Pulmonary Rehabilitation Toolkit

Guidance to Calculating Appropriate Charges for G0424

CMS has reduced the payment for pulmonary rehabilitation.  Many AACVPR members have asked how they can help to reverse this ruling.

AACVPR has led a multi-society effort to address the payment reduction by Medicare that has been in effect for pulmonary rehabilitation programs since January 1, 2012.  We have developed a comprehensive toolkit that explains all of the issues associated with this payment reduction, along with a very specific hospital-by-hospital approach that must be taken as soon as possible to address this payment aberration.  We recognize that this issue is a complex one, and the solution the societies have created is a challenge to all pulmonary rehabilitation program managers/directors.

The participation of each and every PR program in addressing this issue is absolutely critical to ensuring that charges for PR services are accurate so that reimbursement is adjusted accordingly.

Frequently Asked Questions

Q: We’ve taken the tool kit to (administration) (finance office)(manager) and have gotten push-back with the response that: “We don’t want to raise the cost of PR to the patient” or “we don’t want to increase co-payment for PR or etc.”  How do we respond to this reaction?

A: Most pulmonary rehab services are provided to Medicare beneficiaries, and the payment amount is based primarily on “charge” data submitted by hospitals.  Keeping payment (and charges) arbitrarily low affects all hospitals participating in the Medicare program, not just one individual hospital.  In candor, we’re not sure how a program can survive with under 10-15 patients per hour (aggregate payment of approximately $370 for 10 patients) when you consider the broad range of services that are included in G0424.  And why should a COPD patient trigger a payment of $37 for one hour while the non COPDer receiving the exact same service receive a reasonable payment tied to codes G0237-39?

Q: CMS found a median charge for PR of $ 150. Realistically if I have 4 patients in pulmonary rehab for 2 hours each 8 hours X $150 = $1200, I believe this more than covers my costs for delivering PR for that session so I do not see how we would capture more in the cost report even with all of the suggestions made. Is my reasoning flawed?

A: Please do not confuse “charge” with “payment.”  The Medicare payment for four patients in pulmonary rehab, per hour, is approx. $37x4 = $148.  Medicare uses “charge” data submitted with every claim as the primary factor in determining payment for hospital outpatient services.

Also, do not confuse claims data, submitted to receive payment from Medicare, with the hospital’s cost report, which is submitted once annually. CMS has clearly stated that the median charge is low and that hospitals need to calculate “charges” for new, bundled codes carefully, reflecting all the component services that are integral to the new code.  If hospitals keep their “charges” for G0424 at $150 or less, then you will not see payment return to 2010 or 2011 levels any time in the foreseeable future.

Q: In looking at our charge structure (we are below the $150 mark), I am concerned raising it would make it more difficult for patients with private insurance which may raise the amount they are responsible for in the 80-20 plans and also in their overall deductible. We are 60% Medicare so private insurance is a large amount for us. Please address this concern.

A: The issue of co-pays is a legitimate one, and a difficult one to resolve.  Many people believe that it is important for patients (beneficiaries) to have “skin in the game” in order to ensure success. Smoking cessation programs offered free are not as successful as those that charge a fee. We would be happy to simply return to the $63 level, where the co-pay was manageable for 2010 and 2011.

Q: As an RRT, can we charge for procedures that are not the "traditional" RT procedures.  We do the work and document it but we do not charge for it.  For example the glucose monitoring. I was told we could not charge of "classes".  But I see there are codes for Education and Training - is that different than a class?  Because we do all the things listed as the description states in a class room and we document it but do not charge for it.

A: The list of billing codes from the “Toolkit” has a number of codes that represent the services that are often provided in pulmonary rehabilitation, for clarification purposes, the G0424 is the billing code for COPD Medicare only patients. So, I think the question is not can you bill for each of the items in your  attachment but rather, your bundled code of G0424 of $80 – does that amount  truly reflect and encompass the varied services you are delivering to the COPD Medicare patient? For example, you are probably obtaining a 6 MWT (most likely 2 maybe even 3), you are educating MDI/DPI use, teaching exercise basics for implementation of a home exercise program, instruction for safe oxygen therapy use.  We spend about 60 minutes doing an initial evaluation and developing the ITP and assessing the 6MWT. The Toolkit gives an example of what you do and just how much you are doing that you most likely did not factor into the $80 charge. The CMS rules do not say you can charge for “classes” but rather states that 1 session = 1 hour and that exercise must occur in each billed session of PR.

In reference to your comment that, “We do the work and document it but we do not charge for it.” The Toolkit exercise is to get you think about what your charge should be given that many of the unbundled items can no longer be billed separately like the non COPD CMS patients due to the bundling of G0424. If you provide G0239 group services, you may want to refer to the Toolkit for the example on page 17 on using this G0239 (group 2 or more) charge. We also do glucose monitoring for patients who need it based on our policy. All of our staff are respiratory therapists, they have tested and proved competency renewed annually to perform POC testing.

*AACVPR hosted a call for affiliate society leaders on Thursday, March 29, 2012. Phil Porte, GRQ Legislative Analyst, discusses the issue in great detail and explains the importance of this call to action. Listen to the recorded call by clicking here.