Yesterday I met with Palmetto GBA’s Health Information Supply Chain (HISC) Committee for Pulmonary Rehabilitation Services. The topic was Medicare claim denials for ineffective communication of the psychosocial component of pulmonary rehabilitation services and how to reduce them.  The results of past record reviews have identified the Medicare-required psychosocial assessment as being responsible for many of the claim denials. This post addresses a potential solution.

Medicare Requirements: According to Medicare regulations Title 42 CFR Section 410.47 Pulmonary rehabilitation program: Conditions for coverage “Psychosocial assessment means a written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition”. This definition should be understood within the context of the Medicare Pulmonary Rehabilitation Program (PRP) design requirement to “optimize physical and social performance and autonomy.” According to the PRP Medicare regulations, the psychosocial assessment includes:

• An assessment of those aspects of an individual’s family and home situation that affects the individual’s rehabilitation treatment
• A psychosocial evaluation of the individual’s response to and rate of progress under the treatment plan

The output of the root cause analysis currently being performed by each PRP will inform their specific process improvement activities.

While the “root causes” of the ineffective communication are currently being studied by PRPs across Jurisdiction 11 (J11), members of the HISC Committee for Pulmonary Rehabilitation Services have postulated that documentation tools, scales and electronic forms currently in use by many PRPs may not clearly communicate “how aspects of the family and home situation affect the individual’s rehabilitation treatment” (e.g., are they facilitators or barriers)? The unmet need exists principally because these tools, scales, and electronic forms were not designed to communicate this type of information.

A Unifying Framework:  

The concepts and classes of information needed to effectively communicate that a psychosocial assessment has in fact taken place are contained in the International Classification of Functioning, Disability, and Health (ICF). While use of the ICF alpha-numeric codes is not required by Palmetto GBA, the domains and classes of information contained in the ICF will help PRPs successfully communicate the “environmental” aspects of the psychosocial assessment (i.e., aspects of the individual’s family and home situation). This unifying framework will also help organize documentation around the “activity limitations and participation restrictions” (e.g., in mobility and self-care) present at baseline and how these change over time.

Among the concepts and classes of information addressed by the ICF that have potential relevance to PRP psychosocial assessments are:

ICF Component: Activities and Participation

ICF Domain: Mobility

d450 – Walking

d4500 – Walking short distances – Walking for less than a kilometer, such as

walking around rooms or hallways, within a building or for short distances

outside.

d455 – Moving around

d4551 – Climbing – Moving the whole body upwards or downwards, over

surfaces or objects, such as climbing steps, rocks, ladders, or stairs, curbs, or

other objects.

ICF Domain: Self-care

d510 – Washing oneself

d530 – Toileting

d540 – Dressing

d550 – Eating

d560 – Drinking

ICF Component: Environmental Factors

ICF Domain: Support and relationships

e310 – Immediate family

e315 – Extended family

ICF Domain: Attitudes

e410 – Individual attitudes of immediate family members

e415 – Individual attitudes of extended family

These ICF domains and categories are all defined within the ICF framework and are available online via the ICF browser.  The incorporation of ICF concepts into PRP documentation tools, scales, and electronic forms would help decrease documentation errors, denials, and appeals for ineffective communication of the psychosocial assessment. Please explore the ICF-based definitions and share your thoughts.

Articles that may further assist your understanding of the ICF framework:

COPD and Functioning – rehab based on ICF framework Jan 2013 Disability Rehab Med Jr Abstract COPD and Functioning-implications for rehab on ICF framework Aug 2013