Blue Cross Newsletter

August 26, 1997                                                BC-97-16
                                                               ********

TO:          ALL BLUE CROSS CONTRACTING HOSPITALS

FROM:        Donna Bartee, Communications Coordinator
             Provider Relations Department
             Blue Cross and Blue Shield of Kansas, Inc.

SUBJECT:     PULMONARY REHABILITATION PROGRAMS
             *********************************

                 THE FOLLOWING INFORMATION IS 'NOT'
             ******** APPLICABLE TO MEDICARE ********

Our medical staff recently updated the criteria for pulmonary
rehabilitation programs.  The changes are effective immediately
and basically expand the covered diagnoses as well as include
provisions to cover an approved program offered by a professional
free-standing pulmonary rehabilitation clinic.

This information applies only to Blue Cross and Blue Shield of
Kansas or Premier Blue insureds.  The actual coverage is, of course,
determined by the individual insured's contract and referral by
their attending physician and/or primary care physician when
applicable.  In no way does this information imply coverage under
the Medicare program.

A pulmonary rehabilitation program must be approved by Blue Cross
and Blue Shield before benefits are available.  To request
approval, submit to us a detailed program description which
supports program criteria compliance.  The description must
include:

     - program schedule - date/times
     - services and equipment available
     - staffing
     - physician availability
     - patient assessment
     - charge structure

We must also receive a signed attestation certifying the facility's
understanding and compliance with the criteria.  This attestation
is part of the pulmonary rehabilitation requirements document appearing
at the end of this newsletter.  While the initial program approval will
be based upon the program description and attestation, follow-up
review will be conducted during routine visits to your facility by
our provider consultants or as the result of review activity
conducted by our medical review department.

Other details are:

-  programs will normally be considered approved the first of
   the month 'following' receipt of the attestation and supporting
   documents.  You will receive a formal approval letter.

-  insureds will receive eligible benefits for pulmonary
   rehabilitation programs that BEGIN ON OR AFTER THE PROGRAM APPROVAL
   DATE (as indicated immediately above)

-  reimbursement by Blue Cross will be based on a maximum
   allowable payment (MAP) for each day of client participation.  It
   will be necessary to submit your charge structure to us for review.
   Your daily charge should be inclusive of all services except as
   outlined in "III. Other Diagnostic Services" as indicated in the
   criteria.  Specific reimbursement details will be outlined to those
   providers submitting programs to us for review.

-  hospitals with approved pulmonary rehabilitation programs
   will report the charges in the UB-92 claim format with  revenue
   code 419, Other Respiratory Services.  This revenue code requires
   a CPT code, but there is no CPT code specific for pulmonary
   rehabilitation programs.  Therefore, it was necessary for Blue
   Cross to assign a special HCPCS of S9902 to report pulmonary
   rehabilitation services.  The units field should indicate the
   number of days the client participated during the billing period.
   A REMARK would be required.  These billing instructions are only
   applicable to hospitals who have 'approved' programs.

   Pulmonary Rehabilitation    Revenue Code   =  419
   Program Billing Recap:      HCPCS Code     =  S9902
                               Unit           =  # of days the
                                                 client participated
                                                 during the billing
                                                 period
                               Remark         =  PUL REHAB PROG

   Attestations, program descriptions, schedules and charge structure
   should be sent to my attention:

          DONNA BARTEE COMMUNICATIONS COORDINATOR
          PROVIDER RELATIONS DEPARTMENT CC#442E
          BLUE CROSS AND BLUE SHIELD OF KANSAS INC
          1133 SW TOPEKA BLVD
          TOPEKA KS 66629-0001

   Questions should be directed to your provider consultant:

         Vicki Haverkamp  (785) 291-8227 (northern Kansas)
         Angie Martin     (316) 269-1602 (southern Kansas)

             **********************************************
             THIS INFORMATION IS NOT APPLICABLE TO MEDICARE
             **********************************************
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         BLUE CROSS AND BLUE SHIELD COVERAGE REQUIREMENTS
                             FOR APPROVED
           OUTPATIENT PULMONARY REHABILITATION PROGRAMS

I.    DEFINITION

      For purposes of this coverage, a Pulmonary Rehabilitation
      Program is a multi-disciplinary therapy regime provided in a
      hospital outpatient setting or an approved professional free-
      standing pulmonary rehabilitation clinic by a team of physicians,
      respiratory therapists, occupational therapists, nurses,
      dietitians, and social workers to restore an individual with
      chronic pulmonary disease to the highest possible functional
      capacity allowed by his pulmonary condition and overall life
      situation.

II.   REQUIREMENTS FOR COVERAGE

      A.    Pulmonary rehabilitation programs will be considered
            reasonable and necessary only for patients with a clear
            medical need who are referred by their attending
            physician or primary care physician, if in a managed care
            program.  These patients should not be limited physically by
            the severity of the respiratory condition or other disabling
            diseases.  Patients should also demonstrate the personal
            commitment required to successfully complete the program.
            At the end of the program, they should show a 'substantial
            increase' in their exercise tolerance.

            In addition to meeting the criteria above, patients eligible
            for coverage for outpatient pulmonary rehabilitation should
            have a documented diagnosis of the following chronic
            obstructive pulmonary diseases:  asthma, chronic bronchitis
            and/or emphysema or a diagnosis of cystic fibrosis or
            pulmonary fibrosis with restriction.  Coverage is also
            available for ventilator dependent patients, or patient's
            post lung transplantation or lung volume reduction surgery,
            as long as all other requirements for coverage are met.

      B.    Pulmonary rehabilitation programs are subject to the
            following conditions:

            1.    The facility meets the definition of a hospital
                  outpatient department or a free-standing pulmonary
                  rehabilitation clinic, (i.e.), a physician is on the
                  premises available to perform medical duties at all
                  times, and each patient is under the care of a
                  physician.

            2.    The facility has available for immediate use all
                  the necessary cardiopulmonary emergency diagnostic
                  and therapeutic life saving equipment accepted by
                  the medical community as medically necessary, e.g.,
                  oxygen, cardiopulmonary resuscitation equipment,
                  defibrillator, etc.

            3.    The program is staffed by personnel necessary to
                  conduct the program safely and effectively, who are
                  trained in both basic and advanced cardiac life
                  support techniques and in exercise therapy for
                  pulmonary disease.  Services of non-physician
                  personnel must be furnished under the general
                  supervision of a physician.  General supervision
                  means that a physician must be in charge of the
                  program and and be responsible for ensuring that
                  individual patient assessments are performed on at
                  least a weekly basis by the physician or whomever the
                  physician designates as medically competent to perform
                  this duty.

            4.    The non-physician personnel are employees of the
                  hospital or the physician-directed clinic conducting
                  the program.

      C.    Diagnostic Testing

            The patient must be evaluated for suitability to
            participate.  A 6 to 12 minute walk test and a pulmonary
            function test must be performed by either the
            rehabilitation program or the patient's attending
            physician.  Any stress testing performed in the
            hospital's outpatient department or in a physician-
            directed clinic may be covered when reasonable and
            necessary for the development of an exercise program for
            patients with known pulmonary disease.

III.  OTHER DIAGNOSTIC SERVICES

      Medically necessary diagnostic services may be performed and
      charged for separately from the rehabilitation program
      charges.

IV.   THERAPEUTIC SERVICES

      A.    Respiratory Therapy, Occupational Therapy and Patient
            Education Services:

            Health education lectures or counseling providing
            information regarding diet, nutrition, respiratory
            therapy, physical therapy, and occupational therapy, etc.
            are considered to be a part of the rehabilitation program
            and a separate charge cannot be made.  Room and board for
            the patient and/or family members is 'non-covered'.

V.    DOCUMENTATION

      The following data should be documented in the medical record:

      A.    Description of the patient's deficits that require the
            rehabilitation program.

      B.    Stated goals that are measurable to include the patient's
            status related to those goals.

      C.    Physiological status information to include blood
            pressure, heart rate, respiratory rate and oxygen
            saturation levels, if applicable.

VI.   DURATION OF THE PROGRAM

      When the patient has progressed to a maintenance program (not
      to exceed 18 sessions or 6 weeks), coverage will be
      discontinued.  All services provided by the pulmonary
      rehabilitation program in excess of six weeks will be reviewed
      on a case-by-case basis if the claim is accompanied by acceptable
      medical documentation supporting the need for the patient to
      remain in the program longer than six weeks.  Otherwise, the
      claim will be denied on a "not medically necessary" basis.

I HEREBY CERTIFY THAT OUR FACILITY IS IN COMPLIANCE WITH THE ABOVE
CRITERIA AND WILL NOTIFY BLUE CROSS AND BLUE SHIELD OF KANSAS OF
ANY CHANGES WHICH COULD AFFECT OUR ELIGIBILITY.



________________________________________________________________
Name of Pulmonary Rehabilitation Facility


_____________________________________         __________________
Signature                                     Date

8/97