Description
Pulmonary rehabilitation is a physician or nonphysician practitioner-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. Social Security Act (SSA) §§1861 (s)(2)(CC) - Medical and Other Health Services- (fff) Pulmonary Rehabilitation Program
4. 42 CFR §405.929- Post-Payment Review
5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
6. 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
7. 42 CFR §405.986- Good Cause for Reopening
8. 42 CFR § 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage
9. 42 CFR §411.15(k)(1)- Particular services excluded from coverage
10. 42 CFR §424.5(a)(6)- Basic Conditions, Sufficient Information
11. Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 240.8 - Pulmonary Rehabilitation Services
12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2024
13. 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
14. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services,
§140.4- PR Services Effective for Dates of Service On or After January 1, 2024
15. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §140.4.1- PR Services Furnished on or After January 1, 2010
16. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
17. Noridian LCA A52770 Billing and Coding: Pulmonary Rehabilitation Services; Effective 10/01/2015; Revised 10/01/2023
18. Noridian LCA A56152 Billing and Coding: Pulmonary Rehabilitation Services; Effective 10/08/2018; Revised 10/01/2023
19. AMA CPT Code Book
20. HCPCS Level II Codebook