Question:

We received a denial for a claim submitted for pulmonary rehab in a non-hospital setting. The reason for the denial, according to Medicare, was because we did not meet the services were not under the direct supervision of a physician. How can we prevent future denials?

Answer:

A document posted by CGS, one Medicare administrative contractor, at http://www.cgsmedicare.com/parta/pubs/news/2013/0313/cope21508.html says the following.

Non-hospital-based settings: The claim must show the place of service, and if a medical record request is made for the claim after the claim is submitted, the facility must provide documentation to verify a physician is immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. The Code of Federal Regulations (42 CFR § 410.27) provides a further discussion of the meaning of such supervision.

iv. “direct supervision: means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or non-physician practitioner must be present in the room when the procedure is performed. For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or osteopathy, as specified in §§ 410.47 and 410.49, respectively.

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