Pulmonology Coding Alert

Are your services being reported correctly?

Although most pulmonology coders would agree that they don’t need one more audit area to be under the microscope, the recovery audit contractors (RACs) have once again latched onto a respiratory-related service and listed it among their focus areas.

Here’s the scoop: Part B RAC Cotiviti launched a review on March 27 of medically necessary pulmonary rehabilitation.

In black and white: “Pulmonary rehabilitation is a physician-supervised program for COPD and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Medical Documentation will be reviewed to determine if pulmonary rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.”

To ensure that your pulmonary rehabilitation (PR) services are being reported properly, check out the following quick tips.

Tip 1: Let G Codes Be Your Friend

You have several G codes out there to capture pulmonary rehab services. You must know when to use the G codes appropriately. They can be outlined in three groups:

Comprehensive Outpatient Rehabilitation Facilities (CORFs): If the patient’s PR services are taking place at a dedicated CORF, the facility will report the program with G0128 (Direct [face-to-face with patient] skilled nursing services of a registered nurse provided in a comprehensive outpatient rehabilitation facility, each 10 minutes beyond the first 5 minutes). The coverage includes the procedures performed by a registered nurse, but the physician is not required to be physically present in the facility during PR.

Beware:  This code is only reported by the facility, and not to be used for professional (physician) billing. It also covers daily nursing services as part of the facility’s overhead costs, not specific to pulmonary rehab.

COPD Patients: For pulmonary rehabilitation serviced exclusively for patients with moderate to very severe COPD, you will report a special packaged code G0424 (Pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to two sessions per day). Remember to verify that the patient’s COPD has been documented as GOLD classification II, III or IV according to the referral of the treating physician.

HCPCS code G0424 applies to all PR services provided in the physician’s office and in outpatient hospital settings. The provider (hospital or practitioner) can report up to two one-hour sessions each day, but in order to report one session of pulmonary rehab, the treatment must last at least 31 minutes.

CMS does not specify any specific limit on the duration of the PR program, but the coverage is capped to 36 visits.

Caution:  This is a comprehensive service code and allied services like the 6 min. walk test are included in the service.

Non-COPD patients: For all other patients with other pulmonary-related diseases, who require PR services that help them cope with chronic lung diseases, you have the following codes:

• G0237: Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring)
• G0238: Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring)
• G0239: Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)

These are time-based services where you can bill a single 15-minute unit for eight to 22 minutes of CPT^® G0237 and G0238, bill two units for 23-37 minutes, etc. Code G0239 is billable once per day per patient. You would be able to bill for any additional testing such as the six-minute walk when using these G codes. Typically, a therapist will provide and report these services.

Tip 2: Know the Covered Conditions

Make sure that you are billing for the PR services with appropriate and covered diagnoses justifying the medical necessity. You should check with your payer to know which conditions are covered.

Tip 3: Don’t Forget to Report Follow-up Visits

Although you cannot report E/M codes for therapy sessions, you can report follow-up non-PR visits to your pulmonologist with appropriate E/M codes. These visits are important to evaluate the patient’s underlying condition, any exacerbations, and response to medication therapy.

Other than E/M codes, also be sure to report any allied and equipment used for therapy. For instance, you can claim any pulmonary function test that the pulmonologist’s pulmonary function lab performs for all G codes except G0424. Additionally, you may also submit any equipment costs incurred in the office setting such as 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), when applicable.

Tip 4: Document Thoroughly

You will encounter many documentation obstacles where your claim may fall and rebound. Follow these golden rules to foolproof your claims:

• Remember to submit supporting documentation for the patient’s condition, including the GOLD classification, by obtaining records from the referring physician.
• The patient’s medical record must clearly identify the service as hospital based or non-hospital based and you should record the presence of a physician.
• Your documentation must show that there is an improvement in exercise tolerance and decreased symptoms of the disorder. Your pulmonologist should also assess and record the patient’s progress toward short-term goals at the beginning, during, and at the end of PR.

Your pulmonary rehab program documentation should also include the following:

• Physician-prescribed exercise
• Psycho-social assessment
• Outcomes assessment
• An individualized treatment plan
• Education and training tailored to the patient’s needs.