall be connected to back-up generator power via clearly marked wall outlets.
(g) Adequate back-up provisions shall be in place including:
1. Sufficient emergency oxygen delivery devices (i.e., compressed gas or battery operated concentrators); and
2. At least one (1) battery operated suction device available per every eight (8) residents on mechanical ventilation or with a tracheostomy.
(h) The facility shall have an emergency preparedness plan specific to residents receiving Secretion Management Tracheal Suctioning which shall specifically address total power failures (loss of power and generator), as well as other emergency circumstances.
(i) The facility shall have a written training program, including an annual demonstration of competencies, for all staff caring for residents receiving Secretion Management Tracheal Suctioning which shall include alarm response, positioning and transfers, care within licensure scope, and rescue breathing.
(7) When a NF establishes a "Tracheostomy Unit" by accepting Tracheal Suctioning Reimbursement, including Sub-Acute and Secretion Management, for more than three (3) residents on the same day, the licensed respiratory care practitioner described in Subparagraph (6)(a) shall be on site a minimum of daily for assessment, care management, and care planning of residents receiving Tracheal Suctioning.
(8) A NF must be operating in compliance with all of the conditions specified in Paragraph (6) in order to be eligible for Secretion Management Tracheal Suctioning Reimbursement.
(9) Eligibility for and access to ERC services by individuals from out-of-state is governed by 42 C.F.R. § 435.403. A NF shall not recruit individuals from other states to receive ERC in Tennessee. A NF shall not be eligible to receive TennCare reimbursement for ERC services for a resident placed by another state or any agency acting on behalf of another state in making the placement because such services are not available in the individual's current state of residence, including residents admitted to the NF/SNF under the Medicare Skilled Nursing Facility care benefit when such benefit has been exhausted. The NF shall be responsible for arranging, prior to the resident's admission to the facility, Medicaid reimbursement for ERC services from the Medicaid Agency of the state which placed the resident and which will commence when other payment sources (e.g., Medicare, private pay, but not TennCare) have been exhausted.
(10) If the resident has available resources to apply toward payment, including Patient Liability or TPL, which may include LTC insurance benefits, the payment made by TennCare is the per diem rate established by TennCare minus the resident's available resources.

Notes

Tenn. Comp. R. & Regs. 1200-13-02-.04
Original rule filed January 18, 1979; effective March 5, 1979. Amendment filed March 8, 1983; effective April 7, 1983. Amendment filed March 8, 1984; effective June 12, 1984. Amendment filed June 2, 1988; effective July 17, 1988. Repeal filed May 5, 2009; effective July 19, 2009. New rules filed May 1, 2018; effective 7/30/2018.

Authority: T.C.A. §§ 4-5-202, 14-1905, 14-23-105, 14-23-109, 71-5-105, 71-5-109, and 71-5-1413.

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