By Janie Knipper, RN, MA, AE-C, Pulmonary Rehabilitation Supervisor, University of Iowa Hospitals and Clinics

For many of us working in health care — pulmonary rehabilitation specifically — we want to do everything for everyone. We recognize that many people could benefit from the services provided in a pulmonary rehabilitation or respiratory services program, but not all people meet the criteria for participation as defined by the Centers for Medicare and Medicaid Services (CMS), or as required by private insurance companies. There may be temptation to bend the rules a bit to allow a patient to participate in pulmonary rehab when they don’t meet qualifying criteria, or to extend a program longer for some patients. But you must continually ask the question: Are more sessions medically necessary for this patient? If medical necessity isn’t clearly established, billing for those services might be considered unethical or fraudulent. While ethical behavior means we bill only for services and care actually provided and properly documented, it is also unethical to bill for services that aren’t medically necessary. Always consider whether or not the patient requires the skilled services provided in a pulmonary rehab program, or whether the patient can achieve the same outcome without skilled services.

The primary goal of pulmonary rehab is to assist the patient in achieving independence. Interventions aimed at achieving that goal should begin immediately when entering the program and should be promoted throughout. The goal is not to make the patient feel dependent on the pulmonary rehab staff, but rather to develop self-confidence to continue what they learned in the program, and not only exercise independently, but also be confident that they can self-manage their chronic lung disease. With this confidence, they are ready to transition to independent exercise or into a pulmonary rehab maintenance program.

Medical necessity includes a diagnosis of chronic lung disease, as well as one or more of the following:

• Persistent symptoms despite medical therapy.
• Functional limitations.
• Quality of life impairment.
• Increased healthcare utilization.

While dyspnea does have an assigned ICD-10 code, it is a symptom, not a chronic lung disease. Therefore, it is recommended to only accept referrals for patients with a primary diagnosis of some type of chronic lung disease, rather than a primary diagnosis of dyspnea.

Many chronic lung diseases are progressive, and patients may experience exacerbations. The exacerbations may become more frequent as the disease progresses and may cause debilitation resulting in the potential need for additional sessions of pulmonary rehab or respiratory services. This doesn’t mean the patient requires another course of 24 or 36 sessions— the patient should be provided the number of sessions needed to help them return to a level of independence. The duration of the program must be individualized to the needs of each patient.

Unethical or fraudulent practices will only hurt programs in the long run. It may lead to stricter rules, audits and denials. We should all focus on providing excellent service to every patient, every time. Assist patients in their efforts to return to a lifestyle they desire, with improved quality of life — without bending the rules.

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