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Pulmonary Rehabilitation in the United States: December 2021 Updates on Covered Indications and Reimbursement

Francois Abi Fadel M.D. 1-2, Mollie Corbett 3, Karen Lui 4, 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


Current Regulations and Impact

This summary includes CMS (Centers for Medicare and Medicaid Services) US pulmonary rehabilitation (PR) reimbursement updates published in November 2021 including rules and payment for virtual PR, COVID-19, and physician services including office-based PR.

National coverage for PR in the US was established in 2010, when CMS began providing payment for HCPCS (health care common procedure coding system) billing code G0424 for bundled (comprehensive) pulmonary rehabilitation (PR) services for patients with COPD GOLD stages 2-4. This bundled code includes supervised exercise, clinician services, education, outcome assessment including six-minute walk testing, individualized treatment plan (ITP) development and the considerable work of the physician supervising PR. Outpatient PR has faced significant decline and stagnation in reimbursement since 1/1/2012. Lack of equitable reimbursement is attributed to by CMS a low PR geometric mean derived from annual Medicare hospital cost reports [Vol. 86, Federal Register (FR) p. 63562], (82 FR 59306-59309).. Medicare advised PR providers in 2011 of the need to adjust new ‘bundled’ charges, e.g., for G0424 (one hour per unit) to reflect all the expenses not captured in timed codes (76 FR 74224) such as G0237 and G0238 (15 minute codes) to include all aspects of new bundled charges.

Several analyses have found that hospitals continue to underreport and undervalue the bundled costs of PR leading to a lower geometric mean on the annual Medicare hospital cost report, resulting in inadequate payment (1,2).

Medicare 2022 Outpatient PR Payment

CMS final rules for 2022 include both hospital outpatient prospective payment (HOPPS), e.g., center-based PR including its provision of virtual PR, and payment under the physician fee schedule (PFS), e.g., MD office-based services including PR.

During the public health emergency (PHE), Medicare has allowed hospital outpatient PR services to be provided virtually under its “Hospital without Walls” waivers in which sessions could be provided in a patient’s home. “Virtual” is defined by CMS as two-way, audiovisual, real-time communications technology. It is not considered “telehealth.” Hospital billing departments need to understand and follow CMS rules including modifiers for billing for this service. CMS coverage for virtual hospital outpatient PR expires at the end of the PHE (January 16, 2022 at the time of this writing). PHE extensions are normally a maximum of 90 days (see below for details and resources).

Two new billing codes replace G0424 have been developed in part to better align PR services with that of cardiac rehabilitation (CR) and to help address lack of parity of reimbursement. CR is currently paid at more than twice that of PR. According to CMS, in the hospital outpatient setting the new codes do not reflect a significant increase in payment “due to the lower PR geometric mean derived from yearly Medicare hospital cost reports”.  

  • CPT code 94625 [(MD or other qualified HCP services for outpatient PR; without continuous Sp02 (per session)]
  • CPT code 94626 [(MD or other qualified HCP services for outpatient PR; with continuous Sp02 (per session)]
  • The new CPT codes are associated with APC (Ambulatory Payment Classification) 5733 (Level 3 Minor Procedures)


  • ATS, AACVPR and AARC strategies to address PR payment and virtual PR include:
    • A survey of PR providers using the AACVPR database to formulate plan
    • Based on the above survey results, develop education and tools that promote development and use of appropriate PR charges, and tools for providers to Interface with hospital finance leads
    • Upcoming ATS PR Clinical Practice Guidelines will update PR evidence base
    • Multi-society collaboration to address strategies for viability of PR reimbursement and virtual PR

COVID-19 will be covered under new CPT codes. Details for coverage include: 

  • Confirmed or suspected COVID-19
  • Persistent symptoms that include respiratory dysfunction for at least four weeks

Not required: Hospitalization prior to PR, positive COVID-19 test, PFTs or direct MD contact. 

Physician PR Updates

  • MD PR supervision via virtual presence extended to 12/31/22. Virtual PR services provided in MD offices extended until 12/31/23. Estimated MD office PR payment is $75-$83 per session (impacts about 5 US PR programs).
  • MDs signing the initial PR ITP may bill for their role using evaluation and management (E&M) codes. Regulatory language to better align PR with CR includes removal of the monthly “direct patient contact” requirement. The physician is already required to, in consultation with staff, review the ITP every 30 days (42 CFR 410.47). PR staff track the patients’ progress at every session and should identify the need for direct contact when appropriate.

Proposed PR Legislation

  • Increase Access to Quality Cardiac Rehabilitation Act of 2021, HR 1956, will allow non-physician practitioners (NPPs) to independently order and supervise CR/ICR/PR thereby increasing access for PR patients, particularly in rural areas. Bill passage will make effective date 2022 vs current date of 2024.
  • SOS: Sustaining Outpatient Services Act, HR 3348: Allow hospital outpatient CR/PR to receive hospital outpatient reimbursement rate, regardless if located on or off campus thereby improving potential expansion of off-site PR.

Additional PR Reimbursement Information

In addition to the bundled code 94625 and 94626 covering COPD GOLD 2-4 and COVID 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).

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).

Medicare requires that the patient must exercise during every PR session. For 94625 and 94626, the session duration should be at least 31 minutes for one session and at least 91 minutes for two sessions. PR using 94625 and 94626 is limited 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.

PR services are provided by a physician-supervised multidisciplinary team that may include a respiratory therapist (RT), RN, physical therapist (PT), occupational therapist (OT), and / or a clinical exercise physiologist (CEP). Although the physician is not required to be physically present in the room during PR, he or she must be immediately available. As noted above, being immediately available may occur via real time interactive audio and video technology throughout the performance of the procedure during the PHE until 12/31/22 (3).

PR Opportunities during the COVID-19 Pandemic and the PHE

During the PHE, 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 may be delivered in the beneficiary’s home as a PBD for the duration of the PHE, provided several limitations and rules are followed as discussed in an interim final rule (CMS-5531-IFC), published May 8, 2020 (Federal Register, Vol. 85, No. 90). Under this waiver, PR sessions needs to be delivered using real-time interactive audio-video communications technology with all other requirements met, including hospital conditions of participation. There are various processes for operationalizing virtual delivery that each hospital billing office needs to 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.

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 (CFR §410.47), conditions of coverage must be all met, regardless of location, including: clinical indications, and required education and exercise program components, exercise, session duration, 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.

Future Directions and Recommendations

The decline in PR reimbursement 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 GOLD 2-4 was introduced. This code (and the new PR codes replacing G0424 noted above) pay for one hour of PR including all costs of staff, medical director, gym, etc. Several analyses have found that hospitals are underreporting and undervaluing the cost to provide PR in the hospital outpatient setting, leading to inadequate reimbursement (1). 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 the new CPT codes 94625 and 94626 (1,4).

The road to equitable payment and access to PR is clearly a long and complex journey. All major pulmonary societies are working together to improve equity of PR reimbursement. ATS plans to publish a clinical practice guideline in the future to update the evidence base of PR and further define PR’s important role. As the evidence base of effectiveness improves, we all play a role in understanding and working toward patient program access, awareness and adequate payment.

The authors thank Gary Ewart, Anne Marie Hummel, Karen Lui, Mike Nelson and the ATS US PR Reimbursement Working Group.


1-“Pulmonary Rehabilitation Toolkit: Guidance to Calculating Appropriate Charges for G0424”. American Association of Cardiovascular and Pulmonary Rehabilitation. https://www.aacvpr.org/Portals/0/Pulmonary-Rehabilitation-Toolkit_FINAL.pdf Accessed 12/29/21

2- Provider Billing Practices for Pulmonary Rehabilitation with Exercise (G0424). The Moran Company, May 2017. Data Source: 2017 OPPS Final Rule

3-“AACVPR Health Policy & Reimbursement Update Nov 21, 2021 LinkClick.aspx (aacvpr.org) accessed 12/26/21.

4-“Garvey C, Novitch RS, Porte P, Casaburi R. Healing pulmonary rehabilitation in the United States: a call to action for ATS members. Am J Respir Crit Care Med 2019;199: 944 – 946. Accessed 12/26/21


  1. “AACVPR Fact Sheet, Deliver of Cardiac and Pulmonary Rehabilitation Opportunities during the COVID 19 Pandemic. Accessed December 26, 2021.
  2. “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.
  3. “AACVPR Fact Sheet: Extension of PHE”, January 18, 2021. . Accessed 12/29/21

No conflicts of interest
Dmitry Rozenberg receives funding support from the Sandra Faire and Ivan Fecan Professorship in Rehabilitation Medicine