Pulmonary rehabilitation (PR) has experienced some changes in 2022 including new codes. By gaining better comprehension of this service, RT healthcare coding and billing professionals can help ensure accurate coding while safeguarding full reimbursement. Let’s take a look at some of the details and changes that will impact your coding and billing.
Coding Changes for 2022
Understand that historically and until December 31, 2021, PR services completed as a part of a comprehensive PR program benefit, were reported using HCPCS Level II code G0424:
|G0424||Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day.|
2022 saw the arrival of two brand new codes for reporting these services. The codes are differentiated by the need for continuous oximetry monitoring:
|94625||Physician or other qualified health care professional services for outpatient Pulmonary rehabilitation; without continuous oximetry monitoring (per session)
Revenue Code: 0948
|94626||Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session)
Revenue Code: 0948
So, what APC have these new codes been assigned to? Both codes are assigned to APC 5733 (Level 3 Minor Procedures). This is the same APC to which G0424 had been assigned previously—in the 2022 OPPS final rule, with a simulated “per-session” median cost of approximately $56.85 for 2022.
With new codes many coders may wonder what exactly are the billing requirements for these codes and are there any special areas of concern? Understand that in the hospital outpatient setting, payment for PR services will be set by establishing a clinical APC with a median “per session” cost, simulated from historical claims data for similar pulmonary therapy services. Note that Physical therapists cannot bill PT codes separately if they conduct assessments and individual treatment services as part of a PR program. Know that the PT services are now included as part of the overall treatment plan for PR and must be billed using the new CPT® codes 94625–94626 for 2022.
Direct Physician Supervision History
The pandemic created some noteworthy changes to direct supervision requirements that may prove to be confusing, however it is important to understand the circumstances beforehand. Prior to the COVID-19 Public Health Emergency (PHE), CMS rules have traditionally stated that non-physician practitioners, (physician assistants, nurse practitioners, and others) are not permitted to provide “direct supervision” under the PR program in either the physician office or hospital outpatient setting. This also applied to cardiac rehabilitation (CR) and intensive cardiac rehabilitation (ICR). CMS maintained that the law is very specific in using the term “physician” for supervised programs, and that there was no flexibility in expanding the definition to include non-physician practitioners.
Understand that “Direct supervision” by definition required the physician to be “present on the same campus and immediately available to furnish assistance and direction throughout the performance of the procedure.”
For hospitals or CAHs, the “geography” of direct supervision has historically applied to:
- areas in the main buildings of a hospital or CAH that are under the ownership
- and financial and administrative control of the hospital or CAH;
- areas that are operated as part of the hospital; and
- for which the hospital bills the services furnished under the hospital’s or CAH’s CMS Certification Number (CCN).
Note that the direct supervision requirement waiver for small rural PPS hospitals (100 beds or fewer) and CAHs initially expired on December 31, 2014, and again, December 31, 2016.
However, understand that in the 2018 final rule, CMS reinstated the non-enforcement of direct supervision requirements for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for the next two years—2018 and 2019. During the 2020 final rulemaking, CMS finalized a change to the generally applicable minimum supervision level from direct supervision to general supervision.
It is important to know that under general supervision “the procedure is furnished under the physician’s overall direction, but the physician’s presence is not required during the performance of the procedure.” In addition, beginning in 2014, payment for “incident to” hospital or CAH outpatient services (sometimes referred to as hospital or CAH “therapeutic” services) was amended to explicitly require that individuals furnishing these services be in compliance with state law.
Therefore, hospitals and CAHs are encouraged to continue using the APC Advisory Panel process established in 2012 to request changes they believe would be appropriate in supervision levels for individual hospital outpatient therapeutic services. This is especially true for those that have not yet been evaluated by the panel including:
- blood transfusion
- radiation therapy
- and wound care services.
Direct Supervision in 2020 and Beyond
In 2020 and continuing into 2022, as a result of the COVID-19 PHE, additional waivers were granted. The definition of direct supervision was updated to include, during the PHE, a virtual presence through the use of interactive telecommunications technology, for services paid under the Medicare Physician Fee Schedule as well as for hospital outpatient services. This includes:
- and intensive cardiac rehabilitation services.
Moreover, direct supervision requirements were relaxed to allow general supervision throughout hospital outpatient non-surgical extended duration therapeutic services. General supervision may also include a virtual presence through the use of telecommunications technology as well as audio-only. Being mindful of these changes and others are key to encouraging success throughout the year for RT coding and billing.
Explore more billing tips and insight for respiratory CPT coding by ordering our Coding Essentials for RT/Pulmonary Function resource.