Medicare Part B (Medical Insurance) covers pulmonary rehabilitation programs for people with long-term lung diseases. This mainly includes patients with moderate to very severe COPD and those with COVID-19 who still have breathing problems for at least four weeks. Patients need a doctor’s referral to get these services through Medicare.
Medicare pays for services that help improve breathing, build muscle strength, and help patients do daily activities more easily. Programs include supervised exercise sessions along with education and counseling.
Services can be given in different places, such as:
After October 1, 2025, telehealth will only be covered if the patient is in a rural office or medical facility. This may limit access for people living in cities who use virtual programs.
When patients use Medicare Part B for pulmonary rehab, they usually pay 20% of the approved cost if the service is in a doctor’s office. In hospital outpatient departments, patients pay a copay for each session and may have to meet the deductible first. Costs can be different depending on the provider and the billing method.
Billing for pulmonary rehab has changed over time. At first, hospitals used a code called G0424 for all services. This code was created more than 20 years ago. Over time, payments with this code have not kept up and may not reflect the real cost of care.
To fix this, in 2024, CMS started using new CPT codes 94625 and 94626 to replace G0424. These new codes pay better and are more like those used for heart rehab, which usually pays more.
Current CPT codes for pulmonary rehab are:
Medicare pays $58.34 per 60-minute session under APC 5733.
Session limits are:
Every session must include exercise, but Medicare does not say what kind or amount. Providers must make an Individualized Treatment Plan (ITP). A doctor reviews and signs this plan at the start of care and every 30 days after. The plan states the patient’s goals and supports billing for extra sessions.
Even though pulmonary rehab helps patients breathe better and improves outcomes, money issues remain for hospitals and providers. Chris Garvey, a nurse practitioner who works with pulmonary rehab, said that part of the problem with low payments is that hospitals did not change how they billed after the bundled payment code G0424 came in 2010.
Hospitals often report lower costs for pulmonary rehab. This affects Medicare’s cost reports and leads to lower payments than what heart rehab gets. Dr. Francois Abi Fadel, chief of pulmonary medicine at the VA Western New York Healthcare System, suggests that providers work with hospital billing teams to make sure charges for pulmonary rehab are reported correctly.
Access is also a concern, especially in rural areas. Telehealth helped more people get pulmonary rehab during COVID-19, but after September 2025, coverage for telehealth will be limited. This can make it harder for people who cannot travel to a clinic.
The COVID-19 pandemic showed the need for pulmonary rehab for patients with long-term breathing problems after infection. Medicare now covers pulmonary rehab for people with confirmed or suspected COVID-19 who have symptoms lasting four weeks or more. They do not have to be hospitalized or do lung function tests to qualify.
Codes 94625 and 94626 include COVID-related cases, showing that the program fits current health needs and pays the same as for other patients.
Providers need to learn Medicare billing rules for pulmonary rehab. CMS offers detailed billing guides and updates through official requests and manuals.
If providers have questions about billing or coding, they should contact their Medicare Administrative Contractor (MAC). MACs handle Local Coverage Determinations and give advice for specific states or regions. Contact info is available in Medicare databases and CMS sites.
Patients who want to know about coverage and costs can call 1-800-Medicare or visit Medicare.gov. They should also ask their healthcare providers about copays, clinic fees, and coverage options.
Managing pulmonary rehab programs takes a lot of work. This includes scheduling appointments, tracking session times, using the right billing codes, and keeping good records like the Individualized Treatment Plan and doctor approvals.
Medical administrators and IT managers can use AI-powered automation tools to make these tasks easier and reduce mistakes. For example, companies like Simbo AI offer AI-powered phone systems that help with communication and administration.
Benefits of using AI automation for pulmonary rehab programs include:
Using AI front-office automation tools can reduce the workload for staff and improve patient experience by offering 24/7 availability for phone calls, which human operators may not always provide.
By knowing these details and using technology tools, administrators and managers can better run pulmonary rehab programs, get the right Medicare payments, and help patients get respiratory care.
These codes replace G0424 and aim to better align pulmonary rehabilitation (PR) reimbursement with cardiac rehabilitation, addressing previous reimbursement disparities.
Reimbursement has stagnated for over two decades since the introduction of bundled code G0424, leading to underreporting and undervaluing of PR services.
Coverage now includes confirmed or suspected COVID-19 patients with persistent respiratory symptoms for at least four weeks, without hospitalization or PFT requirements.
The physician must review and sign the individualized treatment plan at the start of care and every 30 days, allowing for additional billing under the physician’s fee schedule.
Medicare covers up to 36 sessions, with an additional 36 if medically necessary, requiring documentation of medical necessity for sessions 37-72.
The payment for these codes is $58.34 for 60 minutes of pulmonary rehabilitation.
Each session must include exercise as part of the treatment, though specific types and amounts are not mandated.
The ITP outlines the patient’s rehabilitation goals and is critical for ongoing monitoring and medical necessity for billing.
Challenges include inadequate reimbursement rates, ineffective billing practices, and access issues, especially in rural areas after the termination of certain emergency provisions.
Hospitals should work with billing staff to reconcile charges and reflect the complexity of new billing codes in their Medicare Cost Reports.
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