Pulmonology Coding Alert

Question: Thanks for your article last month on how the recovery audit contractors are scrutinizing pulmonary rehab claims. You mentioned that coverage is capped at 36 visits, but is there a limit on frequency? For instance, can those 36 visits all happen within a nine-month period if the patient comes in weekly? Or can it happen within five years if the patient wants to spread it out?

Codify Subscriber

Answer: CMS allows for up to two daily sessions at one hour each, according to MLN Matters article MM6823. So if the patient comes in twice a day for an hour each, you’d be able to take care of all 36 allowable sessions in just 18 days.

The directive says you can have 36 “lifetime” sessions, but puts no limit on how much time you have to present for those visits. However, pulmonary rehab must adhere the guidelines. The patient does not get to determine the frequency -- the prescribing physician must detail the duration, frequency, mode and intensity of exercise. The physician must review the patient’s progress and sign the plan every 30-days. The program must evidence a benefit or failure to achieve the goal. Failure would result in the need to revise the plan to achieve a better outcome.