Medicare Part A. Pulmonary Rehab Program Services Web-Based Training February 25, Q & As

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1 Pulmonary Rehab Program Services Web-Based Training February 25, Q & As The following are the question and answers from the Pulmonary Rehabilitation Program Services web-based training which was held on February 25, Please note that this program is still in development and contractors are still expecting Change Requests to finalize in the upcoming months on this program. Q1. What revenue code should be used when billing HCPCS G0424? A1. There are no revenue code requirements listed in the current instructions. Providers can bill using the most appropriate revenue code. Providers are not able to use 0948 Pulmonary Rehab as it is currently coded as not billable to Medicare. Q2. We have received guidance from NAS Provider Education that Cardiac Rehab Phase 3 is billable for CAH. What about Pulmonary Rehab Phase 3? Is that allowed to be billed to Medicare also if the facility is a CAH? A2. NAS only covers the cardiac and pulmonary rehab programs that are allowed by CMS in the approved CPT codes provided by CMS; these codes do not include phase III rehab. Phase III Cardiac and Pulmonary Rehab are defined as maintenance programs and are not covered by Medicare. Q3. NGS is my current FI and they do have an LCD that does not include the G0424 code. I do not see a LCD on the Noridian web site. What codes should be used and with what Rev Code? A3. NAS does not have an LCD on Pulmonary Rehab Program Services. Based on CR 6751 providers must bill with HCPC code G0424 for services furnished on or after January 1, There are no revenue code requirements issued in the current instructions. Q4. It covers very severe also, correct? Not just moderate to severe? A4. Yes it covers moderate to very severe COPD. Q5. Is the individualized treatment plan required to be established and signed by the physician prior to the patient being seen at their next scheduled visit? A5. Per 42 CFR , the outcomes assessment program includes beginning and end evaluations. We expect the treatment plan to be signed either before the initiation of treatment or within a few days thereafter. The patient may present for a second session as long as the ITP is signed within a few days of initiation of the Program.

2 Q6. What is your definition of aerobic exercise? A6. Per 42 CFR , high and low intensity exercise is recommended as well as a combination of endurance and strength training at least twice a week. Trained exercise physiologists are expert in documenting appropriate exercise(s) and levels consistent with the CMS requirements. Q7. The individualized treatment plan is required to be reviewed and signed every 30 days. Can the ITP be signed prior to 30 days? Can it be signed after 30 days or is 30 days the maximum? A7. The program is flexible as long as patients are being continuously reviewed and a treatment plan is made for the individuals and attempts are clearly being made to get timely physician certification. Remember that ongoing and active participation of the Program Medical Director is required and certification should not pose unreasonable difficulty. Q8. Are the 36 sessions a 'lifetime benefit' or if the patient has a new incident and new order, can the patient have another 36 sessions? A8. At the current time, CMS envisions the Program as a life-time benefit since the skills taught and chronic disease education provided would be expected to be applicable throughout the course of the disease. Final CMS instructions may provide additional information. Q9. Please clarify if physician supervision must be direct or immediate? A9. There is no distinction between direct and immediate. Please refer to the Physician Supervision article published by NAS on February 23, Here is the link to the article: or The physician must be immediately available. This provision is satisfied if the physician meets requirements for direct supervision for physician office services 42 CFR defines direct supervision as the physician being present in the office suite or immediately available. Direct supervision in the facility setting as discussed extensively in the Final Rule for 2010{LIMK would be useful.} Q10. What is the best way/timing to receive contractor approval for additional sessions? A10. NAS will provide instructions on additional sessions after receiving the final CMS instructions.

3 Q11. Do programs really see patients 2 times per day (a.m./p.m.) in the outpatient setting? A11. Patient can be seen in the morning and again in the afternoon. Q12. How is the physician portion of the assessment or referral billed? Is this rolled into G0424? A12. If the facility provides the rehab program, the facility bills the code. If the physician provides the service is his/her private office/clinic, the costs accrue to the physician and the physician may bill the service. Q13. Can a hospitalist or ED physician with ACLS training meet the incident to supervision requirement? A13. Possibly, see A9. Q14. When do you anticipate adding additional covered diagnoses such as emphysema, chronic bronchitis, or others beyond ICD-9 code 496? A14. NAS will allow all respiratory conditions consistent with moderate to severe COPD. Those physicians who may properly refer and/or write treatment plans for such patients are well aware of the appropriate diagnoses and such will be found in the patients records. Q15. Is G0424 only for patients with COPD and not other diagnoses? Do we still use G0237, G0238 for other diagnoses who also meet criteria for a rehab program? A15. G0424 has been designated for Pulmonary Rehab Program Services. CMS has noted in the regulations that a single period of care can only be billed as one type of treatment service, so hospitals should not bill services reported by HCPCs code G0237, G0238 or G0239 and Pulmonary Rehab services for the same time period for the same patient. HCPCs G0237, G0238, and G0239 describe respiratory services specific to the needs of an individual patient and not programmatic pulmonary rehabilitation. Q16. Please clarify if you must have a Doctor available or on site during treatment? A CFR denotes physician must be immediately available and on-site similar to the instructions on incident to supervision. Q17. How would you report on the claim that it is moderate to severe COPD as there is only 1 diagnosis code (496) for COPD? A17. Documentation must support the level of severity of the diagnosis.

4 Q18. Please describe what is required from the physician in completing outcome assessments? Are they able to synthesis data/info from the PR staff or is the physician required to have face to face time during the outcome assessment? A CFR indicates that outcome assessment must relate to the individuals outcome including self reported measures from patient as well as objective clinical measures of effectiveness. The physician standards in the CFR state that the physician 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 or her treatment plan. Q19. Dr. Hecker has defined immediately available as the response time for a code, is that correct? A19. The NAS Medical Director concur that the requirement for the most urgent response is an arrest. Hence, a response time that at least equals code response time is adequate to fulfill the conditions of immediate availability. Q20. Could you please provide the web address for the NAS articles? A20. NAS articles are available at or Q21. If you are a hospital program and have an ER physician and other physician directly there does that count as present if your medical director is gone for the day? A21. Per the CMS Hospital Open Door forum on 3/4/10, CMS stated that the supervision needs to be completed by a physician, but within that it has to be within their state scope of practice and hospital granted privileges, and protocol. The facility would need to ensure that the ER physician is immediately available at all times for the pulmonary program. The program treatment would need to stop if the ER physician becomes tied up or the session is not reimbursable. Interruption commonly is inappropriate for proper delivery of exercise sessions. Q22. Can you give examples of individual treatment plan goals? What will you be looking for? A22. Contractors are unable to provide rules of thumb, each beneficiary is different and the goals should be individualized for the beneficiary needs and condition. However, both attainable and useful goals (clear improvement in QOL and/or ADLs)

5 based on patient s current condition as well as objectively verifiable measures of same are requirements. Q23. If an MD requests the extended 36 sessions of PR, what is the approval process? A23. NAS will provide instructions on additional sessions after the final CMS instructions/change Request (CR) is complete and finalized by CMS. Q24. Are there other pulmonary diagnoses that will be covered besides moderate to very severe? A24. No, CMS has not included other diagnoses in the current regulations. Q25. Does the 6MWT count as exercise during a session? A25. All services must be medically necessary and appropriate for each individual and the entire time need to be payable per CMS guidelines; 6 MWT alone would not meet the time requirement and is often used for diagnosis or other evaluation. Q26. Can we call for pre approval for Mild COPD patients with recent exacerbation and severe limitations in the ADLs? A26. CMS has currently not allowed prior authorization of additional sessions or allowance of pulmonary rehab program beyond what they have established for this national program. Mild COPD doesn t meet the allowed condition of the national CMS approved pulmonary program per 42 CFR NAS would not be able to approve any other conditions than what CMS is allowing for this national program. Q27. Does a hospitalist or ER physician fulfill the physician coverage issue if they are immediately available if needed? A27. The physician needs to have expertise in the management of individuals with respiratory pathophysiology as well as BLS and/or CPR. Please also see question 21. Q28. Would spirometry results alone that meet the severity category of COPD without a formal diagnosis of COPD be appropriate to use the G0424 code? A28. No. A patient must be under the care of a physician to participate in this Program. Hence, one expects an interpretation of the spirometry results in context of the whole entire patient presentation to be included as part of the documentation of the disease and its severity.

6 Q29. Where do asthmatics stand as far as qualification? Do they have to have developed moderate COPD? A29. A diagnosis of moderate to very severe COPD must be supported for pulmonary rehab to be allowable. Q30. Since revenue code 0948 is not accepted by Noridian, what revenue code should we be using? Will Noridian be adding revenue code 0948 to the allowable revenue codes? A30. There are no revenue code requirements listed in the current instructions. Providers can bill using the most appropriate revenue code that is billable to Medicare. NAS cannot add revenue code 0948 as an allowable revenue code without CMS approval. Q31. If patient is assessed and receives education but is not able to exercise it is my understanding that we cannot bill a session. Is this correct? A31. Education alone does not fulfill al of the components of pulmonary rehab per 42 CFR The patient must exercise during each reimbursable session. Q32. Can you please clarify the role of the pulmonary rehab medical director? Is the medical director required to sign off on treatment plans? A32. Per 42 CFR the medical director means the physician who oversees or supervises the entire PR program. Q33. Will you be publishing a document that shows covered diagnoses (ICD-9 coding)? A33. See A14. No. Providers can access information regarding the GOLD classification system at Q34. I gather that when you say "levels" for Gold standards you are going by post Bronchodilator FEV1 and Fev/FVC not just symptomatology? A34. Please refer to: for information regarding the GOLD classification system. Q35. Will Noridian follow CMS recommendations and cover services for Pulmonary Rehab for Noridian/BCBS clients? A35. We cannot comment on other insurance programs, only NAS Medicare for the states that are in our jurisdiction. We recommend you contact BCBS to ask questions for their coverage of pulmonary rehab.

7 Q36. Will you be providing the pages of the FR where you are reading the definitions for the various Levels of COPD? A36. Moderate to very severe COPD is defined as GOLD classification II, III and IV. Please refer to: for information regarding the GOLD classification system. Q37. Is the limit of 36 sessions per year or event? A37. Please see A8. Q38. Can Cardiac Rehab and Pulmonary Rehab services be provided in the same hospital department room at the same time? This would be a situation where different patients were receiving Cardiac Rehab and others were receiving Pulmonary Rehab. A38. Yes, as long as requirements of each program were met for each specific entity and you are following any of your state laws and protocols. Q39. Can you charge other services with the G code for example, peak flow test and 6 minute walk test? A39. No. The G0424 code for pulmonary rehab program services is the code for all the services during the pulmonary rehab session: ALL exercise, education, assessment, etc. NAS would not expect to see separate billing of such things as peak flow tests and 6 minute walk test or therapy, etc. Q40. Can you please clarify the minimum time for a pulmonary rehab services? We received prior instruction that each session "must be a minimum of 60 minutes". A40. It is limited to a maximum of 2 1-hour sessions. In order to report one session, the duration of treatment must be at least 31 minutes. To report two sessions, the duration of treatment must be at least 91 minutes. Q41. Since admission to Pulmonary Rehab is based on pulmonary function testing for the COPD patient is there a time frame as to when the testing needs to occur i.e., in the past 12 months? A41. Documentation should support the medical necessity and condition that qualifies for the current services being performed or will be performed for the current episode of care. In general, in a patient with chronic COPD pulmonary function will not improve with time unless the PFTs were performed during an acute exacerbation of disease. Documentation must clarify the clinical picture.

8 Q42. Is there a specific provider that can provide these services? A42. The Pulmonary Rehab Program must be furnished in a physician s office or a hospital outpatient setting. Practitioners must be either MD or DO, not NPP, and have expertise in the management of patients with COPD. Q43. We do one hour education and one hour of exercise...how can we incorporate "aerobic" exercise in the first hour? Do therabands and Pflex work? A43. The physician is required to set up individual treatment plans with goals established and outcomes measured. Physicians and exercise physiologists are familiar with those exercises associated with aerobic work. Q44. If a patient has a diagnosis of Cystic Fibrosis and not COPD but their PFT fall in the Gold standards II-IV will they be covered? A44. Cystic Fibrosis doesn t meet the allowed condition of the national CMS approved pulmonary program per 42 CFR NAS would not be able to approve any other conditions other than those established by CMS. Q45. Does a new LCD require a comment period but the revision of a current LCD does NOT require a comment period? A45. See Chapter 13 PIM for LCD information. In most cases, if the LCD revision restricts coverage, a new comment period is required. The pulmonary rehab program is a statutory benefit of the Medicare program, neither an NCD nor LCD. Q46. Is the ITP due to you every 30 days or does it need to include 30 days of information prepared following the 30 days? A46. NAS will not routinely request the ITP when you are billing the service. It is expected that you maintain documentation for the services and submit the information upon request during any claim or medical review. Q47. Can the Medical director sign/establish the initial ITP and the ITPs each 30 days? A47. Per 42 CFR the medical director means the physician who oversees or supervises the entire PR program. The plan must be established, reviewed, and signed by a physician every 30 days.

9 Q48. Can these services be billed on a monthly basis as a series account (like other therapies) versus individual claims per date of service? A48. If billing under a revenue code that is included in the repetitive billing instructions (IOM, 100-4, Chapter 1, Section ), then monthly billing would apply. Further instructions have not yet been received from CMS. Q49. Must the ITP (Individualized Treatment Plan) be signed by the referring physician or the Medical Director? Which physician can sign the every-30-day Progress Report and the discharge report? A49. See A47. Q50. Our program med director requires the patient to have testing PRIOR to acceptance into PR program in order to ensure the patient's safety as well as that they meet the required protocol. Are these still billable if done prior? (i.e., CXR, resting ECG, Pulmonary Function test) A50. Screening is not covered unless congressionally mandated; such as mammography and colonoscopy. All and any diagnostic testing would need to be supported as reasonable and necessary in the documentation for diagnosis of suspected disease or treatment. Q51. Are other CPT codes allowable for services that might be required during pulmonary rehab program participation? (i.e., spirometry, MDI instruct) A51. See A15. Q52. Must the ITP be signed before the patient returns for a second session? A52. See A53. Q53. Does the medical director have to sign the ITP before the initial visit or after the referral and before the patient starts the program? A53. See A5. Q54. Does the COPD diagnosis have to be primary or just on the claim? A54. CMS is not requiring the COPD to be the primary diagnosis however; it must be on the claim. Please follow you coding requirement of billing of services to determine if the service should be billed primary or one of the secondary diagnoses. Q55. Is the referring physician required to sign/establish the initial ITP and subsequent ITPs thereafter or can it be completed by the medical director? A55. See #5 in CFR and A47

10 Q56. If billed as a series, will occurrence and value codes be required as well? A56. At this time CMS has not provided the contractor with any requirements of occurrence or value codes. If this is developed by CMS, then NAS will alert providers who would need to follow the billing requirements. Q57. We also perform a sub-maximal exercise (bike) test prior to acceptance into the program. Is this bundled or billable since it is prior to actual enrollment? A57.See A50 Q58. When will Noridian come out with a LCD for Pulmonary Rehab? A58. The establishment of a statutory benefit January 1, 2010 eliminates the need to and precludes development of an LCD on the topic. The national established program from CMS will be followed. Q59. I have a question about intake of new patients and beginning of service. We are told that intake and service must be within a calendar month, rather than 30 days--this means it is impossible to intake patients during the last week of the month--why? A59. CFR states that Outcomes assessment means a written evaluation of the patient's progress as it relates to the individual's rehabilitation which includes the following: beginning and end evaluations, based on patient-centered outcomes, which are conducted by the physician at the start and end of the program, not month. Q60. Is the medical director expected to sign the individual treatment plan or is the referring physician signature sufficient for payment? A60. See A5. Q61. Within our hospital system the revenue code is listed as 0419 but within our UB Editor the revenue code is 0942 only? A61. See A1. Q62. Who is required to do the education training and the psychosocial assessment? A62. Personnel who provide the services must work within their scope of practice and licensure.

11 Q63. We offer 1 hour of education 2X week during PR--on those days, pts, receive 120 min, of service (exercise + ed)--if we bill 2 units on those days, will they not get their 36 exercise sessions? How do we document education? A63. A maximum of two sessions per day may be reported, regardless of the total duration. To report two sessions, the duration of treatment must be at least 91 minutes. Treatment must include both exercise and education. They will still receive 36 sessions, just over a shorter period of time. The 36 sessions does not mean 36 calendar days. Q64. What will the medical review be looking for to qualify for extended 36 sessions? A64. NAS will be looking for documentation to support medical necessity. For example, the reasons for the extension - why the program could not be have completed within a reasonable 36 session. Note: Services that are repetitive in nature that do not require the skilled services of the professionals of the pulmonary rehab program will not support medical necessity. Q65. Can the ITP be signed by the physician after the initial session and still be covered for the initial session? A65. Yes. See A5. Per CMS, if the patient s treatment plan cannot be fully established/certified before the next session, the patient can come to the next session. As the staff gets a better idea of what the patient needs, the treatment plan can be revised as necessary. The program is flexible as long as patients are being continuously reviewed and a treatment plan is made for the individuals and attempts are clearly being made to get timely physician certification. Remember that ongoing and active participation of the Program Medical Director is required and certification should not pose unreasonable difficulty. Q66. If a patient is referred to program with CHF - shortness of breath at rest and with exertion - no COPD diagnosis - is this acceptable diagnosis using the old method of billing for Pulmonary Rehab? A66. No, a diagnosis of moderate to very severe COPD is the only allowed diagnosis for pulmonary rehab program. Q67. If a patient started PR before January 1, 2010, are they eligible for up to 36 sessions or just the 24 session because they started in 2009? A67. There was no pulmonary rehab program prior to final rule establishing; coverage for pulmonary rehabilitation program services is effective January 1, 2010 per the CFR.

12 Q68. Is the intake appointment not covered because it does not include exercise? A68. Exercise must be included for G0424 to be billable. Q69. Does the event have to be a hospital stay or just a new provider order? A69. The CFR does not require a hospital stay but the condition of moderate to very severe COPD. Any patient with moderate to severe COPD may be referred by a physician for rehabilitation at any time in the course of their disease and/or treatment. A hospital intervention is not a requirement. Q70. In 91 minutes, how many minutes of aerobic exercise if one session? A70. Per the CFR the physician prescribed exercise is physical activity includes techniques such as exercise conditioning, breathing retraining, step, and strengthening exercises. Some aerobic exercise must be included in each pulmonary rehabilitation session. Q71. Can a nurse in cardiac rehab be responsible for the exercise portion of Pulmonary Rehab? A71. CMS has not provided limitations of who can complete the exercise portion of the pulmonary rehab program; staff should be only doing activity that is within their scope of practice and state laws. Q72. Can a physical therapist exercise a patient in pulmonary rehab and use the G0424 code? A72. CMS has not provided limitations of who can complete the exercise portion of the pulmonary rehab program; staff should be only doing activity that is within their scope of practice and state laws. However, if the patient is in the pulmonary rehab program, the therapist may not bill or any other codes but the G0424. Q73. What services are separately billable from Pulmonary Rehab? A73. The G0424 code for pulmonary rehab program services is the code for all the services during the pulmonary rehab session: ALL exercise, education, assessment, etc. NAS would not expect to see services that are part of this program being separately billable. Q74. What constitutes monitoring during exercise? A74. This is individualized by patient in accordance with safety needs. However it is suggested that monitoring promotes safety is identifiable and supports individual treatment goals.