Medicare Part B pays for pulmonary rehabilitation services for patients with moderate to very severe chronic obstructive pulmonary disease (COPD). It also covers people recovering from COVID-19 who still have breathing problems lasting four weeks or more. These services usually happen in outpatient places like doctors’ offices, hospital outpatient departments, and until recently, through telehealth.
Number of Sessions: Medicare pays for up to 36 pulmonary rehabilitation sessions per patient. If more sessions are needed, providers can ask for another 36 sessions (making a total of 72) by submitting correct documentation using a KX modifier.
Billing Codes: Starting in 2024, the old code G0424 was replaced by two CPT codes:
These new codes match pulmonary rehab payments more closely with cardiac rehab services.
Reimbursement Rates: Medicare pays about $58.34 on average for a 60-minute pulmonary rehab session (code 94625) under payment class APC 5733.
Patient Costs: Patients usually pay 20% coinsurance when services are done in doctors’ offices. In hospital outpatient places, patients may pay deductibles and copays based on the provider’s billing rules.
Physician Oversight: A doctor must create and review an Individualized Treatment Plan (ITP) every 30 days. This plan supports continued treatment and billing.
Medicare added telehealth coverage for pulmonary rehab during the COVID-19 emergency. Patients could get services by telehealth anywhere in the country until September 30, 2025. After this date, telehealth payments will only cover rural areas. This may make it harder for patients in cities to get telehealth services and create more work for providers.
The Medicare Coverage Database (MCD) is an online tool run by the Centers for Medicare & Medicaid Services (CMS). It has Local Coverage Determinations (LCDs), Billing & Coding Articles, and National Coverage Determinations (NCDs). Providers use it to find policies and rules about Medicare-covered services like pulmonary rehab.
Before, Local Coverage Determinations (LCDs) included both policy and specific billing and coding instructions.
Now, for most Medicare Administrative Contractors (MACs) except Durable Medical Equipment (DME) MACs, coding and billing details like CPT/HCPCS codes, ICD-10 diagnosis codes, Bill Types, and Revenue codes have moved into Billing & Coding Articles.
DME MACs still keep coding details inside their LCDs.
Admins and billing staff can use the MCD Search tool by typing CPT or HCPCS codes like 94625 or 94626 along with their state. The results will show related Billing & Coding Articles or LCDs. Contact info for the contractors is at the top of these documents to answer billing or coverage questions.
The MCD updates its coverage and coding data weekly, usually on Thursdays.
If the data looks old, users should click “Reset Search Data” in Settings.
The MCD needs browsers with JavaScript turned on to work properly.
Technical problems like slow searches, broken links, or timeouts should be told to Medicare technical support.
Each U.S. region has a Medicare Administrative Contractor (MAC). MACs release LCDs and Billing & Coding Articles for their region. They manage claims processing and coverage rules in their area.
If providers have billing problems or claim denials, they should first contact their MAC. The MAC can explain:
MAC contact information is listed on the CMS website and at the top of each LCD or Billing & Coding Article.
Pulmonary rehab programs have had billing problems because payment methods are old and do not reflect the true cost of services. Nurse practitioner Chris Garvey says many hospitals did not update billing since the bundled code G0424 started in 2010. This caused low payments and reimbursement rates that do not match the work involved in pulmonary rehab.
Dr. Francois Abi Fadel, chief of pulmonary medicine at the VA Western New York Healthcare System, recommends providers work with hospital billing teams to make sure charges are reported correctly. This helps Medicare make better cost reports and improve payment amounts over time.
Another challenge is Medicare lowering telehealth coverage for pulmonary rehab after September 2025. Providers, especially in cities, will need to plan for more visits in person and change how they manage payments.
Claim denials happen sometimes because of complex coding rules and changing coverage policies. If a pulmonary rehab claim is denied, providers should:
This process helps find out if the denial is from changes in coverage, missing paperwork, or mistakes in the claim.
Managing pulmonary rehab programs is hard work for office staff and administrators. New tools using artificial intelligence (AI) and automation can make work easier, improve records, and cut billing mistakes.
Simbo AI offers phone automation and answering service tools using AI. These tools can:
AI systems can help by:
Using AI for these tasks lowers human errors and saves staff time. It also improves communication and helps follow Medicare’s changing rules.
IT managers can connect AI phone assistants and workflow automation with Electronic Health Records (EHR) and practice management systems. This makes patient data, scheduling, and billing codes flow smoothly. It helps send claims correctly and cuts down delays.
Medical practice administrators and owners managing pulmonary rehab services can improve billing and coding by:
Regular Training: Keep staff up to date on Medicare code changes, coverage policies, and how to use the MCD. Set time for monthly reviews or webinars.
MAC Liaison: Pick a staff member to be the main contact with the regional Medicare Administrative Contractor. Use MAC help to answer billing questions quickly.
Use MCD Effectively: Make the Medicare Coverage Database a regular part of billing work. Learn to search by CPT or HCPCS codes and check state-specific coverage info.
Leverage AI Tools: Use AI phone automation and workflow management tools like those from Simbo AI to improve efficiency and reduce mistakes.
Documentation Compliance: Work with clinical teams to keep Individualized Treatment Plans (ITPs) reviewed on time and all medical paperwork current.
Plan for Telehealth Changes: Watch CMS rules about telehealth coverage after 2025 and adjust your program and patient notices as needed.
Understanding Medicare billing and coding for pulmonary rehabilitation means keeping up with new codes, rules, and coverage policies. The Medicare Coverage Database is an important tool for getting current info and sorting out payment questions. Medical administrators should work with their Medicare Administrative Contractors and use AI tools to make workflows easier and billing more accurate.
Using these resources and tools well lets healthcare providers run their programs smoothly and support good pulmonary rehabilitation care.
Contact your Medicare Administrative Contractor (MAC). You can find MACs in the MAC Contacts Report on the CMS website.
Codes are now primarily found in Billing & Coding Articles, rather than in Local Coverage Determinations (LCDs). Use the MCD Search to find codes.
A Change Request (CR) provides instructions for modifying claims processing systems at both the national and local levels based on policy changes.
For Durable Medical Equipment (DME) MACs, CPT/HCPCS codes are still located in LCDs; however, other codes like ICD-10 have moved to Articles.
Enter the CPT/HCPCS code in the MCD Search and select your state. Review the relevant Billing and Coding Article for coverage information.
Check the denial letter for details, use the MCD Search with keywords from the letter, contact your MAC, or call 1-800-Medicare.
NCDs provide coverage policies but do not include claims processing information like codes; supplementary information is available through CRs and the CPM.
MCD is used to look up local coverage, coding guidelines, and claims processing information for various services, including pulmonary rehabilitation.
The MCD data refreshes weekly; if you experience issues, use the Reset Search Data function found in the settings menu.
If you face technical issues, contact technical support for help with broken links, reports not running, or slow search responses.
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