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Pulmonary Rehabilitation ADR Checklist

CGS recommends providers organize the medical documentation in the order indicated below. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process. Please ensure the documentation is submitted within 45 days of the Additional Documentation Request (ADR). If the documentation has not been received, the claim will automatically deny on the 46th day for non-receipt of documentation.

Providers should submit all documentation that is pertinent to support the medical necessity of services for the billing period being reviewed. Ensure services billed are coded accurately for the service provided and the documentation supports those services. This may include documentation that is prior to the review period. Please note that the most common reason for overturned appeals is due to providers submitting new documentation upon the appeal that was omitted with the initial submission of medical records.

*Please include the beneficiary name and date of service on all documentation and include an abbreviation key (if applicable). Documentation must be legible and complete (including signature(s) and date(s)). If you question the legibility of your signature, you may submit a signature log or an attestation statement.

The Checklist below is intended to be utilized by providers as a reference when responding to ADRs to ensure each claim meets the policy requirements prior to the ADR submission. Please submit all documentation as required in the LCD or NCD, if applicable, and in accordance with the Medicare Benefit Policy Manual. It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. Ensure the documentation submitted belongs solely to the intended beneficiary and documentation of another beneficiary is not present within any aspect of the medical record.

Please submit a copy of the ADR letter and enclosed cover sheet with each appropriate DCN to separate applicable documentation for review. Please ensure you include a designated point of contact (name, email, telephone number) with all records submitted in response to each ADR. CGS may contact this individual for an easily curable error identified during the review process in order to prevent a claim denial for missing documentation.

Check Pulmonary Rehabilitation ADR Checklist – Preferred Order
 

1. ADR letter and enclosed cover sheet with each DCN
 

2. Physician orders for pulmonary rehabilitation
 

3. History and physical exam information supporting the diagnosis and treatment (including GOLD classification)
 

4. Practitioner progress notes, including actual minutes of rehab therapy
 

5. All diagnostic reports (lab, radiology, cardiology, etc.); specifically, Pulmonary Function tests (PFTs) as required to support COPD diagnosis
 

6. Documentation should include the following components of a pulmonary rehabilitation/intensive pulmonary rehabilitation program:

(I) Physician-prescribed exercise each day pulmonary rehabilitation items and services are furnished (mode of exercise, target intensity, duration of each session, and frequency of sessions)

(ii) Pulmonary risk factor modification, including education, counseling and behavioral intervention tailored to the patients' individual needs

(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
 

7. If services are provided in a non hospital-based rehabilitation facility, please submit documentation to support physician supervision (policy and procedure for physician supervision, a calendar/schedule/call log, or other documentation to verify the immediate availability of a physician during the performance of the billed services)
 

8. Other relevant documentation to support medical necessity of all services billed

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How to Prevent Common Denials:

Ensure documentation includes:

  • Individualized Treatment Planned (ITP) established, reviewed, signed and dated by physician every 30 days to cover the DOS billed
  • All Pulmonary Rehabilitation Program Component Requirements
    • Physician-prescribed exercise
    • Pulmonary risk factor modification (education or training tailored to meet the pt's needs, including information on respiratory management)
    • Psychosocial assessment (include screening tool utilized)
    • Outcomes assessment (to determine if the interventions did or did not result in some benefit to the pt)
    • ITP
  • Clear documentation of total session minutes provided for DOS billed
  • Physician-prescribed exercise (some aerobic exercise must be included in each session) 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)
  • Diagnostic criteria of the Pulmonary Function Test (PFT) regarding FEV1/FVC < 70% and FEV1<80% for moderate to very severe COPD (defined as GOLD classification II, III and IV)

Claims must have all 5 components in order to be paid. Components may be separate or compiled together in the individual treatment plan.

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Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as an index and prove very helpful to provide the location of key documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter, in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended as documentation may not be legible.

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Please contact J15AMREDUCATION@cgsadmin.com for further questions, concerns, or educational needs related to this review. Be sure to include the facility name and provider number/PTAN for the inquiry. Ensure CGS is current with provider contact information for any educational outreach opportunity.

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