Pulmonary Rehabilitation

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Pulmonary Rehabilitation

New Benefit

The enactment of HR 6331, the Medicare Improvements for Patients and Providers Act
of 2008, established a specific Medicare benefit for pulmonary rehabilitation. The exact
provisions of the law addressing the pulmonary rehab benefit are included at the end of
this document. Please note, however, by law the pulmonary rehab benefit nationwide
does not take effect until January 1, 2010.

The establishment by Congress of a pulmonary rehab benefit sets the stage for
CMS/Medicare to write regulations that will implement the benefit. Much of the detail as
to who is eligible, what services will be covered and therefore paid for, the frequency and
duration of the services, etc., will be determined through the regulatory process.

Unlike other new benefits, presumably CMS will not have to "create" the pulmonary
rehab benefit from scratch because:

   1. Many of the individual components or services that comprise pulmonary rehab
      programs are already covered under Medicare.
   2. Some pulmonary rehab programs have been operational at a Medicare "local"
      level for many years. Therefore, there are local policies that currently set out the
      details of a pulmonary rehab program, thereby establishing templates that CMS
      may chose to use in implementing the new pulmonary rehab benefit.

Current Coverage for Pulmonary Rehabilitation

Medicare contracts with large insurance companies, called Medicare Administrative
Contractors (MACs), formerly known as Carriers and Fiscal Intermediaries, to carry out
the day-to day-operations of the Medicare program. Contractors' administer the
Medicare program at the local, state and even regional levels and, among other things, are
responsible for reviewing claims and reimbursing health care providers. In the absence
of a national coverage policy, MACs also have the authority to determine local coverage
policy, termed Local Coverage Determinations (LCDs) .

It has been under the LCDs that certain MACs have issued coverage policies for
pulmonary rehab programs. But those coverage policies are applicable only to the area of
a MAC's jurisdiction. Current local pulmonary rehab policies can and do vary from
jurisdiction to jurisdiction. MACs also have the discretion to rescind LCDs, and in recent
years there have been several pulmonary rehab policies that have been revoked.

Until January 1, 2010, when the national benefit is implemented, the MACs still retain
the authority to determine and change at their discretion what, if anything is covered or
not covered under the set of services designated as pulmonary rehabilitation.

CPT and HCPCS Codes Used in Pulmonary Rehab Services

There are certain codes that are generally used by current pulmonary rehab programs and
these are noted below. The caveat is that while the codes listed below may be acceptable
to one MAC in one area of the country, they may not be accepted by another MAC.

Although policies to implement the pulmonary rehab benefit will be finalized through the
regulatory process, codes to be used in paying for services under the new program will be
generated through instructions to the contractors. Until that time, the codes noted below
cannot be construed as nationally accepted codes.

Common Codes Pulmonary Rehab Programs Effectively Use

The following information was offered by individuals who have successful pulmonary
rehab programs. Please use it as a guideline or a starting point. The codes or coverage
for their programs may or may not work for your pulmonary rehab service.


   1. There are positive, well documented benefits associated with pulmonary rehab
      programs. Documented outcomes are: fewer emergency room and urgent care
      visits, fewer hospital admissions, decreased length of stay if admitted to the
      hospital and others. These benefits will reduce costs for the facility, generate
      good public relations and increase customer satisfaction.
   2. Clinical procedures such as treatments and testing are provided during pulmonary
      rehab programs; these have CPT codes and can be billed accordingly.
   3. One on one patient training which is provided during pulmonary rehab can be
      billed using a HCPCS "G" Code (see below).
   4. Exercise sessions, individual and group, can be billed using HCPCS "G" codes.
   5. Evaluation and Management (E&M) codes can be used if the physician provides
      the initial visit. In follow-up visits, the patient can see the respiratory therapist
      and E&M codes can be used.
   6. If supplies (i.e., MDI spacer, peak flow meter) are provided to the patient, these
      can be charged using HCPCS codes.
   7. Until January 1, 2010 everything is contingent on the local coverage rules stated
      by the local contractor (MACs).


Examples of HCPCS codes that can be used if supplies are provided include:

A4614              Peak Flow Meter
A4627              Spacer or chamber for MDI
A7003              Nebulizer circuit - disposable

Other HCPCS codes that can be used during pulmonary rehab include:

G0237                 Therapeutic procedures to increase strength or endurance of
                      respiratory muscles (i.e. breathing retraining), face to face, one on
                      one, each 15 minutes (includes monitoring)
G0238                 Therapeutics procedures to improve respiratory function, other than
                      described by G0237, one on one, face to face, per 15 minutes
                      (includes monitoring). This involves a variety of activities, including
                      teaching patients strategies for performing tasks with less respiratory
G0239                 Therapeutic procedures to improve respiratory function or increase
                      strength or endurance of respiratory muscles, two or more individuals
                      (includes monitoring)
*"Appropriate Coding for Critical Care and Pulmonary Services", 2006, ACCP, 10th ed.

CPT Codes

Examples of treatment and testing CPT Codes include:

94010, 94060,         Spirometry
94620                 Pulmonary Stress Test/Simple (Six minute walk)
94664                 Demonstration and/or evaluation of patient utilization of an aerosol
                      generator, nebulizer, meterd-dose inhaler or IPPB device
94640                 MDI or Nebulizer treatments
94667                 Generally for Acapella training or High Frequency Chest Wall
94760, 94761          Pulse Oximetry with appropriate documentation

Education CPT Codes

CMS does not reimburse for education, thus this is FYI

98960, 98961,         Education & Training for Patient Self Management

Evaluation and Management (E&M) Codes

   Non physician providers (NPP) help improve patient flow and increase physician
   NPPs can provide services "Incident To" those of a physician.
   NPPs can provide services that were originally rendered by the physician.
   "Incident To" guidelines specify that the service rendered must be provided to an
    established patient.

99211-99215        E & M codes (99211 used as RT evaluation with MD present)
97001              Physical Therapy department for evaluation
97003              Occupational Therapy for evaluation

   The physician must provide the initial service at the first encounter to initiate the
    course of treatment. (Medicare Rules update section 15501).
   The physician does not need to provide personal service at subsequent encounters
   NPPs must be covered by their state's scope of practice for the procedures performed.

Medicare Improvements for Patients and Providers Act of 2008



`Pulmonary Rehabilitation Program

       ` (fff)(1) The term `pulmonary rehabilitation program' means a physician-
       supervised program (as described in subsection (eee)(2)*(see below for language)
       with respect to a program under this subsection) that furnishes the items and
       services described in paragraph (2).
       ` (2) The items and services described in this paragraph are--
                ` (A) physician-prescribed exercise;
                ` (B) education or training (to the extent the education or training is
                closely and clearly related to the individual's care and treatment and is
                tailored to such individual's needs);
                ` (C) psychosocial assessment;
                ` (D) outcomes assessment; and
                ` (E) such other items and services as the Secretary may determine, but
                only if such items and services are--
                        ` (i) reasonable and necessary for the diagnosis or active treatment
                        of the individual's condition;
                        ` (ii) reasonably expected to improve or maintain the individual's
                        condition and functional level; and
                        ` (iii) furnished under such guidelines relating to the frequency and
                        duration of such items and services as the Secretary shall establish,
                        taking into account accepted norms of medical practice and the
                        reasonable expectation of improvement of the individual.
       ` (3) The Secretary shall establish standards to ensure that a physician with
       expertise in the management of individuals with respiratory pathophysiology who
       is licensed to practice medicine in the State in which a pulmonary rehabilitation
       program is offered--

       ` (A) is responsible for such program; and
       ` (B) in consultation with appropriate staff, is involved substantially in
       directing the progress of individual in the program.'.


(3) EFFECTIVE DATE- The amendments made by this subsection shall apply to
items and services furnished on or after January 1, 2010.


(eee) 2 states the following:

` (2) A program described in this paragraph is a program under which--
        ` (A) items and services under the program are delivered--
                `(i) in a physician's office;
                `(ii) in a hospital on an outpatient basis; or
                `(iii) in other settings determined appropriate by the Secretary.
        ` (B) a physician is immediately available and accessible for medical
        consultation and medical emergencies at all times items and services are
        being furnished under the program, except that, in the case of items and
        services furnished under such a program in a hospital, such availability
        shall be presumed; and
        ` (C) individualized treatment is furnished under a written plan
        established, reviewed, and signed by a physician every 30 days that
                ` (i) the individual's diagnosis;
                ` (ii) the type, amount, frequency, and duration of the items and
                services furnished under the plan; and
                ` (iii) the goals set for the individual under the plan.

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