Pulmonology Coding Alert

As of Jan. 1, legislation for national and local pulmonary rehabilitation (PR) coverage went into effect. Were you ready? What you don't know about PR coding may hurt your bottom line.

Familiarize yourself with five PR essentials and spell the difference between denial and deserved dollars.

CMS has published the final rule for pulmonary rehab, which uses a new HCPCS code G0424 (Pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to 2 sessions per day) for PR coverage. Use G0424 for all PR services provided in the physician's office and in outpatient hospital settings.

Example: A patient, who's diagnosed with COPD (491.20, Obstructive chronic bronchitis without exacerbation), presents to your practice for PR and receives an initial office assessment, including aerobic exercise (sixminute walk) for one hour. A physician and respiratory therapist or physical therapist should manage this patient's pulmonary rehabilitation program. (The insurer would require that a physician first evaluate the patient to determine functional limits, including assessing his/her musculoskeletal system as well as the breathing patterns, cardiovascular and pulmonary responses to activity, equipment needs, and safety issues.) In this case, you should charge the patient with G0424.

The new G code covers one hour of PR, which must include monitored exercise. It carries with it a new APC (ambulatory payment classification) 0102 and pays approximately $50.46 per one-hour unit for hospital outpatient PR only. The payment is much less in the office setting -- $24 to be exact.

Prerequisites: Your pulmonologist's program should complete two PR sessions per day per patient, and must include aerobic exercise. CMS could allow additional services to the specified 36 visits. According to CMS, additional services may be appropriate in certain situations. If you're lucky, local contractors may consider another 36 visits for coverage based on medical necessity.

More importantly, you should be aware of the CMSformulated mandatory components for PR, which include physician-prescribed exercise, education or training, psychosocial assessment, and outcome assessment.

2. Treat Pulmonary Disorders Other Than COPD Differently

CMS expanded the G0424's coverage to include individuals with very severe COPD and will now cover those with moderate to very severe COPD. This means, you'll have to bill patients with other pulmonary-related diseases with respiratory care services using the current, existing codes G0237 (Therapeutic procedure to increase strength or endurance of respiratory muscles, face-toface, one-on-one, each 15 minutes [includes monitoring]), G0238 (Therapeutic procedures to improve respiratory function, other than described in G0237, one-on-one, faceto- face, per 15 minutes [includes monitoring]), and G0239 (Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals [includes monitoring]).

3. Cross Out the 97000 Series

Another important change included in the final rule states that physical therapists can no longer bill for PR using physical therapy CPT codes (97000 series). Previously, physical therapists used the 97000 series to select codes for PR services, which only confused them because that section didn't include any separate codes for pulmonary rehabilitation, says Tiffany Miller, CPC, a coder in Hurricane, W. Va. "PTs were very limited in the codes they could use and be reimbursed. I used to code pulmonary rehab services using the therapeutic exercises code (97110, Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility)."

Why: Because the new G code is "comprehensive." PR programs cannot bill separately for the 6-minute walk test or smoking cessation as part of the PR program. However, comprehensive outpatient rehabilitation facilities (CORFs) can continue to bill using G0237, G0238, and G0239.

Your pulmonologist may not be directly involved in a patient's PR program, but that doesn't mean you're on a dead-end. Your pulmonologist can report E/M codes for periodic visits to evaluate the patient's underlying condition, any exacerbations, and response to medication therapy, explains Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Example: After reporting G0424 for a patient's initial assessment, report follow-up outpatient visits with an E/M code, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) for non-PR patient evaluations for determining pulmonary medications and the patient's pulmonary status. "In other words, CMS' final rule means you cannot report E/M codes for therapy sessions," Pohlig says.

There are associated services and equipment that you should be aware of. For instance, you should add on any pulmonary function tests (94010-94621) that the pulmonologist's pulmonary function lab performs. In addition, any equipment costs incurred in the office setting is reimbursable with A4614 (Peak expiratory flow rate meter, hand held), A4627 (Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler), or A7003 (Administration set, with small volume nonfiltered pneumatic nebulizer, disposable).

You will need to substantiate your practice's provision of PR. First of all, the patient's diagnosis must be a chronic, stable respiratory disorder with disabling symptoms that impair function but do not impede convalescence, such as chronic obstructive pulmonary disease (COPD), 491.20. Most MACs assess current need for PR from measurements of either the carbon monoxide diffusing capacity (DLCO) or the forced expiratory volume in one second (FEV1), says Lana Hilling, CRT, RCP, coordinator of lung health services at John Muir Health System in California.

PR serves the purpose of improving respiratory function, so auditors also want to see documentation that the patient is making progress toward goals, she adds. Your goals should be specific to the activity. For example, the patient wants to take a shower with less shortness of breath. Also, you should consider your documentation crucial. If the pulmonologist's orders specify the PR type, frequency, and duration, you are safe from denial. Your pulmonologist should also note the type of instruction needed, such as ADL, inhaler, medication management, and/or infection control education.

Tip: Instead of prescribing a six-week program, the pulmonologist should outline the schedule: Patient should attend a six-week PR program, two days per week for four weeks, and three days per week for two weeks, for two to four hours each day.