By Chris Garvey, FNP, MSN, MPA, MAACVPR | March 23, 2020

Shared with permission by Trina Limberg RRT.

Despite vast evidence that pulmonary rehabilitation (PR) is highly effective in improving exercise tolerance, dyspnea, quality of life (3), and shortening COPD admissions (4), inadequate PR reimbursement deprives persons with lung disease of this effective intervention, with as few as ∼3% of Medicare beneficiaries with COPD receiving PR (5). All aspects of low reimbursement are not completely understood, yet providers, referring clinicians and hospital administration play a key role in helping to address this important inequity.

Decline of PR reimbursement is complex, and at least in part tied to development of a Medicare PR bundled payment code G0424 for COPD which pays for 1 unit of PR, including all costs of staff, medical director, gym, hospital overhead, etc. for GOLD stages 2, 3, and 4 COPD. A separate set of codes is used for appropriate patients with non-COPD lung disease. Although decline in payment for most PR codes has occurred in the past several years, the decline in payment for G0424 is key to understanding important aspects of this challenge.

In 2010, Medicare arbitrarily established a payment rate of $50.46 for 1 unit of G0424, and subsequently alerted providers that the failure to carefully construct a charge that represents the cost of providing services can have significant adverse impact on future payments (8). Lack of a fair charge for G0424 that reflects the complexity and expense of all components of the service negatively influences reimbursement. An important context for understanding billing vs. reimbursement is that most hospital charges are roughly five fold what is actually paid for services (9).

Summary for Medicare Outpatient Prospective Payment System Hospitals (2015)

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient2015.html accessed 10/1/17

The majority of PR providers and hospitals have not adequately modified PR charges to reflect the increase in resources used for G0424. Medicare uses PR charges (as well as information from the hospital cost report) to calculate annual changes in PR reimbursement. A review of 2016 charges for PR for COPD patients submitted to Medicare from claims billed by 1,350 US hospitals found that low charges for G0424 continue to persist. This has likely contributed to the reality that cardiac rehabilitation reimbursement is now more than double that of PR.

The leadership of AACVPR, the American Thoracic Society (ATS) and the American Association for Respiratory Care (AARC) are working together to address this considerable challenge and to make this a top priority, using a collaborative and strategic approach to improving PR payment inequity. The three societies are collaborating on a reimbursement survey to help inform leaders and experts regarding gaps in knowledge and practice, education needs, and to lay the groundwork for a strategic approach to improving PR reimbursement.

How can you help?

• Please complete the upcoming reimbursement survey.
• Understand PR payment inequities: Know how much you charge for PR using an updated hospital charge master.
  • What’s a reasonable charge? We can’t ‘price fix’ and advise providers what amount to charge for services. However, be aware that hospital charges are typically 4-7 times what is paid for service.
• Reach out to your Medical Director and referring MDs to support your efforts to inform hospital administration and financial leads of the critical need to be part of addressing PR payment inequity. All should know that PR underpayment may ultimately impact PR’s role in reducing COPD readmissions.

We understand that billing and charge masters are both complex, and our goal is to help improve understanding and resources in these critical areas. An important resource is the Pulmonary Rehabilitation Toolkit (https://www.aacvpr.org/Advocacy/Pulmonary-Rehabilitation-Toolkit) (10).

Improving PR reimbursement will not be quick or simple. It will not be corrected by PR societies in the absence of member and provider involvement. We are beginning a long, complex process to improve effective care for our patients. We ask for and need your important involvement.

We thank the leadership of AACVPR, ATS PR Assembly, and AARC* and the ATS PR Reimbursement Work Group** which includes leadership and experts from the three societies and is working to:

1. Define reimbursement gaps, inequities, tools and strategies for improvement of PR reimbursement.
2. Improve awareness of PR reimbursement challenges and strategies for optimization.
3. Develop and update reimbursement resources and tools to support provider knowledge and skills.

*PR society leadership: (AACVPR) Megan Cohen, Ana Mola, Molly Corbett, (ATS) Anne Holland, Judy Corn, (AARC) Tom Kallstrom, Anne Marie Hummell.

**ATS Work group: Brian Carlin, Judy Corn, Richard Casaburi, Gary Ewart, Mary Gawlicki, Ted Gawlicki, Anne Marie Hummel, Aimee Kizziar, Grace Anne Dorney Koppel, Trina Limberg, Karen Lui, Phil Porte, Carolyn Rochester, and Nicole Feijoo.

References

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