Pulmonary Rehabilitation and Respiratory Therapy Services in the Physician Office Setting* Sam Birnbaum, BBA, CMPE; and Brian Carlin, MD, FCCP

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1 CHEST Topics in Practice Management Pulmonary Rehabilitation and Respiratory Therapy Services in the Physician Office Setting* Sam Birnbaum, BBA, CMPE; and Brian Carlin, MD, FCCP Pulmonary rehabilitation services benefit patients with chronic lung disease by reducing symptoms and restoring independent function. With a multidisciplinary approach to individual patient care through education, exercise, and psychosocial interventions, health-care costs and utilization may be reduced. While pulmonary rehabilitation services have typically been provided in a facility setting, many respiratory care services can be safely provided and appropriately reimbursed in the outpatient physician office setting, with appropriate physician supervision. After reviewing the utility of pulmonary rehabilitation for patients with chronic lung disease, the supervision, documentation, coding, and reimbursement requirements for providing rehabilitative respiratory care services in the outpatient office setting are detailed. (CHEST 2006; 129: ) Key words: coding; documentation; physician office; pulmonary rehabilitation Abbreviations: CPT current procedure terminology; RCP respiratory care practitioner Pulmonary rehabilitation is now considered to be a mainstay of treatment for patients with chronic lung disease. The goals of pulmonary rehabilitation are to reduce symptoms, improve activity and daily functioning, and restore the highest level of independent functioning in patients with respiratory disease. 1 Key elements include a multidisciplinary approach to care with a focus on the individual patient through education, exercise, and psychosocial interventions. Appropriate candidates for pulmonary rehabilitation are symptomatic patients with chronic lung disease who are aware of their disability and are motivated to participate actively in their health care. They include not only patients with COPD but also *From Medical Practice Management (Mr. Birnbaum), Hilton Head Island, SC; and Drexel University School of Medicine (Dr. Carlin), Pittsburgh, PA. Manuscript received October 28, 2005; revision accepted November 29, Reproduction of this article is prohibited without written permission from the American College of Chest Physicians ( org/misc/reprints.shtml). Correspondence to: Brian Carlin, MD, FCCP, Assistant Professor of Medicine, Drexel University School of Medicine, Allegheny General Hospital, Suite 300, 490 East North Ave, Pittsburgh, PA ; bcarlin@wpahs.org those with restrictive lung disease (eg, interstitial, alveolar, pleural-based, and neuromuscular types) and cystic fibrosis. Pulmonary rehabilitation has been shown to result in many benefits, including improvements in exercise performance, reduction of dyspnea, improvement in health-related quality of life, and reduction in health-care utilization. 1 7 A recent multicenter, community-based experience 8 (known as the California Collaborative) included nine centers enrolling a total of 647 patients, and showed consistent benefits in dyspnea and quality of life as well as a reduction in health-care utilization (eg, physician visits, telephone calls, hospital days, and urgent care visits) over an 18-month follow-up period. In the recent National Emphysema Treatment Trial, 9 a study of lung volume reduction surgery by the National Institute of Health and the Centers for Medicare and Medicaid Services, pulmonary rehabilitation was included as part of the standard care for patients who were enrolled in the trial. According to the Global Initiative for Chronic Lung Disease consensus statement on the management of COPD, 10 pulmonary rehabilitation should be considered for patients with an FEV 1 of 80% of CHEST / 129 / 1/ JANUARY,

2 the predicted value. Additionally, most national and international guidelines consider pulmonary rehabilitation to be an important treatment option for patients with COPD. 2,11 A recent state-of-the-art article 12 recommended that rehabilitation programs should be part of the therapeutic options for the treatment of a patient with chronic lung disease. Although most commercial insurers and Medicare have recognized the value of pulmonary rehabilitation for their beneficiaries for almost 3 decades, 7 no National Coverage Determination from the Centers for Medicare and Medicaid Services exists for pulmonary rehabilitation, and the reimbursement coverage policies for these services remain inconsistent and confusing. Some commercial insurers have established clear reimbursement policies that recognize the value of pulmonary rehabilitation Nonetheless, others have confusing, inadequate, or nonexistent coverage and reimbursement policies. Many patients undergoing pulmonary rehabilitation are Medicare beneficiaries, and most commercial insurers tend to follow the Medicare policies. Although Medicare currently does not provide specific coverage for pulmonary rehabilitation programs, some of the individual and separately billable components of pulmonary rehabilitation that are identified as respiratory therapy services are clearly covered. The Medicare 2002 physician fee schedule included three new Health Care Financing Administrators Common Procedure Coding System codes, which have been described in the Federal Register as new codes to improve respiratory function. 19 These codes, G0237, G0238, and G0239, are identified as respiratory therapy services, are generally accepted by many payers, and are defined as follows: G0237: therapeutic procedures to increase the strength or endurance of respiratory muscles, which are conducted face-to-face and one-on-one, each of which is charged in 15-min units (includes monitoring); G0238: therapeutic procedures to improve respiratory function, other than those described by code G0237, which are conducted one-on-one and face-to-face, charged in 15-min periods (includes monitoring); and G0239: therapeutic procedures to improve respiratory function, or to increase the strength or endurance of respiratory muscles, conducted with two or more individuals (includes monitoring). However, many payers, including Medicare contractors, may have caveats precluding appropriate beneficiary coverage. Some commercial insurers are amenable to contracting either per diem or by a flat rate for a pulmonary rehabilitation program per patient. Patients with the most severe diseases and, consequently, no potential for rehabilitation, or patients lacking motivation and family support may not be viable candidates for pulmonary rehabilitation. Other issues potentially precluding participation include lack of transportation and inadequate financial resources for copayments and coinsurance. 20 Place of Service Codes G0237, G0238, and G0239 can be provided in a variety of settings, but the rules for the provision of care may vary according to the setting. In a physician office, these codes are considered incident to a physician service, and, therefore, a physician must be present in the office suite. In a physician office, codes G0237 and G0238 are timebased and are reimbursed according to the number of units (usually, 15 min per unit) documented and performed per day. Code G0239 is a single-charge code per day. Scope of Practice Services may be provided by a variety of healthcare professionals comprising the pulmonary rehabilitation team. For reimbursement purposes, respiratory therapists (ie, respiratory care practitioners [RCPs]), nurses, and other ancillary staff typically deliver these services according to their scope of practice, as regulated by their state licensure laws. No prohibition exists to providing these services incident to a physician s service in the office setting under Medicare rules. Request for Services Patients being referred for respiratory therapy services should have a written prescription from the referring physician. As with all written orders, this prescription should identify the patient, show the treating diagnosis, describe the frequency of visits, and define the term of the treatment regime. Also, the written order requesting the respiratory service should be accompanied by any appropriate diagnostic test reports, such as pulmonary function studies, chest roentgenograms, arterial blood gas analyses, and 6-min walk test results. Respiratory Therapy Service Codes Applications and Examples Code G0237 Code G0237 involves therapeutic procedures that are specifically targeted at improving the strength 170 Topics in Practice Management

3 and endurance of respiratory muscles. Examples include pursed-lip breathing, diaphragmatic breathing, and paced breathing (ie, strengthening the diaphragm by breathing through tubes of progressively increasing resistance to flow). Code G0238 Code G0238 involves a variety of activities, including teaching patients strategies for performing tasks with less respiratory effort, and the performance of graded activity programs to increase the endurance and strength of the upper and lower extremities. Codes G0237 and G0238 are time-based and are reported for each 15-min period of one-on-one, face-to-face treatment. More than one unit per patient per day can be reported, depending on the duration of treatment and the amount of time documented in the medical record. Code G0239 Code G0239 represents situations in which two or more patients are simultaneously receiving services (such as those described above in codes G0237 or G0238) during the same time period. The RCP or nurse must be in constant attendance but need not be providing one-on-one contact. For example, an RCP provides medically necessary therapeutic procedures to two patients (A and B) in the same area, for a 30-min period. Both patients perform different graded activities (described by code G0238) to increase the endurance of their upper and lower extremities, while the RCP divides his/her time in intermittent, brief episodes between patients A and B. In this scenario, the RCP bills each patient for group therapy (G0239), because the treatment was provided simultaneously to two patients, and not one-on-one, as required by code G0238. Code G0239 is not a timed code and should be reported only once a day for each patient in the group. 21 The Correct Coding Initiative applies to these respiratory services codes. It is possible to bill using codes G0237 and G0238 for the same patient on the same day, but billing using code G0239 cannot be done on the same day as billing for codes G0237 and G0238. Only one unit of G0239 may be billed per patient per day. Other CPT Codes Other procedures and codes may be used in conjunction with the respiratory service codes. Some are included and bundled into these respiratory service codes, such as monitoring with pulse oximetry, electrocardiography, maximal inspiratory and expiratory pressures, BP measurements, other measurements of strength and endurance, and education of patients regarding the control the sensation of dyspnea, the application of pursed lip breathing techniques, and the measurement of peak respiratory flow. 14 Other CPT codes excluded from the respiratory therapy service codes include pulmonary function testing (codes 94010, 94060, 94375, 94620, and 94621), pulmonary treatments (codes 94640, 94664, 94667, and 94668), and evaluation and management codes (codes to and to 99245), any of which may be billed separately, and are generally reimbursed separately by Medicare and most other payers. Documentation Requirements Codes G0237 and G0238 are time-based code, and the actual time spent providing the service must be documented. The time must be accumulated per code and reported as such. There may be no overlapping of time by multiple providers. Codes G0237 and G0238, which are used for therapy modalities, procedures, tests, and measurements, specify the time spent in 15-min increments. Providers report using codes G0237 and/or G0238 for services delivered on any calendar day, using the appropriate number of units of each service. As with physical medicine and rehabilitation coding, Medicare allows providers to report services with an 8-min minimum duration. For any single code, report a single 15-min unit for treatment 8 min and 23 min. If the duration of a single modality or procedure is 23 min and 38 min, report two units. Time intervals for larger numbers of units are as follows: 3 units for 38 min to 53 min; 4 units for 53 min to 68 min; 5 units for 68 min to 83 min; 6 units for 83 min to 98 min; 7 units for 98 min to 113 min; and 8 units for 113 min to 128 min. The pattern remains the same for treatment times that exceed 2 h. However, do not report services performed for 8 min. If more than one CPT code is reported during a calendar day, the total number of units that can be reported is constrained by the total treatment time. For example, if 24 min of time reported under code G0237 and 23 min of time reported under code G0238 were furnished on the same day, the total treatment time was 47 min, and only 3 units can be reported for the day s treatment. Correct coding mandates reporting 2 units of code G0237 and 1 unit of code G0238, assigning more units to the service that took the most time. CHEST / 129 / 1/ JANUARY,

4 Note that the schedule of times listed above is intended to provide assistance in rounding time into 15-min increments. It does not imply that any minute until the eighth minute should be excluded from the total count, since the timing of active treatment counted includes all time. Some payers who accept these G-codes may not follow the Medicare 8-min-minimum rule, requiring a 15-min threshold before reporting additional units. Codes G0237 and G0238 are for direct (one-onone) activities or procedures. The provider must report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Predelivery and postdelivery services are not to be counted in determining the treatment service time. The time counted equals the time the patient is treated. In other words, two therapists (of the same or different disciplines) working with a single patient for 15 min at the same time equals 15 min of treatment, not 30 min of treatment. 14 Medical Necessity All respiratory services must be reasonable and necessary. Establish medical necessity by identifying the appropriate International Classification of Diseases, ninth revision, clinical modification, diagnosis code that most accurately describes the patient s disease and by reporting that diagnosis code with the submitted claim. As examples, pulmonary rehabilitation may be considered a covered service for sarcoidosis, cystic fibrosis, chronic bronchitis, emphysema, bronchiectasis, and various forms of interstitial lung disease. 22 Some payers have specific medical policies that specify those diagnoses that establish medical necessity. 11 The policy of each payer should be researched on each hospital admission as these policies frequently change. Certification Previously, Medicare and some other insurers required providers of respiratory therapy services to submit a 30-day certification and recertification of the plan of care. Since these respiratory therapy services are generally provided by RCPs or nurses in a physician office setting, this certification, in general, does not apply. Respiratory therapy services are separate and distinct from both physical therapy and occupational therapy, and should not be confused with these disciplines that have a separate series of CPT codes. 14 For example, physical therapists providing these services should not report these G- codes, but rather CPT codes to (typically, CPT code 97110). 19 Problems and Pitfalls There are a number of problems and pitfalls for providers rendering respiratory therapy services as an element of pulmonary rehabilitation. Foremost among the problems is the lack of a National Coverage Determination, resulting in variability of coverage decisions and regulatory guidance among all payers. Some Medicare contractors publish local coverage determinations or local medical review policies, which give some helpful guidance to providers regarding the reimbursement requirements of respiratory therapy services. These are found at Another issue caused by the variability among payers is confusion as to the frequency with which these services may be rendered, resulting either in underutilization with poor patient outcomes or overutilization with carrier denials. Last, the onerous time keeping and documentation thereof is inefficient and may detract from patient care. Conclusions Respiratory therapy services are an important element of pulmonary rehabilitation and are of proven benefit. These services should be expanded from the facility setting to the physician-supervised office setting. Perhaps in the future, in selected patient populations, these services could be provided even without direct medical supervision. References 1 American Thoracic Society (ATS). Pulmonary rehabilitation: Am J Respir Crit Care Med 1999; 159: American College of Chest Physicians (ACCP). Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest 1997; 112: Ries AL, Kaplan RM, Limberg TM, et al. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995; 122: Verrill D, Barton C, Beasley W, et al. The effects of short-term and long-term pulmonary rehabilitation on functional capacity, perceived dyspnea, and quality of life. Chest 2005; 128: Lacasse YL, Brousseau L, Milne S, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev (database online). Issue 3, Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001; 56: Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000; 355: California Pulmonary Rehabilitation Collaborative Group. Effects of pulmonary rehabilitation of dyspnea, quality of life, and healthcare costs in California. J Cardiopulm Rehabil 2004; 24: Topics in Practice Management

5 9 National Heart, Lung, and Blood Institute. National Emphysema Treatment Trial (NETT): evaluation of lung volume reduction surgery for emphysema. Available at: nhlbi.nih.gov/health/prof/lung/nett/lvrsweb.htm. Accessed July 25, Fabbri LM, Hurd SS. Global strategy for the diagnosis, management, and prevention of COPD: 2003 update. Eur Respir J 2003; 22: British Thoracic Society, Standards of Care Subcommittee on Pulmonary Rehabilitation. Pulmonary rehabilitation. Thorax 2001; 56: Troosters T, Casaburi R, Gossselink R, et al. Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005; 172: CIGNA. CIGNA health care coverage position number Availableat: coverage_positions/medical/mm_0212_coveragepositioncriteria_ pulmonary_rehabilitation.pdf. Accessed July 24, Aetna. Clinical policy bulletin. Available at: com/cpb/data/cpba0032.html. Accessed November 28, Regence Group. Medical policy. Available at: regence.com/trgmedpol/um/um07.html. Accessed November 28, Empire Blue Cross Blue Shield. Pulmonary rehabilitation. Available at: medpol ther php. Accessed November 28, Blue Cross Blue Shield of Vermont. Corporate Medical policy: pulmonary rehabilitation. Available at: bcbsvt.com/pages/medicalpolicies/pulmonary.htm. Accessed November 28, Blue Cross Blue Shield of North Carolina. Corporate medical policy. Available at: Accessed November 28, Federal Register. Rules and regulations. November 1, 2001; 66(212): American Association for Respiratory Care (AARC). AARC clinical practice guideline: pulmonary rehabilitation. Available at: Accessed May 30, Federal Register. Rules and regulations. December 31, 2002; 67(251): United Government Services, LLC LMRP. Outpatient pulmonary rehabilitation. Available at: LMRP_UGS/OutPt%20Pulm%20Rehab%20LCD% pdf. Accessed July 26, CHEST / 129 / 1/ JANUARY,