The passing of CMS’ final rule for national coverage of pulmonary rehabilitation (PR) services, does not mean you are free from trouble when coding for your pulmonologist’s outpatient PR program or expanded in-office PR services.

But then worry not. You can take up some important PR coding and coverage insights from these three common situations.

Pulmonologist does not provide direct PR Care

The pulmonolist may not be involved directly, however you will not be short of coding choices. CMS guidelines need a thorough pulmonary rehabilitation program to be physician-supervised. It includes doctor-prescribed exercise, education or training, psychosocial assessment, outcomes assessment, and an individualized treatment plan.

Pulmonologists may bill evaluation/management codes for periodic visits to evaluate the patient’s underlying condition, any exacerbations, and response to therapy. For instance, report follow-ups with an E/M code like 99214 to assess the medical management of the patient’s COPD.

Do not overlook: When there is PR care involved, associated services and equipment are never far behind. Report any pulmonary function tests the pulmonolist carries out unrelated to PR monitoring while some equipment provided in the office setting may be billable for certain diagnoses using these HCPCS codes: A4614, A4627, A7003

Nonphysician practitioner provides RT care

When nonphysican practitioners (NPP), such as respiratory care practitioners, registered nurses, physical therapists (PTs), and occupational therapists (OTs), fill in for the pulmonologist on subsequent PR care, you have to code appropriately based on the type of provider who is providing the service. Select from the following G codes when a respiratory therapist, a registered nurse or qualified ancillary staff provides the pulmonary function service: G0424, G0237, G0238, G0239.

3. PR service needs justification

PR coverage includes individuals with moderate to very severe COPD. Depending on your local Medicare contractor, patients with other pulmonary-related diseases may be eligible for coverage of respiratory therapy services. But you’d bill it as respiratory care services using G0237, G0238, and G0239.

In addition, auditors would want to see documentation that the patient is making progress toward goals since PR is meant to improve respiratory function.

Key: Be specific when defining your goals. For example, you may specify the activity rather than saying the patient wants to breathe better. What’s more, when ordering a PR program, the pulmonogist should specify type, frequency and duration. An ideal outline of the schedule may state that a patient needs to attend six-week PR program, two days each week for four weeks, and three days per week for two weeks, for two to four hours each day. See to it that the PR program is unique and tailor-made for an individual.

For more pulmonology coding, Medical Coding updates, sign up for an audio conference.