Pulmonary Rehab Rules & Regula6ons Janie Knipper, RN, MA AACVPR Liaison to J- 5 Jane- knipper@uiowa.edu Heartland Cardiopulmonary Rehab Conference April 12, 2013 Objec6ves 1. Compare and contrast Medicare and Medicaid. 2. Discuss Jurisdic6on 5 Medicare Administra6ve Contractor (MAC), Wisconsin Physician Services (WPS) 3. Discuss the 2010 changes in Pulmonary Rehabilita6on reimbursement established by the Centers for Medicare and Medicaid (CMS). 4. Differen6ate between the billing and reimbursement for par6cipants with a diagnosis of COPD and those with respiratory pathologies other than COPD. Statement of Disclosure I have no disclosures. The opinions expressed are my own. Center for Medicare and Medicaid (CMS) " Previously known as Health Care Financing Administra6on (HCFA) " A federal agency within the U.S. Department of Health and Human Services (DHHS) " Administers the Medicare program " Works in partnership with state governments to administer Medicaid What is the difference between Medicare and Medicaid? " Medicare is funded en6rely at the federal level & focuses primarily on the older popula6on " Eligibility is based on age & disability " Medicaid is funded at the federal and state level " States provide up to half of the funding " Eligibility is based on need main criterion is limited income and financial resources " Some people are eligible for both Medicare and Medicaid Medicaid Eligibility Categories " Assets " Age " Pregnancy " Disability " Blindness " Income and resources " 2014: Under age 65 with income below 133% Federal Poverty Level (FPL=$14,500) " U.S. ci6zen or lawfully admihed immigrant " Excep6on: Emergency Medicaid for pregnancy and disability 1
Other Medicaid Eligibility Groups " Medically Needy " Op6onal for states " Significant health needs and income is too high to qualify for Medicaid otherwise " Become eligible by spending down the amount of income above a state s income standard " Spend down occurs by incurring expenses for medical and remedial care " Incurred expenses are subtracted from annual income " If income is then at or below the states medically needy income standard, Medicaid eligibility is met Medicare Eligibility " All persons age 65 or older who have been legal residents of the U.S. for at least 5 years OR " People with disabili6es under age 65 if they receive Social Security Disability Insurance (SSDI) OR " Specific medical condi6ons (end stage renal disease and ALS Lou Gehrig s disease) Medicare Benefits " Medicare A: " Hospital inpa6ent " Home health care " Skilled nursing facility " Psychiatric hospital " Inpa6ent rehabilita6on " Hospice services. " Involves a monthly premium if enrollee or spouse have had < 40 quarters of Medicare- covered employment ($248 to $451/month currently) Medicare Benefits " Medicare Part B: " Medically- necessary services or supplies needed to diagnose or treat a medical condi6on & that meet accepted standards of prac6ce, including Durable Medical Equipment " Cardiac and Pulmonary Rehab " Coverage & Premiums " Medicare covers 80% of approved services " Pa6ent co- insurance pays remaining 20% Medicare Benefits " Medicare Part C: Medicare Advantage " Benefits are provided through a private health insurance plan rather than tradi6onal Medicare A/B " Medicare pays the private health plan a fixed amount every month " Members typically pay a monthly premium in addi6on to the Medicare Part B premium to cover items not covered by tradi6onal Medicare " Usually a network of acceptable providers " Deduc6bles & coinsurance varies from plan to plan and can be high! Medicare Benefits " Medicare Part D: Covers outpa6ent prescrip6on drugs " Must enroll in a stand- alone Prescrip6on Drug Plan or Medicare Advantage plan " Not standardized: private insurance companies choose which drugs or classes of drugs they wish to cover, at what level (6er), and can choose to not cover some drugs at all " Deduc6bles and coinsurance: varies from plan to plan 2
How can changes be made in Medicare? " Medicare is a form of social insurance " A government- sponsored program " Eligibility requirements and other aspects of the program are defined by statute or policy " Statutes are wrihen and/or revised by legisla6ve authority only " AACVPR Day on the Hill (DOTH) " Important 6me to speak with members of Congress regarding our desire to change a Medicare- related statute Medicare Administra6ve Contractors " Medicare Moderniza6on Act of 2003 mandated a change from the contrac6ng authority at the 6me [Fiscal Intermediaries (FIs) and Carriers] to Medicare Administra6ve Contractors (MACs) " Country was divided into jurisdic6ons " Private insurance companies placed bids to become the contractor or MAC for a specific jurisdic6on " 15 A/B MAC jurisdic6ons " 2010: Plan for further consolida6on of the MACs " 10 A/B MAC jurisdic6ons Na6onal Coverage Determina6on - NCD " A na5onal coverage determina5on is a na6onwide determina6on of whether Medicare will pay for an item or service. " Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). " In the absence of a NCD, an item or service is covered at the discre6on of the MAC based on a Local Coverage Determina6on (LCD). Local Coverage Determina6on (LCD) " A local coverage determina5on (LCD) is a policy created by MACs. " Pertains to services or items not addressed in NCDs or program manuals " Contains coding and u6liza6on guidelines as well as descrip6ve passages " All LCDs, current and under development from all Carriers in the country are available on the CMS Coverage Database " Links to current LCDs for Iowa, Kansas, Missouri, and Nebraska can be found in the let side naviga6on of the WPS Policy sec6on: hhp://www.wpsmedicare.com/j5macpartb/policy/ac6ve/index.shtml NCD versus LCD " NCD decisions are binding on all Medicare contractors " LCD policy can be no more restric5ve than the NCD, although it can be less restric6ve " There are NO current NCDs for pulmonary rehab " There are some LCDs, but not in J- 5 Who, What and Where is our Medicare Administra6ve Contractor (MAC)? 3
J- 5 MAC: Wisconsin Physician Services (WPS) " If you work in Iowa, Nebraska, Kansas or Missouri your MAC is WPS " UNLESS your ins6tu6on is part of a hospital organiza6on where the mother hospital is located in another jurisdic6on " You must follow your MACs regs, so must know your MAC! MAC Jurisdic6on 5: IA, NE, KS, MO Legacy A and WPS Minnesota, Wisconsin, Illinois, Kansas, Nebraska, Iowa, and Missouri " Some hospitals throughout the country (other than IA, NE, KS, MO) submit claims to WPS as their Medicare contractor " These hospitals were previously serviced by Mutual of Omaha " WPS developed an LCD for Pulmonary Rehab Services (DL5738) for this group of hospitals ONLY " LCD never went into effect. It was RETIRED shortly ater the public comment period ended " Don t use it! If you have a copy of it throw it away so it doesn t confuse you! Links to J5 MAC - WPS WPS website: hhp://wpsmedicare.com 1. Click here 2. Takes you here: 3. Plug in Pulmonary Rehab in search field OR click on Policy: Medicare Administra6ve Contractor- MAC " AACVPR MAC Commihees and Liaisons " As AACVPR liaison responsibili6es: " Liaisons for na6onal policy changes that affect J- 5 " Be familiar with local policies & interpreta6ons " Be connected for MAC- specific communica6ons " J- 5 Commihee meets quarterly via conference call " Minutes are posted on AACVPR MAC webpage: hhps://www.aacvpr.org/healthpublicpolicy/ MedicareAdministra6veContractors/tabid/131/Default.aspx 4
Jurisdic6on 5 MAC Commihee Name Affiliate Society Phone E- mail Janie Knipper (J- 5 Chair) AACVPR H&PP Liaison IACPR Pulm RCP 319-356- 8396 Jane- knipper@uiowa.edu Candy Steele IACPR Cardiac RCP 319-272- 2269 Candace.steele@wyc.org Susan Flack IACPR Past- President 515-263- 5422 flacksk@ihs.org Claire Shannon IACPR President 563-422- 9764 C.Shannon@ palmerlutheran.org Carey Krepel NCVPRN Pulm RCP 402 748-3393 Carey.Krepel@Alegent.org Pam Gaines NCVPRN Card RCP 402-398- 5654 Pamela.Gaines@Alegent.org Lora Ruh NCVPRN President 308-425- 6221 ext. 342 lruh@fcmh.biz Reimbursement ques6ons should go to one of these people. All communica6on with the J5 MAC should be done through these people. Ethical Behavior/Fraud Preven6on " Code of Ethical Behavior: a policy regarding detec6on & preven6on of fraud, waste and abuse " Bill only for services & care actually provided and properly documented " Use billing codes that most accurately describe the services & care provided. " Federal False Claims Act (FCA): prohibits fraud involving any federally funded contract (Medicare/ Medicaid) It is your responsibility to know how to code and bill properly and to do so! If you don t know, contact someone who does! Pulmonary Rehab as a Medicare Benefit " Prior to 2010, CMS did not recognize Pulmonary Rehab (PR) as a Medicare benefit " The 2008 Medicare Improvements for Providers and Pa6ents Act (MIPPA) added payment and coverage improvements for pa6ents with COPD KEY: Pulmonary Rehab Programs are only for COPD pa6ents. Services provided to pa6ents with a respiratory diagnosis other than COPD is called Respiratory Services! - Code of Federal Regula6ons (CFR) 42.CFR 410.47 - Pub 100-02 Medicare Benefit Policy, Transmihal 124, Change Request: 6823, May 7, 2010, CMS Manual System. MIPPA: Defini6on of PRPs " Provided covered benefit for a comprehensive pulmonary rehabilita6on program (PRP) effec6ve January 1, 2010 " Programs authorized for either hospital outpa6ent se{ngs or physician offices " 42.CFR 410.47 Medicare provision for Pulmonary Rehabilita6on Program: Condi6ons of Coverage " Physician supervised program consis6ng of the following mandatory components: " Physician- prescribed exercise " Educa6on or training related to each individual s needs " Psychosocial assessment " Outcomes assessment 1 CMS Change Request 6823 May 7, 2010 42.CFR 410.47: Pulmonary Rehab " Coverage of Pulmonary Rehab for: " Moderate to very severe COPD as defined by GOLD* classifica6on II, III, & IV, and " When referred by the physician trea6ng the chronic respiratory disease " The PR program must meet all requirements and be the ONLY PR service billed. *GOLD = Global Ini6a6ve for Obstruc6ve Lung Disease GOLD Classifica6on of Severity of COPD Stage FEV 1 /FVC FEV 1 I - Mild COPD < 70% FEV 1 >80% predicted II - Moderate COPD < 70% FEV 1 >50% & <80% predicted III - Severe COPD < 70% FEV 1 >30% & <50% IV - Very Severe COPD < 70% FEV 1 <30% OR <50% with signs of chronic respiratory failure GOLD 2011 5
42.CFR 410.47: Pulmonary Rehab " Any addi6onal covered clinical indica6ons for PR would be added using the Na6onal Coverage Determina6on (NCD) process. " Un6l the NCD process is complete, the respiratory services previously allowed by local contractors for other medical condi6ons under other part B benefit categories remain in effect. " Respiratory services... Do not cons6tute a comprehensive PR program but individualized services... To the extent these exis6ng individual respiratory services are reasonable and necessary, a local contractor may s6ll cover them. Respiratory services in J- 5 for pa6ents WITHOUT COPD " There is no official documenta6on from WPS indica6ng the criteria for qualifica6on for Respiratory Services " Email communica6on between Candy Steele, Janie Knipper, and the WPS Medical Director is the only documenta6on of criteria " One of the following must be <60% predicted: FEV 1, FVC OR DLCO 42.CFR 410.47: Pulmonary Rehab Mandatory Components " Physician- prescribed exercise " Educa6on or training " Psychosocial assessment " Outcomes assessment " Individualized treatment plan (ITP) " Includes: medical diagnosis; type, amt, frequency, dura6on of services; and individual goals " Must be established, reviewed and signed by a physician every 30 days for MD to be able to do this, must have face- to- face visit with pa6ent every 30 days 42.CFR 410.47: Medical Direc6on Medicare standards for this posi6on: 1. Is responsible and accountable for the PRP and staff 2. Is involved substan6ally, in consulta5on with staff, in direc6ng the progress of the individual in the program including direct pa5ent contact related to the periodic review of his or her treatment plan 3. Has exper6se in management of individuals with respiratory disease 4. Basic life support training 5. Is licensed to prac6ce medicine in state where pulmonary rehabilita6on program is offered. Direct pa6ent contact What does this mean? " A physician must be physically immediately available and accessible for medical emergencies at all 6mes the program is being furnished " Supervising physician must at all 6mes be interrup5ble to physically respond immediately NOTE: An ED physician is not interrup5ble ; immediately is not defined by 5me, loca5on or distance (AACVPR) Physician Supervision " Remember: " For WPS you must keep a log in the department of who the supervising physician is for the day (month) " Documenta6on in pa6ent chart is not necessary, but is acceptable " If audited, log must go with medical records that are sent 6
9/13/11 Ask- the- Contractor Teleconference 42.CFR 410.47: Medical Direc6on " Medical Director (MD) is involved with: " Outcomes assessment, i.e., pre and post evalua6ons based on pa6ent- centered outcomes " Physician- supervised exercise " Physician review and signature required on all individualized treatment plans (ITPs) " Ini6al ITP, every 30 day reassessment, and program comple6on 42.CFR 410.47: Pulmonary Rehab Session Limits " Sessions limited to a maximum of two 1- hour sessions per day for up to 36 sessions " Contractors may approve up to an addi6onal 36 sessions when medically necessary. " Providing access of up to 72 sessions of PR, when appropriate " Does not specify a dura6on by which sessions must be completed; allowing the maximum allowable number of 72 over a longer period of 6me Clarifica6on: " An addi6onal 36 sessions over an extended period of 6me, if approved by the Medicare contractor does not mean they are PRE- AUTHORIZED sessions! " DO NOT CALL WPS FOR PRE- AUTHORIZATION FOR ADDITIONAL SESSIONS " WPS will review the documenta6on of medical necessity on a case- by- case basis PR Session Limits " PR exceeding 36 sessions must be billed with the KX Modifier " KX indicates that requirements specified in the medical policy have been met " Indicates to CMS that the pa6ent has exceeded 36 sessions, and medical review will likely occur for subsequent sessions to determine medical necessity " Discuss with your billing office to make sure they understand the importance of using the KX Modifier with all sessions beginning with 37! " PR services exceeding 72 session will be denied! Change Request 6823 Common Working File (CWF) " The CWF indicates number of sessions of PR remaining for that pa6ent s life6me: PULMONARY REMAINING (HCPC: G0424) 72 " Respiratory Services codes are not currently being tracked by CMS for # of sessions completed. 7
Pulmonary Rehabilita6on Coding Requirements " COPD ICD- 9: 496 " G0424: Pulmonary rehabilita6on, including exercise (includes monitoring), per hour, per session " Revenue Code: 0948 " Session dura6on: " One session = > 31 minutes " Two sessions = > 91 minutes, with the first session = 60 minutes and second session = 31 minutes " Do NOT bill any other codes for the COPD pa6ent Services for Pa6ents with Respiratory Illness Other than COPD " Federal Register, November 25, 2009 (Volume 74, No. 226), page 61882: Respiratory services previously allowed by local contractors for other medical condi6ons under other Part B benefit categories remain in effect. We do not agree that the limita6on of PR programs to one covered condi6on (moderate to very severe COPD) through the final rule will eliminate the ability of beneficiaries to obtain other respiratory services that are available under local coverage decisions based on other benefit categories. Appropriate Diagnoses with ICD- 9 Codes for Respiratory Services " Obstruc6ve Lung Disease: " Persistent asthma: 493 " Bronchiectasis: 494 " Cys6c fibrosis: 277.03 " Bronchioli6s obliterans: 491.8 AACVPR, Guidelines for Pulmonary Rehabilita6on Programs. 4 th ed. 2010, Champaign, IL: Human Kine6cs Publishers. Appropriate Diagnoses with ICD- 9 Codes for Respiratory Services " Restric6ve Lung Diseases: " Inters66al diseases: 518.89 " Inters66al fibrosis: 516.31 " Occupa6onal or environmental lung disease: 518.89 " Sarcoidosis: 517.8 (Lung involvement ) " Chest wall diseases: " Kyphoscoliosis: 737.3 " Ankylosing spondyli6s: 720.0 AACVPR, Guidelines for Pulmonary Rehabilita6on Programs. 4 th ed. 2010, Champaign, IL: Human Kine6cs Publishers. Appropriate Diagnoses with ICD- 9 Codes for Respiratory Services " Restric6ve Lung Diseases, Con6nued: " Neuromuscular diseases: " Parkinson s: 332 " Postpolio syndrome: 138 " Amyotrophic lateral sclerosis: 335.2 " Diaphragma6c dysfunc6on: 518.89 " Mul6ple sclerosis: 340 " Post- tuberculosis syndrome: 518.89 AACVPR, Guidelines for Pulmonary Rehabilita6on Programs. 4 th ed. 2010, Champaign, IL: Human Kine6cs Publishers. Appropriate Diagnoses with ICD- 9 Codes for Respiratory Services " Obesity- related Respiratory Disorders: " Obesity hypoven6la6on syndrome: 278.03 " Obstruc6ve sleep apnea: 327.23 " Other Lung Disorders: " Lung cancer: 162 " Pulmonary hypertension: 416-417.8 " Post- lung transplant: V42.6 AACVPR, Guidelines for Pulmonary Rehabilita6on Programs. 4 th ed. 2010, Champaign, IL: Human Kine6cs Publishers. 8
Federal Register, Vol. 66, No. 212, November 1, 2001 " Respiratory Therapeu6c Services " G0237: Respiratory therapeu6c procedure to increase strength & endurance, each 15 minutes " Breathing retraining, 1:1 exercise and/or strength training " G0238: Respiratory therapeu6c procedure to improve respiratory func6on other than described by G0237, each 15 minutes " Res6ng vital signs, airway clearance training " G0239: Respiratory therapeu6c procedure, group (2 or more individuals) billed once per session " Plus other per6nent services provided with Respiratory Services Timed CPT Codes (G0237 & G0238) Units Time Units Time 1 unit 8 to 22 min 5 units 68 to 82 min 2 units 23 to 37 min 6 units 83 to 97 min 3 units 38 to 52 min 7 units 98 to 112 min 4 units 53 to 67 min 8 units 113 to 127 min Other Per6nent Interven6ons Related to Respiratory Services " Ini6al Aerosol/MDI Instruc6on: 94664 " Can bill once per day " Tobacco Use Counseling, Intensive - >10 minutes: 99407 (for pa6ents with tobacco- related illness) " Tobacco Use Counseling, Intermediate - >3-10 minutes; (for pa6ents with tobacco- related illness) " G0436 and G0437 are for people who are asymptoma6c of tobacco- related illness Be sure to discuss use of the tobacco counseling codes with your Chargemaster or Compliance Office Na6onal Correct Coding Ini6a6ve (NCCI) Edits " NCCI is CMS s method of controlling improper coding. " Published quarterly: January, April, July and October " NCCI Policy Manual for Medicare Services, Version 16.3, October 1, 2010: " Effec6ve October 1, 2010, procedure codes bundled into G0237- G0239 and G0424 include: " PFTs: 94010, 94150, 94200, 94240, 94250, 94260, 94350, 94360, 94370, 94375, 94400, 94450, 94680, 94681, 94690, 94720, 94725, 94750 " Pulmonary stress tes6ng: 94620 (6MWT), 94621 " Manipula6on of chest wall: 94667, 94668 " Something else to discuss with your billing dept.! Know your state s Medicaid rules! " Iowa Medicaid reimburses for Go239, but not for G0237 or G0238 " Nebraska Medicaid??? What about private insurance? " Most private insurance companies accept the same codes as Medicare " G0424 for pa6ents with COPD " G0237, G0238, and G0239 for pa6ents with respiratory disease other than COPD 9
Func6onal Limita6on Repor6ng Requirements Effec6ve: January 1, 2013 " Func6onal limita6ons must be submihed on claim form by PTs, OTs, and Speech- Language Pathologists " Non- payable G- codes: Used to categorize func6onal limita6on for each pa6ent; Must be submihed with a $0.00 charge " Severity modifiers: Used to indicate the severity of the func6onal impairment " Repor5ng frequency: Ini6al evalua6on, every 10 th visit, at re- evalua6on, and at discharge Change Request 8005, December 21, 2012, CMS Manual System Func6onal Limita6on Repor6ng " Grace period from January 1, 2013 through June 30, 2013 " Applies to all providers (Hospitals, CAHs, SNFs, CORFs, Rehab Facili6es, HHAs, Private Prac6ce) " Example: " Non- payable G- codes: " G8987, Self care func6onal limita6on, current status, at therapy episode outset and at repor6ng intervals " G8988, Self care func6onal limita6on, projected goal status, at therapy episode outset, at repor6ng intervals, and at discharge or to end repor6ng " G8989, Self care func6onal limita6on, discharge status, at discharge from therapy or to end repor6ng Change Request 8005, December 21, 2012, CMS Manual System Func6onal Limita6on Repor6ng Severity/Complexity Modifiers Each non- payable G- code must have a modifier to indicate the severity/complexity for that func6onal measure Modifier CH CI CJ CK CL CM CN Impairment Limita5on Restric5on 0 % impaired, limited or restricted At least 1% but < 20% impaired, limited or restricted At least 20% but < 40% impaired, limited or restricted At least 40% but < 60% impaired, limited or restricted At least 60% but < 80% impaired, limited or restricted At least 80% but < 100% impaired, limited or restricted 100% impaired, limited or restricted Change Request 8005, December 21, 2012, CMS Manual System References 1. Pub 100-02 Medicare Benefit Policy, Transmihal 124, Change Request: 6823, May 7, 2010, CMS Manual System. 2. Global Ini6a6ve for Chronic Obstruc6ve Lung Disease. Global Strategy for the Diagnosis, Management, and Preven6on of Chronic Obstruc6ve Pulmonary Disease; NHLBI/WHO Workshop Report. Bethesda, Md: NHLBI, Na6onal Ins6tutes of Health; Updated 2009. NIH publica6on 2701A. 3. Federal Register / Vol. 74, No. 226 / Wednesday, November 25, 2009 / Rules and Regula6ons. 410.47 Pulmonary rehabilita6on program: Condi6ons for coverage, pgs. 61879-61886; 62002-62003. 4. Pub 100-20 Medicare Benefit Policy, Transmihal 941, Change Request: 7470, August 5, 2011, Common Working File Edi6ng Update for Pulmonary Rehabilita6on Services (PR) and Cardiac and Intensive Cardiac Rehabilita6on Services. CMS Manual System. 5. Federal Register/Vol. 66, No. 212/Thursday, November 1, 2001/Rules and Regula6ons. Changes to the 2002 Physician Fee Schedule and Clarifica6on of CPT Defini6ons; Respiratory Therapy Codes, pg. 55311. 6. AACVPR Guidelines for Pulmonary Rehabilita6on Programs. Fourth Edi6on. Human Kine6cs, 2011. 7. Change Request 8005, December 21, 2012, CMS Manual System. 10