Page 233 - Medicare Benefit Policy Manual

As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:
• With moderate to very severe COPD (defined as GOLD classification II, III, and
IV), when referred by the physician treating the chronic respiratory disease;
• Who have had confirmed or suspected COVID-19 and experience persistent
symptoms that include respiratory dysfunction for at least four weeks (effective
January 1, 2022);
• Additional medical indications for coverage for PR program services may be
established through a national coverage determination (NCD).

PR must include all of the following components:

Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise
combined with other types of exercise (such as conditioning, breathing retraining, step,
and strengthening) as determined to be appropriate for individual patients by a physician.
Each PR session must include physician-prescribed exercise.

Education or training. Education or training that is closely and clearly related to the
individual’s
care and treatment which is tailored to the individual’s needs and assists in achievement
of goals toward independence in activities of daily living, adaptation to limitations and
improved quality of life. Education must include information on respiratory problem
management and, if appropriate, brief smoking cessation counseling.

Psychosocial assessment. Psychosocial assessment means an evaluation of an
individual’s mental and emotional functioning as it relates to the individual’s
rehabilitation or respiratory condition which includes an assessment of those aspects of
an individual’s family and home situation that affects the individual’s rehabilitation
treatment, and psychosocial evaluation of the individual’s response to and rate of
progress under the treatment plan.

Outcomes assessment. Outcomes assessment means an evaluation of progress as it
relates to the individual’s rehabilitation which includes the following: (i) Evaluations,
based on patient-centered outcomes, which must be measured by the physician or
program staff at the beginning and end of the program. Evaluations measured by program
staff must be considered by the physician in developing and/or reviewing individualized
treatment plans. (ii) Objective clinical measures of exercise performance and self-
reported measures of shortness of breath and behavior.

Individualized treatment plan. Individualized treatment plan means a written plan
tailored to each individual patient that includes all of the following: (i) A description of
the individual’s diagnosis. (ii) The type, amount, frequency, and duration of the items and
services furnished under the plan. (iii) The goals set for the individual under the plan. The
individualized treatment plan detailing how components are utilized for each patient,
must be established, reviewed, and signed by a physician every 30 days.