Pulmonology Coding Alert

You have to come out with your guns blazing when it's time to show your intermediary that a patient's pulmonary rehabilitation (PR) services are medically necessary and by the book. This includes following your LMRP's guidelines for documentation and approving patients for service that fall into the accepted diagnosis categories for coverage.

According to Mary Anne Riley, RRT, pulmonary rehabilitation coordinator at Cheshire Medical Center in New Hampshire, "If you are billing for a code and get audited, then you want to be able to go back on the daily flow sheet and prove that you had justification to charge." Documentation must support the choices you make for treatment, especially when you bill for individual therapy G codes.

Sometimes, it may be important for coordinators or billing department personnel to make sure therapists are familiar with the proper documentation requirements for PR, since requirements in LMRPs for this type of service often differ from the way therapists are used to documenting. Riley's LMRP requires that personnel in the program do objective data and a plan each day. Iowa Medicare's LMRP further explains some general documentation requirements:
1.Initial Evaluation. The initial assessment must include the physician's evaluation of the history of the respiratory illness, the patient's rehab potential, treatment diagnosis, and secondary conditions. He must include a review of recent PFTs and other tests, past medical history (such as prior PR services), prior functional level, and psychosocial status. He must identify any specific problems and functional deficits in performing activities, tasks, or ADLs and document the patient's rehab potential in measurable terms.
2.Daily Notes. Clinicians must document each day all activities, tasks, instruction, and treatment given to a patient. This LMRP notes that "the content of this documentation is more important than the format." The documentation must include treatment time, procedure, date of service, signature, and clinician's credentials. Content should cover the patient's response to treatment, progress toward the treatment goal, and rationale for continued PR services. Be sure to show the time the treatment started, the time the treatment ended, and medical necessity.

Most LMRPs only cover patients with certain diagnoses. According to Pamela Neuenfeldt, BS, RCP, RRT, pulmonary rehabilitation coordinator at Unity Hospital, Fridley, Minn., and past president of Minnesota ACVPR, most local intermediaries require you to have a pulmonary diagnosis. Most have recently broadened the acceptable diagnoses to include restrictive lung diseases versus limiting coverage to obstructive lung diseases. These include respiratory conditions that are chronic, but stable and under optimal medical management. Usually the patient would have PFTs revealing DLCO, FVC, or FEV1 of less than 60 percent within a year of treatment, Riley says. Some examples of covered diagnosis codes for Iowa Medicare providers are as follows: