Pulmonology Coding Alert

Question: We reported G0424 (Pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to two sessions per day) for a COPD patient and it got denied. The patient’s COPD definitely qualified him for the service, so what else could be the problem?

Codify Subscriber

Answer: Make sure the pulmonologist writes a referral order for the pulmonary rehab program, and that you stick to the insurer’s strict guidelines for the service. CMS carries the following restrictions when billing for this service:

• Where: Physician office, hospital outpatient setting.
• Who qualifies: Patients with mild to moderate COPD, according to Gold classification II, III or IV. The pulmonary function tests (PFT) results need to exhibit forced vital capacity (FVC), forced expiratory volume (FEV1), and/or a carbon monoxide diffusing capacity (DLCO) of less than 65% of predicted volumes.
• What must the plan of care include: The plan that the pulmonologist prescribes and signs should detail the specific exercises that the patient should perform, including the exercise mode, intensity, duration, and frequency of the exercise.
• How long: Medicare will pay for up to two one-hour sessions per day, for up to 36 lifetime sessions (up to 72 hours).

Keep in mind: Each Medicare contractor may have its own Local Coverage Determination explaining what is covered under pulmonary rehabilitation services, so check with your carrier if you wish to bill for these services. Additionally, payers may want to verify that the patient criteria has been met, so be sure to keep this information accessible for payer review.