Pulmonology Coding Alert

Don't rush into reporting individual respiratory therapy codes until you learn your local medical review policy's (LMRP) guidelines on pulmonary rehabilitation (PR) like the back of your hand. Since CMS leaves your local intermediaries in charge of formulating detailed guidelines for PR, you may find stringent rules in your LMRP that limit the codes you can use, services you can perform, and patients who can qualify for your program.

The Medicare Carriers Manual defines respiratory therapy as services prescribed by a physician for the assessment, diagnostic evaluation, treatment, management and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. CMS has issued guidelines for PR services performed in outpatient departments of hospitals and comprehensive outpatient rehabilitation facilities (CORF). Medicare lists several covered services:
1. The application of techniques to support oxygenation and ventilation in the acutely ill patient
2. The therapeutic use and monitoring of medical gases, aerosols, and equipment such as ventilators
3. Bronchial hygiene therapy
4. Diagnostic tests for evaluation by a physician
5. Pulmonary rehabilitation techniques
6. Periodic assessment of the patient to determine the effectiveness of therapy services.

The process usually begins when a patient is referred to the program, where he undergoes an assessment by a treating physician to determine the safety of rehabilitation, says Mel Burton, MD, Maui Chest Medicine, Maui, Hawaii. The patient will often undergo pulmonary function tests (PFTs) and pulmonary stress tests to assess exercise capacity, which allows for the prescription of a specific program. "The program usually consists of an educational component, breathing training, and muscle reconditioning," Burton says.

Staff can consist of a medical director (physician), respiratory therapists, nurses, occupational or physical therapists, and exercise physiologists. The variety of staff and services offered leads often to complicated coding issues. "Billing can make or break your program," says Mary Anne Riley, RRT, pulmonary rehabilitation coordinator at Cheshire Medical Center in New Hampshire. That is why you must rely heavily on your LMRP's policy on PR, if one exists in your area.

You need to know the ins and outs of respiratory therapy in order to get your codes straight. Riley spells out the process in-depth. Usually the coordinator sees new patients to review their medical records and identify tests that will need to be done. Arespiratory assessment is performed, covering the patient's history, physical condition, and medications. The patient makes an appointment with the medical director and physical therapist. According to Iowa Medicare's LMRP, this initial assessment by the physician is important and certifies the patient for 30 days (or 60 days in a comprehensive outpatient rehabilitation facility). Recertification is required every 30 days. This licensed physician will order, supervise, guide and direct the patient's care throughout the treatment. The physician must attest that the patient has received a physician examination in the past 90 days. Most LMRPs also require the patient to have received PFTs and lab work within a specified time frame.

The program usually consists of 24 sessions, which occur for 2.5 hours, three times a week. Iowa Medicare states that it reviews services beyond 24 sessions on an individual basis. Riley says that sessions consist of education, exercise, group support, one-on-one teaching, and group teaching. You must report services each day and will normally encounter group and individual therapy codes regularly.

Although the physician does not have to be in the office during respiratory therapy, he does have to be active  in each patient's program. According to Riley, in addition to performing the initial evaluation, the doctor in her program stays aware of the patient's progress, performs some educational segments, and decides general medical issues such as how much oxygen to give a patient. He must know enough, through weekly meetings, to sign a summary every 30 days.

Most LMRPs also require an initial evaluation by rehabilitation personnel to determine functional limitations and a plan for treatment, along with periodic reevaluations. You can use several codes for this service: