Required Components of Pulmonary Rehab 2010



Note:

Cigna Government Services (CGS) assumed MAC J15 governance responsibilities as of Monday 10/17/12. I have been able to recently contact representatives of CGS regarding their organizational policy regarding Pulmonary Rehab coverage in their geographic area (Kentucky & Ohio).

CGS has decided to adhere to the national coverage determination (NCD) of January 1, 2010 regarding CMS coverage of pulmonary rehab. In short their will be no change in coverage since under the previous contractor pulmonary rehab was operating under NCD rules. This is good news! It allows for more flexibility in providing our services. Below I listed the program requirements contained within the NCD that has been in effect since January 1,2010. (Also billing practices should not be effected by this change in MAC provider).

There is the possibility that in the future CGS may decide to develop a specific LCD for Pulmonary Rehab. If so the AACVPR MAC J-15 committee as well as national governance colleagues will be actively involved in the process to insure equitable coverage rules for our service.

Warm Regards,

Jim Rosneck RN, MS

MAC J-15 Committee Chairman

Required Components of Pulmonary Rehab 2010

Physician prescribed exercise:  includes techniques such as exercise conditioning, breathing retraining, step and strengthening exercises.  Some aerobic exercise must be included in each pulmonary rehabilitation session. (Physician “prescribed” can be interpreted as the physician reviewing and approving the Initial Treatment Plan (ITP) which should include the exercise Rx and individualized care plan “developed PR staff”) JR

Education or training:  Must be closely & clearly related to individual’s care and treatment tailored to the individual’s needs;

– Education includes information on respiratory problem management and, if appropriate, brief smoking cessation counseling

– Must assist in achievement of individual goals toward independence in ADLs, adaptation to limitations and improved quality of life

• Examples of Education & Training:

(from Proposed Rule)

• Respiratory techniques for physical energy conservation, work simplification and relaxation techniques

• Skills training and education that encourage behavioral changes by the patient which lead to improved health and long term adherence

• Brief smoking cessation

• Proper use of medications, nutrition counseling  (See AACVPR templates note: a wide range of variations to the templates and documentation are acceptable AACVPR PR outcomes matrix a good guide to pick and choose from.) JR 

Psychosocial Assessment:  Written evaluation of the individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition

– Includes assessment of those aspects of individual’s family and home situation that affects the individual’s rehab treatment; (A couple of documented questions during an intake eval re: instrumental home support will suffice) JR

– Includes evaluation of individual’s response to and rate of progress under the treatment plan. (Pre & Post BDI, SF-36 etc.)JR

– Provided by PR staff

Outcomes Assessment:  Written evaluation of the patient’s progress as it relates to the individual’s rehabilitation and includes the following:

– Beginning and end evaluations, based on patient centered outcomes, conducted by the physician at the start and end of the program; (Approved by physician)JR

– Objective clinical measures of effectiveness of the PR program for the individual patient, including exercise performance and self reported measures of shortness of breath and behavior

Individualized Treatment Plan: Written plan established, reviewed, and signed by a physician every 30 days.

• Established by a physician (referring MD or program Medical Director)

• CMS does not stipulate that the physician for PR order would need to be a separate process or part of the ITP-leaving that choice to program’s discretion

– Medical Director must review and sign initial ITP, even if established by referring physician, prior to initiation of PR (This was clarified by the AACVPR to mean that in the absence of concerns that may arise during the patients initial evaluation that require immediate attention of the medical director prior to the patient starting the program, the medical director can review and sign the ITP after the patient begins active participation.)JR

– Input from pulmonary rehab staff on components of plan is acceptable

– MD establishing the plan needs to be one who is involved in the patient’s care and has knowledge of his/her condition and is the physician who signs the 30-day ITPs (This will be a crucial policy judgment call for each program, at our institution the medical director will be this physician. After this approval the patient proceeds with the program and the referring doc is faxed the report and given the ability to change any portion of the plan, sign and FAX back to us)JR… note: if we waited for referring docs to sign-off the program would screech to a halt!

Components of Treatment Plan

• Individual’s diagnosis

• Type, amount, frequency and duration of the items and services under the plan

• The goals for the individual under the plan

[pic]

Qualifying Diagnoses

• Moderate, severe and very severe COPD diagnosis qualifies beneficiary for pulmonary rehab

– Must use new G Code for these dx as of January 1, 2010

– CMS uses GOLD Guideline definitions for COPD classifications • Must use current G Codes and current rules; not new payment methodology or rules

• Non COPD population (interstitial lung disease, CF, restrictive chest wall disease, pulmonary hypertension, etc.) will continue to be covered when specifically authorized by MAC via current LCD

- Must use current G Codes (G0237, G0238, G0239) and current rules; not new payment methodology or rules

• MACs that have not published LCDs may also continue to cover non-COPD diagnoses currently covered for “respiratory therapy” services ( Our MAC contractor has not developed a PR LCD so any patients with non COPD diagnosis should continue to be billed under these G Codes).

[pic]

Program Delivery

• One session: The duration of treatment must be at least 31 minutes

• Up to two sessions per day are permitted, but not required

– First session would equal 60 minutes, second session would equal at least 31 minutes if two sessions are reported.

•  Two sessions may be reported if the duration of treatment is at least 91 minutes

• Must exercise in every session

• No restriction on # of days per week patient can attend PR program

• No calendar restriction on length of PR program

• CMS is silent on CR and PR sharing space/staff

• Up to 36 sessions authorized, based on medical necessity

– Additional 36 sessions at local contractor (MAC) discretion on case-by-case basis (72 sessions lifetime)

• Not granted prospectively

• Justification with evidence of continued medical necessity would need to be submitted to the MAC 

[pic]

Individualized Treatment Plan

• Established by a physician (referring MD or program Medical Director)

• CMS does not stipulate that the physician for PR order would need to be a separate process or part of the ITP-leaving that choice to program’s discretion

– Medical Director must review and sign initial ITP, even if established by referring physician, prior to initiation of PR

– Input from pulmonary rehab staff on components of plan is acceptable (I believe CMS knows that the Docs aren’t going to do this)JR

– MD establishing the plan needs to be one who is involved in the patient’s care and has knowledge of his/her condition and is the physician who signs the 30-day ITPs (This again is your programs choice. A medical director handling this appears to me to be the best way to avoid “paper snags”)JR

Components of Treatment Plan

• Individual’s diagnosis

• Type, amount, frequency and duration of the items and services under the plan

• The goals for the individual under the plan

[pic]

Physician Supervision

• A physician must be immediately available and accessible at all times program is operating 

• A physician must be present and immediately available where the services are being furnished

• For PR programs located in hospital or on campus department, “Physician availability shall be presumed.” (per Public Law 110-275)

• Hospital Campus Definition:      “Campus means the physical area immediately adjacent to the provider’s main buildings, 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 basis, by the CMS regional office, to be part of the provider’s campus." 42 CFR (Code of Federal Regulations) 413.6

• CMS Definition of “In the Hospital”: “…areas in the main building(s) of a hospital or CAH that are under the ownership, financial and administrative control of the hospital or CAH; that are operated as part of the hospital; and for which the hospital bills the services furnished under the hospital’s or CAH’s CMS Certification Number (CCN).”

• CMS does not define “immediately available” by time parameter

• On-campus CR program that has access to a physician-run code team would meet “immediately available” requirement

• For all programs, use of 911 alone does not meet Medicare requirement for physician “immediacy”

• Calling 911 as back-up and for patient transport is appropriate, but doesn’t replace need for an MD who is identified as the MD “immediately available” (Daily docummeentation schedule)JR

• For hospital-owned PR programs located in an off-campus provider-based department (PBD), MD “must be in the PBD of the hospital or CAH and immediately available…”

• This rule applies to other hospital outpatient therapeutic services; is not exclusive to CR/PR

• In the hospital outpatient setting, PR is no longer an “incident-to physician” services (due to new statute), but does remain under CMS “direct physician supervision” rules

• The physician does not have to be present in the room when the procedure (PR) is being performed (on hospital campus, hospital off-campus, or in MD office setting)

• For PR program located in physician office (i.e., MD-owned), physician must be “in the suite”, but does not have to be in the room.

• Nonphysician Practitioners (NP, PA, CNS)

– May NOT provide direct supervision for PR services

– May not serve as supervising MD for the day

– May not sign Individualized Treatment Plan

Can NPPs order PR?

– Not addressed by CMS

– Scope of practice is determined by state law. (OK in Ohio - ? Kentucky)

Supervising Physician

Supervising physician definition: “immediately available and accessible…”

• Supervising physician requirements:

–   Expertise in the management of individuals with respiratory pathophysiology, and cardiopulmonary training and/or certification including basic life support

– Licensed to practice medicine in the state in which the PR program is offered

• Medical Director

Medical Director definition: “Physician who oversees or supervises the PR program.”

•Medical Director requirements:

– Responsible and accountable for PR program, including oversight of PR staff

– Involved substantially, in consultation with staff, in directing progress of the individual in the program including direct patient contact related to the (periodic review of his or her treatment plan)JR

– Expertise in management of individuals with respiratory pathophysiology, and cardiopulmonary training and/or certification including basic life support (Wide range of interpretation here. Probably a pulmonologist or cardiologist are interchangeable given a certain level of cross training in internal medicine)JR

– Licensed to practice medicine in the state where PR program is offered

• Medical Director and Supervising Physician 

•May be same person 

•May be different physicians

•Supervising MD doesn’t have to be same person each day (Should have a plan for a qualified surrogate physician to supervise in the event a scheduled supervising physician is unavailable for immediate consultation) JR

[pic]

Payment

• New, bundled G code, G0424, defined as “pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session”

• For hospital based programs, G0424 crosswalks to new APC 0102, paying $50.46 per session.

• For physician office (subject to Congressional action), work RVU .18 + practice expense .46 + malpractice .01 x conversion factor ($28.40) = $18.46/session

[pic]

Staffing

• There is no required or recommended staff to patient ratio by CMS

• There are no specific discipline requirements for PR staff; CMS recognizes it is a “variety of team members” and that “the work is performed primarily by the multidisciplinary team, and not the physician”

• G codes would be submitted by a licensed professional (Implies at least one licensed professional RT or RN) JR

[pic]

Coding and Billing

• Revenue Code = 0948

• One session: The duration of treatment must be at least 31 minutes

• Physical therapists may no longer bill 97000 series of codes for pulmonary rehab for the new COPD diagnoses

• PT billing may continue as currently accepted for non-COPD dx

• Final rules do NOT apply to CORFs

• Rules remain unchanged from current policy for CORFs that provide respiratory therapy services to pulmonary patients

• New G code is bundled; additional services that are integral to PR patients, such as six minute walk, initial PR program patient assessment, etc. cannot be separately billed

• Medicare Form 700/701 is a “Plan of Care for Outpatient Rehabilitation” and is NOT necessary for PR services

• Physician services that are not typically received by all PR patients in a PR program, such as a physician’s need to acutely provide medication via MDI or aerosol (CPT 94640) would be billed by the MD

• Patients who receive PFTs in a PFT lab, not as part of the PR program, would be billed separately (different department, different services)

[pic]

Additional Issues

• “Monitoring”-this refers to typical monitoring provided to PR patients, such as oxygen saturation, blood pressure, dyspnea scale, RPE, etc.; determined by patient’s individual monitoring needs

• Pulmonary rehabilitation is no longer in the “incident-to physician” payment category due to Public Law 110-275 and a specific coverage statute; HOWEVER, PR services do remain under “direct physician supervision” CMS rules

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download