AARC Working to Fix the Payment Problem for Pulmonary Rehab

February 13, 2012

AARC, working with other pulmonary organizations and societies (ACCP, AACVPR, ATS and NAMDRC) is developing a Pulmonary Rehabilitation Toolkit that will serve as a resource and educational document for hospitals to use to accurately report their charges to Medicare for services furnished as part of a hospital outpatient pulmonary rehabilitation (PR) program (G0424). The Toolkit is expected to be available in the spring after its contents are tested with a diverse group of PR programs to ensure it is understandable and usable.

AARC members who have served as Chair and Chair-elect of the Continuing Care Rehabilitation Section have been instrumental in assisting with this important project as have other experienced PR clinicians from our sister organizations.

As reported previously, pulmonary rehabilitation (PR) programs faced a significant reduction in payment beginning January 1, 2012. While AARC and others tried to get the Centers for Medicare and Medicaid Services (CMS) to postpone any reduction for another year until better data could be evaluated, CMS felt it had more than sufficient claims information to move forward and that the payment rate of $37/per session was adequate. Among other things, the CMS analysis was based on information hospitals submitted to report charges for G0424 (i.e., UB-04 claim form) in order to get paid for their services.

After several in-depth conversations and meetings within the pulmonary community, it became evident that the low payment rate for PR is based on a lack of understanding among hospitals as to what is involved in submitting charges for a single, bundled code when the services that comprise the new code were previously reported as separate distinct codes. CMS highlighted this fact in its final rule when it reminded hospitals that failure “to carefully construct the charge for a new code that reports a combination of services that were previously reported separately, particularly in the first year of the new code, under-represents the cost of providing the service described by the new code and can have significant adverse impact on future payments under the OPPS for the individual service described by the new code.” [see page 74224 in the Nov. 30, 2011 Federal Register].

AARC and others hope to improve and increase future payments for hospital outpatient PR programs by getting hospitals to use the Toolkit as a resource in developing the proper charge for its PR program. It also offers guidance on communicating with key hospital financial personnel who are instrumental in reporting claims data to CMS.

This effort will take time. Unfortunately, there is no short-term solution to the current payment rate. However, if all goes according to plan, changes to the payment rate would most likely be reflected at the earliest in the calendar year 2014 update to the hospital outpatient prospective payment system.

An AARC members’ webinar is being planned to coincide with the formal launch of the PR Toolkit. We will keep you informed when a firm date has been set.