March 8, 2013 - Updated 08.24.16

Pulmonary Rehabilitation: Coverage and Documentation Requirements

Pulmonary rehabilitation may be covered under Medicare Part B ("Part B of A") for dates of service on or after January 1, 2010. Coverage was established in Section 144(fff)(1)) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and CMS declined to establish a National Coverage Determination (NCD) for pulmonary rehabilitation services. The Centers for Medicare & Medicare Services (CMS) published MLN Matters article MM6823, "Pulmonary Rehabilitation (PR) Services," which further describes the guidelines associated with coverage of pulmonary rehabilitation under Medicare. The purpose of this article is to provide the criteria for coverage and the documentation required to meet the conditions of coverage. Documentation to support all services billed and the medical necessity of the services provided must be submitted to CGS upon request.

The Rule states the following:

(b) General rule

(1) Covered beneficiary rehabilitation services. Medicare Part B covers pulmonary rehabilitation services for beneficiary who have a diagnosis of:

(i) Moderate to Very Severe COPD as defined by the Gold Classification

Explanation:

In the documentation provided, CGS expects to see clinical evidence of a physician validated diagnosis of Moderate to Very Severe COPD as defined by the Gold Classification. Results of a Pulmonary Function Test (PFT) may be submitted as evidence of this. Results of PFT must be documented and demonstrate Gold classification.

The Rule:

(2) Components of pulmonary rehabilitation program.

Pulmonary rehabilitation programs must include all of the following:

(i) Physician-prescribed exercise each day pulmonary rehabilitation items and services are furnished.

(ii) Education and Training tailored to the individual's needs including information on respiratory management and if appropriate, smoking cessation.

(iii) Psychosocial assessment

(iv) Outcomes Assessment

(v) An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.

Explanation: When reviewing these cases, CGS finds this set of requirements is often not documented correctly or sufficiently in the medical records provided. The documentation should clearly show that these parameters are met.

(i) Physician-prescribed exercise each day pulmonary rehabilitation items and services are furnished.

There should be documentation in the chart that the physician prescribed a specific exercise for each day (a note or order from the physician, signed and dated) and a record showing the patient did the exercise. This does not mean a physician write an order every day, but that the physician must write an order for what is done, prior to it being done. Remember: documentation requirements include the patient's name, date, a description of the exercise showing the doctor's prescription was followed, and the signature and credentials of the individual who directly supervised that exercise-or supply a reasonable clinical explanation for its not being done. Typically the physician-prescribed exercise can be found as a part of the treatment plan, providing that the treatment plan is signed by the physician.

CGS expects that the physician's prescription for exercise will include:

• Mode of exercise (typically aerobic)
• Target intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs)
• Duration of each session (e.g., "20 minutes")
• Frequency (number of sessions per week)

CGS also expects that the pulmonary rehabilitation professional will use this prescription as a dynamic blueprint and will continuously monitor and record the patient's objective and subjective responses to the exercise therapy. While the supervising physician may not personally orchestrate each change in the exercise program, he or she will certainly rely on recorded data and observations based on the exercise sessions in his or her periodic reviews of the patient's progress.

(ii) Education and training tailored to the individual's needs including information on respiratory management and if appropriate, smoking cessation.

The plan of care prescribed and signed by the physician should include a comment that education needs will be addressed, which education factors are important to this particular patient (e.g., smoking cessation)) and directing education, counseling, and behavioral intervention. The record must contain documentation demonstrating how such education needs were addressed with concurrent notes, signed and dated by the appropriate individual at the time these services are delivered. A form signed and dated stating, "Tobacco cessation education done" is an example of inadequate documentation. There may be an order to address education; for example, "please work on tobacco cessation." There should also be a progress note discussing what education was done and its outcome by the person who does the intervention.

(iii) Psychosocial assessment documentation should be present

This does not mean that a psychologist or psychiatrist must be on staff and personally conduct the psychosocial assessment. Although a psychologist or psychiatrist may conduct this assessment, other acceptable methods of conduction the assessment include recognized tools for depression screening, accompanied by the physician's plan of action based on the results. Regardless of the method used to conduct the psychosocial assessment, documentation is expected to include the signature and date of the health care professional who conducted the assessment; an interpretation of the results; and the signature and date of the physician who utilized the results of the recognized screening tool to prepare the plan of care. A note stating a standardized test was done and its score is not sufficient documentation of a psychosocial assessment.

(iv) Outcomes assessment:

This refers to the need for the program to show the interventions/services did or did not result in some benefit to the patient. For example, if the goal was for the patient to stop smoking by smoking 2 cigarettes less each week, there should be notation in the file of the beginning amount of cigarettes smoked per day was 6 and after 4 weeks, was still 6 and the goal was not met. Or the goal was for the patient to be able to walk for 30 minutes on the treadmill at 2 miles per hour daily without undue shortness of breath and the goal was met or not met. If the goal was not met, it is prudent to include what modifications were made to the care plan to address the failure. Like all such notes, it must be signed and dated by the person doing the assessment, with his or her credentials, on the day the assessment is done.

(i) An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.

This requirement uses the information from (iv) above (outcomes assessment) but specifies the assessment must be done every 30 days by a physician. One method of documenting this is a progress note from the treating physician, done at the time of admission to the pulmonary rehabilitation program in question, explaining:

• The patient's clinical history, and
• Reason for the prescription of pulmonary rehabilitation (the first requirement above),
• A discussion of the individual patient's needs and how they would be met by an exercise program,
• A description of the exercise program,
• A description of the education program detailing what factors need to be addressed for a particular patient's sedentary life style, obesity, tobacco use, etc., and
• Goal(s) for the psychosocial assessment

Further documentation is required from the treating physician, no later than 30 days after the initiation of treatment, which describes,

• The outcomes assessment specifies any modifications needed in the plan of care previously prescribed, or
• Reason(s) to continue the present plan.

The Rule:

(3) Settings:

i. Medicare pays for pulmonary rehabilitation services in one of the following settings:

A. A physician's office

B. A hospital outpatient setting

ii. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for supervision for physician office services, at section 410.26 of this subpart; and for hospital outpatient services at section 410.27 of this subpart.

Explanation: CGS expects that, for hospital–based settings, the immediate availability and accessibility of a physician for medical consultation and medical emergencies is presumed.

Non-hospital-based settings:The claim must show the place of service and the facility must provide documentation to verify a physician is immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. The Code of Federal Regulations (42 CFR § 410.27) provides a further discussion of the meaning of such supervision.

iv. "direct supervision: means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or non-physician practitioner must be present in the room when the procedure is performed. For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or osteopathy, as specified in §§ 410.47 and 410.49, respectively.

Procedures and protocols: Programs providing pulmonary rehabilitation services typically follow a set of procedures, policies, and protocols. CGS anticipates that these protocols would include information about how the direct supervision requirement is met. For example, some facilities have a hospitalist who is on duty in their facility. Providers must maintain documentation which demonstrates there is a procedure in place which meets this requirement and that the procedure was followed in the specific case being reviewed (on the day of service in question). For example: a copy of the section of the procedure, policy, and/or protocol that explains it would suffice. Regardless of the manner in which direct supervision is documented, it is important to show all of the elements required by the rule are met. For a non-hospital based facility, a log identifying the direct supervising physician that is signed and dated by that physician is expected. In addition, when requested, it is expected that a non-hospital based facility provide its policies, procedures, and protocols that ensure adherence to the rules set forth above. The requested records must include the policies, protocols, and procedures, plus the signed and dated log book that clearly shows that an MD was readily available on that particular day.

Physician Supervision: Physician supervision of pulmonary rehabilitation is specifically addressed by statute. Because the Congress explicitly stated services must be "physician-supervised," non-physician practitioners may not serve the supervising role for pulmonary rehabilitation services, even if those practitioners may sometimes supervise other services in other settings under separate legal authority, such as state law.

Non-hospital-based-services:

• The policy and procedure, calendar, schedule, or call log are required to substantiate physician supervision and must be provided.

iv. "Direct supervision means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or non-physician practitioner must be present in the room when the procedure is performed. For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or osteopathy, as specified in §§ 410.47 and 410.49.

Reference:

• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), section 144 (fff)(1)
• Definition of "direct supervision": 42 CFR 410.27
• CMS decision not to establish an NCD for pulmonary rehabilitation services