This was recently posted on the Palmetto blog and may give some information to those programs that are getting denials based on the psychosocial component of Pulmonary rehab. Remember these are only suggestions from Palmetto’s medical director!! Please check back with our website and the AACVP J11 MAC will be providing specific examples to help with this.
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
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
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:
- Category: Featured News