Description
Pulmonary rehabilitation is a physician-supervised program for COPD and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Medical Documentation will be reviewed to determine if pulmonary rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.
Affected Code(s)
94625, 94626
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Social Security Act (SSA) §§1861 (s)(2)(CC) - Medical and Other Health Services- (fff) Pulmonary Rehabilitation Program
9. 42 CFR § 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage
10. Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 240.8 - Pulmonary Rehabilitation Services
11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010
12. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §140.4- PR Services Furnished on or After January 1, 2010
13. AMA CPT Code Book
14. HCPCS Level II Codebook