Respiratory Question for the Week of January 8, 2024

Question:

What are the billing requirements for pulmonary rehabilitation (PR) codes 94625 and 94626?

Answer:

Medicare will reimburse for a maximum of two one-hour sessions per day, for up to 36 sessions for up to 36 weeks for Pulmonary Rehabilitation Program services when documentation supports clinical requirements as set forth in CMS’s Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 231, Medicare Claims Processing Manual, Publication 100-4, Chapter 32, Section 140.4, and National Coverage Determination for Pulmonary Rehabilitation Services, Section 240.8. Programs must provide a comprehensive, evidence-based multidisciplinary intervention for patients with chronic respiratory impairment. Hospitals and practitioners may report a maximum of two 1-hour sessions per day. In order to report one session of PR in a day, the duration of treatment must be at least 31 minutes. Two sessions of PR may only be reported in the same day if the duration of treatment is at least 91 minutes. Physical therapists cannot bill PT codes separately if they conduct assessments and individual treatment services as part of a PR program. The PT services are included as part of the overall treatment plan for PR and are encompassed under CPT®/HCPCS codes 94625 and 94626.