Update on Medicare Models and How these may Impact Pulmonary Rehabilitation Payment and Access in the Future
Michael Belman MD, MPH, pulmonologist and former executive at a large US health insurance firm has generously provided a focused update on the evolution of Medicare models such as Medicare Advantage and Accountable Care Organizations. He has also provided information on COPD national demographics and characteristics as an important consideration for future PR access and payment. Note that this summary represents key elements of a very complex topic. The main message is that further progress in structuring improvement in PR payment must involve an expanded group of individuals from the clinical, health policy and business areas.
PR Reimbursement Toolkit – This webpage also includes links to two focused summaries:
- Key Elements of PR Billing and Payment (summary for PR providers)
- Key PP Medicare and Scientific Updates (summary for CFOs & billing leads)
Article - Billing and Coding: PR Services (A56152) (cms.gov)
Medicare uses claims data to set PR payment rates based on information submitted by hospitals for PR CPT codes 94625 & 94626 (31-90 minutes per unit).
- 94625 (PR; without continuous oximetry) & 94626 (PR with continuous oximetry)
- Diagnoses: (1) GOLD COPD stage 2-4 and (2) confirmed or suspected COVID–19 + persistent symptoms + respiratory dysfunction for > 4 weeks ).
- Services for other symptomatic lung diseases may be covered under ‘Outpatient Respiratory Services’ (ORS). See AACVPR.org for details on requirements and billing for ORS.
| Service | Procedure Code (per unit)* | Payment |
|---|---|---|
| Pulmonary Rehabilitation | 94625,* 94626* | $57.48 |
| Cardiac Rehabilitation | 93797, 93798 | $120.07 |
*31-90 minutes
- 94625 (PR; without continuous oximetry) & 94626 (PR with continuous oximetry)
- Diagnoses: (1) GOLD COPD stage 2-4 and (2) confirmed or suspected COVID–19 + persistent symptoms + respiratory dysfunction for > 4 weeks ).
| Service | Procedure Code (per unit | Payment |
|---|---|---|
| Pulmonary Rehabilitation | 94625,* 94626* | $56.85 |
| Cardiac Rehabilitation | 93797, 93798 | $118.55 |
*31-90 minutes
ADDITIONAL UPDATES
National social media campaign including infographic and social media blitz; "Pulmonary Rehabilitation & Cost Savings in the United States” in collaboration with 20 national scientific and clinical societies and patient organizations
- Legislative Activities and Updates
- AACVPR is collaborating with partner professionals to improve access to PR as well as cardiac and intensive cardiac rehabilitation (PR/CR/ICR) services for Medicare beneficiaries.
- MESSAGE: Two Bills Together = Powerful Progress for Programs & Patients!
- H.R.1406 — 118th Congress (2023-2024)To amend title XVIII of the Social Security Act to permanently extend certain in-home cardiopulmonary rehabilitation flexibilities established in response to COVID-19, and for other purposes. Sponsor: Joyce, John [Rep.-R-PA-13] (Introduced 03/07/2023)
H.R. 1406 will:
- Allow delivery of cardiopulmonary rehabilitation services via virtual (real-time, audio-video) telecommunications technology in the beneficiary’s home, designating that home as a provider-based location of a hospital outpatient department,
- Allow virtual direct supervision of physician, physician assistant, nurse practitioner, or clinical nurse specialist, through two-way audio-visual communications technology,
- Provide reimbursement for services delivered by a physician or a practitioner, or by a hospital,
- These flexibilities will be extended permanently.
- H.R.955 — 118th Congress (2023-2024)SOS: Sustaining Outpatient Services Act. Sponsor: Smith, Adrian [Rep.-R-NE-3] (Introduced 02/09/2023).This bill would end the current 40% payment reduction if a program relocated to a new or different off-campus location.
These bills are found on www.congress.gov Simply enter the bill # to get to bill information.
| ATS PR Working Group Members | |
|---|---|
| Chris Garvey – ATS, AACVPR | Trina Limberg – ATS, AACVPR, AARC |
| Brian Carlin – ATS, AACVPR, AARC, ACCP | Karen Lui – AACVPR |
| Rich Casaburi – ATS, COPD Foundation | Katy Menson – ATS, AACVPR |
| Judy Corn – ATS | Mike Nelson – ATS, ACCP |
| Rebecca Crouch – ATS, AACVPR, APTA | Miriam O'Day – AARC |
| Grace Anne Dorney Koppel – Dorney Koppel Foundation | Phil Porte |
| Gary Ewart – ATS | Carly Rochester – ATS |
| Mary Gawlicki – ATS, Gawlicki foundation | John Studdard – ACCP, AACVPR |
| Aimee Kizziar – AACVPR | |
*The Working Group thanks Alex Jenkins, Enya Daynes and Francois Abi Fadel for their expert help
