Take a Deep Breath - Effectively Managing Pulmonary Rehabilitation Program Requirements

If your facility bills comprehensive pulmonary rehabilitation services, and it’s not part of your compliance audit plan, you may want to think again! CGS, a Medicare Administrative Contractor (“MAC”), performed multiple reviews of comprehensive pulmonary rehabilitation services in 2013 and 2014 and denied one third to one half of all claims for one or more reasons. Similarly, the Office of Inspector General (“OIG”) released a report in 2015 in which half of the comprehensive pulmonary rehabilitation claims for a New Jersey hospital did not comply with one or more of Medicare’s diagnostic and documentation requirements.

Adding to the complexity, comprehensive pulmonary rehabilitation patients are often comingled with therapeutic respiratory therapy patients; but Medicare’s diagnostic and documentation requirements, as well as reimbursement, vary considerably.  It is vital to understand the distinctions prior to initiating a review and ensure that the services for each program are in compliance with the applicable Medicare guidance.

I. Background

Prior to the Medicare Improvements for Patients and Providers Act of 2008 (“MIPPA”), the Center for Medicare and Medicaid Services (“CMS”) covered specific respiratory therapy services which focused exclusively on therapeutic procedures to improve respiratory function.  

Effective January 1, 2010 and as part of the MIPPA, CMS established coverage for comprehensive pulmonary rehabilitation services, which emphasized patient education and disease-specific awareness to engender self-care.  The program incorporates numerous components for managing patients with chronic respiratory disease to improve the overall quality of a patient’s life, reduce symptoms and increase participation in physical and social activities. 

II. Comprehensive Pulmonary Rehabilitation Program Requirements Defined

One of the program requirements differentiating comprehensive pulmonary rehabilitation services from therapeutic respiratory therapy services, is the requirement that the patient have a diagnosis of moderate to very severe COPD as defined by the GOLD Classification II, III and IV.  Additionally, emphasis is placed on developing individually tailored programs intended to empower patients to exercise independently while mitigating psychosocial barriers and improving quality of life.

Being attuned to the CMS mandated components of the program is vital to mitigating risk, as summarized below.

i. Physician Prescribed Exercise

A signed order is required, defining the type of exercise prescribed, to include some form of aerobic exercise and strength training.  In addition to the mode of exercise, the physician’s prescription should also detail target intensity, duration and frequency, as well as the number of sessions per week.

ii. Education or Training

Education and training is intended to assist patients towards independence in the activities of daily living, adaptation to limitations, and improved quality of life.  Documentation should reflect the specific needs of the individual, the directives addressed and by whom they were delivered.

iii. Psychosocial Assessment

Medicare states the psychosocial assessment is “a written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition.”  In addition to the psychological, cognitive, and social barrier evaluation, the documentation should reflect appropriate interventions for any concerns identified as stipulated by Medicare: “It should include: (1) an assessment of those aspects of the individual’s family and home situation that affects the individual’s rehabilitation treatment, and, (2) a psychological evaluation of the individual’s response to, and rate of progress under, the treatment plan.” Periodic re-evaluations are necessary to ensure the individual’s psychosocial needs are being met throughout the program and promoting long-term maintenance.

iv. Outcomes Assessment

Assessment of exercise performance, breathing and oxygen saturation levels at the onset of the program as well as at the end, are critical documentation components. CMS points to evaluation of such clinical measures as the 6-minute walk, weight, exercise performance, and self-reported dyspnea. Behavioral measures such as supplemental oxygen use and smoking status, as well as a Quality of Life assessment are also documented.

v. Individualized Treatment Plan “ITP”

The ITP embodies the comprehensive nature of a pulmonary rehabilitation program, demonstrating a mix of exercise, education, training as well as psychosocial interventions tailored to the patient. While elaborating on measurable and expected outcomes and estimated timetables to achieve outcomes, the ITP should be individualized and reflect well-defined goals.  CMS expects specificity within the ITP regarding the type, amount, frequency, and duration of comprehensive pulmonary rehabilitation services furnished to the individual.

As a patient progresses through pulmonary rehabilitation, the ITP should be evaluated and signed every thirty (30) days by the physician supervising the program. Modifications, or reasons to continue the existing plan, should also be documented in the record.

vi. Physician Involvement

The services must be furnished under direct supervision in a physician’s office or hospital outpatient setting with the physician immediately available and accessible for medical consultations and emergencies.  The supervising physician must also be an expert in managing individuals with respiratory pathophysiology. 

CMS further stipulates that the supervising physician must be involved substantially, in consultation with staff, in directing the progress of the individual in the program.  Additionally, CMS requires the supervising physician to have initial, direct contact with the individual prior to treatment and every (30) thirty days.

“Direct contact” is not explicitly defined, nor does CMS state how these direct patient contacts are to be documented. For the initial contact, one MAC suggests a progress note documenting the clinical history, reason for pulmonary rehabilitation, the individual’s needs and how they would benefit by an exercise program, a description of the program, education and lifestyle factors that need to be addressed as well as intent to assess psychosocial needs of the patient.

CMS has also not defined direct contact in the context of the thirty (30) day requirement, however CGS Medicare offers that patient contact every thirty (30) days is “A brief (1-2 minute) conversation between the physician and patient, i.e., ‘eyeballing the patient’, would meet the ‘direct patient contact’ requirement for pulmonary rehab. The Medical Director attending the educational session and interacting with the patients would meet this requirement.”

vii. Staff Qualifications

While §231, Chapter 15, CMS IOM 100-02 Medicare Benefit Policy Manual stipulates physician involvement integral to supervising and administering mandated requirements, we can find no further specificity which defines the types of practitioners or personnel eligible to render exercise, training and support components of the pulmonary rehabilitation program.   The 2010 Final Rule Comments suggest that CMS envisioned a multidisciplinary approach in a pulmonary rehabilitation program with services tailored to the patient’s specific needs as follows: “We anticipate that a variety of team members will contribute to pulmonary rehabilitation during a session, and we have blended the values of the types of staff that we believe would most commonly be used.”

III. Pulmonary Rehabilitation versus Respiratory Therapy Services

Exercises intended to increase strength and improve pulmonary function are a key component of comprehensive pulmonary rehabilitation as well as therapeutic respiratory therapy services.  The distinguishing elements which characterize the therapeutic respiratory therapy program are as follows:

·     Focused exclusively on therapeutic procedures to improve strength and/or respiratory function, requiring a written order and furnished under a physician-established respiratory therapy plan of treatment.

·     Considered medically necessary for patients with respiratory impairment that do not meet the COPD Gold Classification II, III or IV.

·     Physician-prescribed exercise, education, psychosocial assessment, outcomes assessment and an individualized treatment plan are not expected documentation and service elements.   Rather, documentation should establish that respiratory services rendered were reasonable and medically necessary and required the skills of a licensed respiratory therapist.

·     CMS is vague relative to supervision requirements, specifically the role of the facility physician. CMS indicates that he/she must be present in the facility for a “sufficient time to provide, in accordance with accepted principles of medical practice, medical direction, medical care services and consultation.” Determinations of medical necessity for respiratory therapy services are delegated to the local MAC’s.

·     Per Medicare’s requirement, respiratory therapy services are provided by "a qualified respiratory therapist, as defined at 42CFR485.70(j).”

Understanding and incorporating the required documentation and service elements integral to both the comprehensive pulmonary rehabilitation program and therapeutic respiratory services is crucial to ensure that programs, especially programs existing out of the same location, are in compliance with Medicare guidance.

Our consultants spend a great deal of time researching and analyzing governmental guidelines and regulations.  We offer a full Service Line specifically geared to assisting healthcare providers’ manage the ever-changing professional regulatory environment.   If you have any questions about the 2017 Physician Coding and Policy Updates, please contact Vonda Moon, Principal atvondamoon@sunstoneconsulting.com or Joli Fitzgibbons, Senior Manager at jolifitzgibbons@sunstoneconsulting.com.