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Pulmonary Rehab Reimbursement Alert

24 Apr 2012 6:37 PM | Julie Feirer (Administrator)

COPD Patients:

Pulmonary Rehab Reimbursement Alert

The Medicare reimbursement for pulmonary rehabilitation for patients with COPD was reduced on January 1, 2012 from approximately $68.00 per session to $37.00 per session. Therefore, it is imperative that ALL pulmonary rehab programs work with their billing departments to determine if you are charging an appropriate amount for G0424 (Pulmonary Rehab for patients with COPD). The toolkit provides a step-by-step approach to do this. I am happy to help anyone with this if you need clarification or assistance. It is important that your hospital adjust your charge for G0424 as soon as possible so your charge is consistent with what is outlined in the toolkit. If we don’t do this, programs are at risk of closing because of the low reimbursement rate for G0424 of $37.00 per session. If we act now, the earliest we may see an improvement in the reimbursement rate is 2014. So, please don’t delay in evaluating your current charge for G0424.

That being said, the codes that are listed in the toolkit are examples of codes that could POTENTIALLY be bundled into the G0424 code. In other words, if we didn’t have G0424 to bill COPD patients for pulmonary rehab services, we would be charging for each individual service we provide, and the codes listed in the toolkit are examples of what services we might be charging. Therefore, every possible service we provide to COPD patients should be considered when determining the amount you charge for G0424.

Patients with a non-COPD diagnosis:

Your natural reaction as you read the toolkit might be: Should we be charging non-COPD patients for all of the services listed in the toolkit? Not necessarily. Charges reflecting the services we are providing to our non-COPD patients may vary depending on the MAC jurisdiction in which we work. Your MAC may not allow use of some of the codes. For example, oximetry is typically bundled into G0237, G0238, and/or G0239; therefore you would not bill separately for that service. The same is true for the six minute walk test.

Reminder: the PFT criteria for non-COPD patients participating in Pulmonary Rehab is as follows: FVC, FEV1, OR DLCO < 60% predicted. This may be different than what you used in the past if you are not working in Iowa. However, the J5 MAC Medical Director has specifically instructed us to follow this PFT criteria for non-COPD patients.

If you have any questions about whether or not you should use a particular code, you should check with your Compliance Office, contact your MAC liaison for your jurisdiction (that is me for MAC J5), or do both.

Janie Knipper, RN, MA, FAACVPR, AE-C J5 MAC Liaison
Phone: 319-356-8396

Additional Information:

Clarification from William Ruiz at CMS on use of Modifier 59 for pulmonary rehab:

Pulmonary Rehab no longer has to use Modifier 59 when billing for more than one of the non- COPD “G” codes on the same day. So, for example, if G0238 and G0239 were charged on the same visit, you don’t have to use Modifier 59. 

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