Respiratory Therapy Capture on the MDS

Key Requirements in the RAI User's Manual v1.20.11, Effective Oct. 1, 2026

Accurate respiratory therapy capture on the MDS begins with determining whether the services meet the requirements for skilled respiratory care. Before validating O0400D, Respiratory Therapy, for reimbursement and assessment accuracy, facilities must review O0390D, Respiratory Services. Documentation must establish the resident's clinical need, the qualifications of the person providing care, and the skilled treatment time that supports coding.

Establishing the clinical foundation

Under the MDS 3.0 RAI User's Manual v1.20.11, effective Oct. 1, 2026, respiratory services must be medically necessary and provided after admission or readmission to the nursing home. A physician or authorized practitioner, including a physician assistant, nurse practitioner, or clinical nurse specialist, must order the services based on an assessment by a qualified respiratory therapist or respiratory nurse. The assessment and treatment plan must be documented in the resident's medical record.

The order must specify the frequency, duration, and scope of treatment. Services must be directly and specifically related to an active written treatment plan based on an initial evaluation by a qualified person. After a hospital stay, a qualified person must perform an initial evaluation after the resident enters or reenters the facility. The care plan must include respiratory care, including an assessment-based problem statement, measurable goals, and resident-specific interventions. A goal to "increase lung capacity" is not sufficient to demonstrate the resident's baseline, goals, or progress toward the goal. The qualified person must periodically evaluate whether the resident still needs the services and whether the treatment plan remains effective.

The record should demonstrate why the services are reasonable and necessary for the individual resident's condition. Respiratory therapy addresses the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function. An order alone does not establish that every activity performed constitutes skilled respiratory therapy.

Determining which minutes qualify

A reportable day requires at least 15 minutes of skilled respiratory therapy in each 24-hour day. To code O0390D, this threshold must be met on one or more days during the seven-day look-back period. Only time the respiratory therapist or respiratory nurse spends with the resident providing qualifying skilled services counts toward the daily total. Time spent documenting care is excluded.

Qualifying time may include resident evaluation and assessment, treatment, administration and monitoring, and setup and removal of treatment equipment when the activities meet skilled therapy requirements. The service must require the skills, knowledge, and judgment of a qualified person. Therapy may occur inside or outside the facility, but only services provided while the individual is a resident of the nursing home may be coded.

Respiratory modalities may include coughing, deep breathing, qualifying nebulizer-related services, assessment of breath sounds, and mechanical ventilation. The presence of a modality does not, by itself, establish that the time qualifies. Facilities must apply the skilled-service criteria to the actual care provided.

Recognizing excluded activities

Time when a resident self-administers or receives a nebulizer treatment is not included in the skilled respiratory therapy total. Facilities should distinguish this treatment time from any separately qualifying skilled assessment, administration, or monitoring performed by the respiratory therapist or respiratory nurse.

Maintenance or prophylactic incentive spirometry without clinically indicated or medically necessary supervision by a respiratory therapist or respiratory nurse is also excluded. Administration of metered-dose inhalers and dry powder inhalers does not qualify. Routine respiratory activities should not be counted simply because they appear on the medication or treatment administration record.

Applying the requirements to O0400D

O0400D may be coded only when respiratory therapy is coded in O0390D. The applicable therapy coding guidance from O0390D must also be applied to O0400D. Enter the number of days during the seven-day look-back period on which the resident received at least 15 minutes of qualifying skilled respiratory therapy. A day with fewer than 15 qualifying minutes does not meet the definition of a therapy day.

Building a record that supports validation

The medication administration record, treatment administration record, or other supporting documentation must identify the exact minutes of qualifying care provided. The record should connect those minutes to the resident's assessed needs, ordered treatment, and active treatment plan so reviewers can determine whether the daily threshold was met.

Facilities must also establish the credentials of the personnel providing treatments and performing required assessments on the MAR, TAR, or other respiratory treatment log, including the resident's response to treatment and progress toward goals. When a respiratory nurse provides services, maintain support that the nurse is proficient in the respiratory treatment modalities provided and that the practice is permitted under the applicable State Nurse Practice Act and other state laws.

This information may be requested by a CMS contractor, Medicare Advantage plan, state Medicaid auditor or contractor, state surveyor, or Quality Improvement Organization.

Accurate capture depends on a complete clinical record: medically necessary services, an individualized assessment and treatment plan, qualified personnel, and documented skilled minutes. Reviewing these elements before coding helps facilities support both MDS accuracy and reimbursement validation.

Alicia Cantinieri, MBA, BSN, RN, CHC, RAC-MT, RAC-CTA, DNS-CT, QCP, is the managing director, clinical reimbursement and regulatory compliance, Zimmet Healthcare Services Group.

Comments or question? Contact Patrick Connole at pconnole@parkplacelive.com.