Pulmonary Rehabilitation

Pulmonary Rehabilitation

Pulmonary Rehabilitation Meeting Medicare Guidelines Connie Paladenech, RRT, RCP GBA J-11 and NCCRA 2012 2013 2014 Monthly AACVPR and MAC -11 Conf. Calls Cardiac Rehab Audits

Pulmonary Rehab Audits begin Dr. Pilley, Med Dir. MAC 11 Feb 2012 State NCCRA Meeting guest speaker Dr. Pilley Monthly AACVPR and MAC -11 Conf. Calls Cardiac Rehab Audits stop Cardiac Rehab LCD Pulmonary Rehab Audits intensify July 25 AARC

Webinar/Audits Aug 2013 MAC 11 Webinar PR Program denial rates increase in MAC 11 Summer 2016, Dr. Feliciano named MAC-11 Senior Medical Director Fall 2013, Ed Haver contacted Dr. Feliciano to request conf. call Nov 8 Dec 5 MAC 11 met faceto-face with Dr. Feliciano Jan 16 AACVPR Porte/Lui; AARC; NAMDRC, ATS, COPD Foundation, Dr.

Lamberti, Dr. Ohar, G Connors, C Paladenech teleconference Jan 28 MAC 11 Dr. Feliciano Conference Call Feb Webinar and MAC J11 to be determined Dr. Feliciano offers to speak at state meetings Target date to reduce denials to <50% moved to July 1, 2014 Palmetto working on Webinar to provide education re: PR audits end of March 2014

Components (E-CFR 410.47 7/13 per Federal Register) Physician prescribed exercise Education or training including information on respiratory problem management and smoking cessation, if warranted Psychosocial assessment Outcomes assessment ITP

Education or Training Only education & training which addresses needs particular to the patient that will further their independence in ADLs As necessary to ensure proper use and compliance with use, care, cleaning of home respiratory care equipment Mandatory Components - Examples Education or Training Skills training that leads to improved health and long-term adherence Energy conservation techniques

Work simplification techniques Brief smoking cessation Proper use of medications Healthy food choices Guidelines for losing/gaining weight Coping with shortness of breath during or after meals Coping skills Relaxation techniques Physician Prescribed Exercise

Physician prescribed exercise program Training in benefits of and safe exercise techniques Individualized Treatment Plan (ITP) Established, reviewed and signed by a physician who is involved in the pts care and has knowledge related to his or her condition every 30 days Plan must include:

Diagnosis Scope of services Type Amount Frequency Duration Individualized treatment goals Psychosocial Assessment Written narrative report of: Family & home situation that affects individuals

rehabilitation treatment; consider referrals to support groups, community and/or home care Pts need as appropriate for depression management, stress reduction, relaxation techniques, and strategies for coping with lung disease Knowledge test

Changes in Behavior (Wt loss/gain, smoking Six Minute Walk Test RPD/RPE Education (SelfManagement Skills) Exercise Psychosocial evaluation of individuals response to and rate of progress under treatment plan Screening and

evaluation of individuals lifestyle and other Outcomes Assessment Written evaluation of patient progress as it relates to individuals rehabilitation: Beginning and end evaluations based on patient centered outcomes conducted by the physician at the beginning and end of the program Objective clinical

measures of effectiveness of the PR program for the individual pt. Exercise performance Self-reported measures of shortness of breath and behavior Measure at beginning, prior to each 30 day

review of treatment plan, and no later than end of program Considered part of program and may not be billed separately. 6MWT Weight Exercise performance CMS AUDITS of G0424 data used in AARC July Webinar State

MAC Kentucky J15 Ohio J15 North Carolina J11 South Carolina J11 Virginia J11 % Denial Rate 83.8% 77.7% 88%

87% 63% MAC J-11 Dec 11-19-13 to 12/04/13 Claim Review NC 96 % Denied SC 100% Denied WV/VA 98% Denied Palmetto GBA divides claims into different levels of RISK on an Impact Severity Risk Map and PR falls into MAJOR RISK CATEGORY!!!!!!!!! Identifying Reasons for Denials Ask for the DDE biller comments on page 4 on each claim will

detail out the granular error key Know the required documentation to pass a MAC 11 audit its all about Granular Errors Understand G0424 COPD diagnosis requirements Know the ICD-9 Diagnosis for medical necessity for the Respiratory Therapy G codes, G0237,G0238, G0239 State the documentation support required for physician supervision, psychosocial intervention, education, therapeutic exercise and outcomes CMS AUDIT Denial Reasons Records not submitted Claim level denial for multiple line denials Beneficiary signature requirements not met Sessions did not include required services

Services not documented Physician Supervision NOT documented PR NOT WARRANTED for Diagnosis NCD Denial No Diagnosis/Documentation to support medical necessity Palmettos Aug. 2013 Webinar MOVE ON do NOT concern yourself with Aug 2013 Webinar DATA Documentation & Audits

Original ADR on Top with Bar Code of Submitted Audit documentation Each Claim must have all parts of documentation (if audit is for the last weeks of claim should submit from Day 1 in PR to show progression) Facility Policy for Supervising MD with each claim Calendar/schedule/call list for each day treatment provided to prove supervision Signature page required to read MD, staff signatures

Print MDs name under signature Often 2 sided documents are NOT received Must include interpreted copy of post-bronchodilator PFTs Granular Error 001 MD Referral o COPD GOLD II- IV POST Bronchodilator Both FEV1 and Ratio qualification MUST be met NO MD justification letter accepted for why Ratio is not <0.70 o MD signature MUST be legible Print MD name below signature Dr. Feliciano will provide an answer regarding physician extenders

writing a referral for PR GOLD Stages Post-Bronchodilator Spirometry Stage 2: Moderate o FEV1/FVC < 0.70 o FEV1< 80% predicted PROGRAM EXPANSION Stage 3: Severe o FEV1/FVC < 0.70 o FEV1< 50% predicted Stage 4: Very Severe o FEV1/FVC < 0.70 o FEV1< 30% predicted

Pulmonary Rehabilitation Lives in 2 WORLDS of Documentation & Coding CMS Pulmonary Rehabilitation National Coverage Policy - G0424 billing code only for COPD GOLD II - IV Medicare Administrative Contractors (MACs) Respiratory Therapy Local Coverage Decision (LCD) G0237, G0238 & G0239 billing codes o Remember MACs are allowed to INTERPRET CMS Rules Physician Referral Documentation Minimum/suggested information the referral should include o ICD-9 diagnosis (ICD-10 - Effective October 1, 2014)

o H & P, to include medication list (within 90 days at least) o Complete Pulmonary Function Test o MUST have Pre/Post Bronchodilator spirometry and qualifying FEV1 and Ratio is from the actual POST Bronchodilator data, both MUST qualify for G0424 Granular Error 001 continued Orders HCPC Code G0424 BUNDLED & GLOBAL Therapeutic Exercise Physician-prescribed exercise

Physical activity to include: aerobic exercise, prescribed and supervised by a MD that improves or maintains an individuals pulmonary functional level Exercise conditioning Breathing retraining Stretching & strengthening exercises CMS Documentation Individualized Treatment Plan Individualized Treatment Plan include: (ITP)

MUST o Diagnosis o Type, amount, frequency, duration and progression of items/services under the plan o Individual goals o Exercise Each session must include some aerobic physician prescribed exercise o Be established, reviewed and signed by MD Medical Director must sign initial ITP prior to pt beginning PR Every 30 days ITP continued May be developed by referring MD or medical director, but medical director must review and sign prior to initiation

Reviewed every 30 (calendar) days Medical director to have initial direct contact with the individual One direct contact with beneficiary within each 30 day period Individualized Treatment Plan (ITP) LAW PFS 7/2013 Federal Register 410.47 Description of diagnosis Type, amount, frequency and duration of items and services to be furnished Goals Each session must include some MD prescribed

aerobic exercise Granular Error 002 Is there documentation present for all dates of service o Use internal AUDIT tool to verify all components of required documentation is in each patient record sent for audit CMS Documentation PHYSICIAN SUPERVISION A Physician (MD or DO) must be physically immediately available MUST be accessible for medical emergencies at all times the PR program is treating patients MUST be interruptible to physically respond immediately PR medical director and supervising MD do not have to be the same person

Qualification of Supervising MD or DO o Expertise in management of respiratory disease o Cardiopulmonary training or certification in BLS or ACLS o Licensed to practice medicine in the state where the PR program is located Granular Error 003 Does patient have moderate to severe COPD as defined as GOLD classification II IV and per 42 CFR 410-47 Granular Error 004 Does documentation show post-bronchodilator pulmonary function studies where FEV1 is less than 80% predicted and Actual Ratio is < .70 Granular Error 005

Is the supervising MD immediately available and accessable for medical consultations and emergencies at all times when services are being provided under the program as defined in 42 CFR 410-47 o Include copy of policy and procedure for MD supervision o Include calendar schedule of supervising MD for every date of service billed/audited Supervising Physician MD immediately available & accessible for medical consultations & medical emergencies at ALL times items & services are being furnished under the PR program Must be documented on each pulmonary rehabilitation session, exercise/education

Granular Error 006 o Is there an individualized treatment plan signed by a physician and reviewed every 30 days as required in 42CFR 410-47 present in record Granular Error 007 o Does the Pulmonary Rehabilitation program contain mandatory components as defined in 42CFR 410-47 Physician prescribed exercise Education or training (including information on respiratory problem management and smoking cessation, if needed) Psychosocial assessment o Need some narrative, not just a score o Should address pts family and home situation that affects individuals rehabilitation treatment o Pts need as appropriate for depression management, stress

reduction, relaxation techniques, strategies for coping with lung disease o Psychosocial evaluation of individuals response to and rate of progress under treatment plan ITP Outcomes assessment Granular Error 008 o Is there a physician prescribed exercise program MODE FREQUENCY INTENSITY DURATION

PROGRESSIO N Lap Walking 3 days/week RPD 3-5 20 minutes Increase by 2 min/session to 30 min

Granular Error 009 o Is there documentation of the patients education or training as it relates to care and treatment How was it presented? To whom? Pt/family response? Granular Error 010 o Is there a psychosocial assessment of the individuals mental and emotional functioning as it relates to their rehabilitation or respiratory condition Pt needs to sign Staff member needs to sign Medical director must review and interpret

Granular Error 011 o Is there an outcomes assessment of the patients progress related to the rehabilitation Granular Error 012 o Does documentation reflect pulmonary rehabilitation services up to 36 sessions and no more than two sessions per day as defined in 42 CFR 410-47 Granular Error 013 o Does documentation reflect pulmonary rehabilitation services up to 72 sessions with KX Modifier and no more than two sessions per day as defined in 42 CFR 410-47 Pulmonary Rehabilitation Program Services (PRPS) CMS Conditions for COVERAGE

Jan. 1, 2010 is the 1st time CMS provides payment for exercise & other services as part of a comprehensive treatment plan for COPD ONCE in a LIFE TIME Benefit started 1-1-2010 Payment is for beneficiaries with moderate to very severe COPD o Stage II - IV GOLD o LCD Resp. Therapy for COPD that does not qualify in G0424 HCPC Code G0424 bundled & global codes Bundled o all providers use same code

Global o code means one reimbursement amount Survival The Pulmonary Rehabilitation TOOL KIT Guidance to Calculating Appropriate Charges for G0424 HCPC Code G0424 cont. bundled & global codes ONCE IN A LIFE TIME BENEFIT o started 1/1/2010

Up to 36 sessions o No specified # of weeks o No specified # of months o No specified # of years Up to an additional 36 sessions may be approved by MAC based on medical necessity o CMS specified maximum # of sessions at 72 Some exercise must be included in each PR Session Documentation of HCPC Code

G0424 Minimum of 60 min. per session o Must be > 31 minutes for one session to be billed o May go over 60 minutes o 2 sessions must be at least 91 minutes (60 + 31) DISTINCT Periods of exercise in each session Session includes monitoring (cannot bill separately for monitoring)

Maximum of two sessions/day HCPC Code G0424 cont. HCPCS CODE G0424 must be used for all PR services BUNDLED & GLOBAL = TOOL KIT o Assessment 6 MWT Psychosocial o A written evaluation of mental/emotional functioning o Assessment of those aspects of individuals family & home situation that affects the individuals rehabilitation treatment o Evaluation of the individuals response to & rate of progress under the treatment plan HCPC Code G0424 cont.

BUNDLED & GLOBAL Education/training Related to individuals care & treatment Tailored to individuals need Includes info on respiratory problem management desensitization to dyspnea If appropriate brief smoking cessation counseling Must assist in achievement of individuals goals towards:

o independence in activities of daily living o adaptation to limitations o improved quality of life BILLING & CODING UB04 BUNDLED & GLOBAL REV CODE 948 KX Modifier used for medically necessary PR sessions 37 - 72 o Used with HCPC code GO424 o Insurance authorization for G0424 must look up services from a Common Working File (CWF) system to determine how many life time session available Modifier 59 used when more than one

Respiratory Therapy G code (G0237,238,239) The Respiratory Therapy G Codes ARE NOT BUNDLED & NOT GLOBAL G0237 NOT BUNDLED & NOT GLOBAL o Therapeutic procedures to increase strength or endurance of respiratory muscles o Face to face 1:1, each 15 min G0238 NOT BUNDLED & NOT GLOBAL

o Therapeutic procedures to improve respiratory function, includes monitoring o Other than described by G0237 o Face to face 1:1, each 15 min The Respiratory Therapy G Codes ONLY if your MAC allows ARE NOT BUNDLED & NOT GLOBAL G0239 NOT BUNDLED & NOT GLOBAL o Therapeutic procedures to improve respiratory function or increase strength or

endurance of respiratory muscles, includes monitoring o 2 or more individuals (group) Respiratory services G codes has a proposed 2014 rate of $39.33 per 15 minutes for the timed procedure codes (G0237, G0238) and the un-timed group exercise therapy code, G0239 (CMS released July 8, 2013) The co-payment is also $7.87 The Respiratory Therapy G0237 & G0238 FACE to FACE, 1:1, each 15 minutes ARE NOT BUNDLED & NOT GLOBAL

Unit Treatment time 1 unit: 8 min 22 min 2 units: 23 min 37 min 3 units:

38 min 52 min 4 units: 53 min 67 min 5 units: 68 min 82 min 6 units: 83 min 97 min 7 units: 98 min 112 min 8 units: 113 min 127 min 9 units: 128 min 142 min 10 units: 143 min 157 min 11 units:

158 min 172 min 12 units: 173 min 187 min CMS Definition of PR as it Relates to Documentation A physician supervised program Documentation should reflect how the PR program is optimizing the patients Physical performance Social performance and Autonomy FUNCTIONAL DOCUMENTATION Physical assistance, cueing & coaching

Key Documentation WORDS Physical Medicine community has established documentation language accepted by Medicare o called Functional Independent Measures (FIMs) Allows for precise documentation of the skilled treatment intervention Specific content areas to document are: o level of physical assistance o cueing Key Documentation WORDS cont. Medicare understands the physical

medicine language to document the need for skilled level of therapist intervention the pulmonary rehabilitation community must begin to use this language to document the cueing needed in education and level of physical assistance/cueing needed during the therapeutic supervised exercise Home Exercise Documentation Essentials Medicare expects patients to exercise at home during the program. How do you document this?

Exercise Charting Dos & Donts Total gym time MAY NOT ALWAYS EQUAL billed time Total Exercise Time o Total gym time is time patient arrives in the gym to when they walk out of the gym, o THIS TIME IS NOT WHAT IS BILLED TO INSURANCE since it may not be monitored the entire time and does not require skilled

intervention o Billed time must document skilled level of supervision MONITORED TOTAL TIME o is the time YOU have taken to MONITOR the patient, this DOES NOT INCLUDE time patient may have to wait for equipment since there is no medical reason for monitoring skilled intervention Warm up/cool down cannot be included in billing once patient can perform without skilled intervention of physical assistance or cueing (usually after 3-4 visits or per patient) Documentation of HCPC Code G0424

cont. Education/training Related to individuals care & treatment Tailored to individuals need Includes info on respiratory problem management desensitization to dyspnea If appropriate - brief smoking cessation counseling Must assist in achievement of individuals goals towards: o independence in activities of daily living

o adaptation to limitations o improved quality of life EDUCATION/TRAINING DOCUMENTATION cont. o LEARNING OBJECTIVES: patient trained in the following: Date/ Start Time/Staff Initial Individual Trained /Teaching Method Outcome/End time Total time

Pt. Education Dos & Donts DO Document Variables affecting learning (culture, language, literacy, pain, hearing, etc.) DO NOT document you are completing forms DO NOT document you are using audio tapes, video tapes etc. DO NOT document patient did relaxation training with an audio tape NO SKILLED LEVEL OF INTERVENTION MEANS NO BILLING Correct Coding & Documentation = Reimbursement

PROVE The Need for YOUR Skilled Level Of Intervention THANK YOU! Connie Paladenech, RRT, RCP Manager Cardiac and Pulmonary Rehabilitation & Pulmonary Diagnostics Wake Forest Baptist Health [email protected]

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