Knowledge Base Article

On May 7, 2010, CMS released two transmittals that manualize the requirements for Pulmonary Rehabilitation (PR) services.  Following is a summary of some of the key points of those transmittals.  However, MMP, Inc. strongly encourages providers to carefully review the manual content contained in these transmittals for a complete understanding of coverage and billing requirements.  Transmittal 124 updates the Medicare Benefits Policy Manual and Transmittal 1966 updates the Medicare Claims Processing Manual.  Both transmittals are effective January 1, 2010 for claims processed on or after October 4, 2010.

“A pulmonary rehabilitation (PR) program is typically a physician-supervised, multidisciplinary program individually tailored and designed to optimize physical and social performance and autonomy of care for patients with chronic respiratory impairment. The main goal is to empower the individuals’ ability to exercise independently.”

• Medicare covers PR items and services for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease.
• Program components must include:
Physician-prescribed exercise.  Some aerobic exercise must be included in each session.

Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling.

Psychosocial assessment.  A written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehab or respiratory condition.

Outcomes assessment conducted by the physician at the start and end of the program, including objective clinical measures of the effectiveness of the program.

An individualized treatment plan that includes the type, amount, frequency, and duration of PR items and services.  It must also include measurable and expected outcomes and estimated timetables to achieve these outcomes. 

The plan must be established, reviewed, and signed by a physician every 30 days.  It may initially be developed by the referring physician or the PR physician.  If the plan is developed by the referring physician who is not the PR physician, the PR physician must also review and sign the plan prior to the start of the PR services.

• Must be furnished in a physician’s office or a hospital outpatient setting.
• The setting must have the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment to treat chronic respiratory disease.  
• A physician must be immediately available and accessible for consultation and emergencies; for hospital outpatient services, this means the physician must be present on the campus for on-campus services and in the provider-based department for off-campus services.
• The supervising physician must meet the following requirements:
Expertise in the management of individuals with respiratory pathophysiology

Licensed to practice medicine in the state in which the PR program is offered

Responsible and accountable for the PR program

Involved substantially, in consultation with staff, in directing the progress of the individual in the PR program.

• Services should be billed with HCPCS code G0424 – Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session.
• Only 13X and 85X types of bill (TOB) are acceptable.  All other TOBs shall be denied.
• Use revenue code 0948.
• Sessions are limited to a maximum of 2 1-hour sessions per day.  Claims will be denied if units exceed 2 on the same date of service.
• Treatment must last at least 31 minutes to report a unit of 1 session.  Two sessions may only be reported on the same day if the duration of treatment is at least 91 minutes.  The minutes of service of several shorter periods of PR must be added together for reporting in 1-hour session increments.  See CPM transmittal for examples.
• Medicare covers up to 36 sessions, with the option for an additional 36 sessions if medically necessary.  Providers must append modifier –KX to medically necessary sessions beyond 36 (sessions 37-72).  Claims that exceed 36 PR sessions without a KX modifier will be denied.  Claims that exceed 72 PR sessions (with or without a KX modifier) will be denied.  The CWF will display the remaining PR sessions on all CWF provider query screens.