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Pulmonary Rehab 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, such as an Individualized Treatment Plan (ITP). Please note that the most common reason for overturned appeals are 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 Additional Documentation Requests (ADR) 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.

Click on the table below for a printable version.

checklist

Helpful Links:

How to Prevent Common Denials:

Ensure Documentation includes:

  • All Pulmonary Rehabilitation Program Component Requirements

    Claims must have all 5 components to be paid. Components may be separate or compiled together in the Individualized Treatment Planned (ITP).
    • Physician-prescribed exercise each day pulmonary rehabilitation items and services are furnished (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., "31 minutes")
      • Frequency (number of sessions per week)
    • Pulmonary risk factor modification (education, behavioral intervention or training tailored to meet the patient's (pt's) individualized needs, including education on respiratory management)
      • Education/training should assist in achievement of individual goals towards independence in activities of daily living ADL), adaptation to limitations, and improved quality of life
      • Providing educational pamphlets with no follow up or providing only patient assessments at the beginning and end of the program are not acceptable to support the intervention
    • Psychosocial assessment (include screening tool utilized)
      • Must be thorough and occur at periodic intervals
      • Provide information on the patient's support system, family, how diagnosis affects their life, counseling, etc. (Psychosocial testing results such as PHQ-9 can be submitted)
      • Example: How does the patient view their quality of life and what education is important to them?
    • Outcomes assessment (to determine if the interventions did or did not result in some benefit to the pt)
      • Provide an ongoing evaluation of the interventions and goals for the patient including results or modifications required
      • Example: If smoking cessation is a goal how is that being addressed and how is the pt progressing to meet that goal or not?
    • Individualized Treatment Planned (ITP) established, reviewed, signed and dated by physician every 30 days to cover the dates of service (DOS) billed
      • This may require submitting the ITP competed prior to the review period
      • Example: The DOS billed on the claim- 11/04/22, 11/06/22, 11/08/22, 11/14/22, 11/25/22 and 11/29/22. The ITP submitted is dated 11/25/22. This only covers DOS 11/25/22 and 11/29/22 for this claim (the ITP dated 11/25/22 is valid until 12/25/22, 30 days). This will result in a partial denial unless the previous ITP completed is submitted to cover all the DOS billed. The ITP dated 10/25/22 must be submitted as well to cover the 11/04/22, 11/06/22, 11/08/22, and 11/14/22 DOS billed. (the ITP dated 10/25/22 is valid until 11/25/22, 30 days).
  • Clear documentation of total session minutes provided for each DOS billed
    • 1 billed session must be at least 31 minutes and 2 billed sessions must be at least 91 minutes
    • Sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time, if approved by CGS
    • If the sessions exceed 36 sessions and are not billed with the KX modifier, services will be denied
  • Physician order for pulmonary rehabilitation signed legibly and dated. If the physician's signature is not signed electronically, the physician's 'NAME' and Credentials must be PRINTED on the order. A signature log or attestation statement may be submitted. If the signature is illegible and the name is not printed, the claim will be denied.
    • History and physical exam, pulmonology office note(s) or other provider note(s) which include information supporting the diagnosis and treatment
      • For a diagnosis of Chronic Obstructive Pulmonary Disease (COPD):
        • COPD must be indicated as moderate to very severe as defined by the Gold Classification II, III or IV
        • A physician signed pulmonary function test (PFT) including FEV1 and FEV1/FVC results both meeting diagnostic criteria must be included.
          • If one of the lab values is not present or one value does not meet diagnostic criteria, the claim will deny for no diagnosis
            • Diagnostic criteria: Must include BOTH values
              • FEV1/FVC must be <70%
              • FEV1 must be <80%.

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.

We encourage all CGS providers to utilize myCGS Portal, a free service available 24/7, which offers access to beneficiary eligibility, claim and payment information, forms allowing you to submit redetermination requests, and respond to Medical Review Additional Documentation Requests (ADRs) and much more. Please enroll for myCGS if you have not already done so.

Check the Calendar of Events to sign up for any webinars that may be of interest.

Please contact J15AMREDUCATION@cgsadmin.com for further questions, concerns, or educational needs related to the TPE process. 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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