In the News

CMS Makes Substantive Changes to Pulmonary Rehabilitation Provisions

Bookmark and Share

November 3, 2009

The combined efforts of AARC, working with our sister 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 January 1, 2010.

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” October 30 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 in November.

Physician fee schedule
Pages 61879-61886 (overall provisions), 62002-62003 (summary text).

Hospital outpatient provisions
Pages 60566-60574 (payment/supervision), 60575-60591 (comments/supervision summary).

“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. Any expansion of the coverage criteria will be handled as part of the National Coverage Determination (NCD) process.
  • 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.
  • CMS made some minor adjustments to the physician fee schedule which amounts to a small increase in the office setting to around $19 per 1-hour session, or a total of approximately $38 for two 1-hour sessions per day

Direct Physician Supervision

  • 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.