By Denise Williams | News & Views
Medicare recognizes that pulmonary rehabilitation (PR) is similar to cardiac rehab (CR) in terms of value, complexity and importance…so why isn’t that reflected in the billing?
Chris Garvey, FNP, MSN, MPA, MAACVPR, sums up the issue by sharing one eye-opening statistic: PR is paid at a rate of less than 50% of the rate for CR. The math is startling, especially considering that it has been more than a decade since Medicare designated PR as a covered benefit and adopted temporary bundled billing code for comprehensive care.
The code was meant to include many of the critical but time-consuming activities and costs of PR that go beyond the exercise component and cannot be pigeon-holed into a specific line item for billing purposes. They are many of the same activities and costs – from assessments and discharge planning to equipment purchases and physician work – that CR programs have successfully been able to include in the cost of care for years. Regretfully, Garvey admits, the PR discipline allowed the opportunity to slip through its fingers. Rather, Medicare data reveals, hospital PR programs have continued to bill at rates that don’t reflect the complexity of the patient and comprehensive services. Per Medicare, hospitals need to adequately adjust the amount charged for 60 minutes of comprehensive, bundled PR and be aware of how that differs from the prior 15-minute PR charge codes. Otherwise, programs risk missing out on the payments they earned and deserve.
Got You Covered
There’s a second chance to leverage the billing power of PR, now that permanent CPT codes for comprehensive care took effect at the start of this year. “Medicare describes us as a bundled service,” Garvey notes, “and that’s what we’re trying to capture.” The landscape looks a little more favorable for change this time around, too.
One reason, she explains, is the “clear clinical and evidence-based rationale for pulmonary rehabilitation.” Garvey notes significant outcomes correlated with PR – including improved function, quality of life, symptoms and mood as well as improved survival following COPD admission – that were not as well documented 10 years ago. “What’s different now is that we have remarkably strong evidence of the effectiveness, value and cost-effectiveness of pulmonary rehabilitation. We have scientists and leaders who are supporting our efforts because they know that pulmonary rehab is needed,” she continues. “But without equitable payment, we’re going to continue to be challenged in terms of program access, awareness and survival.”
Another likely reason that might have held PR back from that goal before, Garvey speculates, is the complex nature of the billing. It’s far from straightforward, she states matter-of-factly. Although policy and PR experts put together a payment toolkit right after PR was brought under the Medicare umbrella in 2010, it was complex and not easy to digest for many professionals whose work revolves around clinical care rather than billing. With that in mind, Garvey joined a team of representatives from AACVPR, the American Thoracic Society, the American Association for Respiratory Care and the American College of Chest Physicians to roll out a new and improved toolkit for clinicians.
With support from the several pulmonary and respiratory societies, the developers have assembled a collection of resources and guidance that Garvey says focuses on “the key points of pulmonary rehab payment, effective strategies to improve ways a PR provider can interface more successfully with their hospital billing and finance department and additional tools and key concepts.” Understanding the limited amount of free time that providers have, they have included a brief summary of the 20-page toolkit in order to bottom-line the major points at a glance. Additionally, they penned a short synopsis for clinicians to share with hospital CFOs and billing departments to improve their understanding as well. “We’re trying to meet them where they are,” Garvey says.
On September 1, 2022, she was joined on an AACVPR live webinar by reimbursement specialists Debbie Koehl, MS, RTT-NPS AE-C, FAARC, and Susan Flack, RN, MS – both of whom work in PR daily. In their presentation, they aimed to put viewers on the right track to understanding modern PR billing and payments, getting the process right and knowing where to find support.
One of the main messages the trio hoped to convey to webinar attendees was "that they are not alone,” says Garvey. “There are tools and resources to help them. We’re in this together.”
Like the toolkit itself, the webinar was free to all attendees, regardless of their AACVPR member status. ”AACVPR has done a remarkable job, making sure they’re doing everything possible to improve pulmonary rehabilitation payment,” Garvey add, noting the lack of barriers both to participating in the webinar and accessing the toolkit.
Please find the webinar recording below.