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October 16, 2013

Outpatient Pulmonary Rehabilitation (HCPCS Code G0424): Complex Medical Review, Kentucky - Continued

The J15 Part A Medical Review department performed a service-specific complex review in Kentucky on HCPCS code G0424 (outpatient pulmonary rehabilitation, including exercise (includes monitoring), one hour, therapeutic, prophylactic, or diagnostic). The edit was conducted from February through April 2013.  Based on the results summarized below, this will continue as a Complex Service Specific edit in Kentucky.  For coverage and documentation requirements related to this review, please refer to the CGS article “Pulmonary Rehabilitation: Coverage and Documentation Requirements.”

Kentucky Service-specific Complex Edit Results: Outpatient Pulmonary Rehabilitation, including exercise (includes monitoring), one hour, therapeutic, prophylactic, or diagnostic (HCPCS code G0424)
  Charges Claims
Reviewed $115,508.07 133
Denied $64,245.65 89
Charge Denial Rate 55.6%  

The top denial reasons associated with this review are:

5D901 – Pulmonary Rehab Not Warranted for Diagnosis- (48.9% of denied dollars)

  • Reason for denial:
    • The claim was fully denied because the condition required for coverage of pulmonary rehabilitation services was not submitted in the medical record.
    • The CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 32, section 140.4External PDF, states: “As specified in 42 CFR 410.47, Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease.”
  • How to prevent denials:
    • Review the requirements for coverage in the CGS article “Pulmonary Rehabilitation: Coverage and Documentation Requirements.”
    • There must be a clinical evidence of a physician-validated diagnosis that meets the coverage requirement of moderate to very severe COPD, as described in this article.
    • Submit the information required for coverage when responding to the Additional Documentation Request (ADR) letter.

For more information, refer to:

5D902- Documentation did not Include Required Components - (37.38% of denied dollars)

  • Reason for denial:
    • This claim was fully denied because the following components of the pulmonary rehabilitation program were not submitted in the medical record:
      • Physician-prescribed exercise
      • Education or training tailored to the beneficiary’s needs
      • Psychosocial assessment
      • Outcomes assessment
      • An individualized treatment plan  
  • How to prevent denials:
    • Review the requirements for coverage in the CGS article “Pulmonary Rehabilitation: Coverage and Documentation Requirements.”
    • The exercise prescription must include certain required elements.
    • What education factors are relevant and important to the specific patient (e.g., tobacco cessation)?  How were these factors addressed?  Concurrent notes are required to demonstrate how these factors were addressed.
    • Include results of the psychosocial assessment and the physician’s plan of action to address the results.  There are a number of other required elements; refer to the CGS article noted in this section for additional information.
    • Documentation of outcomes assessment must reflect whether the interventions and services did or did not benefit the patient and any related objective measures to demonstrate this.  If the plan was modified as a result of the outcomes assessment, include this documentation as well.
    • An individualized treatment plan must be established, reviewed, and signed at least every 30 days by a physician.  Again, the CGS article provides additional details.  We strongly recommend you review the article in its entirety.

For more information, refer to:

Completed review results will be posted on the CGS website.  Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please contact the Medical Review department at 803.763.4999.

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