Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Pulmonary Rehabilitation Services
Policy #:MA10.001a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Pulmonary rehabilitation (PR) services are considered medically necessary and, therefore, covered for individuals with moderate to very severe chronic obstructive pulmonary disease (COPD) when referred by the professional provider treating the chronic respiratory disease.

In accordance with Medicare, pulmonary rehabilitation services are limited to a maximum of two one-hour sessions per day for 36 sessions, with an option for an additional 36 sessions up to a total of 72 sessions for the individual if medically necessary in an individual's lifetime. Additional sessions beyond 72 sessions are non-covered.


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

Pulmonary rehabilitation (PR) services must include all of the following components:
  • Professional provider--prescribed exercise. This physical activity includes techniques such as exercise conditioning, breathing retraining, and step and strengthening exercises. Some aerobic exercise must be included in each PR session. Both low- and high-intensity exercise is recommended to produce clinical benefits, and a combination of endurance and strength training should be conducted at least twice per week.
  • Education or training. This should be closely and clearly related to the individual’s care and treatment and tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling. Any education or training must assist in achievement of individual goals towards independence in activities of daily living, adaptation to limitations, and improved quality of life (QoL).
  • Psychosocial assessment. This assessment means a written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition. It should include: (1) an assessment of the aspects of the individual’s family and home situation that affect the individual’s rehabilitation treatment, and (2) a psychological evaluation of the individual’s response to, and rate of progress under, the treatment plan. Periodic re-evaluations are necessary to ensure the individual’s psychosocial needs are being met.
  • Outcomes assessment. These should include: (1) beginning and end evaluations based on patient-centered outcomes, which are conducted by the professional provider at the start and end of the program, and (2) objective clinical measures of the effectiveness of the PR program for the individual patient, including exercise performance and self-reported measures of shortness of breath, and behavior. The assessments should include clinical measures such as the 6-minute walk, weight, exercise performance, self-reported dyspnea, behavioral measures (supplemental oxygen use, smoking status), and a QoL assessment.
  • An individualized treatment plan describing the individual’s diagnosis and detailing how components are utilized for each individual. The plan must be established, reviewed, and signed by a professional provider every 30 days. The plan may initially be developed by the referring professional provider or the PR professional provider. If the plan is developed by the referring professional provider who is not the PR professional provider, the PR professional provider must also review and sign the plan prior to imitation of the PR program. It is expected that the supervising professional provider would have initial, direct contact with the individual prior to subsequent treatment by ancillary personnel, and also have at least one direct contact in each 30-day period. The plan must have written specificity regarding the type, amount, frequency, and duration of PR items and services furnished to the individual, and specify the appropriate mix of services for the individual’s needs. The plan must also include measurable and expected outcomes and estimated timetables to achieve these outcomes.

PULMONARY REHABILITATION PROGRAM SETTING REQUIREMENTS

PR items and services must be furnished in a professional provider's office or in a hospital outpatient setting. The setting must have the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and a defibrillator) to treat chronic respiratory disease. All settings must have a PR professional provider immediately available and accessible for medical consultations and emergencies at all times that the PR items and services are being furnished under the program.

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, pulmonary rehabilitation is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

Pulmonary rehabilitation (PR), as defined by the American Thoracic Society/European Respiratory Society (ATS/ERS) and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), is a comprehensive intervention based on a thorough patient assessment followed by individual-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of individuals with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.
References

Agency for Healthcare Research and Quality (AHRQ). Pulmonary rehabilitation for COPD and other lung diseases. Available at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id43TA.pdf Accessed September 10, 2019.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. 231: Pulmonary rehabilitation services furnished on or after January 1, 2010. [CMS Web site]. 02/01/19. Available at: https://www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 3, 2019.

Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services. 140.4: Pulmonary rehabilitation services furnished on or after January 1, 2010. [CMS Web site].02/08/19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c32.pdf. Accessed July 3, 2019.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 240.8: Pulmonary rehabilitation services. [CMS Web site] Original: 9/25/07. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=320&ncdver=1&bc=AgAAgAAAAAAA&. Accessed July 3, 2019.

Evidence of Coverage.

Spruit MA, Singh SJ, Garvey C, et al. An official American thoracic society/European respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013; 188(8):e13-64. Accessed July 3, 2019.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

Report the most appropriate diagnosis code in support of the medical necessity for pulmonary rehabilitation




Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

n/a



HCPCS Level II Code Number(s)



G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to 2 sessions per day

S9473 Pulmonary rehabilitation program, nonphysician provider, per diem



Revenue Code Number(s)

0948 Other Therapeutic Services - Pulmonary Rehabilitation




Misc Code

:


THE FOLLOWING MODIFIER MUST BE APPENDED TO G0424 AND S9473 IN ORDER TO BE CONSIDERED FOR REIMBURSEMENT

KX - Requirements specified in the medical policy have been met




Coding and Billing Requirements






Policy History

MA10.001a
12/30/2019The version of this policy will become effective 12/30/2019.

The intent of this policy remains unchanged; however, the policy has been updated to clarify the current Medicare coverage limits.





MA10.001
06/06/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Rehabilitation.
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
08/31/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Rehabilitation.
03/05/2015This version of the policy will become effective 03/06/2015. The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Rehabilitation.
01/01/2015This is a new policy.






Version Effective Date: 12/30/2019
Version Issued Date: 12/30/2019
Version Reissued Date: