Pulmonary Rehabilitation
Effective 1/1/2010, Medicare Part B pays for PR if specific criteria are met by the Medicare beneficiary, the PR program itself, the setting in which it is administered and the physician administering the program, as outlined below.
As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:
- With moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease;
- Who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective 1/1/2022);
- Additional medical indications for coverage for PR may be established through an NCD.
PR must include all of the following components:
- Physician-prescribed exercise during each pulmonary rehabilitation session
- 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.
- Psychosocial assessment
- Outcomes assessment
- An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.
HCPCS codes for PR services effective 1/1/2022:
- 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)
Effective for dates of service on or after 1/1/2010, hospitals and practitioners may report a maximum of two one-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.
In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes, if two sessions are reported.
If several shorter periods of PR are furnished on a given day, the minutes of service during those periods must be added together for reporting in one-hour session increments.
Example: If a patient receives 20 minutes of PR in the morning and 35 minutes of PR in the afternoon of a single day, the hospital or practitioner would report one session of PR under one unit of HCPCS code/CPT code for the total duration of 55 minutes of PR on that day.
For more billing examples, please see: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4.1.
Effective for claims with dates of service on or after 1/1/2010, Medicare contractors shall deny all claims (both professional and institutional claims) that exceed 36 PR sessions without a KX modifier included on the claim line.
Allowed POS for PR:
- POS 11 is used for PR services provided in a physician’s office.
- POS 22 is used for PR services provided in a hospital outpatient setting.
All other POS codes shall be denied.
All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program.
- This provision is satisfied if the physician meets the requirements for direct supervision.
Reviewed 10/11/2023