Janie Knipper RN, MA, AE-C, MAACVPR, provides details regarding the reasons for low reimbursement rates for pulmonary rehabilitation, what AACPVR is doing to try to improve them, and what pulmonary rehabilitation professionals need to do to help.
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More depth is provided, by Janie Knipper RN, MA, AE-C, MAACVPR, regarding Medicare policy and reimbursement for pulmonary rehabilitation, in 2018.
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IACPR members, Janie Knipper RN, MA, AE-C, MAACVPR and Kim Eppen PT, PhD, gave multiple presentations regarding various aspects of pulmonary rehabilitation, at the national conference, in October. In the next few weeks, the summary of each presentation will be posted. This is valuable information an well worth your time.
In this article Janie Knipper applies her decades worth of knowledge to provide a summary of the components necessary to create a comprehensive pulmonary rehab program
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An inquiry was sent to WPS to seek clarification on a question raised at the IACPR Conference in April:
In June of 2016, WPS replied to a series of questions posed by the J5 MAC Committee. In the reply, WPS responded that not only pulmonary rehab ITPs, but cardiac rehab ITPs must be signed by the physician prior to the patient’s first treatment session. This is not in the CR regulations (Code of Federal Regulations), but it is in the PR regulations. So we asked for clarification again regarding the need for the CR physician to sign the treatment plan prior to the patient's first treatment session.
The response from WPS is as follows:
Thank you for the inquiry you sent to Wisconsin Physicians Service (WPS) Government Health Administrators (GHA) regarding cardiac rehabilitation. I contacted our Medical Review department including our Contractor Medical Director (CMD) for assistance with your inquiry. The Medical Review staff and CMD indicates, the cardiac rehabilitation treatment plan is considered an order and must be signed prior to treatment in order to be valid. The physician’s order is written prior to the services being done to document the services being ordered.
It is surprising WPS is calling the ITP an “order”, but they are so we need to follow this rule. Please contact Janie Knipper if you have further questions about this.
Janie Knipper, RN, MA, AE-C
Pulmonary Rehabilitation Supervisor
University of Iowa Hospitalsand ClinicsIowa City, IA 52242
P: 319-356-8396F: 319-353-7199
Please take time to read this important document! The future of pulmonary rehabilitation depends on each and every one of us! The following provides important information to make you aware of the AACVPR’s efforts to improve reimbursement for pulmonary rehab, and it involves you taking action in each of your hospitals. Please read carefully, and contact Janie Knipper, firstname.lastname@example.org with any questions. More information will be coming as this effort continues to move forward.
IACPR Reimbursement Update June 2017
Pulmonary rehabilitation programs are struggling to remain financially viable in this ever-changing health care environment, and the AACVPR is ready to take on the challenge of improving reimbursement for pulmonary rehabilitation services (G0424). Please read and tak action!
In 2010, when CMS authorized use of HCPCS code G0424 for billing of pulmonary rehab services, the Agency admitted it had no historical data on which to base a payment amount, and arbitrarily assigned a payment amount of $50. Unfortunately, as the years passed and CMS collected data on which to base its payment rate, the reimbursement rate for pulmonary rehab decreased rather than increased! In the November 30, 2011 Federal Register (page 74224, establishing payment for pulmonary rehab), CMS explicitly stated,
Hospitals should be especially careful to thoughtfully establish charges for new codes that use a single code to report multiple services that were previously reported by multiple codes. It is vital in these cases that hospitals carefully establish charges that fully include all of the charges for all of the predecessor services that are reported by the new code. To fail to carefully construct the charge for a new code that reports a combination of services that were previously reported separately, particularly in the first year of the new code, under-represents the cost of providing the service . . .
Plain and simple: programs or persons responsible for rate setting for G0424 did not identify all of the beneficial services that are provided in one session pulmonary rehab, and therefore set very low rates for one session of G0424. In response to this problem, all the pulmonary societies combined their efforts to create the Pulmonary Rehabilitation Reimbursement Toolkit (available on the AACVPR website – www.aacvpr.org). The Toolkit provided a guide for programs to identify the broad array of services integral to pulmonary rehabilitation that must be considered when computing the charge that must appear on all claims submitted to Medicare.
Unfortunately, in 2017, it appears that many hospitals have still not adjusted the charge for G0424 to reflect the full hour of services! The AACVPR recently invested in significant data mining associated with G0424, focusing on several key parameters:
The key findings are as follows:
This data was vital for the AACVPR as they examined ways to focus future plans to secure appropriate payment for pulmonary rehabilitation services. The AACVPR formed the PR Reimbursement Task Force to work with the MAC Liaison Task Force and the MAC Resource Groups (MRGs) to move this project forward.
Based on recommendations of the PR Reimbursement Task Force, a charge amount threshold of $400/session was chosen. All hospitals with charges of $400 or higher were eliminated from the work sheet. The AACVPR MAC Liaison Task Force and the MRGs are now charged with collecting additional data from programs charging <$400/session, and who submitted > 250 G0424 claims/year. This is not to say that those programs submitting < 250 G0424 charges/year are not important. The premise is that the impact on Medicare aggregate calculations from the smaller programs would be minimal. In addition, by cutting the original number of hospitals from 1350 to 680, the effort becomes more manageable.
There are only 12 pulmonary rehab programs in Iowa that have submitted > 250 G0424 charges/year. The MAC Liaison, Janie Knipper, will be contacting each program to gather additional information. But the rest of us are not off the hook! Even if you are not one of the 12 programs, we ALL must revisit the Pulmonary Rehabilitation Reimbursement Toolkit, and schedule meetings with our Chargemaster or whoever is responsible for your rate setting. Share the Toolkit with those people so they better understand the tremendous amount of time and energy involved in one session of pulmonary rehab (G0424). As stated above, the first goal is to encourage ALL programs to establish a charge of > $400/session for G0424. It is clear this will take communication between the AACVPR, pulmonary rehab program directors, hospital CEOs, and hospital CFOs. Stay tuned for more news as additional data is collected and this project moves forward
The AACVPR had provided some additional resources related to the impending CMS changes to cardiac rehab bundles and incentive payment models. It is AACVPR’s goal to provide all cardiac rehabilitation professionals with resources and tools to help you and your local members/attendees prepare for the changes that will inevitably affect your programs. The following are links to the information video.
1. We have provided the file via Dropbox for easy download – you may distribute this link via email: https://www.dropbox.com/sh/k21qb8xdnfgemm6/AAB6KQ7dSWp5vz2zFCrLLVrba?dl=0
2. We have posted the video to YouTube – you may distribute this link via email: https://youtu.be/O1deVWCbE3s
If you have any questions accessing the video, please let AACVPR know. They are committed to our continued effort to provide you with up-to-the minute information regarding these changes to your programs. Please don’t forget to visit the AACVPR website for more information on the Roadmap to Reform Resource Page and the Regulatory & Legislative Information Page.
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)
330 N. Wabash Avenue, Suite 2000, Chicago, IL 60611
Main Line: 312321-5146
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The AACVPR has created a webpage, “What’s New in My MAC?”, as a resource for members to stay updated with all MAC news/updates. Unfortunately, it can be difficult to find.
Follow this link: https://www.aacvpr.org/Advocacy/Whats-new-in-my-MAC ,
and sign in to access the “What’s New in My MAC?” page.
J5/J8 Reimbursement Update June 29, 2016
Wisconsin Physician Services (WPS), the Medicare Administrative Contractor for Jurisdiction 5 and Jurisdiction 8 finally agreed to a conference call with Susan Flack and Janie Knipper, IACPR, to discuss cardiac rehab (CR) and pulmonary rehab (PR) reimbursement. The call was held on June 2, 2016. Questions related to reimbursement were submitted to WPS prior to the call; however the representatives from WPS chose to not respond to any questions during the call, but rather provide written feedback.
The AACVPR MAC Liaison Task Force created a PowerPoint presentation on CR and PR for the purpose of educating MACs about these services. Janie presented the PowerPoint during the call. The WPS representatives on the call commented that none of the presentation was a surprise to them; they found the information to be consistent with their understanding of CR and PR. WPS representatives included Mary Sue Gardner, RN/BSN, WPS Provider and Outreach Education (POE) Specialist, Dr. Cheryl Ray, WPS J5 Medical Director, and 2 people from the claims department. Dr. Noel, J8 Medical Director was invited to attend but declined. We asked the claims representatives if they had noticed anything in CR and PR billing practices that raised a red flag, and they denied seeing any red flags.
The written responses from WPS were received on June 24, 2016, and are summarized below with comments from Janie. The answers pertain primarily to pulmonary rehab. There were no issues related to cardiac rehab, other than the question of Nonphysician Providers independently ordering CR & PR, and clarification for WPH about # of CR session/week.
1. Nonphysician Provider (NPP) – Can NPPs independently order CR/PR?
a. No – the regulation wording states “physician” referral.
2. Number of CR Sessions per Week:
a. WPS is aware of and in agreement with the removal of the requirement for CR patients to participate in a minimum of 2 CR sessions each week. Public Law 110-275, effective 1-1-2010, allows up to 36 sessions of CR over 36 weeks.
3. The Individualized Treatment Plan (ITP):
a. Must be signed prior to the patient’s first exercise rehab treatment session
b. WPS views the first visit to be the “initial assessment” for evaluation of the patient, and not a treatment session. In my opinion, the initial assessment has to include some type of exercise evaluation to allow us to write the exercise prescription. However, there is no way to charge for that initial evaluation, unless you charge for a 6-‐Minute Walk Test (6MWT), which you could do if you are not charging for a “treatment” session.
c. WPS did include cardiac rehab in their response regarding the ITP being signed prior tothe patient’s first treatment session. We will be seeking further clarification on this, as this is not in the CR regulations. I would not change your practice at this point; but wait for further clarification.
4. Pulmonary Rehab- Direct Patient Contact by the Physician:
a. Must be done during each 30-day period. The regulation is not at 30 days, but within that 30 day period.
b. In the event a patient is not present in rehab on the day the physician will be establishing or re-evaluating the ITP, it is necessary to reschedule the day for the direct contact within that 30 days. Note: the regs do not state the ITP needs to be signed the same day the physician sees the patient. We will be requesting clarification on this.
5. Log of Supervising Physician:
a. CMS does not dictate the format of the log for documenting physician supervision. However, the documentation regarding the supervising physician should be documented somewhere in the medical record for that day of service. Logs are acceptable, however, this information could be contained anywhere in your documentation, so long as it is reproducible if selected for medical review. This differs from a 2011 response stating it did not need to be in the medical record; we will seek clarification.
6. PFT Requirements for COPD Diagnosis for Participation in PR:
a. There are NO timeline requirements for completing the PFTs prior to starting a PR program, only that the GOLD classification requirements must be met (moderate to very severe COPD). In other words, if you require new patients to have PFTs within 6 or 12 months prior to starting PR, this is not correct. There is no such requirement anymore.
b. There are NO regulations that state PFTs need to continue on a yearly basis. Medicare would only cover services that are reasonable and necessary for the treatment of a patient at the time of service. Janie recommends changing your practice/policies if you still require PFTs within a year prior to enrollment in PR.
7. Billing for 1:1 Respiratory Therapeutic Services:
a. If 1:1 supervision of the patient is not medically necessary or indicated, it should not be billed to Medicare. The situation is the same with a group session or class and only one patient shows up for the session – this may not be billed as individual or 1:1 care.
8. Documentation of Daily Sessions:
a. All items must be documented in the ITP or an updated treatment plan. It must be ordered and signed by the physician prior to the session. This was in response to our question that arose from the audit done by the Office of Inspector General (OIG) in October 2015. The OIG seemed to want all documentation to be done in the ITP, and didn’t care about other documentation. WPS seems to agree. We will seek clarification on this since the ITP requirements are for a “reassessment of progress made toward goal achievement”, not details from every session. However, we should all review our ITPs and make sure there is adequate documentation of the services provided.
March 2016 Summary - Janie Knipper and Susan Flack
Prior to DOTH, Senators Grassley and Ernst were already co-sponsors of S.488, and Representative Loebsack (District 2) was a cosponsor of HR3355. Janie and Susan personally met with Representative Young from District 3, and he was very receptive to our “ask”. So much so that he signed on as a co-sponsor later that day! The meetings with Legislative Aids in the offices of Representative Blum (District 1) and Representative King (District 4) were also well-received, and we are continuing dialogue with them. We are hopeful that they, too, will sign on as co-sponsors. Thank you to all who sent letters to the Congressmen. The letters were hand-delivered to the offices by Janie and Susan.
Medicare Regulations for Cardiac & Pulmonary Rehabilitation: Meeting Compliance in 2016
The Individualized Treatment Plan
March 23, 2016
There have been several audits of cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs over the last few years. The audits have helped provide clarification in some areas, but also raise questions regarding Medicare regulations for CR and PR. The information included in this summary will highlight the recommendations as discussed at the AACVPR conference held in conjunction with AACVPR Day on the Hill in Washington, D.C., March 23, 2016. The conference also addressed the individualized treatment plan (ITP), as a Medicare requirement as well as the ITP requirements for AACVPR program certification. This information is also summarized below.
The most recent audit of CR and PR was not requested by the Centers for Medicare and Medicaid Services (CMS), but rather was conducted by the Office of Inspector General (OIG). The OIG is under Congressional mandate to audit and investigate numerous government branches. The OIG Audit Report, published in December 2015, reviewed 100 random claims for CR and PR in one hospital in New Jersey over a 2-year period. There were 46 claims found to be out of compliance with Medicare requirements, many of which were related to the individualized treatment plan (ITP). In fact, the only CR/PR document the OIG seemed to be interested in was the ITP.
Click here to learn what must be in the ITP for either PR or CR to meet Medicare regulations in 2016.
Contributions to the IACPR: Becky Paxton
Becky has served on the IACPR Board of Directors since 2006, and has served as the IACPR Treasurer since 2007, which also includes serving as Chair of the Budget and Finance Committee. Becky’s responsibilities as Treasurer are vital in overseeing how money is spent, and in making recommendations to the BOD regarding the financial ability of the organization to carry out their stated aims and objectives. She has consistently provided the BOD and the general membership with organized reports regarding the financial status of the organization.
Becky’s accurate records and supporting documentation has been kept with a reasonable level of detail that provides a clear audit trail.
Becky has guided the organization through difficult financial times, and her leadership in this position has helped keep the IACPR viable as an organization. Becky is always very prompt in her communication with the BOD and members in need of her service, as well as in providing members with authorized reimbursement.
I commend Becky for her long and continued service to the IACPR BOD.
Nomination submitted by:
Janie Knipper, University of Iowa Hospitals and Clinics, Pulmonary Rehabilitation Clinical Supervisor