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PULMONARY REHABILITATION BEST PRACTICE & REIMBURSEMENT UPDATE

PULMONARY REHABILITATION BEST PRACTICE & REIMBURSEMENT UPDATE. ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣. April 29, 2018 9:00 am – 10:00 am Gerilynn L. Connors, RRT, BS, MFAACVPR, FAARC Clinical Manager, Respiratory Care Outpatient Services

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PULMONARY REHABILITATION BEST PRACTICE & REIMBURSEMENT UPDATE

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  1. PULMONARY REHABILITATION BEST PRACTICE & REIMBURSEMENT UPDATE ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ April 29, 2018 9:00 am – 10:00 am Gerilynn L. Connors, RRT, BS, MFAACVPR, FAARC Clinical Manager, Respiratory Care Outpatient Services Pulmonary Diagnostics, Pulmonary Intervention & Pulmonary Rehabilitation gerilynn.connors@inova.org 703-776-3070

  2. No Disclosures

  3. OBJECTIVES • Palmetto GBA Updates – MAC JJ & JM • LCD Respiratory Therapy • LCD Cardiac Rehabilitation • ARTICLE Cardiac Rehabilitation • June 4, 2018, 10:00 – noon, JM OPEN DRAFT LCD Meeting: Agenda: Drafts: Supervised Exercise Therapy For the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication DL37774 • Active Case Findings & Performance Measures Expectations in AACVPR Program Certification • AACVPR Program Cert. Performance Measures • OSA • Smoking Cessation

  4. PALMETTO GBA • MAC JJ • Alabama • Georgia • Tennessee • MAC JM • Virginia • West Virginia • North Carolina • South Carolina

  5. PALMETTO GBA • MAC JJ & JM Committee Conference call early April: • Waiting for clarification from Palmetto Medical Directors: Dr. Feliciano and Dr. Sculmbrene regarding: • Is requirement G0424 for 31 min of exercise or 31 min. of session length in order to charge for a session?

  6. Pulmonary Rehabilitation Lives in 2 WORLDS of Coding • CMS Pulmonary Rehabilitation National Coverage Policy - G0424 billing code • Medicare Administrative Contractor’s (MAC’s) Respiratory Therapy Local Coverage Decision (LCD) – G0237, G0238 & G0239 billing codes • Remember MAC’s are allowed to INTERPRET CMS “Rules”

  7. Palmetto GBA LCD Respiratory Therapy L34430 Revision Effective Date: Jan 29, 2018 Revision History: **Jurisdiction J Part A Alabama, Georgia and Tennessee are now being serviced by Palmetto GBA **These 3 contract numbers are being added to this LCD **NO COVERAGE, CODING or OTHER substantive changes in this revision **CPT code 94621 (cardiopulmonary exercise testing)revised due to CPT/HCPCS Code Update

  8. The Respiratory Therapy G CodesPalmetto GBA Has a LCD ARE NOT BUNDLED & NOT GLOBAL • G0237 • Therapeutic procedures to increase strength or endurance of respiratory muscles • Face to face 1:1, each 15 min • G0238 • Therapeutic procedures to improve respiratory function, includes monitoring • Other than described by G0237 • Face to face 1:1, each 15 min • G0239 – Group • Other Resp Procedure

  9. The Respiratory Therapy G Codes G0237 & G0238 Units of Treatment

  10. Respiratory Therapy LCD – G0237, 238, 239 • Treatment/services reasonable • Medically necessary • Prove the need for your skilled level of intervention • Documentation of the patient’s pulmonary illness • No PFT qualifying numbers in the LCD • ICD10 Diagnosis include COPD, ILD, PH, etc

  11. Spirometry Documentation for GO424 • Post Bronchodilator FEV1 and Ratio • Patient does not qualify for GO424 will qualify under GO237, GO238, GO239 codes • Must have interpretation on spirometry/ MD signature • MAC M - How old the spirometry is based on the referring MD decision • MAC M has NOT set qualifying months/years for spirometry

  12. G0424 - GOLD Stages Post Bronchodilator • Stage 2: Moderate • FEV1/FVC < 0.70 • FEV1< 80% predicted – PROGRAM EXPANSION • Stage 3: Severe • FEV1/FVC < 0.70 • FEV1< 50% predicted • Stage 4: Very Severe • FEV1/FVC < 0.70 • FEV1< 30% predicted

  13. EMR DOCUMENTATION OF OUTCOMES • Electronic Medical Records bring challenges to PR for detailed documentation • Do not just have numbers of values on ITP • Explain what the outcome is, what the significance of the number is and based on the number what intervention should be done • CAT- COPD Assessment Test MUST be used for COPD outcomes • Patient Outcomes pre-post documents must be scanned into EMR ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣

  14. Palmetto GBA LCD Cardiac Rehabilitation L34412 • MAC JJ and JM LCD • Revision Effective March 8, 2018 • Revision History: **Jurisdiction J Part A Alabama, Georgia and Tennessee are now being serviced by Palmetto GBA **These 3 contract numbers are being added to this LCD **NO COVERAGE, CODING or OTHER substantive changes in this revision

  15. Local Coverage Article – on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation • Supplemental Instruction Article (A53775)

  16. Palmetto GBA JM DRAFT LCD DL37774 • June 4, 2018, 10:00 – noon • JM OPEN DRAFT LCD Meeting • Agenda: Drafts: Interoperative radiation therapy, MRI Guided High Intensity Focused Ultrasound for Essential Tremor and Supervised Exercise Therapy For the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication DL37774

  17. Pulmonary Rehabilitation Performance Measures Active Case Findings • Functional Capacity • 6MWT assesses exercise capacity and response to treatment • Beginning of the PR program completed within the first week of the PR program. • Completion of the PR completed during the last week of the PR program • The patient must complete at least 10 PR sessions within a 3 month period to be included in the functional capacity measure. • The minimum change in score correlated with a meaningful change in patient outcome is estimated at 30 meters (93.48 feet)

  18. Pulmonary Rehabilitation Performance Measures Active Case Findings • Dyspnea • performed within 1 week of PR program entry • Performed within 1 week of PR program completion • Tools: • Modified Medical Research Council Scale (mMRC) • the University of California, San Diego Shortness of Breath Questionnaire (USCD SOBQ) • the Baseline and Transition Dyspnea Indices (BDI/TDI)

  19. Pulmonary Rehabilitation Performance Measures Active Case Findings UCSD SOBQ • 24-item instrument • assesses the occurrence of shortness of breath on a 6-point scale during 21 activities of daily living (ADLs) associated with varying levels of exertion • If the activity is not performed, the patient estimates their rating • The score ranges from 0 to 120; a higher score is associated with greater dyspnea with ADLs • Swigris and colleagues reported validity for the UCSD SOBQ in ILD patients to measure dyspnea over time

  20. Pulmonary Rehabilitation Performance Measures Active Case Findings Minimum Change in Score **Modified Medical Research Council Scale (mMRC – 1 unit) **University of California San Diego Shortness of Breath Questionnaire (USCD SOBQ – 5 points) ** Baseline and Transition Dyspnea Indices (BDI/TDI – 1 unit) from the beginning to the end of • completed at least 10 PR sessions within a 3 month period • the PR program can run longer than 3 months.

  21. Pulmonary Rehabilitation Performance Measures Active Case Findings Health-related Quality of Life • Performed within one week of PR program entry and again within one week of PR program completion • TOOLS: • Chronic Respiratory Disease Questionnaire (CRQ) • the St. George’s Respiratory Questionnaire (SGRQ) • the COPD Assessment Test (CAT)

  22. Pulmonary Rehabilitation Performance Measures Active Case Findings Minimum Change in Score **the Chronic Respiratory Disease Questionnaire (CRQ – 0.5 units) **St. George’s Respiratory Questionnaire (SGRQ – 4 units) **the COPD Assessment Test (CAT – 2 units) **testing done at the beginning and the end of least 10 PR sessions within a 3 month period

  23. ACTIVE CASE FINDINGSSLEEP HYGIENE & SLEEP APNEA • Assessment tool: STOP - Bang • BMI, Age, Neck Diameter, Sex • Sleep study • Prescribed BiPAP/CPAP • DME issues

  24. Active Case Findings – Sleep Apnea STOP - Bang Questionnaire Screening Tool • S = SNORING **Do you SNORE loudly (loud enough to be heard through closed doors)? • T = TIRED **Do you often feel tired, fatigued, or sleepy during daytime? • O = OBSERVED **Has anyone observed you stop breathing during sleep? • P = Blood PRESSURE **Do you have or are you being treated for high blood pressure?

  25. STOP – Bang • B = BMI > 35 • A = Age > 50 years • N = Neck Circumference: > 40 cm • G = Gender/MALE SCORING: High Risk of OSA: Yes to > 3 questions Low Risk of OSA: Yes to < 3 questions From: Chung F., et. Al. British Jr. Anesthesia 108 (5); 768-75 (2012)

  26. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Sleep disorders are common in patients with HF. A study of adults with chronic HF treated with evidence-based therapies found that 61% had either central or obstructive sleep apnea (202). It is clinically important to distinguish obstructive sleep apnea from central sleep apnea, given the different responses to treatment. Continuous positive airway pressure (CPAP) for obstructive sleep apnea improves sleep quality, reduces the apnea-hypopnea index, and improves nocturnal oxygenation (200, 201).

  27. American Thoracic Societyhttp://www.thoracic.org/patients/patient-resources/fact-sheets-az.php Obstructive Sleep Apnea (OSA) and Heart Disease 2013
 English Obstructive Sleep Apnea (OSA) in Adults **English Obstructive Sleep Apnea in Children 2012
English | Spanish | Italian | Portuguese Obstructive Sleep Apnea, CPAP 2015
English

  28. ACTIVE CASE FINDINGS TOBACCO Use & Cessation • Pack year HX • Smoking cessation programs; ALA, AARC, BreathFree2, Pfizer, etc. • Nicotine replacement • Other Medications • Phone Apps to help patient’s; Quit Right, Pfizer

  29. Cost of Cigarettes….July 2017 • New York: $13.95 • Pennsylvania: $11.85 • DC: $9.19 • New Jersey: $8.55 • Maryland: $7.58 • West Virginia: $6.49 • Virginia: $6.12 • North Carolina: $6.00 • South Carolina: $6.00

  30. BreatheFree2 Smoking Cessation Program • Currently BreatheFree2 is a joint project between the International Commission for the Prevention of Alcohol and Drug Dependency, the General Conference of Seventh-day Adventists, with support from Loma Linda University School of Public Health • BreatheFree2 is an updated (2012-ongoing) smoking cessation program working with the successful Adventist program that was started in 1959

  31. BreatheFree2 Smoking Cessation Program • Phone applications: • Quit Right application • Free phone application to support client • http://quitrightapp.com/

  32. https://www.breathefree2.com/welcome

  33. Pharmacotherapy for Smoking Cessation The Referring MD Role The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to clients trying to quit smoking. (Strength of Evidence = A)

  34. First-Line Pharmacotherapy Three classes of FDA-approved drugs for smoking cessation: • Nicotine replacement therapy (NRT) • Nicotine gum, patch, lozenge, nasal spray, inhaler • Psychotropics • Sustained-release bupropion (Zyban) • Partial nicotinic receptor agonist • Varenicline (Chantix)

  35. Bupropion SR: Mechanism of Action • First non-nicotine medication approved by FDA for smoking cessation treatment (1997) • start 1-2 weeks before quit date • Atypical antidepressant thought to affect levels of various brain neurotransmitters • Dopamine • Norepinephrine • Clinical effects •  craving for cigarettes •  symptoms of nicotine withdrawal

  36. Varenicline (Chantix) • FDA-approved in 2006 • Is neither a nicotine replacement therapy nor an anti-depressant drug • Start varenicline one week before quit date • Unique mechanism of action: Partial agonist/antagonist Varenicline acts on nicotine receptors with two actions: It blocks some of the rewarding effects of nicotine (acts as an antagonist) and at the same time stimulates the receptors in a way that reduces withdrawal (acts as an agonist).

  37. Chantix Black Box Warning REMOVED Dec 2016 2010

  38. Combination Therapy • Combination NRT • Long-acting formulation (patch) • Produces relatively constant levels of nicotine PLUS • Short-acting formulation (gum, lozenge, inhaler, nasal spray) • Allows for acute dose titration as needed for withdrawal symptoms • Bupropion SR + NRT • The safety and efficacy of combination of varenicline with NRT or bupropion has not been established

  39. Inpatient Psychiatric Facility Quality Measures FY 2017 Effective for the FY 2017 payment determination and subsequent years, CMS added four measures to the IPFQR Program. Three are chart-abstracted measures: Tobacco Use Screening (TOB-1); Tobacco Use Treatment Provided or Offered (TOB-2) and the subset Tobacco Use Treatment (TOB-2a); and Influenza Immunization (IMM-2).

  40. NEW Technology: Breathe Technologies Life 2000 - ventilator • 1-lb, wearable, life support ventilator for the treatment of patients who require noninvasive mechanical ventilation. • 3 individual prescription settings, • Control, Assist/Control, Assist w/Apnea Backup • Set Volume Range: 50 – 750ml • (Total VT up to 2000 ml via Venturi effect) • Breath to breath PIP monitoring • Optional PEEP: 0-10 cmH2O • FIO2 Range: 35-45% The Life2000h ventilator is designed to address ventilation while promoting functional activities, patient ambulation, physical therapy, and pulmonary rehabilitation in hospital, institutional, and home settings.

  41. THANK YOU! Gerilynn L. Connors, RRT, BS, FAARC, MAACVPR Clinical Manager, Respiratory Care Outpatient Services Pulmonary Diagnostics, Interventional Program & Pulmonary Rehabilitation Fairfax Hospital, Falls Church VA Gerilynn.connors@inova.org 703-776-3070

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