Eli's Rehab Report

Hint: If your provider performs these services incident-to, look to G codes

Payers may seem notoriously difficult when you're trying to obtain pulmonary rehab service payment, but the guidelines you follow can make the difference between denial and deserved dollars.

Our experts have distilled the essentials into five easy strategies to help you code correctly for pulmonary rehabilitation every time.

1. Report CPT 97001 for First Evaluations

If a patient presents to a practice for pulmonary rehabilitation, most PTs know that they should report 97001 (Physical therapy evaluation) for the initial evaluation. But some therapists don't know that they can report 97001 for evaluations that they perform on patients who will not return for the rehabilitation course.

In some instances, a physician and respiratory therapist will manage the patient's pulmonary rehabilitation program, but the insurer will require that a physical therapist first evaluate the patient to determine functional limits, including assessing his  musculoskeletal system as well as his breathing patterns, cardiovascular and pulmonary response to activity, equipment needs, and safety issues. If a physician calls your physiatrist and asks her to perform this service and then send the patient back to the physician for all follow-up care related to the pulmonary condition, you can still report 97001 for the evaluation.

"The evaluation code, 97001, is not timed," says Robert Huhn, PT, MA, a physical therapist at the Human Performance Center in Santa Barbara, Calif. Therefore, you should report one unit of 97001 regardless of how much time you spend evaluating the patient.

2. Use Codes From CPT's 97000 Series

Although therapists normally flip to CPT's Physical Medicine and Rehab section to select codes, a quick glance at the 97000 series may confuse PTs, because that section doesn't include any separate codes for pulmonary rehabilitation, says Tiffany Miller, CPC, a coder in Hurricane, W.Va. "PTs are so limited in the codes they can use and be reimbursed for, and OTs are even more restricted," she says. "I normally code pulmonary rehab services using the therapeutic exercises code (97110)." This code may fit your therapists' services given that pulmonary patients frequently require exercise reconditioning to increase strength and endurance. 

Most payers outline which CPT codes they accept for pulmonary rehab programs. For example, Anthem Health Plans of New Hampshire reimburses the following codes as long as you meet the other policy guidelines and limits:

• 97001-97004 -- PT and OT evaluations

• 97110 -- Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

• 97150 -- Therapeutic procedure(s), group (2 or more individuals)

• 97535 -- Self-care/home management training (e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

• 97750 -- Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.

Some therapists are surprised to find that Anthem's list, along with other payers' policies, excludes 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) as a payable code for pulmonary rehab. But our experts agree with the exclusion. "Code 97140 is manual therapy, and unless you are doing manual therapy with chest wall stretching, etc., I don't think it's appropriate," says Ellen Hillegass, PhD, PT, CCS, FAACVPR, legislative/reimbursement chair of the American Physical Therapy Association's Cardiovascular and Pulmonary Section.

Other payers include additional codes, such as 97116 (... gait training), as part of their pulmonary rehab guidelines.

Best bet: Get your payer's guidelines and restrictions in writing so you know your reimbursement odds.

3. Learn When to Use G Codes

Although Medicare has published three G codes for pulmonary rehabilitation (G0237-G0239), you shouldn't automatically assume ou'll use these codes for the services your physical therapists provide. 

Key: You need to look at the individual patients' goals that your physical therapist is trying to reach -- such as respiratory muscle rehab versus general overall increase in muscle strength and endurance.

According to Noridian Part A for Minnesota and North Dakota, you should look for the following information to determine which G code to use:

For therapy targeting improving the strength and endurance of respiratory muscles, use G0237 (Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes [includes monitoring]). For instance, your provider might focus on pursed-lip breathing, diaphragmatic breathing, and paced breathing.

If your provider performs a variety of activities, including teaching patients strategies for performing tasks with less respiratory effort, use G0238 (Therapeutic procedures to improve respiratory function, other than described by G0237, one-on-one, face-to-face, per 15 minutes [includes monitoring]). An example of this is  showing the patient how to conserve energy during activities of daily living.

If your provider performs services simultaneously on two or more patients during the same time period, use G0239 (Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals [includes monitoring]).

Heads up: Although these G codes are not restricted to provider type, often respiratory therapists provide these types of pulmonary rehab services.

According to Empire of New York's local coverage determination (LCD), physical and occupational therapists or physicians personally providing these services can bill codes 97110, 97124, 97150, and 97535 (for pulmonary conditions) and codes G0237-G0239. However, if any other health professional performs the service "incident-to," you must use G0237-G0239.

4. Scrutinize Coverage Limits

Most insurers maintain extremely strict coverage guidelines for pulmonary rehabilitation, and you should review them up-front so you'll know whether your patient's services will be reimbursable.

For instance: If you learn during your evaluation that the patient smokes, most insurers will balk at reimbursing your pulmonary rehab services. For example, Aetna will only reimburse pulmonary rehab if the patient is a non-smoker, or if he quit smoking at least three months before the rehab began.

Aetna also states, "Pulmonary rehabilitation is not considered medically necessary in persons who have very severe pulmonary impairment as evidenced by dyspnea at rest, difficulty in conversation (one-word answers), inability to work, cessation of most or all usual activities making them housebound and often limiting them to bed or chair with dependency upon assistance from others for most ADL."

If you ever have any doubts about coverage limits, call your insurer and ask a representative to send you a recent policy on pulmonary rehabilitation coding and reimbursement.