Pulmonology Coding Alert

Limitation: G0424 requires monitored exercise, and an hour's therapy of up to two sessions per day per patient.

You can bill a pulmonary rehabilitation (PR) program with an all-inclusive G code, but did you know it must include monitored exercise? Without the necessary essentials, the whole PR coding process will not be an easy task. Check out these related scenarios, and apply four tips to your solutions.

Scenario 1: A patient diagnosed with COPD (491.20, Obstructive chronic bronchitis without exacerbation) presents to your office for PR evaluation and planning. The patient receives -- from the pulmonologist -- an initial office assessment, including baseline testing (e.g., six-minute walk, PFTs) to determine the appropriateness and/or treatment plan before initiating PR. The patient then proceeds with 35 minutes of pulmonary rehab. How should you report this?

Scenario 2: Throughout the course of the PR program, the same patient reports for follow-up outpatient visits where the pulmonologist determines the patient's pulmonary status and medications. What CPT code should you apply?

Tip 1: Bundled HCPCS Code Deals With All PR Services

In case of the first scenario, you should charge the patient with the HCPCS code G0424 (Pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to two sessions per day) linked to 491.20.

Quick fact: Most insurers require that a physician first evaluate the patient to determine functional limits, including assessing his musculoskeletal system, as well as the breathing patterns, cardiovascular and pulmonary responses to activity, equipment needs, and safety issues before you can report G0424. Then, both the physician and respiratory therapist or physical therapist will implement the designed PR program. Make sure that the physician is in the office and immediately available during PR sessions.

HCPCS G0424 applies to all PR services provided in the physician's office and in outpatient hospital settings. The code covers one hour of PR (a minimum of 31 minutes, up to 90 minutes), which must include monitored exercise, and allows for up to two PR sessions (a minimum of 91 minutes) per day per patient.

CMS does not specify any specific limit on the duration of the PR program, but the code should cover only up to 36 visits. However, CMS points that additional services may be appropriate in certain situations. Don't forget the CMS-formulated mandatory components for PR:

• physician-prescribed exercise
• education or training
• psychosocial assessment
• outcome assessment
• an individualized treatment plan detailing how the components are used for each patient.

Tip 2: Other Pulmonary Disorders? Look To G0237-G0239

Only patients with moderate to very severe COPD (defined as GOLD classification II, III and IV) will be covered by G0424. If the patient has other pulmonary-related disease, then you would have to use respiratory care codes G0237 (Therapeutic procedure 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 in G0237, one-on-one, face-to-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]).

Additional codes that may support medical necessity are including:

• 277.00 -- Cystic fibrosis without meconium ileus
• 416.0-416.2 -- Primary pulmonary hypertension-chronic pulmonary embolism
• 491.1 -- Mucopurulent chronic bronchitis
• 491.22 -- Obstructive chronic bronchitis with acute bronchitis
• 492.8 -- Other emphysema
• 493.10-493.91 -- Intrinsic asthma unspecified-asthma unspecified type with status asthmaticus
• 494.0 -- Bronchiectasis without acute exacerbation
• 494.1 -- Bronchiectasis with acute exacerbation
• 500 -- Coal workers' pneumoconiosis
• 501 -- Astestosis
• 502 -- Pneumoconiosis due to other silica or silicates
• 506.4 -- Chronic respiratory conditions due to fumes and vapors
• 714.81 -- Rheumatoid lung

Tip 3: Let E/M Codes Do The Work For Follow-Up Outpatient Visits

Like the second scenario, you would report periodic visits to evaluate the patient's underlying condition, any exacerbations, and response to medication therapy 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...).

When you bill an E/M code, be on the lookout for associated services and equipment. 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).

Tip 4: Document! Document! Document!

Regardless of the scenario, you should always substantiate your practice's provision of PR. Your claim would likely get approved if the patient's diagnosis is a chronic, stable respiratory disorder with disabling symptoms that impair function but do not impede convalescence, such as 491.20. Pay attention to the patient's measurements of carbon monoxide diffusing capacity (DLCO) or the forced expiratory volume in one second (FEV1), since most MACs base current need for PR from these factors, reminds Lana Hilling, CRT, RCP, coordinator of lung health services at John Muir Health System in California.

Auditors would also want to see documentation that the patient is making progress toward goals to verify the PR's purpose of improving respiratory function, she adds. Keep your documentation solid including PR type, frequency, and duration specifics. Your pulmonologist should also note the type of instruction needed, such as ADL, inhaler, medication management, and/or infection control education.