Pulmonary Rehabilitation Program Services
Insufficient Documentation Causes Most Improper Payments
Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for pulmonary rehabilitation program services:
- Missing the authenticated physician order
- Missing the authenticated physician individualized treatment plan
- Missing the psychosocial assessment
Physician’s order: must be signed, dated and indicate the prescribed exercise. This physical activity includes techniques such as exercise conditioning, breathing retraining, step and strengthening exercises. Some aerobic exercise must be included in each PR session. Both low and high intensity exercise is recommended to produce clinical benefits and a combination of endurance and strength training should be conducted at least twice per week.
Individual treatment plan: describing the individual’s diagnosis and detailing how components are utilized for each patient. The plan must be established, reviewed and signed by a physician every 30 days. The plan must have written specificity with regards to the type, amount, frequency and duration of PR items and services furnished to the individual and specify the appropriate mix of services for the patient’s needs. It must include measurable and expected outcomes and estimated timetables to achieve these outcomes.
Psychosocial assessment: a written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition. It should include: (1) an assessment of those aspects of the individual’s family and home situation that affects the individual’s rehabilitation treatment, and (2) a psychological evaluation of the individual’s response to and rate of progress under, the treatment plan. Periodic reevaluations are necessary to ensure the individual’s psychosocial needs are being met.
Related Content
The Centers for Medicare & Medicaid Services Internet-Only Manuals
- Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 231 (Pulmonary Rehabilitation (PR) Program Services Furnished On or After January 1, 2010)
- Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4 (Pulmonary Rehabilitation Program Services Furnished On or After January 1, 2010)
- Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature requirements)
Reviewed 11/14/2024