| LCD ID Number back
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| L1605 |
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| LCD Title back
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| Pulmonary Rehabilitation |
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| Contractor's Determination
Number back
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| 1605 |
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| AMA CPT / ADA CDT Copyright
Statement back
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| CPT codes, descriptions and other data
only are copyright 2006 American Medical Association (or such other
date of publication of CPT). All Rights Reserved. Applicable
FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT)
(including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association.
© 2002, 2004 American Dental Association. All rights reserved.
Applicable FARS/DFARS apply. |
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| CMS National Coverage
Policy back
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CMS does not currently have a national
policy on Pulmonary Rehabilitation. However, the following CMS
documents are pertinent and references to CMS policies are quoted
from those sources:
Title XVIII of the Social Security Act,
Section 1862 (a)(1)(A). This section excludes coverage of items or
services that are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a
malformed body member.
Title XVIII of the Social Security
Act, Section 1862 (a)(7). This section prohibits Medicare payment
for any expenses on items and services incurred for routine physical
examinations.
Title XVIII of the Social Security Act, Section
1833 (e). This section prohibits Medicare payment for any claim that
lacks the necessary information to process the claim.
Title
XVIII of the Social Security Act, Section 1835(a)(2)(c). This
section addresses physician certification.
CMS Publication
6, Medicare Coverage Issues Manual, Section 80-1 addresses patient
education programs.
CMS Publication 9, Medicare Outpatient
Physical Therapy Provider Manual, Section 210.21 details Department
of Labor pulmonary rehabilitation therapy services; Section 252
describes coverage of services rendered in CORF facilities; Section
253.3 defines respiratory therapy services.
CMS Publication
10, Medicare Hospital Manual, Section 210.10(A) defines respiratory
therapy services.
CMS Publication 10, Medicare Hospital
Manual, Section 282 outlines certification/recertification
requirements for physical and occupational therapy services.
CMS Publication 12, Medicare Skilled Nursing Facility
Manual, Section 230.10(C) defines respiratory therapy services.
CMS Pub 100-2, 1-§100 defines respiratory therapy services.
CMS Transmittal No. AB-00-39, May 1, 2000, consolidates HCFA
Program Memoranda for outpatient rehabilitation therapy services.
CMS Transmittal Nos. AB-98-14 (April 1998) and A-99-5
(February 1999) address The National Institute of Health’s National
Emphysema Treatment Trial (NETT). |
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| Primary Geographic Jurisdiction back
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New Jersey
Tennessee
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| Secondary Geographic Jurisdiction back
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Alaska
Alabama
Arkansas
Arizona
California -
Entire
State
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
- Entire State
Mississippi
North Carolina
North
Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
- Entire
State
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode
Island
South
Carolina
Tennessee
Texas
Utah
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Vermont
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West
Virginia
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| Oversight
Region back
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| Region IV |
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| Original Determination
Effective Date back
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| For services performed on or after
05/20/2002 |
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| Original Determination
Ending Date back
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| Revision Effective
Date back
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| For services performed on or after
12/31/2005 |
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| Revision Ending
Date back
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| Indications and Limitations
of Coverage and/or Medical Necessity back
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Definition of Pulmonary
Rehabilitation
Patients with diagnosed Chronic
Respiratory Diseases have a progressive increase in the mechanical
work of breathing and limited respiratory reserve capacities. These
factors may lead to symptoms of chronic dyspnea on exertion,
wheezing, chronic cough, and debilitating functional disabilities,
which limit exercise and Activities of Daily Living (ADLs) due to
chronic respiratory inflammation, edema, mucous plugging, hypoxemia,
carbon dioxide retention, pulmonary hypertension, or cor pulmonale.
Pulmonary Rehabilitation (PR) services provide a physician-directed,
individualized plan of care using multidisciplinary qualified health
professionals to impart self-care techniques that enhance pulmonary
toilet, encourage respiratory reconditioning and accommodate
residual functional deficits.
The function of pulmonary
rehabilitation services as covered by Medicare is not to achieve a
maximum exercise tolerance, but to educate and train the patient to
maximize his endurance through a self-care program in the home.
Unless the patient will be able to conduct ongoing self-care at
home, there will not be a lasting benefit from the pulmonary
rehabilitation services. The endpoint of treatment, therefore, is
not when the patient achieves maximal exercise tolerance or
stabilizes, but when the patient or his or her attendant is able to
continue the PR at home. Treatment is individualized, based on
orders from the patient’s attending physician or PR Medical
Director. Medicare does not cover services of a maintenance exercise
program where a skilled therapist's services are not medically
necessary.
Additional monitoring (e.g. PFTs) and treatment
(e.g. bronchial hygiene) BEYOND normal maintenance services may be
indicated during the course of PR. These are reimbursable only if
the individual services would be medically necessary outside the PR
setting. Services that the patient self-administers at home are not
medically necessary as therapist's services unless specifically
ordered in association with a contemporaneous physician
examination.
Objectives:
The three primary objectives
of PR services are:
1. To control, reduce, or alleviate the symptoms and
pathophysiologic complications of chronic pulmonary diseases;
2. To provide the patient with tools to reach the highest
possible level of independent functioning within the limitations
of the pulmonary disease; and
3. To train and motivate the
patient to become an active partner in the management of the
disease.
Coverage of Services:
While some
programs are compact and intensive and others are more protracted,
in general the entire process can be accomplished within 39 sessions
(36 therapeutic and 3 assessment). Services extending beyond 36
therapeutic and 3 assessment sessions will be reviewed on an
individual basis for evidence of medical necessity. The key
determinants for approval of extension will be the presence of
comorbid conditions that would reasonably delay the training
process, coupled with evidence of steady progress to date and an
expectation of imminent completion. As PR is primarily an education
and training activity, a patient who interrupts PR for any reason is
expected to pick up where he left off; this is therefore not
typically a medically necessary indication for additional
sessions.
Re-enrollment following a completed course of
rehabilitation is seldom medically necessary, again because PR is
primarily an educational activity. Abbreviated retraining programs
will be reviewed for medical necessity on an individual basis. The
key determinant here will be the presence of a recent change in a
pulmonary or comorbid condition that would necessitate the
acquisition of a skill that was not required prior to the change and
which would not be routinely included in a typical pulmonary
rehabilitation program. An isolated non-physician assessment to
evaluate the need for enrollment or reenrollment is not covered
because, under the Medicare Program, it is not considered reasonable
or necessary for clinicians to routinely screen patients for a
potential need for skilled services.
Given that there is not
a global entity known as "pulmonary rehab" that is a recognized
benefit under the existing Medicare benefit structure, all covered
components (services) of a PR program must be independently
reimbursable under Medicare guidelines. In general this requires all
covered PR services to meet the following criteria:
1. Be ordered by a physician.
2. Qualify as a
covered service within a standard Medicare benefit
category.
3. Be reasonable and necessary for the diagnosis
and/or treatment of a pulmonary illness listed below.
4.
Be consistent with the nature and severity of the individual’s
symptoms and diagnosis.
5. Be reasonable in terms of
procedure/modality, amount, frequency and duration of the
treatment.
6. Be generally accepted by the professional
community as being safe and effective treatment for the purpose
used.
7. Be of a level of complexity that the services can
be rendered only by a skilled clinician.
8. Be delivered
by qualified health professionals in accordance with state and
federal regulations.
9. Be individualized, with group
sessions occurring in groups of no more than four (4) to six (6),
which are conducted by a qualified health professional.
10. Have an expectation of measurable improvement in the
patient’s condition within a reasonable timeframe, and demonstrate
that the improvement (exercise tolerance, improved ADLs, decreased
symptoms) is actually occurring.
Medical Necessity for Pulmonary Rehabilitation (Local
Coverage Decision)
This section sets forth the
requirements to establish medical necessity. Denials for medical
necessity are based on the Social Security Act Section 1862 (a) (1)
(A).
Indications for Pulmonary Rehabilitation
Services:
Services must be reasonable and medically
necessary. Patients who require PR treatment must meet all of the
following criteria:
1. Diagnosis of a chronic, yet not acutely decompensated,
respiratory system impairment that is under optimal medical
management. (See "ICD-9 Codes That Support Medical Necessity.").
2. Pulmonary Function Tests (PFTs) within twelve months of
initiating PR services with the most recent values demonstrating
DLCO, FVC or FEV1 <60%, of uncorrected for volume.
3.
Exhibits symptoms due to pulmonary diseases that significantly
impairs patient's level of functioning in such areas as
ambulation, employment or independent living.
4.
Expectation of measurable improvement in a reasonable and
predictable timeframe.
5. Be physically able, motivated
and willing to participate in PR.
6. Not be actively
involved in aggravating the existing disease state (i.e. patient
may not be smoking).
Physician Orders and
Certification:
The PR physician or patient’s attending
physician must document the following prior to the initiation of PR
services:
1. That a physical examination performed within the last
ninety (90) days indicates that the patient is capable of
participating in the plan of care. This must include evidence of
an appropriate level of cognition, as an integral part of the
program involves comprehension and retention of new learning.
2. That the patient is medically stable and not limited by
another serious medical condition that would negate the benefits
of the PR program
3. That the patient is willing to
cooperate and participate in the plan of care.
4. That the
patient has successfully stopped smoking prior to the course of PR
services.
Coverage limitations on Specific
Components of Pulmonary Rehabilitation:
PT/OT
re-evaluations (CPT codes 97002, 97004) are covered only if the
documentation shows significant change in the patient's co-morbid
condition that supports the need to perform a formal re-evaluation
of the patient's non-respiratory status. Duplicative reassessments
and routine reassessments are not covered.
To be covered,
patient education and instruction must:
- be individualized to the patient’s specific medical needs as
identified in the initial assessment(s);
- be part of the pulmonary rehabilitation treatment session;
- be reasonable and necessary for the treatment and effective
management of the patient’s illness; and
- not exceed the patient's need.
For example,
while it is recognized that the general pathology of respiratory
illnesses may be of interest to patients, such generalized knowledge
is not essential to the effective management of a patient's
particular condition, and would be considered excessive. However,
when education is directed to the specific respiratory illness,
education about the illness may be necessary to help the patient
understand the medical need for compliance with his or her
medications and compensatory breathing techniques. Individualized
instruction and training in the proper and effective use of
bronchial hygiene therapy, effective coughing techniques, oxygen
therapy, aerosol medications, and respiratory care equipment are
frequently components of the rehabilitation process. Clinicians must
document the patient’s carryover of education, instruction, and
training into his or her daily activities.
Therapeutic
Exercise. An individualized physical conditioning and exercise
program using proper breathing techniques coupled with a home
functional maintenance program (FMP) is an integral part of PR.
Breathing retraining, energy conservation, and relaxation techniques
are often used. Inspiratory muscle resistance training (IMT) may be
considered reasonable and necessary in a very select population of
pulmonary patients who demonstrate significantly decreased
respiratory strength and who remain symptomatic despite optimal
therapy.
The objectives of exercise training are to: 1)
advance the intensity and duration of exercise as tolerated by the
patient and 2) assure the patient's understanding of the nature and
role of continued life-long exercise. (NIH, National Emphysema
Treatment Trial ( NETT) Manual, Section 4.3.6) Clinicians must
clearly document the rationale for continued skilled intervention
for any exercise program. Routine exercise, or any exercise, without
a documented need for skilled care, is not
covered.
Activities of Daily Living (ADLs) Compensatory
Techniques: When problems with daily life tasks are identified
in the initial assessment, an individualized program of exercise and
compensatory techniques, breathing retraining, and energy
conservation may be reasonable and necessary. The patient's ability
to carry over learned skills to the home and community environments,
as well as the reduction of identified disabilities and handicaps,
should be emphasized and clearly documented. The provider should
recognize that these services may not be required with every patient
or for prolonged periods of time. Although OT and other disciplines
may be involved, this is still primarily a RT service which
therefore necessitates the use of G0239 for a session containing
this activity.
Individual (one-to-one) Training and
Conditioning: Although pulmonary rehabilitation is usually
provided in small groups, there may be occasions when one-to-one
services may be valuable to supplement or replace group activities.
As long as these services are substituted for group sessions on a
one for one basis, this represents a provider choice and medical
necessity is not an issue.
Psychological Services:
Although not formally a part of Medicare-covered PR services,
psychological services may be needed for a patient with a documented
psychological diagnosis that would interfere with participation in
pulmonary rehabilitation services. Psychological services are not
routinely reasonable or necessary; the research to date does not
support the benefits of short-term psychological interventions for
PR therapy patients. Medically necessary psychological services of
physicians, clinical psychologists and other clinicians would only
be appropriate in limited clinical situations, must be provided as
individual therapy, and should appropriately be separately billed to
the carrier.
Plan of Care:
In the CORF environment
the plan of care is a benefit category requirement; in other
environments it is needed to support medical
necessity.
Discharge Criteria and Follow-Up:
A
patient should be discharged from PR services when the documentation
shows any of the following:
1. The PR treatment goals are achieved or the patient has
reached maximum medical benefit;
2. There is minimal or no
potential for further significant progress;
3. The patient
is non-compliant with the established plan of care or with
self-care, including smoking cessation; and/or
4. The
patient no longer requires skilled PR services (See "Coverage of
Services").
Ongoing medical care is the responsibility of
the patient's physician.
Medical Necessity for
Face-to-face encounters:
For the purposes of claims
adjudication by the FI, more than three physician/physician extender
face-to-face encounters to support delivery of Pulmonary Rehab will
not be considered medically necessary as physician level services
without documentation of an acute problem that would otherwise
warrant physician intervention. |
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| Coverage Topic back
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Outpatient Hospital
Services
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