We are providing clarification of coverage and documentation requirements for pulmonary rehabilitation services based on Noridian medical review findings. Pulmonary rehabilitation services are covered by Medicare as either: a) Individual component services when medical necessity requirements are met or as; b) Pulmonary Rehabilitation Program services when specific program requirements are met.
A. Individual Components
These services must be provided by a qualified clinician, i.e., physician, non-physician practitioner (NPP), respiratory therapist (RT), physical therapist (PT), occupational therapist (OT) or appropriately supervised/qualified therapist assistant (physical therapist assistant (PTA) or occupational therapist assistant (OTA)). If all the Pulmonary Rehabilitation Program requirements listed in Section B below are not met, individual pulmonary rehabilitation components are still payable, using the GXXXX or 97XXX codes, when the documentation supports:
- It is tailored to meet the individual patient’s specific needs based on a thorough evaluation.
- It is at a level of complexity that requires a qualified clinician to perform.
- It is medically reasonable and necessary for the treatment of an individual patient’s acute/exacerbated pulmonary condition.
These services must be billed as follows:
- Use HCPCS G0237-G0239
- Services are provided under a physician plan of care by incident-to staff or RT. Note: Incident-to services cannot be provided by a PTA and/or OTA.
- Inclusive services that are not separately billable include - pulse oximetry, counseling, education, and the 6-minute walk test.
- Therapy modifiers and revenue codes should not be coded (GP/GO and 42x/43x).
- Use CPT® 97xxx Codes
- Services are provided under a therapy plan of care by a physician/NPP/incident-to or by PT or OT.
- Inclusive services that are not separately billable include - pulse oximetry, counseling, education, and the 6-minute walk test.
- Therapy modifiers and revenue codes should be coded as applicable, GP/GO and 42x/43x).
B. Pulmonary Rehabilitation (PR) Programs - effective on or after January 1, 2010
All requirements of the CMS Internet Only Manual (IOM) Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 231 and IOM Medicare Claims Processing Manual, Publication 100-4, Chapter 32, Section 140.4 and National Coverage Determination (NCD) Pulmonary Rehabilitation Services 240.8 must be fulfilled. Programs must provide a comprehensive, evidence-based multidisciplinary intervention for patients with chronic respiratory impairment.
Medicare covers Pulmonary Rehabilitation Program services for:
- Moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease.
- As per the 2022 Physician Fee Schedule Final Rule (86 FR 65244 dated November 19, 2021), CMS finalized revisions to the conditions of coverage for pulmonary rehabilitation (PR) specified at 42 Code of Federal Register 410.47. These revisions included coverage for confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective January 1, 2022).
Note: Additional medical indications for coverage for Pulmonary Rehabilitation Program services may be established through an NCD.
Medicare will pay for a maximum of 2 one-hour sessions per day, for up to 36 sessions for up to 36 weeks for Pulmonary Rehabilitation Program services when documentation supports that all of the following program requirements are met:
- Physician has ordered and prescribed exercise and 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 and is provided at each treatment session.
- An individualized plan of care plan detailing how components are utilized for each patient is initially established by the physician as well as reviewed and signed by the physician every 30 days.
- Services must be provided only in the following place of service (POS): 11 (physician’s office), 19 (Off-Campus Outpatient Hospital or 22 (On-Campus Outpatient Hospital). All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when program services are being furnished. Physicians acting as the supervising physician must possess all of the following:
- Expertise in the management of individuals with respiratory pathophysiology.
- Cardiopulmonary training in basic life support or advanced cardiac life support.
- Be licensed to practice medicine in the State in which the PR program is offered.
- 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. The education requirement is not met by:
- Handing out a booklet, "How to Stop Smoking with no additional follow-up."
- Having the patient take an assessment at the beginning and end of the program.
- Documenting sporadic and/or vague instruction provided e.g., "discussed self-management techniques."
- Psychosocial assessment and reassessment must be thorough and occur at periodic intervals. This includes evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition, 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.
- Significant outcomes assessment with clinical measures (initial/ending) must be evident in the medical record. This includes evaluations based on patient-centered outcomes, objective clinical measures of exercise performance and self-reported measures of shortness of breath and behavior.
The patient may require an additional 36 sessions for COVID-19 if he/she has already received pulmonary rehabilitation services for COPD initially or vice versa. When billing for these additional sessions for the second approved condition, providers must append the KX modifier to the second 36 sessions.
Hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session of PR in a day, the duration of treatment must be at least 31 minutes. Two sessions of PR may only be reported in the same day if the duration of treatment is at least 91 minutes. Therapy modifiers (GN/GO/GP) and revenue codes (42x/43x) should not be coded.
CMS deleted the Pulmonary Rehabilitation Program HCPCS code G0424 effective 12/31/2021. The following CPT® codes replaced G0424 for the Pulmonary Rehabilitation Program effective January 1, 2022, and may only be billed when all the above program requirements are met.
- 94625 - Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session), or
- 94626 - Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session.
Public Health Emergency Telehealth Services
On March 6, 2020, the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth services during the COVID-19 public health emergency (PHE) so beneficiaries can get a wider range of services from their doctors and other clinicians without traveling to a health care facility. These guidelines are effective for dates of service (DOS) on and after March 1, 2020, until the end of the designated PHE.
Telehealth services- Visits conducted between a provider and a patient using two-way telecommunication systems with audio and video capabilities.
- Use of two-way, real-time interactive audio/video telecommunication capability is needed.
- Bill professional claims for all telehealth services with DOS on and after March 1, 2020, and for the duration of the PHE to Medicare with place of service (POS) equal to what it would have been had the service been furnished in-person (example: POS 11 for office or POS 19 for provider-based outpatient hospital).
- Bill appropriate covered telehealth service code(s).
- Modifier 95 should be applied to claim lines for services furnished via telehealth.
Only 94625 and 94626 have been added to the list of Covered Telehealth Services found here.
Due to the Public Health Emergency (PHE) ending on May 11, 2023, this exception is no longer in effect as of May 11, 2023.
Sources:
- Social Security Act (SSA) 1862(a)(1)(A);
- 42 Code of Federal Regulations (CFR), Part 410, Subpart B, Sections 410.17, 410.26, 410.27, 410.47;
- National Coverage Determination 240.8;
- IOM Medicare Benefit Policy Manual, Publication 100-02, Chapter 12, Section 40.5 and Chapter 15, Sections 220-230, 230.5, 231;
- IOM Medicare Claims Processing Manual, Chapter 5, Section 20(C) and Chapter 32, Section 140.4;
- CMS MLN Matters® MM6823-Revised
- Transmittal 11426CP, CR 12613 dated May 20, 2022
