Local Coverage Article Billing and Coding

Billing and Coding: Pulmonary Rehabilitation Services

A52770

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Article Information

General Information

Article ID
A52770
Article Title
Billing and Coding: Pulmonary Rehabilitation Services
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
05/19/2022
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

N/A

Article Guidance

Article Text

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.



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

Coding Information

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

The codes below are used to bill for those outpatient respiratory services listed in Section A above.

Group 1 Codes
CodeDescription
G0237 THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, FACE TO FACE, ONE ON ONE, EACH 15 MINUTES (INCLUDES MONITORING)
G0238 THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BY G0237, ONE ON ONE, FACE TO FACE, PER 15 MINUTES (INCLUDES MONITORING)
G0239 THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION OR INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, TWO OR MORE INDIVIDUALS (INCLUDES MONITORING)

Group 2

(2 Codes)
Group 2 Paragraph

The codes below are used to bill for a Pulmonary Rehabilitation Program as outlined in Section B above.

Group 2 Codes
CodeDescription
94625 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL SERVICES FOR OUTPATIENT PULMONARY REHABILITATION; WITHOUT CONTINUOUS OXIMETRY MONITORING (PER SESSION)
94626 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL SERVICES FOR OUTPATIENT PULMONARY REHABILITATION; WITH CONTINUOUS OXIMETRY MONITORING (PER SESSION)

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

The diagnosis codes below are applicable only when performing pulmonary rehabilitation services billed with CPT® codes 94625 and 94626.

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(10 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
U09.9* Post COVID-19 condition, unspecified
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*For diagnosis code U09.9 assign a diagnosis code(s) for the related to the previous COVID-19 infection, if known.  

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
05/19/2022 R5

Clarified HCPCS codes G0237-G0239 are for outpatient respiratory services in the HCPCS/CPT Codes Group1 paragraph. Added the statements “The diagnosis codes below are applicable only when performing pulmonary rehabilitation services billed with CPT® codes 94625 and 94626.” in the Group 1 Paragraph and “For diagnosis code U09.9 assign a code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known.” In the Asterisk Explanation portion n the ICD -10-CM Codes That Support Medical Necessity section. Added diagnosis codes for chronic bronchitis.

Clarified the appropriate use of the KX modifier when billing for services related to 94625 and 96426 for both COPD and COVID-19.

Added the following DX codes:

  • J41.1 Mucopurulent chronic bronchitis
  • J41.8 Mixed simple and mucopurulent chronic bronchitis

Corrected the hyperlink to CR 12613 under Resources in the Article Text and providers need to note in Revision History #2 J40.0, J40.1 & J40.9 should be J44.0, J44.1 & J44.9.

03/06/2022 R4

Updated the coverage requirements for the Pulmonary Rehabilitation Program as outlined in CR 12613, 100-02 Benefit Policy Manual, Chapter 15 Section 231 and 100-4 Claims Processing Manual Chapter 32, Section 140.4.1, 140.3.1, 140.4, and 140.4.2.5 and clarified 94625 and 94626 can only be billed when all the Pulmonary Rehabilitation Program requirements are met in Section B.

In Section A reworded the statement “When one or more individual pulmonary rehabilitation components are still payable when the documentation supports:” to “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:”.

03/06/2022 R3

Clarified section A-Individual Components-that these services do not meet the requirements of a pulmonary rehabilitation program. Removed G0424 and added 94625 and 94626 as codes to bill for services the meet the requirements of a pulmonary rehabilitation program per 42CFR 410.47, clarified that the formal education must assist in achievement of individual goals towards independence in activities of daily living, adaptation to limitations and improved quality of life in section B and added the information under Public Health Emergency Telehealth Services in the Article Text.

Added text to the Group 1 Paragraph to indicate G0237-G0239 are to be used when performing the Individual Components and in the Group 2 Codes Section added explanatory text and codes to use for the formal pulmonary rehab services.

Added the following diagnosis codes.

  • J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
  • J43.1 Panlobular emphysema
  • J43.2 Centrilobular emphysema
  • J43.8 Other emphysema
  • J40.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
  • J40.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  • J40.9 Chronic obstructive pulmonary disease, unspecified
  • U09.9 Post COVID-19 condition, unspecified
10/08/2018 R2

Article converted to Billing and Coding, no change in coverage made.

10/08/2018 R1

This Jurisdiction F Part B (JFB) article has been revised to add the Jurisdiction F Part A (JFA) contract. Both JFA and JFB contract numbers will have the same final MCD article number A52770. No change in coverage was made.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
06/09/2022 05/19/2022 - N/A Currently in Effect You are here
03/02/2022 03/06/2022 - 05/18/2022 Superseded View
01/11/2022 03/06/2022 - N/A Superseded View
09/29/2020 10/08/2018 - 03/05/2022 Superseded View
09/27/2018 10/08/2018 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Pulmonary
  • Rehabilitation
  • Programs
  • Individual Components
  • NCD 240.8
  • G0237
  • G0238
  • G0239
  • 94625
  • 94625
  • KX