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Medicare Coverage for Pulmonary Rehabilitation (PR) Services


Pulmonary Rehabilitation (PR) is a multi-disciplinary program of care for patients with chronic respiratory impairment who are symptomatic and often have decreased daily life activities.

A PR program is individually tailored and designed to optimize physical and social performance and autonomy. The program must provide an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory impairment. CMS did (and still does) cover medically reasonable and necessary respiratory treatment services in Comprehensive Outpatient Rehabilitation Facilities (CORFs), as well services to patients with respiratory impairments who are not eligible for PR but for whom local contractors determine respiratory treatment services are covered. MIPPA added payment and coverage improvements for patients with COPD (ICD-9 CM 496) and other conditions, and now provides a covered benefit for a comprehensive PR program for patients with moderate to very severe COPD under Medicare Part B effective January 1, 2010.

Effective January 1, 2010, MIPPA provisions added a physician–supervised, comprehensive PR program for patients with moderate to very severe COPD. Medicare will pay for up to two (2) one-hour sessions per day, for up to 36 lifetime sessions (in some cases, up to 72 lifetime sessions) of PR. The PR program must include the following mandatory components:

1. Physician-prescribed exercise;
2. Education or training;
3. Psychosocial assessment;
4. Outcomes assessment; and
5. An individualized treatment plan.

Medicare contractors will pay claims for HCPCS code G0424 (PR) only when services are provided in the following places of service (POS): 11 (physician’s office) or 22 (hospital outpatient). Medicare will deny claims for HCPCS code G0424 performed in other than, and billed without, POS 11 or 22, using the following:

Claim Adjustment Reason Code (CARC) 58 – “treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

Remittance Advice Remark Code (RARC) N428 – “Service/procedure not covered when performed in this place of service.”

Group Code PR (Patient Responsibility) assigning financial liability to the patient if the claim was received with a GA modifier indicating a signed Advance Beneficiary Notice (ABN) is on file or Group Code CO (Contractual Obligation) assigning financial liability to the provider if the claim is received with the GZ modifier indicating no signed ABN on file.

Medicare contractors will pay claims for PR services containing HCPCS code G0424 and revenue code 0948 on Types of Bill (TOB) 13X and 85X under reasonable cost.

Contractors will pay for PR services for hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission on an outpatient basis, TOB 13X, in accordance with the terms of the Maryland waiver.

Frequency and Limitation

Medicare will deny PR services that exceed two units on the same date of service and, in doing so, will use the following:

CARC 119 – “Benefit maximum for this time period or occurrence has been reached.”

RARC N362 – “The number of days or units of service exceeds our acceptable maximum.”

Group Code PR assigning financial liability to the patient if the claim was received with a GA modifier indicating a signed ABN is on file or Group Code CO assigning financial liability to the provider if the claim is received with the GZ modifier indicating no signed ABN on file.

Medicare will normally pay for 36 sessions of PR, but may pay up to 72 sessions when the claim(s) for sessions 37-72 includes a KX modifier. Claims for HCPCS code G0424 which exceed 36 sessions without the KX modifier will be denied using the following:

CARC 151 – “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.”

Group Code PR assigning financial liability to the patient if the claim was received with a GA modifier indicating a signed ABN is on file or Group Code CO assigning financial liability to the provider if the claim is received with the GZ modifier indicating no signed ABN on file.

Medicare contractors will deny claims for HCPCS code G0424 when submitted for more than 72 sessions even where the KX modifier is present. In the denials, contractors will use the following:

CARC B5 - “Coverage/program guidelines were not met or were exceeded.”

Group Code PR assigning financial liability to the patient if the claim was received with a GA modifier indicating a signed ABN is on file or Group Code CO assigning financial liability to the provider if the claim is received with the GZ modifier indicating no signed ABN on file.

References:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm6823.pdf

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