ANNOUNCEMENT CONCERNING IN-FACILITY PULMONARY REHABILITATION SERVICES FOR BLACK LUNG BENEFICIARIES - 06-02-2022

Effective January 1, 2022, in accordance with guidance set forth by the Centers for Medicare and Medicaid Services (CMS), DCMWC introduced two new pulmonary rehabilitation procedure codes, 94625 and 94626, to be billed for pulmonary rehabilitation services.

Effective July 1, 2022, the Healthcare Common Procedure Coding System (HCPCS) pulmonary rehabilitation procedure code G0424, will no longer be covered.

Please note that DCMWC will not pay for at-home pulmonary rehabilitation services.

Preauthorization is not required for in-facility pulmonary rehabilitation services.

Pulmonary rehabilitation providers must be enrolled in the DCMWC provider network to treat miners and receive payment for services. To enroll as a DCMWC provider, please access: the Web Bill Processing Portal<https://owcpmed.dol.gov/portal/> for enrollment instructions.

All bills for pulmonary rehabilitation services must be submitted on the OWCP-1500 claim form. A downloadable OWCP-1500 form<https://www.dol.gov/sites/dolgov/files/owcp/dfec/regs/compliance/owcp-1500.pdf> is available. Providers must use current procedure codes 94625 and 94626 when billing for pulmonary rehabilitation services. A bill for pulmonary rehabilitation services must include at least one of the following mandatory components:

1. Physician-prescribed exercise;
2. Education or training;
3. Psychosocial assessment;
4. Outcome's assessment; or
5. An individualized treatment plan.

DCMWC will pay for up to a maximum of 60 one-hour treatment sessions during any 90-day period; or a maximum of 90 one-hour sessions during any 12-month period. Lifetime maximums may also apply.

In accordance with 20 CFR 725.707(b), DCMWC may require reports of treatment from time to time, including an individualized treatment plan for each patient.

There is no change in the procedures for billing for other medical services that may be related to pulmonary rehabilitation services. For example, bills for established patient office visits and pulmonary function tests still do not require a Certificate Medical Necessity (CMN) and can be billed separately as they are now. There is also no change in the procedures for prescriptions for durable medical equipment (DME) or home nursing care, which will require a CMN.

All medical bills should be sent to:

DCMWC/Federal Black Lung Program
P.O. Box 8302
London, KY 40742-8302

IMPORTANT NOTICE CONCERNING COVERAGE OF LUNG TRANSPLANTS BY THE FEDERAL BLACK LUNG PROGRAM - 06-06-2022

The Federal Black Lung Program requires approval of the pre-evaluation processes for lung transplants and the lung transplant itself for Black Lung beneficiaries (20 CFR 725.706).

Information about an individual's general eligibility for medical benefits may be obtained by calling the District Office where the patient's claim file is located, or by calling the Black Lung toll-free number at 800-638-7072. Eligibility for medical benefits does not automatically include approval for a pre-evaluation or a lung transplant.

Before seeking approval for a pre-evaluation or a lung transplant, a medical center must be approved as a lung transplant center by the Center for Medicare and Medicaid Services (CMS) or the request will automatically be denied. The list of approved transplant centers is available on CMS' S&C QCOR page (see List of CMS Approved Organ Transplant Programs):

https://qcor.cms.gov/default.jsp?referer=http://qcor.cms.gov/main.jsp

Approved lung transplant centers must determine if the patient's medical benefits are the responsibility of a coal mine operator or insurer or the Black Lung Disability Trust Fund. The patient should have this information. In order for a pre-evaluation or transplant to be considered, it must be necessitated by the coal miner's black lung condition and directly related conditions. If the patient is covered by an insurer or coal mine operator, you must obtain that company's approval prior to a pre-evaluation or transplant. Pre-evaluation and transplant coverage is decided on a case-by-case basis. We expect coal mine operators or insurers to provide the same coverage we do. The documentation that coal mine operators or insurers require to determine whether or not they will approve coverage may vary.

If the patient is covered by the Black Lung Disability Trust Fund, only the Chief, Branch of Policy Analysis & Program Standards of the Division of Coal Mine Workers' Compensation has the authority to grant approval of a pre-evaluation or a transplant. You must initiate the approval process by contacting DCMWC-Public@dol.gov or by calling our toll free number 800-347-2502.

The pre-evaluation request must include:

  1. Name of the hospital in which the lung transplant would occur
  2. The hospital's pre-evaluation protocol
  3. The hospital's lung transplant protocol
  4. List of procedure codes
  5. Post-op care services described in detail (with procedure codes)

The referring physician must be a board certified pulmonary medicine physician.

You will be asked to submit:

  1. Copies of medical records for the past twenty-four months (in chronological order)
  2. A list and written impression of all diagnostic studies in the past 2 years, and the most recent pulmonary related studies (eg., CT, MRI, sonogram, etc.) if the study was not done within the past 2 years
  3. A comprehensive narrative report that must address the claimant's:
    1. Current chief complaint
    2. A narrative history of the claimant's pneumoconiosis and medical management to the current date of service
    3. Past medical history
    4. Social history (including smoking, drug abuse, social support, etc.)
    5. Family medical history
    6. Comprehensive review of symptoms
    7. Relevant physical findings
    8. Relevant diagnostic studies
    9. All diagnoses and medical conditions
    10. Medical assessment and recommendation for future medical management that includes the following:
      1. Summary of the claimant's current health status, medical management, relevant history and options for future medical management.
      2. The referring physician will need to review the "International Guidelines for the Selection of Lung Transplant Candidates: 2006 Update" and will need to address the Patient Selection Section (Indications, General Contraindications, and Timing of Referral) and any items in "DISEASE-SPECIFIC LUNG TRANSPLANTATION CONSIDERATIONS" section that apply.
      3. We must receive a report that addresses all items under the Patient Selection Section and the "DISEASE-SPECIFIC LUNG TRANSPLANTATION CONSIDERATIONS" section that applies.
      4. If the referring pulmonary medicine physician believes a different consensus guideline is more appropriate, instead of the "International Guidelines for the Selection of Lung Transplant Candidates: 2006 Update," the physician must identify the guideline to the Black Lung program, explain why the guideline is more appropriate than the 2006 International guidelines, and provide the Black Lung program with a report using the proposed guideline. Black Lung will decide on a case by case basis whether the utilization of a different guideline will be approved.
      5. Importantly, the pulmonary physician must clearly state that given the available information, whether the claimant's life expectancy after transplantation would exceed life expectancy without the procedure.

After the Division of Coal Mine Workers' Compensation evaluates the information you provide, you will be notified of DCMWC's decision on coverage. Any pre-evaluation or transplant (unilateral/bilateral) performed prior to receiving an approval by the Federal Black Lung Program will be denied.

If you have any questions about pre-evaluations or transplants, you may contact the Division of Coal Mine Workers' Compensation at DCMWC-Public@dol.gov or by calling our toll-free number 800-347-2502.