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Contractor's Policy Number

02-01-R4

Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LMRP Title

Outpatient Pulmonary Rehabilitation Services

AMA CPT Copyright Statement

CMS National Coverage Policy

· Section 1862(a) (1) (A) of Title XVIII of the Social Security Act. This section excludes expenses incurred for items of services that are not reasonable and necessary of the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

· Section 1835(a) (2) (c) of Title XVIII of the Social Security Act, Section. This section addresses physician certification.

· Section 1833(e) of Title CVII of the Social Security Act. This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

· HCFA Publication 10, Medicare Hospital Manual, Sections 210, 230, and 282. Physical Therapy, Occupational Therapy, and Respiratory Therapy Furnished by the Hospital; 1997.

· HCFA Publication 6, Medicare Coverage Issues Manual, Chapter II - Coverage Issues Appendix; Section 80-1. Patient Education Programs; February 1983.

· HCFA Publication 13, Medicare Intermediary Manual, Section 3101.10A. Coverage of Services - Patient Education Programs; October 1981.

· HCFA Publication 9, Medicare Outpatient Physical Therapy Provider Manual, Addendum C. Billing Procedures; April 1986.

· HCFA Publication 15, Medicare Provider Reimbursement Manual, Chapter 21, Section 2108. Reimbursement for Services by Provider-Based Physicians; July 1975.

· HCFA Transmittal No. AB-00-39. This consolidated HCFA Program Memoranda for outpatient rehabilitation therapy services; May 2000.

· HCFA Transmittal No. A-99-5. This addresses The National Institute of Health's National Emphysema Treatment Trial (NETT).

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

08/15/2002

Original Policy Ending Date

Revision Effective Date

01/01/2004

Revision Ending Date

12/31/2003

LMRP Description

Introduction

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 functional disabilities due to chronic respiratory inflammation, edema, mucous plugging, hypoxemia, carbon dioxide retention, pulmonary hypertension, or cor pulmonale, which limit exercise and Activities of Daily Living (ADLs). Although comprehensive Pulmonary Rehabilitation Programs are not a Medicare benefit, Pulmonary Rehabilitation (PR) services may be incorporated into a physician-directed, individualized plan of care using multidisciplinary qualified health professionals to enhance the effective management of pulmonary diseases and the resultant functional deficits.

The goal of pulmonary rehabilitation services as covered by Medicare is not to achieve a maximum exercise tolerance, but rather a level of function that allows for the transfer of treatment from the clinic, hospital, or doctor to self care in the home by the patient, the patient's family, or the patient's caregiver. Unless the patient will be able to conduct ongoing self-care at home, there will be only a temporary 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 and supervised by the patient's attending physician or PR Medical Director. Medicare does not cover services of maintenance exercise.

Medicare beneficiaries may receive PR services in the outpatient (OP) departments of acute hospitals and Comprehensive Outpatient Rehabilitation Facilities (CORFs).

PR services incorporate the following:

1. Assessment by the physician and multidisciplinary qualified health professionals.

2. Education and training.

3. Therapeutic exercise and activities including breathing retraining.

4. Bronchial hygiene and aerosol medications.

5. Assistance with or instructions in Activities of Daily Living (ADLs).

6. Clinical monitoring of the patient's pulmonary functioning during rehabilitation services.

Purpose:

The three primary objectives of PR services are:

To control, reduce, and alleviate the symptoms and pathophysiologic complications of chronic pulmonary diseases;
To train the patient how to reach the highest possible level of independent functioning for his/her Activities of Daily Living (ADLs) within the limitations of the pulmonary disease; and
To train the patient to self-manage his/her daily living consistent with the pulmonary disease process to obtain the highest possible level of independent function.

Indication and Limitations of Coverage and/or Medical Necessity

Services must be reasonable and medically necessary. Patients who require PR treatment will meet all of the following criteria:

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.");
Pulmonary Function Tests (PFTs) revealing DLCO, FVC or FEVI <60%, uncorrected for volume, within three months of initiating PR services. If symptoms due to pulmonary disease are very disabling and significantly impair the patient's level of functioning, other objective evidence of impaired pulmonary physiology may be allowed on an individual consideration basis;
Exhibit symptoms such as breathlessness or fatigue that produce significant disability or handicap, as defined by the American Thoracic Society (ATS) Position Statement, 1999.
Expectation of measurable improvement in a reasonable and predictable timeframe; and
Be physically able, motivated and willing to participate in PR.

Patients with other severe or chronic pulmonary disorders (e.g., lung cancer, neuromuscular diseases, lung transplant, scoliosis, kyphoscoliosis, etc.) may benefit from PR. Some patients may not meet the criteria in this policy, yet are still appropriate for PR because of other severe or chronic disorders. All such cases will be reviewed on an individual basis.

Coverage of Services:

PR services are defined as those services that are medically necessary for the assessment, diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of pulmonary function. Participation in PR services, after the initial assessment is performed, usually occurs three (3) or more days a week, for one to three (1-3) hours per day. Such services, when given continuously, are generally medically necessary for a period of six (6) to ten (10) weeks. Services beyond thirty sessions will be reviewed on an individual basis to determine medical necessity to continue PR as a skilled service.

It is recognized that some patients, because of an exacerbation or new complications (e.g., disease worsening, beginning use of supplemental oxygen, chronic hypercapnia, respiratory failure, use of oxygen at night or noninvasive ventilation, etc.), may benefit from additional participation in PR. Medical record documentation must support the need for the additional PR sessions. All PR services must meet the following criteria:

Be ordered by a physician.
Qualify as a covered service.
Be reasonable and necessary for the diagnosis and/or treatment of a pulmonary illness listed below.
Be consistent with the nature and severity of the individual's symptoms and diagnosis.
Be reasonable in terms of procedure/modality, amount, frequency, and duration of the treatment.
Be generally accepted by the professional community as being safe and effective treatment for the purpose used.
Be of a level of complexity, or the patient's condition must be such, that the services can be rendered only by a skilled clinician.
Be delivered by qualified health professionals in accordance with state and federal regulations.
If patient training occurs in groups, the groups consist of no more than four (4) members for each qualified health professional.
Not exceed the patient's particular PR needs.
Promote recovery, restore function, and ensure safety affected by illness or injury.
Have an expectation that there will be measurable improvement of the patient's condition in a reasonable and generally predictable period of time; and
Demonstrate practical improvement as evidenced by increased exercise tolerance, improved Activities of Daily Living (ADLs), and decreased symptoms (i.e., cough, dyspnea, wheezing).

Physicians Orders and Certification:

A licensed physician, who has training and experience in the treatment of patients with pulmonary disease will order, supervise, guide, and direct each patient's PR plan of care. All treatment orders for PR therapies must:

Be specific as to the type, frequency, and duration of the procedure, modality, or activity. (A blanket pulmonary rehabilitation (PR) order is not acceptable.)
If given verbally or by telephone, be cosigned and dated by the physician prior to billing the claim.

The PR physician or patient's attending physician will document the following prior to the initiation of PR services:

That a physical examination performed within the last ninety (90) days indicates that the patient is capable of participating in the plan of care.
That the patient is willing to cooperate and participate in the plan of care.
That the patient has quit smoking or will participate in smoking cessation activities prior to or during the course of PR services.

For Physical Therapy (PT) and Occupational Therapy (OT) services billed under revenue codes 42X and 43X in a hospital outpatient setting, the initial order will serve as certification for the first thirty (30) days. Thereafter, recertification for PT and OT services is required every thirty (30) days. If the patient is still receiving PR services in a hospital outpatient setting beyond thirty (30) days, the physician must document that the patient remains capable of participation and continues to benefit from the services.

All services rendered to Medicare beneficiaries in Comprehensive Outpatient Rehabilitation Facilities (CORFs) must be certified by a physician prior to initiation of those services and must be recertified at intervals of at least once every thirty (30) days.

Typical Components of Pulmonary Rehabilitation Services:

PR services use a physician-directed multidisciplinary approach with Respiratory Therapists (RTs), Registered Nurses (RNs), Physical Therapists (PTs), and Occupational Therapists (OTs), and other qualified personnel, and may include any combination of these services. A duplication of services occurs when there is a direct overlap of services, or where a single discipline can provide the care. When there is an order for the same treatment modality or procedure for multiple clinicians (e.g., therapeutic exercise, breathing retraining), each clinician is expected to provide skilled treatment that reflects his or her unique skills and knowledge without exceeding the patient's skilled care needs. The treatment is directed toward each clinician's patient-specific goals. This is critical to establish that the services provided by various disciplines are reasonable, necessary, and distinct from each other. Frequency, duration, goals, and measurable objectives of each service provided are to be clearly documented.

The primary components of PR services typically include the following:

1. Assessment/Reassessment (CPT codes 97001, 97002, 97003, 97004, 97750, and 99211) An initial evaluation by rehabilitation personnel is required. Components of this assessment include the patient history, relevant review of systems, pertinent physical assessment and tests/measurements and the reason for the initial referral.

It will also include determination of functional limitations, assessment of strength, flexibility, posture, and gait, and determination of the initial intensity for exercise training. This should include a history and physical examination by a physical/occupational therapist, respiratory therapist, nurse trained and experienced in pulmonary rehabilitation, or other qualified personnel. An assessment, determination of goals, and therapeutic prescription for strength, flexibility, posture, and gait should be completed. (The National Institute of Health (NIH), National Emphysema Treatment Trial (NETT) Manual, Section 4.3.4) Reevaluations are covered only if the documentation shows significant change in the patient's condition that supports the need to perform a formal reevaluation of the patient's status.

Clinicians are to bill for evaluation services using the CPT codes below:

· 97001-evaluations performed by PTs

· 97003-evaluations performed by OTs

· 99211-evaluations performed by other qualified personnel

Clinicians are to bill for revaluation services using the CPT codes below:

· 97002-re-evaluations performed by PTs

· 97004-re-evaluations performed by OTs

· 99211-re-evaluations performed by other qualified personnel

Routine screening and assessments during admission to care, and routine reassessments are not covered.

2. Education/Instruction (CPT code 97535): Education and instruction are key components of training the patient for independent, or modified, self-care and to maximize his or her rehabilitation potential. The patient, and his or her family or caretakers, should have a basic understanding of the specific therapeutic interventions they will be asked to follow. Patient education and instruction must:

· be individualized to the patient’s specific medical needs as identified in the initial assessments;

· be part of the therapy 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 carry over of education, instruction, and training into his or her daily activities.

In order to be covered by Medicare, patient education services must be rendered via direct, one-on-one contact with the clinician. For example, viewing of films or videotapes, listening to audiotapes, and completing interactive computer programs do not qualify as covered PR services. Likewise, group sessions that only offer generalized (i.e., non-individualized) education and training are not covered.

3. Therapeutic Exercise (CPT codes 97110, 97112, 97116 and 97150): An individualized physical conditioning and exercise program using proper breathing techniques, and a home functional maintenance program (FMP), should be considered for any patient with exercise limitations. 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 lifelong 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.

4. Bronchial Hygiene/Aerosol Medications (CPT codes 94640, 94664, 94667 and 94668): These therapeutic procedures are not routinely rendered to all patients receiving PR services. Documentation in the medical record must support the medical necessity for the individual services for the particular patient receiving these services.

5. Activities of Daily Living (ADLs) (CPT code 97535): When problems with daily life tasks are identified in the initial assessment, an individualized program of exercise and ADLs (using compensatory techniques, breathing retraining, and energy conservation) may be reasonable and necessary. The patient's capacity 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.

Psychological Services: Psychological services are not a routinely reasonable or necessary component of pulmonary rehabilitation services.

G0302, G0303, G0304, G0305

These codes are to be billed in association with Lung Volume Reduction Surgery (LVRS) for pre-operative and post-discharge LVRS services. (Pub 100-03, §240.1)

HCPCS codes 94010 and 94640

These codes are not reimbursed more than once per day.

HCPCS codes 93005 and 93041

ECGs are not routinely performed on patients receiving PR services.

Non-Covered Services:

Non-individualized (i.e., generalized) treatment, education and training.
Routine psychological screening and/or routine psychological therapy
Duplication of services between OT, PT, RT, RN and/or other qualified personnel.
Treatment that exceeds the patient’s needs for the identified condition.
Routine, non-skilled and/or maintenance care, such as:

Repetitive services for chronic baseline conditions
When there is a plateau in patient’s progress toward goals
When there is an inability to sustain gains
When there is no overall improvement

Generalized exercise
Services delivered to patients who have poor rehabilitation potential, as evidenced by poor motivation to quit smoking and/or failure to meet indicators listed above for participation in PR services.
Treatment that is not reasonable and necessary due to lack of significant objective findings in preliminary pulmonary diagnostic testing.
Therapy groups with greater than four (4) patients per provider, and/or that are not individualized to each patient’s goals.
Routine follow-up visits.
Viewing of films or videotapes; listening to audio tapes; completing interactive computer programs; or supervised or independent technology-based instruction.
This policy does not apply to those individuals in the National Institute of Health National Emphysema Treatment Trial (NETT). Those individuals are covered under NETT. (See PM A-00-05, CR 789, February 2000)
The following are not reimbursable under the Medicare Program either directly or indirectly:

· Exercise equipment or supplies.

· Biofeedback services for relaxation.

· General education and training not related to the patient’s illness.

Plan of Care:

· An individualized plan of treatment is developed for each patient based on the identified problems. All treatment orders for PR services must be specific as to the type, frequency, and duration of activity. The treatment orders must specify which clinicians will render the services that are unique to their area of expertise.

· The treatment plan must be reasonable and directed at achieving specific goals established for each patient. Specific goals must be individualized to each patient's specific needs and capabilities, stated in objective, measurable, functional terms, and developed mutually by the patient and clinical team.

· Clinicians should specify the time frame, or target date for achievement, for both short-term and long-term goals.

· The discharge plan is an integral part of the plan of care. The discharge plan is addressed from the start of care. An important part of the discharge plan is a post-discharge functional maintenance program (FMP) that the clinicians develop for the patient during the course of PR services.

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; and/or

4. The patient no longer requires skilled PR services (See "Coverage of Services").

· If the patient's condition changes, new components of PR treatment may be ordered for the patient. If new components are repetitive of prior services rendered, documentation must support the need for such additional services. Under the Medicare Program, it is not considered reasonable or necessary for clinicians to routinely screen patients for potential need for skilled services.

CPT/HCPCS Section

Medicine, Pulmonary and Physical Medicine and Rehabilitation

Type of Bill Code

13X, 75X, 85X

Revenue Codes

41X, 42X, 43X, 46X (not to be used for routine PR services), 730 (for use with 93005 and 93041 only)

Please note that not all revenue codes apply to each HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. See CPT/HCPCS Codes section for appropriate HCPCS and revenue code combinations.

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

For revenue code 41X, use HCPCS/CPT Codes as follows:

G0237		Therapeutic procedures to increase strength or endurance of respiratory
		muscles, face to face, one on one, each 15 minutes (includes monitoring)
G0238		Therapeutic procedures to improve respiratory function, other than described
		by G0237, one on one, face to face, per 15 minutes (includes monitoring)
G0239		Therapeutic procedures to improve respiratory function, other than described
		by G0237, two or more (includes monitoring)

For revenue codes 42X and 43X, use HCPCS/CPT Codes as follows:

97001**	©	Physical therapy evaluation
97002**	©	Physical therapy reevaluation
97003***	©	Occupational therapy evaluation
97004***	©	Occupational therapy reevaluation
97110	©	Therapeutic procedure, one or more areas, each 15 minutes; therapeutic
		exercises to develop strength, and endurance, range of motion and flexibility
97112	©	neuromuscular reeducation of movement, balance, coordination,
		kinesthetic sense, posture, and proprioception
97116	©	gait training (includes stair climbing)
97150*	©	Therapeutic procedure(s), group (2 or more individuals)
97535	©	Self-care/home management training (e.g., activities of daily living (ADL) and
		compensatory training, meal preparation, safety procedures, and instructions in use
		of adaptive equipment) direct one on one contact by provider, each 15 minutes
97750	©	Physical performance test or measurement (e.g., musculoskeletal, functional
		capacity), with written report, each 15 minutes
		(Note: Use this code to bill the 6-minute walk test.)

For revenue code 46X, use HCPCS/CPT Codes as follows:

(Note: The diagnostic and therapeutic codes below are not routinely rendered to all patients receiving PR services.)

94010	©	Spirometry, including graphic record, total and timed vital capacity, expiratory
		flow rate measurement(s), with or without maximal voluntary ventilation
		(Note: Not reimbursed more than once per day.)
94060	©	Bronchospasm evaluation: spirometry as in 94010, before and after broncho-
		dilator (aerosol or parenteral)
		(Note: Not reimbursed more than once per day.)
94640	©	Non-pressurized inhalation treatment for acute airway obstruction
94664	©	Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum
		induction for diagnostic purposes; initial demonstration and/or evaluation
94665	©	subsequent
94667	©	Manipulation chest wall, such as cupping, percussing, and vibration to facilitate
		lung function; initial demonstration and/or evaluation
94668	©	subsequent
94760	©	Noninvasive ear or pulse oximetry for oxygen saturation; single determination
94761	©	multiple determinations (e.g., during exercise)

For revenue code 730, use HCPCS/CPT Codes as follows:

(Note ECGs are not routinely preformed on patients receiving PR services.)

93005	©	Electrocardiogram, routine ECG with at least 12 leads; tracing only,
		without interpretation and report
93041	©	Rhythm ECG, one to three leads; tracing only without interpretation and report

The following codes are to be billed in association with pre-operative and post-discharge services related to lung volume reduction surgery (LVRS):

G0302		Pre-op service LVRS com
G0303		Pre-op service LVRS 10-
G0304		Pre-op service LVRS 1-9
G0305		Post-op service LVRS min

Ó CPT American Medical Association

Not Otherwise Classified (NOC)

Not Applicable

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

135		Sarcoidosis (Note: Bill code 517.8, Lung involvement in other diseases
		classified elsewhere, as secondary)
277.00		Cystic fibrosis without mention of meconium ileus
277.02		With pulmonary manifestations
277.03		With gastrointestinal manifestations
277.09		With other manifestations
491.0		Simple chronic bronchitis
491.1		Mucopurulent chronic bronchitis
491.20		Obstructive chronic bronchitis without exacerbation
491.8		Other chronic bronchitis
492.8		Other emphysema
493.20		Chronic obstructive asthma, unspecified
494.0		Bronchiectasis without acute exacerbation
494.1		Bronchiectasis with acute exacerbation
496		Chronic airway obstruction (COPD), not elsewhere classified
500		Coal workers’ pneumoconiosis
501		Asbestosis
502		Pneumoconiosis due to other silica or silicates
503		Pneumoconiosis due to other inorganic dust
504		Pneumonopathy due to inhalation of other dust
505		Pneumoconiosis, unspecified
506.0		Bronchitis and pneumonitis due to fumes and vapors
506.4		Chronic respiratory conditions due to fumes and vapors
506.9		Unspecified respiratory conditions due to fumes and vapors
508.1		Chronic and other pulmonary manifestations due to radiation
515		Post-inflammatory pulmonary fibrosis
516.0		Pulmonary alveolar proteinosis
516.2		Pulmonary alveolar microlithiasis
516.3		Idiopathic fibrosing alveolitis
516.8		Other specified alveolar and parietoalveolar pneumonopathies
518.1		Intersitial emphysema
518.89		Other disease of lung, not elsewhere classified

Diagnosis that Support Medical Necessity

All diagnoses listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

ICD-9 Codes that DO NOT Support Medical Necessity

All ICD-9 codes not listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Diagnosis that DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Reasons for Denial

· Services to a patient who would be expected to spontaneously return to his or her prior level of function without skilled therapeutic intervention.

· Services for maintenance of a chronic baseline condition or level of function.

· Patients with acute and/or unstable disease.

· Patients incapable of participating in PR due to mental or physical limitations.

· Patients where documentation does not support measurable benefit.

· Patients who are unable or unwilling to use training.

· Patients who continue to smoke and refuse a smoking cessation program.

· There is no physician order.

· There are no Pulmonary Function Tests documented within the previous three months.

Non-covered ICD-9 Code(s)

Any diagnosis code not listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Non-covered Diagnosis

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this policy.

Coding Guidelines

General Information:

· Each clinician's services are billed separately for the modalities or procedures delivered.

· Itemize the UB-92 by discipline using Revenue Codes 41X, 42X, 43X, and 46X; Date of Service; HCPCS/CPT codes; and Units.

· Charges for the evaluation and treatment services of RTs, respiratory nurses, or other qualified personnel should be billed under revenue code 41X. Evaluation and treatment services by PTs should be billed with revenue code 42X and by OTs with revenue code 43X. Pulmonary function tests should be billed under revenue code 46X. Electrocardiographic services should be billed with revenue code 730. (See detailed information below.)

· Each treatment procedure or modality billed must match the documentation in the daily therapy notes.

· A global daily fee billing is not acceptable.

Specific Information

· 97150 is to be billed only once per day per discipline.

· 97001 and 97002 are to be billed with revenue code 424

· 97003 and 97004 are to be billed with revenue code 434

· For revenue codes 42X and 43X, providers are required to report one of the following modifiers to distinguish the type of therapist who performed the outpatient rehabilitation service or, if the service was not delivered by a therapist, then the discipline of the Plan of Treatment under which the service is delivered should be reported:

-GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy Plan of Care

-GP Service delivered personally by a physical therapist or under an outpatient physical therapy Plan of Care. (CMS Transmittal No. AB-00-39, CR 1155, May 2000)

Documentation Requirements

Initial Assessments/Evaluation:

It may be reasonable and necessary for multiple clinicians to address a patient's particular needs. If so, then each clinician must perform a unique, individualized, skilled evaluation within his or her scope of practice and in his or her specific area of expertise. Each initial evaluation will identify the problems, develop a specific plan of treatment, and set specific goals. The assessment(s) should include the following information:

Physician's evaluation of the history of the respiratory illness, patient's rehabilitation potential, treatment diagnosis, and any relevant secondary diagnoses.
Physician's review of recent (within three months) pulmonary function tests, arterial blood gases, treadmill stress tests, or other relevant tests as indicated for a particular patient.
Review of any other diagnostic tests necessary to identify the patient's specific pulmonary need and potential for rehabilitation.
Past medical history, including any prior PR services.
Prior functional level (at baseline, or before the most recent exacerbation of the respiratory illness).
Psychosocial status. Patients with rehabilitation potential will have sufficient motivation, willingness, and cognitive skills to fully participate in his or her rehabilitation process. This includes a carry over of learned skills to make lifestyle changes.
Identification of specific problems and functional deficits in performing activities, tasks, or ADLs. These problems must be described in measurable, objective, and functional terms. These identified problems must be amenable to skilled therapy delivered by RTs, RNs, PTs, OTs, and other qualified personnel in order for these services to be medically necessary.
The patient's rehabilitation potential must be documented in measurable terms.

Daily Notes:

Each clinician is required to document all activities, tasks, instruction, and treatment rendered. This documentation must be done each time the patient receives any PR service. The content of this documentation is more important than the format. The clinician must include the following with each daily note:

The treatment time, procedure or modality, date of service, signature, and clinician's credentials.
Notes that match the revenue codes, HCPCS codes, units, and charges billed on the UB-92 (see "Coding Guidelines").
Content that addresses each individual patient's specific response to treatment, progress toward the stated goals, and the rationale for the continued need of the unique skilled PR services

Specific documentation of progress toward the stated goals would include patient demonstration of proper breathing techniques, proper cleaning procedure of respiratory equipment, proper self-administration of aerosol medication, increasing exercise tolerance with effective use of compensatory breathing skills, and carry over of learned activities to specific goals in the home and community. The documentation should reflect when the patient reaches each goal.

All documentation must demonstrate clinical rationale for skilled intervention.

· The patient's medical record must contain documentation that fully supports the medical necessity for Pulmonary Rehabilitation services as covered by Medicare (see "Indications for and Limitations of Coverage"). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

· Documentation in the medical record must support the medical necessity of the individual services for the particular patient receiving these services.

Utilization Guidelines

· Participation in PR services, after the initial assessment is performed, usually occurs three (3) or more days a week, for one to three (1-3) hours per day.

· Such services, when given continuously, are generally medically necessary for a period of six (6) to ten (10) weeks.

· Services beyond thirty sessions will be reviewed on an individual basis to determine medical necessity to continue PR as a skilled service.

Other Comments

Administrative Costs:

The following costs are not covered separately; they are considered indirect costs of providing PR services:

Teaching and education done by a pharmacist or dietitian;
General nutritional counseling;
Medical social services;
Team and/or family conferences;
Documentation time;
Discharge summaries; and
Educational books, pamphlets, audio/video tapes, CDs, DVDs, other computer software, or any other materials not considered medical supplies.

Limitation of liability and refund requirements apply when denials are based on medical necessity. They do not apply when the test, item or procedure is done for screening purposes. The provider must notify the beneficiary if the provider is aware that the test, item or procedure may not be covered by Medicare.

Financial Responsibility:

Provider Liable

The provider of the service or the ordering physician must have notified the patient in writing, prior to the service, and obtained a signature verifying Advance Beneficiary Notice. Without prior notice, services denied as not medically necessary cannot be billed to the beneficiary. The provider is liable.

Beneficiary Liable

If there is clear evidence that the beneficiary was issued and signed an Advanced Beneficiary Notice (ABN) prior to the service, the liability rests with the beneficiary. Claims for dates of service prior to January 1, 2003 should contain the condition code 20 and occurrence code 32, with date to signify that an ABN was issued to the beneficiary. Absence of these codes will result in a provider liable determination

Claims for dates of service beginning January 1, 2003 should contain the occurrence code 32 with date to signify that an ABN was issued to the beneficiary. Absence of this code will result in a provider liable determination.

Reference: PM AB-02-168, CR 2415

Sources of Information and Basis for Decision

· American Thoracic Society (ATS), Pulmonary Rehabilitation - I 999. Am J Respir Crit Care Med 1999; 159:1666-1682-Eligibility criteria in our policy have been drawn from this ATS Position Statement.

· Other Medicare contractors' policies (California Part A, Ohio Part A, Maryland Part B)-Many aspects of our policy have been based on the California Part A LMRP.

· The National Institute of Health, National Emphysema Treatment Trial (NETT) Manual, Sections 4.3.4-4.3.6, September 1999-The components of PR services and the usual duration of those services noted in our policy reflect those found in the NETT Manual.

Annual ICD-9-CM updates, FY 2004, PM AB 03-091, CR 2763.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Start Date of Comment Period

05/01/2002

End Date of Comment Period

06/15/2002

Start Date of Notice Period

07/01/2002

Revision History

Number	Date	Change
02-01-R4		Addition of G0302-G0305 for services related to LVRS. Updated format. Moved CPT/HCPCS codes to CPT/HCPCS code section.
02-01-R3	10/01/2003	Annual update of ICD-9 codes, changed verbiage for 491.20 and 493.20 (PM AB 03-091, CR 2763). Expand
		494 to 494.0 and 506 to 506.0.
02-01-R2	01/01/2003	Annual update of CPT/HCPCS codes. Code 94665 discontinued with 3-month grace period.
02-01-R1	10/01/2002	Annual update of ICD-9 codes for 2003. See bulletin on website for specifics.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE AT NO-COST FROM OUR WEBSITE AT http://www.marylandmedicare.com/.

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.