| Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs | |
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This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for pulmonary rehabilitation services (PR). It is not intended to replace the published guidelines. Healthcare providers retain responsibility to submit complete and accurate documentation.
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Documentation description |
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Documentation is for the correct beneficiary. |
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Documentation is for the correct date of service. |
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Documentation contains a valid and legible signature. |
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Documentation includes evidence that the beneficiary has moderate to severe Chronic Obstructive Pulmonary Disease (COPD) (defined as GOLD classification II, III and IV). |
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Documentation includes referral by the physician treating the chronic respiratory disease. |
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Documentation includes evidence that the pulmonary rehabilitation program includes the following components: Physician-prescribed exercise; with evidence of some aerobic exercise; Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling; Psychosocial assessment; Outcomes assessment; and An individualized treatment plan detailing how components are utilized for each patient. |
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Documentation includes evidence of total time spent in sessions on the selected date of service for review. |
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Documentation includes evidence of a qualified physician providing supervision of the program (i.e. immediate availability and accessible for medical consultations and emergencies) at all time items and services are being furnished under the program. The physician must meet all of the following requirements: Expertise in the management of individuals with respiratory pathophysiology; Licensed to practice medicine in the state in which the PR program is offered; Responsible and accountable for the PR program; and Involved substantially, in consultation with staff, in directing the progress of the individual in the PR program. |
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If applicable and required, submitted documentation should include a beneficiary waiver of liability. | This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.
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