Pulmonology Coding Alert

Support your PR program with diagnosis of moderate to severe COPD.

The passing of CMS' final rule for national coverage of pulmonary rehabilitation (PR) services, effective beginning  an. 1, doesn't mean you're trouble-free when coding for your pulmonologist's outpatient PR program or expanded in-office PR services.

But don't worry. You can pick up some essential PR coding and coverage insights from these 3 common situations.

1. Pulmonologist Doesn't Provide Direct PR Care

The pulmonologist may not be directly involved, but you won't be short of coding options. CMS guidelines require a comprehensive pulmonary rehabilitation program to be physician-supervised. It includes physician-prescribed exercise, education or training, psychosocial assessment, outcomes assessment, and an individualized treatment plan. Pulmonologists may bill E/M codes for periodic visits to evaluate the patient's underlying condition, any exacerbations, and response to therapy. For example, report follow-ups with an E/M code, such as 99214 (Office or other outpatient visitfor 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) to assess the medical management of the patient's COPD.

Don't overlook: Where there's PR care involved, associated services and equipment are never far behind. Report any pulmonary function tests (94010-94621, 94680-94750, and 94770) the pulmonologist performs unrelated to PR monitoring, while some equipment provided in the office setting may be billable for certain diagnoses using these HCPCS codes:

• A4614 -- Peak expiratory flow rate meter, hand held
• A4627 -- Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
• A7003 -- Administration set, with small volume nonfiltered pneumatic nebulizer, disposable.

2. Nonphysician Practitioner Provides RT Care

When nonphysician practitioners (NPPs), such as respiratory care practitioners, registered nurses, physical therapists (PTs), and occupational therapists (OTs), fill in for the pulmonologist on subsequent PR care, you have to code appropriately based on the type of provider who is providing the service. Choose from the following G codes when a respiratory therapist, a registered nurse or qualified ancillary staff provides the pulmonary function service:

• G0424 -- Pulmonary rehabilitation, including exercise and monitoring, per hour, per session
• G0237 -- Therapeutic procedure to increase strength or endurance of respiratory muscles, face-toface, one-onone, each 15 minutes (includes monitoring)
• G0238 -- Therapeutic procedures to improve respiratory function, other than described in 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). Physical and occupational therapists are prohibited from reporting codes G0237, G0238, G0239 and G0424. Their scope of practice typically extends beyond respiratory function improvement. Physical and occupational therapists should report codes 97001-97799 (rehabilitation services), which best represent their practice.

3. PR Service Needs Justification

PR coverage includes individuals with moderate to very severe COPD (with forced expiratory volume in one second [FEV1] less than 80 percent predicted). Depending on your local Medicare contractor, patients with other pulmonary-related diseases may be eligible for coverage of respiratory therapy services. However, you would bill it as respiratory care services using G0237, G0238, and G0239.

Additionally, auditors would want to see documentation that the patient is making progress toward goals since PR is meant to improve respiratory function, says Lana Hilling, CRT, RCP, coordinator of lung health services at John Muir Health System in California.

Important: Be specific when defining your goals. For instance, you must specify the activity (i.e., taking a shower with less shortness of breath) rather than saying the patient wants to breathe better. Also, when ordering for a PR program, the pulmonologist should specify type, frequency, and duration. An ideal outline of the schedule may state that a patient needs to attend 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. Make sure the PR program is unique and tailor-made for an individual.

Note: Read the article CCI 16.3 Highlights Pulmonary Rehab with Mutually and NME Edits on page 1, and keep up with latest on pulmonology CCI Edits.