Medicare Pulmonary Rehabilitation (PR) Benefit Frequently Asked Questions June 2010 (Latest Updates: December 18, 2013 and February 12, 2014)

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1 Medicare Pulmonary Rehabilitation (PR) Benefit Frequently Asked Questions June 2010 (Latest Updates: December 18, 2013 and February 12, 2014) Coverage Criteria Q. CMS has stated that only patients with moderate, severe and very severe Chronic Obstructive Pulmonary Disease (COPD) as defined by the GOLD classification guidelines II-IV can receive PR services under the national benefit. How are these different levels defined? (Revised December 18, 2013 updated GOLD Classification standards) A. When coverage for pulmonary rehabilitation was first established in 2010, it was based on the 2008 GOLD Guidelines. However, the guidelines have recently been updated and the criteria revised. The 2013 GOLD guidelines classify the severity of airflow limitation in COPD (based on post-bronchodilator FEV 1 ) in patients with FEV 1 /FVC < 0.70 as follows: GOLD Classification II: Moderate 50% FEV 1 < 80% predicted GOLD Classification III: Severe 30% FEV 1 < 50% predicted GOLD Classification IV: Very Severe FEV 1 < 30% predicted A Pocket Guide to the 2013 GOLD Classification Guidelines can be accessed at: Q. What happens to patients who were receiving PR services prior to January 1, 2010 and don t meet the COPD criteria? Will they still be able to get coverage? A. Yes. Individual respiratory or pulmonary services previously covered by local Medicare contractors for other medical conditions prior to the effective date of the new PR benefit remain in effect to the extent they are medically necessary for an individual patient (74 FR 61882). Such services, however, should be reported using the appropriate CPT or HCPCS codes identified in the local policies. The G0424 code is used only for the comprehensive PR benefit. Q. What is the difference between the PR program covered under the comprehensive benefit and the local policies that existed before the new provisions went into effect? (Revised December 18, 2013 added G0237-G0239 codes) A. For PR services to qualify under the PR benefit, the program must contain mandatory components that constitute a comprehensive program. According to CMS, individual respiratory services covered by local policies do not constitute a 1

2 comprehensive PR program, but rather are considered individualized services that may be a component of a comprehensive program (74 FR 61881). The mandatory components of a PR program under the national benefit are: Physician-prescribed exercise Education or training Psychosocial assessment Outcomes assessment Individualized treatment plan Individual respiratory services are described as follows and may be covered if determined to be medically necessary for patients that do not meet the GOLD Classification standards. This includes patients who have been diagnosed with COPD but do not meet the moderate, severe or very severe criteria. G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring) G0238 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (including monitoring) It is important to keep in mind that pulmonary rehabilitation is often provided in group sessions in the hospital outpatient setting, although patients commonly require additional one-on-one care in order to participate fully in the program. However, when billing either G0237 or G0238 for individual respiratory services for those patients who do not meet the pulmonary rehabilitation GOLD guidelines, be careful to ensure that the documentation supports face-to-face care, if required. The faceto-face codes are billed in 15-minute increments whereas the G0239 code is a single payment for a group session. (Added February 12, 2014) Q. What happens if the Medicare Contractor has not developed a local coverage determination (LCD) for pulmonary rehabilitation or respiratory therapy services? (Added December 18, 2013) A. It is not uncommon for a Medicare contractor to choose not to develop a LCD for a particular service or procedure, especially if there are national guidelines in place, such as those for pulmonary rehabilitation. In the absence of a LCD, the contractor can choose to review claims for payment on a claim-by-claim basis. It does not mean that a service or procedure is not covered just because a LCD does not exist. In all cases, however, the service or procedure must be determined to be medically necessary in order for payment to be made. Q. Are COPD and non-copd patients permitted to be in same PR program? (Revised February 12, 2014) A. Yes, as long as you adhere to the differences between the coverage and coding policies for the PR benefit versus the local policies. As noted above, for PR services furnished to individuals who meet the COPD criteria under the comprehensive PR benefit, the single code G0424 is used. For individuals who do not meet the diagnosis and coverage criteria for the PR 2

3 benefit, including those with COPD who do not meet the GOLD Guidelines, the criteria and appropriate CPT and HCPCS codes outlined in the local coverage policies apply. These policies generally include codes G0237, G0238 and G0239. Q. Is CMS expected to expand coverage to include other chronic respiratory conditions in addition to COPD in the near future? A. CMS has stated that any additional conditions will be considered under its National Coverage Determination (NCD) process. Use of the NCD process is discussed in the proposed rule at 74 FR and at 74 FR of the final rule. For the record, the NCD process is an entirely different process from the regulatory one CMS used to implement the new PR benefit mandated by law. Although AARC and our sister organizations in the pulmonary community provided substantial scientific evidence to support inclusion of other medical conditions in addition to COPD, such as cystic fibrosis, interstitial lung disease, restrictive chest wall disease, and pulmonary hypertension among others, CMS doesn t believe the clinical data they have reviewed to date substantiates covering conditions beyond COPD on a national basis (74 FR 61881). AARC, in collaboration with the pulmonary community, will continue to work with CMS as well as local contractors in support of expanding coverage as appropriate. Settings Q. I work in a Comprehensive Outpatient Rehabilitation Facility (CORF). Are the PR services I provide in this setting part of the new benefit? A. No. The Medicare CORF benefit is separate and distinct from pulmonary rehabilitation and has its own set of laws, rules and regulations. Since the CORF benefit provides rehabilitative services for the injured, sick and disabled which include a majority of physical therapy, CMS maintains such services are not directed to chronically ill patients such as those with COPD (74 FR 61883). Q. Would a stand-alone physical therapy clinic located in a mall qualify to provide PR services under the new benefit? A. No. There are only two settings that may qualify to furnish PR services under the new Medicare benefit a physician s office and a hospital outpatient department. While the law permits CMS to designate other settings, they have chosen not to do so at this time. Q. Are PR services in a Critical Access Hospital setting covered under the new PR benefit? (Added November 19, 2010) A. Yes. Q. Are there specific requirements that must be met with respect to the PR settings? A. Yes. The settings must have the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment 3

4 and a defibrillator) to treat chronic respiratory disease. The settings must also have a physician immediately available who meets the direct supervision requirement specified in Medicare regulations. The direct supervision issue is discussed more fully in answer to other questions below. Individualized Treatment Plan (ITP) Q. Can the individualized treatment plan (ITP) be developed by the referring physician? A. Yes. The ITP may be developed by the referring physician. However, if the referring physician is not the PR physician, the PR physician must also review and sign the plan prior to initiation of the PR services (74 FR 33613). The important thing to remember is the physician who establishes, signs, and reviews the plan every 30 days must be involved in the patient s care and have knowledge related to his or her condition (74 FR 62002). Q. Can the PR staff develop the ITP and get the PR physician to simply sign it or must the PR physician personally establish the plan? A. The PR staff can provide input in establishing the ITP and recommend modifications to the ITP based on changes in the patient s condition, but the law and the regulations are clear that the physician is ultimately responsible for establishing, reviewing and signing the ITP every 30 days (74 FR 61883). Q. Who is responsible for providing direct patient contact required by the final rules? The physician standards suggest that this is the Medical Director s role but the definition of individualized treatment plan infers it can be the PR physician. A. As we understand it, there is flexibility with respect to this issue. CMS expects the supervising physician or Medical Director to have at least direct contact with the beneficiary in each 30-day period. If the Medical Director is a different individual than the supervising physician (e.g., the Medical Director is more remotely located), the supervising physician would provide the direct contact. The key is that CMS expects supervision and evaluation of the patient rather than a physician simply signing off on the plan. Physician Supervision Q. Does the physician supervising and providing oversight of the PR program (i.e., Medical Director) have to meet certain requirements? A. Yes. The physician who oversees or supervises the PR program (i.e., Medical Director) must meet the following standards: Has expertise in the management of individuals with respiratory pathophysiology; Is licensed by the state in which the services are provided. Is responsible and accountable for the PR program; and 4

5 Is involved substantially, in consultation with staff, in directing the progress of the individual in the program including direct patient contact related to the periodic review of his/her treatment plan. Q. In order to comply with the direct supervision rule, what, if any, requirements does the physician providing that service have to meet and are there any special requirements that apply to the hospital outpatient setting versus the physician s office? (Updated November 19, 2010 revised definition) A. For PR services, direct supervision must be provided by a physician of medicine or osteopathy. Direct supervision in the physician s office: In a physician s office, the physician must be present in the office suite and immediately available and accessible for medical consultations and medical emergencies at all times services are being furnished under the PR program. It does not mean the physician has to be in the same room when the service or procedure is being performed. Direct supervision in the hospital or CAH, or in an outpatient department of the hospital or CAH, both on and off campus: Direct supervision for PR services in these settings means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room where the procedure is being performed. In the hospital means areas in the main building(s) of the hospital that are under the ownership, financial and administrative control of the hospital; that are operated as part of the hospital; and for which the hospital bills the services furnished under their CMS Certification Number. CMS revised its definition of direct supervision in the hospital outpatient setting in its final rules to the Calendar Year (CY) 2011 payment update to the hospital outpatient prospective payment system (CMS-1504-FC, page 1266 text version). The new definition no longer ties immediate availability to a particular physical boundary, such as the provider-based department. On May 28, 2010, CMS issued clarifying guidance to Medicare contractors as to its expectations in meeting the direct supervision requirement in the hospital outpatient setting (Transmittal 128/Change Request 6996: July 2010 Update of the Hospital Outpatient Prospective Payment System). For ease of reference, the instructions discuss direct supervision in detail as outlined below. As of the November 2010 update, these instructions have not been changed. Immediate Availability: Although CMS has never defined immediate in terms of time or distance, their recent instructions state that immediately availability requires the immediate physical presence of the physician. For example, lack of immediate availability would be a situation where the supervisory physician was performing another procedure or service and could not be interrupted. An example of services furnished on-campus of a hospital where immediate availability would be considered lacking is that the physician is so physically so far away on-campus from the location where the PR services are being furnished that he or she could not intervene right away. Scope of practice requirements: In order to meet the direct supervision requirements in the outpatient setting, the supervisory physician must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, 5

6 skills, ability and privileges to perform the service or procedure. According to CMS, it does not necessarily expect the physician providing direct supervision to operate specialized therapeutic equipment that is normally operated by trained ancillary staff and technicians, buts CMS does expect the physician to be knowledgeable about the therapeutic service and be clinically appropriate to furnish the service. Clinically appropriate credentials: CMS expects hospitals to have credentialing procedures, bylaws and other policies in place to ensure that hospital outpatient services furnished to Medicare beneficiaries, including pulmonary rehabilitation, are being provided only by qualified practitioners in accordance with all applicable rules. For services not furnished directly by a physician, CMS expects the hospital bylaws and policies would ensure that the therapeutic services are being supervised in a manner commensurate with their complexity, including personal supervision when appropriate. Ability to take over service or procedure: CMS has stated repeatedly that direct supervision requirements are more than just being immediately available to respond to an emergency situation or provide medical consultation. The physician must also have the ability to take over performance of a procedure and, as appropriate, to change a procedure in the course of care for a particular patient. In those instances, CMS would not expect the supervisory physician to make all decisions unilaterally without informing or consulting the patient s treating physician. In other words, as noted above, the supervisory physician must be clinically appropriate to supervise the service or procedure. Q. Can non-physician practitioners, such as physician assistants, nurse practitioners, or clinical nurse specialists provide direct supervision under the new PR benefit? A. No. The statute and regulations are very clear that the program must be physician-supervised. CMS uses the definition of physician as being a medical doctor or a doctor of osteopathy as outlined in CMS regulations (74 FR & 60591). This supervisory limitation does not, however, preclude non-physician practitioners from furnishing services as part of the multidisciplinary PR team. Q. I keep hearing folks make reference to the 250 yard rule when talking about direct supervision. I don t know what that means. Can you explain? A. The 250 yard rule distinguishes whether a building or facility that is adjacent to the main building of a hospital is considered to be on campus or off campus. A hospital campus is defined in part as the physical area immediately adjacent to the provider s main buildings, any other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis. If your facility is located more than 250 yards from the main building of the hospital, it is considered off-campus. Some exceptions to the rule may be made but it would be up to the appropriate CMS Regional Office to decide. Q. My PR program is in a Critical Access Hospital (CAH) where requiring a physician to provide direct supervision at all times services are being furnished causes an extreme burden. Are we exempt from the direct supervision requirement? (Updated December 18, 2013 non-enforcement notice rescinded) 6

7 A. No. Critical Access Hospitals (CAHs) must adhere to the same rules as other hospitals with respect to direct physician supervision for PR services. Because CMS has made a literal interpretation of the law, this means that the direct supervision requirement cannot be provided by a non-physician practitioner, such as a nurse practitioner or physician assistant. Recognizing the burden CAHs face in adhering to this rule, CMS instructed its Medicare contractors not to evaluate or enforce the supervision requirements for outpatient therapeutic services, including PR services, furnished in CAHs from calendar year 2010 through calendar year However, as discussed in the 2014 update to the hospital outpatient prospective payment rules (78 FR ), the non-enforcement instructions will expire December 31, 2013 and CAHs will be expected to comply with the direct physician supervision rules effective January 1, Sessions/Staffing Q. If COPD beneficiaries who meet the coverage criteria under the new PR benefit were enrolled in a PR program prior to January 1, 2010, do we pick up the number of sessions already completed or are we permitted to start over in counting toward the initial 36-session rule? A. If the beneficiary meets the diagnosis and coverage criteria under the new PR benefit, they are eligible to start the initial 36 sessions as of January 1, Prior to that effective date, there was no comprehensive PR program established under Medicare. Individual respiratory care services for beneficiaries with various pulmonary diagnoses were covered under local coverage policies. The rules governing those policies remain in effect for non-copd patients and are not impacted by the new PR benefit. Q. Is there a time limit as to when the 36 sessions must be completed? I don t recall seeing anything in the regulations to address this issue. A. No. There is no timeframe specified. CMS noted in the final rule that because the programs are highly individualized, they did not specify a duration by which sessions must be completed. According to CMS, this decision allows for the possibility of additional sessions up to the maximum allowable of 72 sessions over a longer period of time. (74 FR 61882). Q. Do we need to document each session with respect to start and end times for each unit reported, especially aerobic exercise? A. Since some aerobic exercise is required during each session, we highly recommend that you document the start and end times for each unit reported in order to validate your charges. This is also important because CMS has set out minimum requirements with respect to the minutes billed for each session (see below). Q. Is there any guidance from CMS as to the ratio of staff to patients? A. No. CMS does not specify any requirements for patient/staff ratios. Our recommendation would be to follow clinical guidelines established by nationally recognized organizations such as those from the American Association for Cardiovascular and Pulmonary Rehabilitation. They currently recommend a ratio of 1:4 for exercise and 1:8 for education. 7

8 Q. CMS says it will be up to the individual Medicare contractors to determine if additional sessions beyond the initial 36 are medically necessary? Do we need to check with the local contractor before proceeding with additional sessions? A. No, pre-approval is not required or necessary. However, in order to bill for sessions beyond the initial 36, the provider of services must have documentation on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for the individual beneficiary. There are no specific rules or local contractor policies at this time that discuss acceptable evidence to extend the sessions beyond the initial 36 or documentation requirements for medical necessity. It is up to the physician who establishes, signs, and reviews the plan every 30 days and is involved in the patient s care and has knowledge related to his or her condition to make the decision as to the medically necessity of additional sessions beyond the initial coverage criteria and to provide sufficient documentation in the patient s medical record to substantiate the decision. See below for further discussion of billing for sessions 37 and beyond. Coding and Billing Q. Is it true that all services furnished as part of the comprehensive new PR benefit are bundled under one code and billing separately for the initial assessment, 6-minute walk, and other services that used to be billed using separate codes is no longer permitted? A. Yes, a single bundled code is used to bill for the comprehensive services furnished as part of the PR benefit. That code is G0424, Pulmonary rehabilitation, including aerobic exercise (includes monitoring), per session, per day. CMS has also noted in its May 7, 2010 transmittal to contractors updating the Medicare Claims Processing Manual (Transmittal 1966/Change Request 6823, Pulmonary Rehabilitation (PR) Services) that for claims effective with dates of service on and after January 1, 2010, place of service (POS) code 11 shall be used for PR services provided in a physician s office and POS 22 shall be used for services provided in a hospital outpatient setting. However, POS codes will not be implemented until October 4, 2010, in order to allow for contractor systems changes. After that date, if the POS codes are not included on the claim form, the claim will be denied. Q. Since physical therapists have their own benefit category under Medicare, are they allowed to bili separate CPT codes for PR services they may furnish as part of the multidisciplinary team? A. No. CMS has made it very clear that the PT benefit is separate and distinct from pulmonary rehab and that any services furnished by a physical therapist as part of the PR program are not separately billable. Further CMS has stated that it would be uncommon for a patient who is receiving care under a PR plan to also receive PT services in the same day and they plan to monitor claims for both PR services and additional therapy services to ensure the rule is being followed. This rule also applies to occupational therapists (74 FR 61883). Q. If we are allowed to bill for only two 1-hour sessions a day, is there a minimum number of minutes required to bill for each session? 8

9 A. Yes. If you are billing for only one session in a day, the patient must receive at least 31 minutes of PR services. Two sessions can be reported on the same day if the duration of treatment is at least 91 minutes. However, according to CMS if several shorter periods of PR are furnished in a single day, the minutes from those sessions must be added together for reporting in 1-hour session increments. Keep in mind that each session must contain some aerobic exercise, although there is no minimum specified by CMS. CMS provides the following examples in its instructions to their contractors. Example: If only 20 minutes of PR services are furnished in the day, you cannot use G-0424 to report the service because it is less than 31 minutes. Example: If 20 minutes of PR services are furnished in one session and 35 minutes are furnished in a second session in a single day, one session can be reported using G-0424 because the total duration is 55 minutes of PR on that day. Example: If 70 minutes of PR services are furnished in one session with a second session lasting 25 minutes in a single day, two sessions of PR services using G-0424 can be reported because the total duration of PR services on that day totaled 95 minutes (e.g. exceeds the 91 minute minimum.) Example: If 70 minutes of PR are furnished in one session and 85 minutes of PR are furnished in a second session on the same day, two sessions can be reported using G-0424 totaling 155 minutes. Regardless of the total duration of the PR services, only two sessions per day can be reported. Q. What codes do I use to bill for patients that are in our program who don t meet the COPD coverage criteria but are covered under the local coverage policies? A. As noted elsewhere, whatever coding and billing that was permitted under the local coverage policies prior to January 1, 2010 remain in effect for patients that do not meet the COPD coverage criteria under the new comprehensive PR benefit. We expect G-0237 through G-0239 to be used in most circumstances. G-0424 is not appropriate for these patients. Q. Are there any specific instructions on how to bill for sessions 37 and beyond? A. Yes. On May 7, 2010, CMS issued updated billing instructions and revisions to the Medicare Claims Processing Manual that includes information on how to bill for PR claims which exceed the initial 36 sessions (Transmittal 1966/Change Request 6823, Pulmonary Rehabilitation (PR Services). Effective October 4, 2010, the KX modifier should in included on the claim when billing for PR sessions beyond the initial 36. Keep in mind, that by using the modifier, the provider is attesting to the fact that there is documentation on file verifying that the treatment is medically necessary. It is very important in the event of an audit that appropriate documentation of medical necessity be included in the patient s medical record prior to the submission of a claim for the services. Even though the effective dates for PR services are on or after January 1, 2010, the October implementation date is necessary to allow adequate time for contractor s systems changes. In the interim, if you plan to submit a claim for a session beyond the initial 36, the G-0424 is still appropriate until October 4. However, once the KX modifier is implemented, if it is not included on claims that exceed the 36 sessions, the claims will be denied. Q. My contractor is not accepting revenue code 948 that was identified for PR during one of the Hospital Open Door forums a while back. Is there anything I can do to correct the situation? 9

10 A. The situation should be cleared up with the release of the new CMS transmittal to contractors and the update to the claims processing manual on May 7, 2010, which now instructs contractors to pay for PR services on and after January 1, 2010 when submitted on a type of bill 13X and 85X only, along with Revenue Code Again, this instruction has an implementation date of October 4, 2010 to allow for systems changes. Q. For the past few years, the payment rate for pulmonary rehabilitation in the hospital outpatient setting for G0424 has been extremely low. Considering initial payment for PR services in this setting was $60 per session and it is $39.35 beginning in calendar year 2014, what caused the rate to drop so low? (Added December 18, 2013) A. When PR became a national benefit and a new code was assigned, CMS determined at the time there were no claims data that represented the full scope of the comprehensive services that comprised the PR benefit. A proxy payment method was established and that s how CMS first come up with the $60 payment rate. Subsequently, as a robust number of claims have been submitted for the G0424 code, CMS was able to use its standard methodology of determining the payment rate which has resulted in a much lower amount based on actual data. AARC and our sister pulmonary societies (AACVPR, ACCP, ATS and NAMDRC) believe part of the problem may be hospitals failure to develop appropriate charges for the bundled code G0424 that reflect a board base of services previously billed separately before the PR benefit became effective. To assist hospitals in calculating the appropriate charges for G0424, the societies developed a Pulmonary Rehabilitation Toolkit. We encourage respiratory therapists to review the Toolkit and to engage appropriate hospital administrative staff in charge of submitting claims to Medicare to ensure that charges accurately reflect the complexity of providing PR services. The PR Toolkit can be accessed at: Q. With an increase in claims audits, what can respiratory therapists do to ensure that proper documentation for PR services is submitted to the Medicare program? (Added December 18, 2013) A. The general rule of thumb for any documentation is that it must demonstrate that the coverage criteria have been met. Under certain circumstances, if there is a LCD, the contractor may indicate that certain documentation need only be presented upon request. For pulmonary rehabilitation specifically, one contractor, CGS operating in Kentucky and Ohio, has developed a guide for PR coverage and documentation requirements. This is very useful information and RTs are encouraged to read it carefully. It can be accessed at: 10

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