Francois Abi Fadel M.D. 1-2, Mollie Corbett 3, Chris Garvey FNP, MSN, MPA 4.
1-Cleveland Clinic, Respiratory Institute, Cleveland, Ohio
2-Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
3-Executive Director AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation), Chicago, Illinois
4-University of California San Francisco, San Francisco, California (retired)
Current Situation:
Formal payment for pulmonary rehabilitation in the US was established in 2010, when CMS (Centers for Medicare and Medicaid Services) began providing payment for HCPCS (health care common procedure coding system) billing code G0424 for bundled pulmonary rehabilitation (PR) services for patients with COPD GOLD stages 2-4. This bundled code includes supervised exercise, clinician services, education, and the considerable work of the physician supervising PR. Despite the CPT code, outpatient PR has faced significant decline in reimbursement, especially since 1/1/2012 when CMS began to reduce reimbursement [1,2].
In addition to the bundled code covering COPD described above, services may be covered on a regional basis for select non COPD diagnoses based on respiratory care services local coverage determinations (LCDs) by Medicare Administrative Contractors (MACs) using CPT billing codes G0237, G0238 and G0239.
- G0237 includes therapeutic procedures to increase strength or endurance of respiratory muscles (i.e. breathing retraining), face to face, one on one, each 15 minutes (includes monitoring).
- G0238 includes therapeutics procedures to improve respiratory function other than described by G0237, face to face, one on one, each 15 minutes session (includes monitoring).
- G0239 includes therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring [1,2].
G0238 and G0239 involve a variety of activities including teaching patient strategies for performing tasks with less respiratory effort, activities of daily living (ADLs), stair climbing, ongoing physical activity and exercise needs. Used in PR, this also includes pre and post-activity vital signs, dyspnea measurement and management [1,2].
General rules apply, e.g., the patient must exercise during every session. For G0424, the session duration should be at least 31 minutes for one session and at least 91 minutes for two sessions.
Lifetime sessions for G0424 are limited by Medicare* to a maximum of two 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions (not to exceed 72 sessions) if medically necessary. Medical necessity should be clearly documented in the medical record.
Expected reimbursement and copays for Medicare patients in 2021 may vary by region and are estimated below [3]:
G0424: $55.66; Copay $11.14.
G0237 and G0238: $24.66; Copay $4.94.
G0239 $33.84; Copay $6.77.
PR services are provided by a physician-supervised multidisciplinary team that may include an RCP, RN, physical therapist (PT), occupational therapist (OT), and / or a clinical exercise physiologist (CEP). Normally, the physician is not required to be physically present in the room during PR but must be immediately available except during wavier under the public health emergency (PHE). CMS expanded the definition of direct supervision to allow a physician to be immediately available using virtual presence through audio/visual real-time communications technology (excluding audio-only) “until the later end of the calendar year in which the PHE ends or December 31, 2021.” CMS has further clarified that for the physician providing this supervision, being immediately available does not require real-time presence or observation of the service via interactive audio and video technology throughout the performance of the procedure [4].
Pulmonary Rehabilitation Opportunities during the COVID 19 Pandemic and the Public Health Emergency
During the Public Health Emergency (PHE) related to COVID-19, CMS has taken actions to address a broad range of health policies impacted by the pandemic. Options are available to establish PR under rules in place during the PHE through the ‘Hospitals without Walls’ initiative that allows a beneficiary’s home to serve as a provider-based department (PBD) of the hospital for PR services. PR is one of the hospital outpatient services during the PHE that is eligible to be delivered in the beneficiary’s home as a PBD for the duration of the PHE, provided several limitations and rules are followed [4,5]. This is discussed in an interim final rule (CMS-5531-IFC), published May 8, 2020 (Federal Register, Vol. 85, No. 90). Under this waiver, PR sessions would need to be delivered using real-time interactive audio and video technology with all other requirements met, including hospital conditions of participation. There are various processes for operationalizing virtual delivery that each hospital billing office will need use, including necessary modifiers, based on the PR program’s location on or off the hospital campus. Reimbursement rate for virtual depends on numerous factors, including location, application for Extraordinary Circumstances Relocation Request, etc. Rate will be PFS-equivalent for some (40% less than HOPPS rate) 1/18/2021 American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Reimbursement Update [4]. AACVPR recently learned that HHS intends to extend the PHE through the end of 2021.
AACVPR provides fact sheets and regular PR reimbursement updates. The authors recommend that at least one staff person in a PR program join AACVPR to fully understand this complex and rapidly changing area. Also, per the Medicare provisions for PR (410.47), conditions of coverage must be all met, regardless of location, including: clinical indications, required education and exercise program components, exercise requirements, session duration requirements, and physician supervision.
PR requirements include an MD/DO referral order obtained prior to enrollment, initial assessment, including psychological and outcomes assessment with development of an Individualized treatment plan (ITP) prior to start of care and every 30 days that is reviewed and signed by the medical director.
Hospitals should bill as if the services were furnished in the outpatient hospital department. Currently procedure code G0424 for COPD GOLD stages 2-4 appears to be the only PR diagnoses covered for virtual PR. Hospital billing departments must be prepared to use proper modifiers for services as appropriate. This important and complicated process is described on AACVPR FACT SHEET 2-21.
Future Directions and Recommendations:
Reasons for the decline in PR reimbursement are complex. It is at least in part tied to the above-mentioned Medicare changes in PR reimbursement in 2010, when the new “bundled” payment code “G0424” for COPD was introduced. This code pays for one hour of PR including all costs of staff, medical director, gym, etc. Several analyses have found that hospitals are underreporting the cost to provide PR in the hospital outpatient setting, leading to inadequate reimbursement. [6]. To help improve reimbursement, PR providers should systematically detail and document the charges that are included in the institution’s yearly Medicare Cost Report submitted to CMS to confirm that current hospital charges reflect the expense and complexity of CPT G0424. [6].
The road to equitable payment and access to PR is clearly a long and complex journey. As the evidence based of effectiveness improves, we all play a role in understanding and working toward patient program access and adequate payment.
*Fee for service Medicare, a model separate and distinct from Medicare Advantage Organizations (MAO).
References:
2- Garvey, Chris. Reimbursement for Pulmonary Rehabilitation. Accessed December 30, 2020.
AACVPR Fact Sheet: Extension of PHE, January 18, 2021. Accessed 2/23/2021.
4-“Waivers during Public Health Emergency (PHE), CMS Guidance to Delivering CR/ICR/PR Using Home as a Provider-Based Department (PBD)”; Federal Register, Vol 85, No. 90, May 8, 2020/Rules and Regulations. Pgs. 27560-27566.
This quarterly bite has been superseded
