OPR Coverage – Is this What we Expected?

On May 7, Medicare finally released the transmittals which summarize the basic rules for documentation, coding and billing of outpatient pulmonary rehabilitation (OPR) services. Multiple updates to the Medicare manuals were provided via two CMS transmittals – 124 (CR 6823) and 1966 (CR 6823) which describe the national coverage guidelines for OPR. 

Gone are the two G-codes which once defined one-on-one sessions as 15-minute increments. Also gone is the separate G-code for group sessions. A single HCPCS now describes the billable service which is reported in 1-hour increments.

 G0424: Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session

Also gone is application of the 8-minute rule for billing the first unit of service. The new HCPCS requires a minimum of 31-minutes of service be recorded before billing an exercise session. 

• 1 billable unit = 31 – 90 minutes must be recorded to bill for the first hour.
• 2 billable units = 91- 150+ minutes must be recorded for a second unit of service.
• A maximum of 2 billable units is allowed even if time recorded exceeds 151 minutes.
• Multiple sessions of 30 minutes or less are added together to calculate a 1-hour billable increment.

In addition to exercises for strength and endurance, each session must include some aerobic exercise. Documentation of each form of exercise as well as the start and stop time for each will be integral to ensuring accurate billing and payment of services.

The new guidelines stipulate that the supervising physician be “substantially involved” in the program providing consultation with staff and direct patient contact with regard to the patient’s treatment plan. 

Regardless of the setting – physician clinic or outpatient hospital department – the supervising physician and department personnel must be able to adequately respond to an emergent situation. Additionally, the new guidelines stipulate that a “physician must be immediately available and accessible for medical consultations and emergencies at all times when services are being provided under the program.”

Unfortunately, CMS has once again not defined the term “immediate”, but provides example of the lack of immediate response:

• a physician who is performing another procedure or service that he or she could not interrupt in order to respond to an emergency,
• the physician has limited ability to intervene right away because of being physically located on-campus at a distance far away from the rehabilitation area.   

What’s New @ MediRegs Tuesday May 11, 2010 - R1966CP Pulmonary Rehabilitation (PR) Services

 What’s New @ MediRegs Thursday May 27, 2010 - MLN Matters® Number: MM6823

Submitted by: Robin Miller Zweifel, MT (ASCP)

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