Medicare Advantage Medical Policy Bulletin

Pulmonary rehabilitation services are covered for patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease. (See Glossary for definitions of the GOLD classifications.)

Pulmonary rehabilitation programs must include the following components:

Physician-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 those aspects of the individual’s family and home situation that affects 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 physician 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 patient: The plan must be established, reviewed, and signed by a physician every 30 days. The plan may initially be developed by the referring physician or the PR physician. If the plan is developed by the referring physician who is not the PR physician, the PR physician must also review and sign the plan prior to implementation of the PR program. It is expected that the supervising physician 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 with regards to the type, amount, frequency, and duration of PR items and services furnished to the individual, and specify the appropriate mix of services for the patient’s needs. It must include measurable and expected outcomes and estimated timetables to achieve these outcomes.

Pulmonary rehabilitation services supervised by a physician are eligible only if the physician meets all of the following requirements:

expertise in the management of individuals with respiratory pathophysiology,
licensed to practice medicine in the state in which the PR program is offered,
responsible and accountable for the PR program, and,
involved substantially, in consultation with staff, in directing the progress of the individual
in the PR program.

Pulmonary rehabilitation must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician immediately available and accessible for medical consultation and emergencies at all time services are being furnished under the program. All settings must also have the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and defibrillator) to treat chronic respiratory disease.

Pulmonary rehabilitation program sessions are limited to a maximum of two 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions over an extended period of time if approved. The additional 36 sessions are covered when reported with the KX modifier indicating all medical necessity criteria have been met.

Services should not exceed 72 in the member's lifetime.

When reporting pulmonary rehabilitation services, the following guidelines apply:

In order to report one session of pulmonary rehabilitation services in a day, the duration of treatment must be at least 31 minutes.
Two sessions of pulmonary rehabilitation services may only be reported in the same day if the duration of treatment is at least 91 minutes.
If several shorter periods of pulmonary rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.

Reasons for Noncoverage

Services that do not meet the medical necessity criteria or frequency guidelines on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

When there is an expectation of a medical necessity denial, suppliers must enter a GA modifier on the claim line if they have obtained a properly executed Pre-Service Denial Notice. Services submitted with a GA modifier will be denied as not medically necessary and are billable to the member.

When there is an expectation of a medical necessity denial, suppliers must enter a GZ modifier if they have not obtained a valid Pre-Service Denial Notice. Services submitted with a GZ modifier will be denied as not medically necessary and are not billable to the member.

Claim lines billed without a GA or GZ modifier will be rejected as missing information.

Documentation Requirements

Documentation should include the length each session or total length of time per day.

Documentation should include a spirometry report , performed as a component of pulmonary function testing, confirming the existence of COPD and supporting medical necessity.

The treatment plan must be established, reviewed, and signed by a physician, who is involved in the patient’s care and has knowledge related to his or her condition, every 30 days.

For additional information on Smoking Cessation and Tobacco-Use Cessation, see Medicare Advantage Medical Policy Bulletin N-20.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Report individual therapy services included in each sessions, e.g., physical medicine.

Use codes 99406 or 99407 to report smoking cessation counseling.

Report the KX modifier when claims exceed 36 sessions if the medical necessity criteria are met.

Report the GA modifier if there is a signed Pre-Service Denial Notice on file.

Report the GZ modifier if an Pre-Service Denial Notice is not on file.

Medical Policy Update

08/2010, Pulmonary rehabilitation for moderate to severe COPD covered for Medicare Advantage

Facility Bulletin

05/2013, SIX MEDICARE ADVANTAGE MEDICAL POLICIES TO APPLY TO FACILITIES ON JUNE 3, 2013

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-line Manual 100-02, Chapter 15, Section 231

CMS On-line Manual 100-03, Section 240.8

CMS On-line Manual 100-04, Chapter 32, Section 140.4 -140.4.1

CMS On-line Manual 100-3, section 240.8 Effective 09/25/2007.

Transmittal 78 NCD, CR 5834

Transmittal 1871 CP, CR 6751

Transmittal 124 BP, CR 6823

Transmittal 1966 CP, CR 6823

Federal Register Vol. 74, No. 226, November 25, 2009

Term	Description
Stage I: Mild COPD	FEV₁/FVC<70% FEV₁≥80% predicted Chronic cough and sputum production may be present. At this stage, the individual may not be aware of abnormal lung function.
Stage II: Moderate COPD	Worsening airflow limitation (FEV₁/FVC < 70%; 50% ≤ FEV₁ < 80% predicted) Shortness of breath typically developing on exertion. This is the stage at which most patients typically first seek medical attention because of dyspnea or an exacerbation of their disease.
Stage III: Severe COPD	Severe COPD further worsening of airflow limitation (FEV₁/FVC < 70%; 30% ≤ FEV₁< 50% predicted) Greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients’ quality of life.
Stage IV: Very Severe COPD	Severe airflow limitation (FEV₁/FVC < 70%; FEV₁≤ 30% predicted or FEV₁ 50% predicted plus chronic respiratory failure) Patients may have Very Severe (Stage IV) COPD even if the FEV₁ is > 30% predicted, whenever this complication is present.

Section:	CMS National Guidelines
Number:	N-194
Version:	004
Topic:	Pulmonary Rehabilitation - NCD 240.8
Effective Date:	June 15, 2012
Issued Date:	June 3, 2013

G0424
Revenue Codes
0948