There is overwhelming evidence that pulmonary rehabilitation (PR) can greatly benefit COPD patients. What about other respiratory patients? Does that include asthma? What about those with restrictive lung disease? Is anything other than COPD actually covered? Who should be eligible and how is that decided? And finally, which diagnoses are most likely to be reimbursed by Medicare and other insurers?
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) has published “Guidelines for Pulmonary Rehabilitation Programs,” now in its third edition, that lists conditions appropriate for pulmonary rehabilitation. This is a wide-ranging and very inclusive list. Many experienced PR practitioners would agree that patients with these conditions can benefit by participating in a PR program.
But Medicare and other payors don’t deal in “conditions.” They want a specifically stated diagnosis with the documentation to back up that diagnosis. They also want assurance, again documentation, that the patient will benefit from PR, can and will participate in PR, and has quit or will quit smoking.
To get the “Big Picture,” here are the five most widely accepted inclusion criteria: A patient must have:
- a specific respiratory diagnosis (eg, chronic airways obstruction, ICD-9 code 496);
- a pulmonary function test (PFT) showing an FVC <65%, or FEV1 <65%, or DLCO <65% of predicted (some insurers use FVC or FEV1 or DLCO <60%);
- documentation (eg, recent history and physical examination) that activities of daily living (ADLs) have been adversely affected;
- cognitive ability and willingness to participate in PR;
- and, finally, the patient must be a nonsmoker or have quit or be willing to concurrently participate in a smoking cessation program.
Examples of Conditions Appropriate for Pulmonary Rehabilitation
- Obstructive Diseases
COPD (including alpha-1 antitrypsin deficiency)
- Restrictive Diseases
- Interstitial fibrosis
- Occupational or environmental lung disease
Chest wall diseases
- Ankylosing spondylitis
- Parkinson’s disease
- Postpolio syndrome
- Amyotrophic lateral sclerosis
- Diaphragmatic dysfunction
- Multiple sclerosis
- Posttuberculosis syndrome
- Other Conditions
Primary pulmonary hypertension
Pre and post thoracic and abdominal surgery
Pre and post lung transplantation
Pre and post lung volume reduction surgery
Pediatric patients with respiratory disease
Obesity-related respiratory disease
Printed by permission of the American Association of Cardiovascular and Pulmonary Rehabilitation. Pulmonary Rehabilitation Fast Facts located at www.aacvpr.org.
That makes it sound pretty straightforward, but the fact is a uniform policy does not exist. Even though the Centers for Medicare and Medicaid Services (CMS) has long recognized PR as a covered service, the agency has never set a national policy for the reimbursement of PR services.
Eligibility Is Not Guaranteed
Most of the patients receiving PR have Medicare coverage, and, for more than a decade, the eligibility criteria have been set by the insurance companies contracted by CMS to handle Medicare claims. Many of these insurance companies, until very recently known as Fiscal Intermediaries (FIs), stated the eligibility criteria in their own published documents, known as Local Coverage Determinations or LCDs. These LCDs listed the diagnoses that would be accepted and other inclusion criteria such as PFT results.
Currently, things have become even more complicated for those of us in PR because CMS is going through a transition. The FI system is being phased out and replaced with Medicare Administrative Contractors (MACs). So far, these new MACs—again they are the insurance companies being contracted by CMS to handle the Medicare claims that we submit—do not have LCDs that state the eligibility criteria for PR. CMS has signaled that the new MACs cannot make changes without giving notice to us, the providers of PR services. This situation will require our close monitoring in the coming months.
So, how do you decide who is “in” and which patients are “out”?
First, a patient referred to you for PR should be considered a candidate. They are not automatically in just because they have been referred. You need to put on your clinician’s hat and gather information about the PR candidate.
As a starting point, you must have a recent history and physical (H&P) from the referring physician. That H&P must be based on a physical examination done within the last 90 days preceding the referral. The H&P must address the inclusion criteria mentioned above: diagnosis; activities of daily living adversely affected; patient’s cognition and willingness; and smoking status. Also required are PFT results (ideally, a complete PFT with DLCO) less than 1 year old. If a recent physical and PFT have not been done, you will need to approach the referring physician to get them ordered.
PFT criteria are widely accepted and a convenient and very useful way to identify those patients likely to benefit from PR. Staging of COPD using the GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria is a very important step and should be done long before the patient is referred to PR.
Notice that the GOLD staging criteria (Figure) do not line up exactly with the Medicare eligibility criteria. Welcome to “the real world” of PR and dealing with Medicare. For those PR candidates who are not diagnosed with COPD, but have some other respiratory disease identified, a PFT that shows an FVC or FEV1 or DLCO <60% of predicted will still help you document the need for PR.
There is a lot of other useful information that will help you make the inclusion/exclusion decision. Most is not mandatory, but absolutely essential if you are to identify appropriate patients and provide PR that is both safe and beneficial.
|From the Global Strategy for the Diagnosis, Management and Prevention, of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2006. Available at: www.goldcopd.org|
Both you and the referring physician need to fully understand that you are about to launch a high-risk patient on a serious exercise program. There are risks! Every PR program should have policies and procedures (P&P) in place that identify required tests and information. That P&P must have the complete buy-in and approval of your medical director.
Most PR candidates have comorbid conditions such as cardiac disease, peripheral vascular disease, diabetes, etc. If stable, these comorbid conditions might not exclude the candidate, but you sure need to know about them—not just if they are present; you need to understand the degree of impairment and how it limits your PR candidate. By the way, occasionally you will find your PR candidate redirected to, for example, a cardiac workup instead of starting PR.
Activists for PH
Several organizations have been actively involved in moving legislation through Congress that would force CMS to recognize pulmonary and cardiac rehabilitation as covered services. You can keep up to date by going to any of the following Web sites:
American Association of Cardiovascular and Pulmonary Rehabilitation www.aacvpr.org
American Association for Respiratory Care www.aarc.org
American College of Chest Physicians www.chestnet.org
A list of information to be gathered and/or tests to be done prior to PR should include an exercise stress test (some might opt for a 6-minute walk test), a recent chest x-ray, blood work (CBC and CMP), and ABGs. Some or all of these tests might have been performed prior to referral and, in that case, all you will need to do is gather the information. You will, of course, need to get a properly signed and dated medical records release from your PR candidate as soon as possible after the referral.
Tests for any missing information will need to be ordered as soon as possible. By the way, spirometry alone, while valuable for collecting critical information, is not a substitute for a complete PFT. Some referring physicians will question the need for additional testing after they have made their referral. It is often seen as unnecessary and a delay to starting PR. This is where having the full support of your medical director, to provide the referring physician with a “peer-to-peer” explanation, becomes essential.
By paying attention to detail, and by gathering the information and documentation, you will be able to identify the appropriate PR patients. It helps to ensure that you are providing safe and effective PR for those patients accepted and, finally, gives you some degree of confidence that your program will be reimbursed for the services provided.
A Wait and See Game
At the time of this writing, early January 2008, many of the pulmonary rehabilitation issues are in a dynamic state. There is a bill, Medicare legislation left over from 2007, awaiting congressional action. Among other things, it includes language that would force CMS to recognize both pulmonary and cardiac rehabilitation as bona fide covered services. If this Medicare legislation passes and is signed into law, we can hope to see a uniform national policy, a National Coverage Determination, developed by CMS for PR. Everyone involved in providing PR services should be monitoring this closely.
Carl Willoughby, RRT, RCP, is pulmonary rehabilitation coordinator, Mad River Community Hospital, Arcata, Calif. For further information, contact [email protected]