Pulmonary Rehab Requirements and Happy Respiratory Care Week

on Tuesday, 20 October 2015. All News Items | Outpatient Services | MAC Reviews

Caring and Complying

Whether you entered healthcare as a career because you wanted to help others or for the job security, pay, and benefits, a part of your job almost assuredly involves treating and/or serving patients. After all, caring for patients is what we do. But much to the surprise of many, you must also write tomes of documentation and understand and comply with the rules of healthcare payers such as Medicare.

Keeping with the theme of medical review activity by the Medicare Administrative Contractors (MACs) in our newsletter this week, we note that Palmetto GBA reported the results of the 9th quarter of their service-specific targeted prepayment review of Pulmonary Rehab (PR). This also ties in nicely with our recognition of Respiratory Care Week which is next week, October 25 – 31. Medical Management Plus commends all respiratory therapists who work to restore and improve lung health to patients’ lives.

According to the website www.respiratorytherapistlicense.com/,

“Respiratory therapists diagnose, assess, monitor, and treat patients suffering from dysfunctions of the cardiopulmonary system, including any type of disease or disorder that impacts breathing and lung capacity. Respiratory therapy continues to be a vital part of patient care due to rising incidences of chronic lung conditions and diseases, such as chronic bronchitis, COPD, and emphysema. According to the American Lung Association, COPD is the third leading cause of death in America. It is also estimated that nearly 24 million U.S. adults have evidence of impaired lung function.”

In 2010, Medicare finally recognized Pulmonary Rehabilitation as a covered Medicare benefit. To be eligible for Medicare coverage, the Pulmonary Rehab must meet the following requirements:

  • Medicare covers PR items and services for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease.
  • Program components must include:
    • Physician-prescribed exercise.  Some aerobic exercise must be included in each session.
    • Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling.
    • Psychosocial assessment.  A written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehab or respiratory condition.
    • Outcomes assessment conducted by the physician at the start and end of the program, including objective clinical measures of the effectiveness of the program.
    • An individualized treatment plan that includes the type, amount, frequency, and duration of PR items and services.  It must also include measurable and expected outcomes and estimated timetables to achieve these outcomes.
    • The plan must be established, reviewed, and signed by a physician every 30 days.  It may initially be developed by the referring physician or the PR physician.  If the plan is developed by the referring physician who is not the PR physician, the PR physician must also review and sign the plan prior to the start of the PR services.

Palmetto’s denial rates for the Pulmonary Rehab audits for the last four quarters are summarized below:


The main reasons for the pulmonary rehab denials are:

  • Pulmonary rehab not warranted for the diagnosis
  • Documentation did not include the required components
  • No order/referral for pulmonary rehab services
  • Requested records not submitted
  • Services not documented

Palmetto also provides more specific details of the denials in their “granular” findings. For example:

The documentation submitted does not represent a patient with moderate to severe Chronic Obstructive Pulmonary Disease (COPD) as defined by the GOLD classification II, III and IV per 42 CFR 410.47.

The documentation of post-bronchodilator pulmonary function studies does not meet the requirement of FEV1 less than 80% of predicted and FEV1/FVC less than 70%.

The documentation submitted does not represent an individualized treatment plan signed by a physician and reviewed every 30 days as required in 42 CFR 410.47.

There is no outcomes assessment of the patient's progress related to the rehabilitation.

There is no psychosocial assessment of the individual's mental and emotional functioning as it relates to their rehabilitation or respiratory condition.

There is no documentation of the patient's education or training as it relates to care and treatment.

There is no physician's prescribed exercise program present in the documentation.

There is no physician’s order/referral for admission to pulmonary rehabilitation services present.

Also remember that pulmonary rehab is limited to a maximum of 2 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary. A KX modifier must be appended to pulmonary rehab line items on claims where pulmonary rehab exceeds 36 sessions; inclusion of the KX modifier attests that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary. Pulmonary rehab is covered in a physician’s office or hospital outpatient setting and a physician must be immediately available and accessible for medical consultations and emergencies at all times during the service.

So while you are taking good care of your patient’s respiratory health, be sure to follow the rules and include the appropriate documentation.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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