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Reimbursement for Pulmonary Rehabilitation

Chris Garvey, FNP, MSN, MPA
Coordinator, Pulmonary and Cardiac Rehabilitation
Seton Medical Center
Daly City, CA


The Centers for Medicare and Medicaid Services (CMS), has directed intermediaries (organizations that process and pay submitted Medicare claims, interpret Medicare procedures and perform Medicare claims review) to develop a local medical review policy (LMRP) for services that are not governed by national policy. Draft policies are published for a 45-day comment period. Final policies become effective for claims received 30 days after publication date. If a national policy is established for any of the local policies, the national policy will take precedence over the local policy. The following summary will include information on the new LMRP for Regions III, V and IX (California, Nevada, Hawaii, Michigan, Wisconsin, West Virginia, U.S. South Pacific Trust territories of American Samoa, Guam and the Commonwealth of Northern Mariana Islands), as well as links to LMRPs or guidelines for other regions. General information about Medicare and a glossary of terms can be found at http://cms.hhs.gov/

Summary of Region III, V and IX LMRP

United Government Services (UGS) is one of the fiscal intermediaries for California, Nevada, Hawaii, Michigan, Wisconsin, West Virginia and US South Pacific Trust territories of American Samoa, Guam and the Commonwealth of Northern Mariana Islands (Regions III, V and IX). The UGS published the LMRP U01.15.02 for Outpatient Pulmonary Rehabilitation on July 8, 2002 (see http://www.ugsmedicare.com). This contains an explanation of covered Outpatient Pulmonary Rehabilitation services for Medicare beneficiaries in Regions III, V and IX.

The LMRP includes a description of patients appropriate for Outpatient Pulmonary Rehabilitation (PR), appropriate providers, goals, clinical interventions, objectives, summary of physician certification and physician orders. The initial physician order serves as certification for the initial 30 days of service (60 days in a comprehensive outpatient rehabilitation facility or CORF). Recertification for PT and OT outpatient services is required. Requirements include that a physician certifies that the patient has had a physical examination within the past 90 days. If the patient is still receiving PR services beyond the certification date, the physician must document that the patient remains capable of participation and benefits from the PR. The physician orders must be specific regarding type, frequency, and duration of the service. The physician is not required to be physically present in the facility during PR.

Educational instruction must be documented, including the patients' carryover of education instruction and training into his or her daily activities. Reduction of identified disabilities and handicaps must be documented. Therapeutic exercise must include a rationale for continued skilled intervention. Inspiratory Muscle Training is restricted to patients whose medical record supports its use.

The PR services are provided by a physician-directed multidisciplinary team that may include an RCP, RN, PT, OT, and an appropriate, qualified exercise physiologist. Documentation is needed to show that services by the various disciplines are reasonable, necessary and distinct form each other with frequency, duration, goals and measurable objectives for each service needed.

Patients appropriate for PR must have a diagnosis of a chronic, stable respiratory disorder with disabling symptoms that impair the patient's function. PFTs need to show FVC, FEV1 and/or DLCO of <65% predicted on PFT within 1 year of PR. There must be the expectation of measurable improvement in a reasonable and predictable amount of time, and the patient must be able, motivated and willing to participate.

PR is generally provided for 4-6 hours per week for an 8-12 week period. Group training ratios must not exceed four patients to a qualified clinician. Documentation must show that there is improved exercise tolerance and decreased symptoms of the disorder. Team conferences need to occur at the beginning and end of PR, and during PR as needed. The patient's progress toward short-term goals should be assessed at these conferences.

The LMRP restricts the use of CPT codes 97000-97799 and creates three temporary G codes. CPT codes 97001 - 97799 are to be used only by PT or OT. Please check the fiscal intermediary LMRP in specific regions for discipline-specific billing of CPT codes. G codes in the United Government Services LMRP include:

G0128: Direct (face-to-face) skilled nursing services of an RN provided in a CORF, 10 minutes each beyond the first 5 minutes.

G0237: Therapeutic procedure to increase strength or endurance of respiratory muscles, face to face, one on one, 15 minutes each (including monitoring).

G0238: Therapeutic procedure to improve respiratory function, other than described in G0237, face to face, one on one, 15 minutes each (including monitoring).

G0239: Therapeutic procedure to improve respiratory function, face-to-face, other than described in G0237, two or more (including monitoring).

For CPT G0236 and G0237, a single 15 minute unit is 8-22 minutes of service, 2 units are 23-37 minutes, etc. Use HCPCS code G0238 for 6-minute walk performed by an RN, RPC or exercise physiologist.

Cardiopulmonary testing can be reimbursed before, during or after outpatient pulmonary rehabilitation when medically necessary.

Links for Outpatient Pulmonary Rehabilitation Local Medical Review Policies (LMRPs)

Below are links for Medicare Fiscal Intermediaries that have LMRPs or guidelines for outpatient pulmonary rehabilitation services.


Administar Federal, Inc.
At the website, click on: Part A (Intermediary) Services, Medical Policy, Current Local Medical Review Policies (LMRPs)
States: Illinois, Indiana, Kentucky and Ohio

Associated Hospital Services
States: Maine, Massachusetts, New Hampshire and Vermont

State: Arizona

Blue Cross Blue Shield of Montana
click on: Providers, Medical Policy (password required), Alphabetical, The letter "R"
State: Montana

Blue Cross Blue Shield of Rhode Island
State: Rhode Island

Blue Cross Blue Shield of Wyoming
State: Wyoming
This is a noncoverage policy for outpatient pulmonary rehabilitation.

Cahaba Government Benefit Administrators -- Alabama [BlueCross BlueShield of Alabama]
State: Alabama

Cahaba Government Benefit Administrators -- Iowa [BlueCross BlueShield of Iowa]
States: Iowa, South Dakota

Carefirst of Maryland, Inc.
States: Maryland, Washington, D.C.

Chisholm Administrative Services [BlueCross BlueShield of Oklahoma]
State: Oklahoma

Empire Medical Services
click on: Part A - CT, DE, MA, NY, Medicare News Update (CT, DE, MA, NY), Part A Provider (Intermediary) Newsletter , October 2001, Issue #10, Pulmonary Rehabilitation Services
States: Connecticut, Delaware, Massachusetts and New York

First Coast Service Options, Inc.
State: Florida

Georgia Medicare Part A [BlueCross BlueShield of Georgia]
State: Georgia

Mutual of Omaha Insurance Company
Acts as Fiscal Intermediary for 6000 providers throughout the United States.
States: Every state except New York

Noridian Administrative Services [Nordian Mutual Insurance Company, formerly BlueCross BlueShield of North Dakota]
States: Minnesota, North Dakota

Palmetto GBA
click on: Providers, Part A Intermediary, North Carolina Part A Intermediary, Medical Policies, Final
States: North Carolina, South Carolina

Riverbend Government Benefits Administrator [BlueCross Blue Shield of Tennessee]
States: New Jersey, Tennessee

Trailblazer Health Enterprises, Inc.
States: Colorado, New Mexico, Texas

Trispan Health Services [BlueCross BlueShield of Mississippi] click on: Provider Information, Local Medical Review Policy, LMRP Search, Type in: Pulmonary Rehabilitation
States: Louisiana, Mississippi, Missouri

United Government Services, LLC
click on: Provider Services, Local Medical Review Policies, Active Final Local Medical Review Policies (LMRPs), Index for Outpatient and Skilled Nursing Facility LMRPs
States: California, Hawaii, Michigan, Nevada, Pacific Rim (American Samoa, Guam, Northern Mariana Islands), Virginia, West Virginia and Wisconsin


We would like to thank Sue Lareau, Bonnie Fahy, and Linda Nici for their contributions and review of this article.