Tuesday, September 08, 2009

Update on the ongoing CMS pulmonary rehabilitation issue

The following is from a weekly e-newsletter published by the government affairs staff at the American Thoracic Society. It not only repeats what I posted before from the Coalition for Pulmonary Fibrosis about the need to cover pulmonary rehabilitation for pulmonary fibrosis patients, but it also addresses an issue of compensation for health care providers.

You can read below, but personally, it doesn't seem like much compensation to keep a program up and running. There's also the issue that some programs are more than an hour a day - in fact, I think that's pretty common.

Here's the info:


Pulmonary Rehabilitation - Covered Conditions

The ATS is extremely disappointed with the proposed coverage and reimbursement policy developed by CMS. CMS is proposing to cover pulmonary rehabilitation services for all Medicare beneficiaries who have moderate or severe COPD (level II and level III COPD as defined by GOLD). While the proposed rule recognizes that research suggests other respiratory conditions may benefit from PR, CMS claims the evidence is insufficient, at this time, to include other conditions in the coverage policy. In the proposed rule, CMS notes that coverage of additional conditions can be accommodated through the Notice of Coverage Determination process as further research is conducted.

The ATS recommended CMS cover very severe COPD and a number of other respiratory conditions. Our comments provided extension references on the effectiveness of PR for a number of respiratory conditions.


Pulmonary Rehabilitation - Duration of Benefit, Reimbursement and Bundled Services

CMS is proposing to pay for up to 36 1-hour sessions as part of the PR benefit and will limit payment to one session per day. CMS is proposing to pay for PR using a new G-code (GXX30), which has a reimbursement rate of approximately $15 in hospital outpatient departments and $16.71 in the physician office. Bundled in the reimbursement are a number of monitoring services that currently are separately billable (including the 6-minute walk test).


The ATS is extremely concerned about CMS's proposed duration and reimbursement policy. The treatment guidelines published by all the major societies recommend at least 70 hours as part of the pulmonary rehabilitation program. Further, many pulmonary rehabilitation programs successfully provide 2-3 hours of therapy a day, as is well documented in the literature. In fact, CMS coverage policy for lung volume reduction surgery requires patients receive pulmonary rehabilitation therapy in two-hour sessions - up to 60 hours. It is unclear why CMS is proposing more restrictive policy for pulmonary rehabilitation patients compared to LVRS patients.


The proposed reimbursement rate is also extremely problematic. CMS is effectively paying $15-$17 for a 1-hour PR session, replacing the current reimbursement of $70 - a cut of more than 70 percent. The reduction in payment is even greater when calculating services that are currently separately billable under the current policy (6-minute walk test) that CMS is proposing to bundle into the GXX30 code.
The ATS recommended CMS allow physician offices and hospital outpatient departments to continue to use the existing G0237-9 codes for billing PR services and to further allow separate billing for related PR services.

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