CMS Issues Clarification on PR (Pulmonary Rehabilitation) Guidelines

As part of the initial implementation of the PR program January 1, 2010, CMS recently issued Transmittal 124 (May 7^th 2010) within the Medicare Benefit Policy Manual clarifying medical necessity along with program specifications and supervision requirements. As many of the new preventative services offered by CMS, the goal of the program is patient awareness and education to facilitate more aggressive self care. 

As outlined in 42 CFR 410.47, CMS will cover PR services for patients diagnosed with moderate to very severe COPD (GOLD classification II, III and IV). Five program components have been outlined and should be well documented in the medical record to meet the guideline criteria.

1. Physician Prescribed Exercise - CMS guidelines require that PR conditioning include both low and high intensity exercise to produce maximum clinical benefit at the minimum of twice per week.
2. Education and Training – CMS encourages the physician to individualize the education and training based on the patient’s medical condition and social situation. Program goals include guidance on daily living independence, understanding and adapting to personal limitations and improving other overall quality of life.
3. Psychosocial assessment – Documentation should support a patient’s mental and emotional status as it relates to respiratory conditioning. CMS recommends the assessment should include an evaluation of the patient’s home situation affecting the treatment parameters along with overall response and progress gained as part of the treatment plan.
4. Outcome Assessment – Both beginning and ending assessments are required to assess overall outcome of the PR program. Clinical parameters should be measured including but not limited to the 6 minute walk, weight, exercise performance, self-reported shortness of breath, emotional well being and quality of life.
5.  Individual Treatment Plan – Each plan must be documented according to the patient’s individual diagnosis. It must be established, reviewed and signed by the PR physician every 30 days. Plans may be developed by the referring provider but officially approved and signed off from the PR physician.

In accordance with 42 CFR 410.26 and 410.27, if the program is administered by a non-physician provider, direct supervision guidelines must be met depending on place of service. Lastly, the transmittal outlines requirements the PR physician must meet in order to facilitate and/or supervise the PR program. 

For specific coding and billing guidelines, link onto Publication 100-04 Medicare Claims Processing Manual, Chapter 32, section 140.4.

Written by Jana Gill, MA, CPC