Pulmonology Coding Alert

Question: Does Medicare cover the pulmonary rehabilitation services such as exercises to improve respiratory function and strength for all respiratory conditions?

Texas Subscriber

Answer: Pulmonary rehabilitation (PR) programs are covered by Medicare for patients with the diagnosis of moderate/severe/very severe COPD (chronic obstructive lung disease), as per the Global Initiative for Chronic Obstructive Lung Disease (GOLD COPD) guidelines.

Take note of the following preconditions for coverage of pulmonary rehabilitation services for COPD patients:

• Do not bill for more than two one-hour sessions on a single day.
• The service should have been provided in a physician’s office or a hospital outpatient department.
• All individual components of the PR services furnished are bundled into a single billable code, G0424 (Pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to two sessions per day). These services are not separately billable.
• Do not bill G0424 for non-COPD patients.

In case the rehabilitative treatment is for conditions other than above, or if the patient does not meet the GOLD criteria, you may bill for the respiratory care services separately, but this would not come under the term “pulmonary rehabilitation” per se. You may use the following:

• 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]).