Pulmonology Coding Alert

Hint: The diagnosis is COPD is crucial.

Do you have to come out with guns blazing to show your payer that your pulmonary rehabilitation (PR) services claim is medically justified and by the book? Confused about how to code for your pulmonologist’s outpatient PR program? Don’t worry. Here are some essential PR coding tips for you to pick up and get going on your PR claims.

Basics: “Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease,” according to the Joint Statement of the American Thoracic Society and the European Respiratory Society (http://www.atsjournals.org/doi/pdf/10.1164/rccm.200508-1211ST).

In other words, a pulmonary rehabilitation program is a physician-supervised program that includes exercise, education and training, psychosocial and outcomes assessment. 

Requirements for Coverage: What Makes Your Claim Eligible 

Here are a few points to remember about the CMS’s criteria for coverage of pulmonary rehabilitation:

• Where: Physician office, hospital outpatient setting. 
• For whom: Patients with mild to moderate COPD, according to Gold classification II, III or IV. The pulmonary function tests (PFT) results need to exhibit forced vital capacity (FVC), forced expiratory volume (FEV1), and/or a carbon monoxide diffusing capacity (DLCO) of less than 65% of predicted volumes. 
• By whom: Although one or more members of the multidisciplinary team, including RTs, can provide individual components of the compre­hensive PR program, none of those services are separately billable under the PR benefit, according to the American Association for Respiratory Care (AARC) guidelines (https://www.aarc.org/app/uploads/2014/10/coding_guidelines.pdf). Also, non-physician practitioners may not supervise the pulmonary rehabilitation services on the whole.
• How long: Medicare will pay for up to 2 one-hour sessions per day, for up to 36 lifetime sessions (up to 72 hours).

“Each Medicare carrier may have its own policy called a LCD or Local Coverage Determination, regarding what is covered under pulmonary rehabilitation services, so check with your carrier if you wish to bill for these services, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

Know Your G Codes Well

You will have to report a single HCPCS code G0424 (Pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to two sessions per day), which also covers the individual services furnished prior to the PR benefit as well, according to AARC coding guidelines. Remember not to use this code in billing services for non-COPD patients.

Non-COPD patients: If a patient does not meet the COPD criteria above, their services can be covered as individual respiratory care services (not pulmonary rehabilitation). Also, for all other patients with other pulmonary-related diseases, who require PR services that help them cope with chronic lung disease, you have the following codes:

• G0237 (Therapeutic procedures to increase strength or endurance or respiratory muscles, face to face, one on one, each 15 minutes [includes monitoring]) 
• G0238 (Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes [includes monitoring])
• G0239 (Therapeutic procedures to improve respiratory function or increase strength or endurance or respiratory muscles, two or more individuals [includes monitoring])

These being time-based services, you may bill a single 15-minute unit for 8-22 minutes of service with CPT^® G0237 and G0238, bill two units for 23-37 minutes, and so on. You may bill code G0239 only once per day per patient.

Caveat: Physical and occupational therapists may not report codes G0237, G0238, G0239 and G0424. Instead, they may report codes 97010-97799 (physical medicine and rehabilitation evaluations), best representing their practice.

Proper Diagnosis Reporting a Mainstay for Medical Necessity

Make sure that you are billing for the PR services with appropriate and covered diagnoses justifying the medial necessity. Check with your payer for allowed diagnosis codes. According to the CMS Local Coverage Article (educational article — pulmonary rehabilitation (PR) Services [A526960]), some of the diagnoses include:

• J41.0 (Simple chronic bronchitis)
• J41.1 (Mucopurulent chronic bronchitis)
• J41.8 (Mixed simple and mucopurulent chronic bronchitis)
• J43.0 (Unilateral pulmonary emphysema [MacLeod’s syndrome])
• J43.1 (Panlobular emphysema)
• J43.2 (Centrilobular emphysema)
• J43.8 (Other emphysema)
• J43.9 (Emphysema, unspecified)
• J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection)
• J44.1 (… with [acute] exacerbation)
• J44.9 (… unspecified)

Heed the Must-Have Five Components of PR

Apart from ensuring that the patient has a physician validated diagnosis of moderate to very severe COPD, there are some important components of the PR program which need documentation according to CGS Medicare, a Medicare Administrative Contractor for CMS. Here are the components:

1) Physician-prescribed exercise each day: Documentation requirements include the patient’s name, date, a description of the exercise showing the doctor’s prescription was followed, and the signature and credentials of the individual who directly supervised that exercise-or supply a reasonable clinical explanation for its not being done. The provider’s ‘FITT’ exercise prescription plan must include the exercise frequency (sessions per week), intensity, time (or duration) and type (or mode). Also, the provider needs to document patient’s response to the exercise and carry out a periodic progress review.

2) Patient specific education: Documentation should include that the patient was counseled and provided education according to his requirement, say smoking cessation, and the outcome of the counseling.

3) Psychosocial assessment: Although a psychologist or psychiatrist may conduct this, assessment with recognized tools for depression screening, if accompanied by the physician’s plan of action based on the results.

4) Outcomes assessment: Auditors look for documentation that the patient is making progress toward goals since PR is meant to improve respiratory function. The outcome, should be documented quantitatively. If the goal was to stop smoking within two weeks, you need to document at the end of week two whether the person was able to quit smoking, or whether he was able to bring down the intake from 10 cigarettes to 2 cigarettes.

The provider could also measure the goals for walking capacity as measured by a six minute walk test which is the GOLD standard in Pulmonary Medicine, says Berman.

Obtaining a six minute walk test at the beginning of the program and then repeating it midway and at the end of the PR program is appropriate for an outcome assessment, he says. If the goals were not met, the provider must include what modifications he made to the care plan to address the failure.

5) Place of service: Use the place of service (POS) 11 (Physician’s office) or 22 (Hospital outpatient). A provider should be immediately available and accessible for medical consultations.

Know What to Do For Follow-Ups and Other Services

You can report follow-up non-PR visits to your provider with appropriate E/M codes such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity...). These visits are important to evaluate the patient’s underlying condition, any exacerbations, and response to medication therapy.

Salvage Your Dollars on Associated Services

In services related to pulmonary rehabilitation, the provider may bill for equipment using these HCPCS codes:

• A4614 — Peak expiratory flow rate meter, hand held
• A4627 —  Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
• A7003 — Administration set, with small volume nonfiltered pneumatic nebulizer, disposable.

Final takeaway: “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,” says Mary Anne Riley, RRT, pulmonary rehabilitation coordinator at Cheshire Medical Center in New Hampshire. Documentation must support the choices you make for treatment, especially when you bill for individual therapy G codes.

References:

• https://www.aarc.org/app/uploads/2013/07/Pulmonar­yRehab_FAQs_Final_rev2-12-14.pdf
  
• https://www.aarc.org/app/uploads/2014/10/coding_guidelines.pdf
• http://www.cgsmedicare.com/parta/pubs/news/2013/0313/cope21508.html