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Physician supervision in pulmonary rehabilitation programs

This is an excerpt from Guidelines for Pulmonary Rehabilitation Programs 6th Edition by AACVPR.

By Susan Flack, RN, MS, FAACVPR; Chris Garvey, FNP, MSN, MPA, MAACVPR

Physician supervision for PR services is defined as a physician being immediately available and accessible for medical consultation and medical emergencies at all times while services are being furnished. As of 2024, supervision may be provided by MD, DO, or nonphysician provider (NPP) (e.g., nurse practitioner, physician assistant, or clinical nurse specialist). CMS currently allows NPP supervision of PR. However, NPPs cannot currently order PR, sign individualized treatment plans, or serve as a PR medical director. Virtual supervision (real-time, audiovisual) options are available for both hospital- and physician office–based programs through 12/31/26.

VIRTUAL PR MODELS IN THE UNITED STATES

At the time of this writing, virtual PR services are not covered by CMS for outpatient hospital services (e.g., center-based programs providing and billing for virtual PR services). Coverage is currently slated to end 12/31/26 for virtual PR billed using the physician’s fee schedule.

HOME HEALTH CARE (HHC) AND SIMULTANEOUS PR CONSIDERATIONS

Patients referred to PR should be asked if they are undergoing (or planning to undergo) home health care (HHC) and the reasons for HHC. Unless a policy states otherwise, under certain circumstances CMS beneficiaries may receive HHC and PR services concurrently, depending on several factors. Some considerations include the following:

• Assessing the patient carefully to determine if current or further HHC is reasonable and necessary prior to beginning PR visits. For example, those still receiving in-home physical therapy due to significant deconditioning and debility may benefit from waiting for reassessment before transitioning to a pulmonary rehabilitation program.
• Communication with HHC staff may be valuable to determine best options for patients.
• Cardiac and pulmonary rehabilitation are considered physician services, which are excluded from HHC consolidated billing rules. The CPT codes used for PR services should not conflict with consolidated HHC billing codes.;
• HHC rules include that a patient may be considered homebound if the absences from the home are infrequent or for periods of relatively short duration or are for the need to receive health care treatment (from Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7, §30.1.1). This may include leaving home for medical treatment or short, infrequent absences for nonmedical reasons (from the CMS & Home Health Care government booklet (CMS Product No. 10969 August 2023):
  • There should be justification and documentation of how a patient receiving HHC is receiving PR and how PR is medically necessary and not duplicative of HHC services.
  • ORS limits on simultaneous HHC are unknown.

More Excerpts From Guidelines for Pulmonary Rehabilitation Programs 6th Edition

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