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PEP Webinar -- Update on Pulmonary Rehabilitation Reimbursement and Audits

Posted on December 19, 2016   |   
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This post was authored by Jane Martin, BA, LRT, CRT, COPDF Associate Director of Education. The goal of the Pulmonary Empowerment Program -- or PEP -- is to support pulmonary rehabilitation health care professionals so they may help individuals with COPD have the best possible pulmonary rehabilitation experience through optimal physical conditioning, education in effective health-management and ongoing engagement to stay as healthy, active and independent as possible. For more information on PEP, please contact Jane at

An “Update on Pulmonary Rehabilitation Reimbursement and Audits” was presented at the PEP Webinar on Tuesday, December 13, 2016. Our special guest speaker was Gerilynn Connors, RRT, FACVPR, FAARC (, the Director of the Pulmonary Rehab program at Inova Fairfax Medical Campus in Fairfax, Virginia.

The event's learning objectives:

  • Describe pulmonary rehabilitation documentation & billing codes
  • Identify the AACVPR National Committee you need to communicate with for coding, billing and documentation questions
  • Review the New Jersey Pulmonary Rehabilitation OIG Report from December 2015
  • Review the latest evidence-based publications including the newly released GOLD strategy
  • Discuss the future of pulmonary rehabilitation

Main points:

The Law - Follow the law that went into effect January 1, 2010. The Federal Register specifies what is needed for pulmonary rehabilitation to be a covered service for individuals with COPD (G0424 billing code).

Know your Medicare Administrative Contractor (MAC). Your MAC determines coverage in your region, so know what MAC you are in and find out what you need to know. Respiratory Therapy Local Coverage Decision (LCD) on these billing codes: G0237, G0238 & G0239. MACs are allowed to interpret CMS “Rules.” G0424 is a bundled code. It’s important to work closely with the charge master and billing department in your hospital or clinic.

Gerilynn discussed the role of the GOLD Guidelines in criteria for pulmonary rehabilitation, specifics of the individualized treatment plan (ITP), physician supervision, psychosocial assessment, proper documentation, extended number of pulmonary rehab sessions beyond 36 as well as how to document session times.


Call to Action: Medicare is cutting Pulmonary Rehabilitation Reimbursement Rates – drastically. WE HAVE TO COMMENT and share our concerns with CMS. Share your thoughts at this link (this may look like an incorrect link, but it is correct). The deadline for comments is December 31, 2016.

Webinar Questions and Answers:

Question #1 - Is there a cap on the respiratory service codes? I have heard from some programs in my state (MI) that CMS will reimburse for only 1 unit of G0237 and 1 unit of G0238.

Answer #1 - There is some dialogue regarding caps. I have heard that. AACVPR has a webinar coming up next week and may have some info on that. Some info may be there and updated. Main cap that we know of is G0424 has lifetime 72. G0237-G0238 more than 8 units in one day you will often get audited and questioned about it.

Question #2 - What psychosocial assessment tool do you recommend using?

Answer #2 – If you’re looking to do AACVPR program registry then they recommend some specific tools. The Saint George Respiratory Questionnaire is one of those. The CAT is also good.

Question #3 - What did the reimbursements rates get cut to for G codes going into 2017?

Answer #3:

G0424 $54.53

G0237 $28.37 (per 15-minute increment)

G0238 $28.37 (per 15-minute increment)

G0239 $28.37

Unanswered Questions Open for Group Discussion:

Question #4 - I have been having problems finding the common working file to verify how many visits the patient has received for COPD. What department did you find in your hospital that had access to this file?

Question #5 - If a patient starts on 1/1/17, and the doctor signs a progress report on 1/20/17, does that re-set the 30 day requirement? In other words does the next progress report have to be signed before 2/20/17, or is it 30 days from their starting date, regardless of when the last progress report was signed?

Question #6 - Does the medical director have to sign the ITP for the very day the evaluation was done? If the patient is unable to start until 32 days after the evaluation, what do we document on the ITP? Could we state patient was unable to start due to "pending cardiac clearance?"

Please share your thoughts in the comments below!


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  • The GOLD strategy recommendations, which do indeed call for an expansion of education, self-management, and integrative care programs (as well as pulmonary rehab, of course) are available here:

    Chapter 4 covers the management of stable COPD, and the detailed discussion of PR and other supportive programs starts on page 87. There are other areas where these strategies are discussed, so the entire document is worth a read. Enjoy!

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