CMS Makes Substantive Changes to
Pulmonary Rehabilitation Provisions
(11/3/09)
The combined efforts of AARC, working with their
state affiliates including the PSRC and other respiratory/pulmonary
organizations, have had a positive result with the issuing of the final
regulations for the new Medicare pulmonary rehabilitation (PR) benefit
that will go live on
The Centers for Medicare and Medicaid (CMS)
listened to the concerns and written comments the pulmonary community
raised over the proposed
regulations and made substantive changes in the final rules.
These rules went on “display” November 2 at the Federal Register.
The PR regulations are in 2 separate sites:
The FY 2010 update to the physician fee schedule and the FY 2010
payments to hospital outpatient departments.
Publication will take place later this month.
Link to physician fee schedule:
[Pages 673-712 (overall provisions); 1242-1248 (summary text)]
http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf
Link to hospital outpatient provisions: [Pages 898-924 (payment); 931-983 (supervision)] [
http://www.federalregister.gov/OFRUpload/OFRData/2009-26499_PI.pdf“While it isn’t everything we wanted, said Cheryl
West, Director of Government Affairs, it’s a vast improvement over the
proposed rules that not only would have limited access for patients with
respiratory illnesses, but most likely would have put a number of
programs out of business because of the low reimbursement rate.”
President Tim Myers added “We are pleased that CMS has listened to the
respiratory community in making very important changes to its proposed
rule so that the health and improved lifestyles for our respiratory
patients can be advanced.
We hope that as time goes by we can continue to improve upon this
important benefit for our patients.”
Highlights of the changes are listed below:
Coverage
Criteria, Number of Sessions and Other Provisions
·
Patients
with “very severe COPD” have been added to the list of covered
conditions.
·
While not
including other conditions beyond COPD at this time, CMS agreed to
continue to provide coverage for those diagnoses currently covered under
local PR coverage policies until it can review additional conditions as
part of the National Coverage Determination (NCD) process. [NOTE:
AARC and our partners requested a formal NCD to add additional
conditions on September 29, 2009.
http://www.aarc.org/headlines/09/10/pr_coverage/ .]
·
The
number of covered sessions has been expanded from 36 sessions to permit
up to 72 sessions. This
boils down to allowing local contractors at their discretion to cover an
additional 36 sessions if they deem them medically necessary.
·
The
number of billable sessions has been increased from one, 1-hour session
per day to two 1-hour sessions per day.
·
A corresponding change has been made to the
descriptor for the new HCPCS code G0424 to include the terms “per hour,
per session” to permit longer treatments and to determine when one
session of PR ends and the second session begins.
·
The important role of the
interdisciplinary team, including RTs, is acknowledged by adding the
physician’s interaction with the PR staff in the definition of
“Physician Standards.”
Payment Provisions
·
In the
hospital outpatient setting, payment for PR services will be set by
establishing a new clinical APC with a median “per session” cost of
approximately $50, simulated from historical claims data for similar
pulmonary therapy services (e.g., using G codes 0237, 0238, and 2039.)
instead of the proposed payment of around $15.
With the ability to bill two sessions a day, this adds up to
around $100.
·
In the physician office setting,
CMS has made payment modifications which
increased the practice expense relative-value units (RVUs).
We are in the process of determining how this impacts the
original proposed payment rate to physicians and will inform our members
once we have a figure.
·
Non-physician practitioners, such as physician assistants, nurse
practitioners and others are not permitted to provide “direct
supervision” under the PR program in either the physician office or
hospital outpatient setting.
This ruling also applies to cardiac rehabilitation (CR) and
intensive cardiac rehabilitation (ICR).
CMS maintains that the law is very specific in using the term
“physician” supervised program and that there is no flexibility in
expanding the definition to include non-physician practitioners.
·
“Direct
supervision” in the hospital outpatient rule is modified to allow the
supervisory physician (or non-physician practitioner as it applies to
therapeutic services other than PR, CR and ICR) to be anywhere on the
hospital campus, including a physician’s office, an on-campus
Skilled Nursing Facility, Rural
Health Clinic or other non-hospital space.
This means “present on the same campus and immediately available
to furnish assistance and direction throughout the performance of the
procedure.”
·
In the
hospital or critical access hospital (CAH), the definition is finalized
as meaning “areas in the main building(s) of a hospital or CAH that are
under the ownership, financial and administrative control of the
hospital or CAH; that are operated as part of the hospital; and for
which the hospital bills the services furnished under the hospital’s or
CAH’s CMS Certification Number (CCN).
·
No changes are being made to the
requirement that the physician or non-physician practitioner must be
present in the off-campus provider-based department and immediately
available to furnish assistance and direction throughout the performance
of the services.
Miscellaneous Issues
·
The PR
settings have not been expanded to include Comprehensive Outpatient
Rehabilitation Facilities (CORFs).
This is a separate benefit under Medicare with different
statutory requirements and is not impacted by the new PR provisions.
The current G codes 0237, 0238 and 0239 are still used in this
setting.
·
Physical therapists will not be
permitted to bill PT codes separately if they conduct assessments and
individual treatment services as part of a PR program. These services
are considered part of the overall treatment plan for PR and are to be
billed using the new code G code.
The final rules, while by no means perfect, are a far cry from what CMS initially proposed, so the Agency appears to be moving in the right direction. Although the final rule offers a comment period, it does not request further comments on pulmonary rehabilitation (translation: any comments offered will not be reviewed or considered). That means we will most likely have to wait until next year to continue to work on refining the provisions and requesting further changes. It is also important that we continue to work with CMS as they review the request for additional conditions under the NCD process where additional refinements could be made.