COPD Patients:

Pulmonary Rehab Reimbursement Alert

The Medicare reimbursement for pulmonary rehabilitation for patients with COPD was reduced on January 1, 2012 from approximately $68.00 per session to $37.00 per session. Therefore, it is imperative that ALL pulmonary rehab programs work with their billing departments to determine if you are charging an appropriate amount for G0424 (Pulmonary Rehab for patients with COPD). The toolkit provides a step-by-step approach to do this. I am happy to help anyone with this if you need clarification or assistance. It is important that your hospital adjust your charge for G0424 as soon as possible so your charge is consistent with what is outlined in the toolkit. If we don’t do this, programs are at risk of closing because of the low reimbursement rate for G0424 of $37.00 per session. If we act now, the earliest we may see an improvement in the reimbursement rate is 2014. So, please don’t delay in evaluating your current charge for G0424.

That being said, the codes that are listed in the toolkit are examples of codes that could POTENTIALLY be bundled into the G0424 code. In other words, if we didn’t have G0424 to bill COPD patients for pulmonary rehab services, we would be charging for each individual service we provide, and the codes listed in the toolkit are examples of what services we might be charging. Therefore, every possible service we provide to COPD patients should be considered when determining the amount you charge for G0424.

Patients with a non-COPD diagnosis:

Your natural reaction as you read the toolkit might be: Should we be charging non-COPD patients for all of the services listed in the toolkit? Not necessarily. Charges reflecting the services we are providing to our non-COPD patients may vary depending on the MAC jurisdiction in which we work. Your MAC may not allow use of some of the codes. For example, oximetry is typically bundled into G0237, G0238, and/or G0239; therefore you would not bill separately for that service. The same is true for the six minute walk test.

Reminder: the PFT criteria for non-COPD patients participating in Pulmonary Rehab is as follows: FVC, FEV1, OR DLCO < 60% predicted. This may be different than what you used in the past if you are not working in Iowa. However, the J5 MAC Medical Director has specifically instructed us to follow this PFT criteria for non-COPD patients.

If you have any questions about whether or not you should use a particular code, you should check with your Compliance Office, contact your MAC liaison for your jurisdiction (that is me for MAC J5), or do both.

Janie Knipper, RN, MA, FAACVPR, AE-C J5 MAC Liaison
Phone: 319-356-8396
E-mail: jane-knipper@uiowa.edu

Additional Information:

Clarification from William Ruiz at CMS on use of Modifier 59 for pulmonary rehab:

Pulmonary Rehab no longer has to use Modifier 59 when billing for more than one of the non- COPD “G” codes on the same day. So, for example, if G0238 and G0239 were charged on the same visit, you don’t have to use Modifier 59. 

For more information and to download a brochure, see the Continuing Education page.

CMS has clarified a coding requirement for cardiac rehabilitation services that was not included in the Cardiac Rehabilitation Change Request 6850, published May 21, 2010. Change requests are specific billing instructions sent to providers. Your billing department would have received these change requests for both cardiac and pulmonary rehabilitation. The change request for pulmonary rehabilitation is # 6823, published May 7, 2010.

When billing for more than one session of cardiac rehabilitation per day, modifier “-59” must be used. This is because two CR sessions in a day are considered different patient encounters. The policy for Modifier -59 is found in the CMS publication, MLN Matters SE0715 (CLICK HERE to access). This means whenever any combination of CPT/HCPCS 93798 and 93797 are provided for two CR sessions in one day, proper billing requires use of the modifier. Failure to use the modifier -59 when submitting two charges for one day has resulted in denial of payment for some CR programs.

Pulmonary rehabilitation (PR) does NOT need to use modifier -59 because of coding edits that CMS put in place with the new procedure code, G0424 in January, 2010. However, the procedure codes, G0237-39, used previously for pulmonary rehabilitation and now used for respiratory therapy services (i.e., non-COPD diagnoses) continue to require use of the modifier -59. (This requirement was discussed in AACVPR News & Views, May/June, 2009.)

If you are a member of AACVPR, you will receive the most up-to-date reimbursement information. Please consider joining now!

Photos from the first annual Heartland Conference in Des Moines, 2011. If you have photos you'd like to share, email them to Candy Steele or Leah Lenz. Be sure to identify the people in your photos!

Above: Nancy Steingraeber (left), Skiff Medical Center, Laura Mackaman (center), Iowa Health - Des Moines, recipient the IACPR Distinguished Member of the Year Award, and Susan Flack, IACPR President (right)

Claire Shannon-Klann, IACPR President-elect, greets visitors at the IACPR informational booth.

Clarification on coverage from questions asked of John Wrynn, Outreach Analyst for WPS Medicare on teleconference held 02/23/11. Mary Sue Gardner, RN, BSN, Medicare Outreach Nurse Analyst (Omaha office) was also on the call and this includes her feedback. 

1. Cardiac Rehab is covered for 36 sessions or 36 weeks, which ever comes first.

2. If you are billing beyond 36 sessions, be sure to bill using the KX modifier. An ABN is not necessary, but in the absence of an ABN the provider is liable for the bill if the modifier is not used. Services beyond 36 sessions are subject to medical review, and no pre-authorization is required.
3. Although cardiac rehab is covered up to 36 sessions, it still must be medically necessary for the patient to continue. Patients are not entitled to 36 sessions; that what is allowed based on medical necessity. It is the physician’s responsibility to document medical necessity. He/she must be fully involved and aware of patient status and condition. Please note that CMS makes specific reference to outcomes. If a patient has not progressed in a reasonable amount of time, they should be discharged from the program.
4. Physician supervision: CMS changed physician supervision rules for 2011 by removing any reference to any particular physical boundary and removing the reference to ‘on the same campus’ or ‘in the off-campus provider-based department’ (italics are CMS’ exact words on pg 72008, Fed Reg, 11-24-10).
5. Per CMS, MI is the only diagnosis with the 12 month time limit from event. For the other diagnoses, WPS will not enforce a time limit. However, physician documentation must still support medical necessity in order to participate.
6. If a patient has another event during cardiac rehab participation, you have two choices for continued participation:
   1. Discharge the patient from the current service and readmit with new diagnosis. Even if this is the same diagnosis (i.e., PCI), the onset date will be different.
   2. Continue with current service, and if medically necessary, continue treating patient up to 72 sessions using the KX modifier as described above. Duration of participation is always based on medical necessity.
7. If services beyond 72 sessions are ordered, medical necessity and appropriate diagnosis must exist. It is essential to get an ABN in these rare instances or the provider will be liable for the bill. The patient should also be aware that coverage beyond 72 sessions will undergo medical review and they will be liable for the bill if CMS determines services do not meet criteria for medical necessity.
8. Patients cannot switch back and forth between CR and ICR.

Submitted by Candy Steele

CALL FOR ACTION -- SUPPORT FOR HR 6376 (10/21/2010)

A bill has been introduced in the House of Representatives that will correct a misguided interpretation of the cardiac and pulmonary rehabilitation Medicare provisions enacted by Congress in July, 2008 and effective January 1, 2010.

As the Centers for Medicare and Medicaid Services moved forward with implementation of Section 144 of PL 110-275 (new statutory coverage of cardiac and pulmonary rehabilitation programs), it made a very narrow, strict interpretation of the statute, declaring that:

1. Only physicians could actually supervise a cardiac or pulmonary rehabilitation program, precluding the role of non physician practitioners (NPPs) such as physician assistants and nurse practitioners filling that role, despite a broad change in the 2010 rules for hospital outpatient services that now permit  NPPs to provide direct supervision of certain hospital outpatient therapeutic services because those services are analogous to physicians’ services; 
2. In critical access hospitals (CAHs), where NPPs can fill in for physicians in the Emergency Department, CAHs that provide either cardiac or pulmonary rehabilitation services must have physician supervision; 

The practical effect of these interpretations means that other hospital outpatient services that permit NPPs to meet the physician supervision requirement of Medicare do not apply to either cardiac or pulmonary rehabilitation.  Likewise, even though CAHs may have an Emergency Department staffed by NPPs, such hospitals must have a physician supervise a cardiac or pulmonary rehabilitation outpatient program.

The plan is for HR 6376 to be included as part of a larger “physician fee fix” bill that Congress will need to adopt to forgo major cuts to physician payments slated for later this year.  Hence, the “legislative vehicle” for HR 6376 will be the legislation addressing a physician fee fix. This will only happen if we get strong support from our US House congressional members for HR 6376.

ACTION TO BE TAKEN:  Write to your Congressman/Congresswoman today and urge him to sign on as a co-sponsor to HR 6376.  A letter has been provided at the link below for you to send to the US Representative in your District. THIS IS A VERY EASY LETTER SUBMISSION PROCESS AND WILL TAKE ONLY MINUTES OF YOUR TIME. The successful passage of HR 6376 will provide flexibility for cardiac and pulmonary rehabilitation programs in meeting physician supervision requirements.

You should include the NPs/PAs in your institution in this effort-it very directly affects their role in the hospital setting.

Physician supervision is an issue of concern for providers of the services, not for patients. Please do not include a patient letter campaign.

CLICK HERE TO TAKE ACTION!

Thursday, October 7th, 2010 11:30 – 12:30 CT

Room 202 DE at the Frontier Airlines Center, Milwaukee, WI

Iowa Chronic Care Consortium (ICCC) at the AACVPR Annual Meeting

Join a gathering of committed thought leaders and innovators in discussing how together we can create a positive future for cardiac and pulmonary rehabilitation.

Health care reform has created a fertile field for innovation that targets the optimal management of chronic diseases, the adoption of population health models, and improvement in health outcomes.  This interactive discussion, hosted by the Iowa Chronic Care Consortium, is built from the belief that cardiac and pulmonary rehabilitation professionals are perfectly poised to be active players in this changing world of health care delivery.  Join a gathering of your colleagues in discussing how to create an expanding role for cardiac and pulmonary rehabilitation.  

Box lunch is provided to the first 100 to register: click here to register.

The discussion will be facilitated by William Appelgate, PhD, Kathy Kunath, RN, Jody Hereford, BSN, MS and Karen Lui, BSN, MS.

The Iowa Chronic Care Consortium has at the heart of its mission a commitment to reduce the burden of chronic disease and build capacity in partner organizations to effectively manage the most prevalent chronic diseases.  For questions, please contact Jody Hereford.

Marolyn Nuzum was nominated for this award by Barbara Burmeister in recognition of the many years of managing the membership responsibilities for IACPR.  Here are some of Marolyn's contributions and accomplishments:

Member of IACPR 

Member of AACVPR

Marolyn has been in charge of IACPR memberships since 2002.  She has been very dedicated to this role and has spent many hours sending and receiving yearly renewals.  She has sat outside many TriNetwork Conferences collecting dues so she can do her job in a timely manner.  She always does so with a smile and a kind word.  She can always be counted on to have accurate records.  Marolyn is a great example of a Distinguished Member for this organization.

Marolyn has worked in the field of Cardiac Rehab since the mid 1980s in a newly developed Phase III program at the local Council Bluffs YMCA which was all volunteer.  She continued to volunteer there for 10 years.  She started working part-time in Phase II Cardiac Rehab at Mercy Hospital in Council Bluffs in the 1990s and is now in a full-time position that includes both Cardiac and Pulmonary Rehab.  

She has been certified as a Cardiac Rehab Nurse through the ANCC since 1999.

She received the Spirit of Mercy Award in 1993 and has been a recipient of the Positive Image of Nursing Award presented through the Nebraska Nurses Association. 

She is a strong patient advocate and is frequently willing to give of her time for hospital and community events.

2010: The Beginning of a New Era

Seventeenth Annual TriNetwork Conference

April 23-24, 2010, Sioux Falls, SD

You can find the change request here. 

The statuatory changes for Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, and Pulmonary Rehabilitation effective 01/01/10 can be found in convenient links on the AACVPR website under the Legislative and Regulatory Resources tab, as well as in the following links to the Federal Register and CMS Manual System.

It is your responsibility to be aware of these legislative changes and apply them to your Cardiac and Pulmonary Rehabilitation programs. There is a FAQ section on the AACVPR website that is also very useful for putting these new laws into practice.

2010 Hospital Outpatient Regulations for Cardiac and Pulmonary Rehab (November 20,2009)

2010 Physician Fee Schedule for Cardiac and Pulmonary Rehab (November 25, 2009)

2010 Physician Fee Schedule: Section 410.49-Cardiac Rehabilitation Program: Conditions for Coverage (November 2009)

2010 Physician Fee Schedule: Section 410.47-Pulmonary Rehabilitation Program: Conditions for Coverage (November 2009)

Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services (Rev.1871, 12-11-09)