Billing Code Overview

HCPCS Level II code G0238 describes therapeutic procedures to improve respiratory function, other than described by G0237, provided one-on-one, face-to-face, per 15 minutes (includes monitoring). This code represents an individual component of outpatient respiratory therapy or pulmonary rehabilitation that is billed in 15-minute increments. Typical sites of service include outpatient settings such as a comprehensive outpatient rehabilitation facility (CORF) or other rehabilitation clinics. Data not available in the input.

Clinical Context

A 68-year-old patient with chronic obstructive pulmonary disease (COPD) presents to an outpatient rehabilitation clinic for individualized respiratory therapy to improve pulmonary function and reduce dyspnea. The patient is seen one-on-one by a respiratory therapist for focused therapeutic procedures such as airway clearance techniques, breathing retraining, chest physiotherapy, and monitored endurance exercises. Each 15-minute face-to-face interval of these therapeutic procedures is documented and billed using HCPCS Level II code G0238 (therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes, includes monitoring). The clinical workflow includes pre-session assessment of respiratory status and oxygen saturation, delivery of the therapy with continuous monitoring as indicated, documentation of time-based units in 15-minute increments, and post-session reassessment with progress notes forwarded to the supervising pulmonary disease physician. Typical payors for coverage determinations include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.

Coding Specifications

• Modifier 59 — Distinct Procedural Service: used when a separate, identifiable service is performed on the same date of service that is not normally billed together; apply when documentation supports a separate procedure distinct from other services that day.

• Modifier 76 — Repeat Procedure by Same Physician: used when the same practitioner performs a repeat procedure or service on the same day; apply when the record documents a separate, subsequent session of the same therapeutic intervention.

• Associated provider taxonomies and specialties:

• Pulmonary Disease Physician — taxonomy 207RP1001X: represents physicians specializing in pulmonary disease who may direct or supervise outpatient pulmonary rehabilitation programs and interpret clinical status.

• Respiratory Therapist, Certified — taxonomy 227900000X: represents certified respiratory therapists who commonly provide the one-on-one therapeutic procedures described by HCPCS Level II code G0238.

• Critical Care Respiratory Therapist — taxonomy 2278C0205X: represents respiratory therapists with critical care specialization who may perform advanced respiratory therapeutic procedures in outpatient rehabilitative settings.

Related Diagnoses

• J43.0 — Unilateral pulmonary emphysema [MacLeod's syndrome]

  Clinical relevance: Localized emphysematous disease can impair respiratory mechanics and benefit from targeted therapeutic procedures to improve ventilation and airway clearance.

• J43.1 — Panlobular emphysema

  Clinical relevance: Diffuse destruction of alveolar walls reduces gas exchange and may require individualized respiratory therapy to optimize breathing patterns and functional capacity.

• J43.2 — Centrilobular emphysema

  Clinical relevance: Common in smoking-related COPD; one-on-one respiratory therapy can address dyspnea and secretion management.

• J43.8 — Other emphysema

  Clinical relevance: Emphysematous conditions not classified elsewhere that can lead to impaired respiratory function and indicate therapeutic intervention.

• J44.0 — Chronic obstructive pulmonary disease with (acute) lower respiratory infection

  Clinical relevance: Acute infection on COPD may worsen symptoms; monitored therapeutic procedures can assist in secretion clearance and respiratory support during recovery.

• J44.1 — Chronic obstructive pulmonary disease with (acute) exacerbation

  Clinical relevance: Exacerbations increase dyspnea and functional limitation; time-based, one-on-one respiratory therapy may be provided to improve function and monitor response.

• J44.9 — Chronic obstructive pulmonary disease, unspecified

  Clinical relevance: General COPD diagnosis for which individualized therapeutic respiratory procedures may be indicated to improve breathing and endurance.

• U09.9 — Post COVID‑19 condition, unspecified

  Clinical relevance: Post‑acute sequelae of COVID-19 can include persistent respiratory impairment; targeted one-on-one therapeutic procedures may address ongoing pulmonary dysfunction.

Related Codes

• G0237 — Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring).

  Relation: G0237 specifically describes respiratory muscle strengthening/endurance procedures; it is closely related and may be selected instead of G0238 when the documented therapy specifically targets muscle strengthening rather than other respiratory function improvements.

• G0239 — Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring).

  Relation: G0239 is the group-session counterpart; use when two or more patients are treated together. It is an alternative to G0238 when the service is delivered to multiple individuals rather than one-on-one.

• 94625 — Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session).

  Relation: 94625 represents a per-session physician or qualified professional pulmonary rehabilitation service without continuous oximetry. It may be reported in the broader pulmonary rehabilitation workflow as a session-level code, while G0238 is used for time-based, one-on-one therapeutic procedure units within a session.

• 94626 — Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session).

  Relation: 94626 is the per-session pulmonary rehabilitation code when continuous oximetry monitoring is performed. It may be used in the same clinical program as G0238 for session-level billing decisions; G0238 remains the time-based, one-on-one therapeutic component billed in 15-minute increments.

Notes: These related codes are commonly used together in a comprehensive outpatient pulmonary rehabilitation program; G0237 is a closely related one-on-one code with a different procedure focus, G0239 is the group equivalent, and 94625/94626 are session-level physician or qualified professional rehabilitation codes used as alternatives or complements depending on monitoring and billing policies.

National mean rates for HCPCS Level II code G0238 show Medicare at $11.79 versus the BUCA (average commercial) mean of $13.87, with BUCA about $2.08 higher than Medicare. Commercial payers span a broader range above and below Medicare, with Blue Cross Blue Shield and UnitedHealthcare reporting the highest mean rates among the listed payers.

Rate dispersion (P75 minus P25) varies by payer: UnitedHealthcare has the widest spread (20.00 - 11.00 = 9.00), Blue Cross Blue Shield follows (17.80 - 9.33 = 8.47), BUCA and Aetna show moderate dispersion (6.00 and 6.00 respectively for Aetna; 15.00 - 9.00 = 6.00 for BUCA), while Cigna Health and Medicare are tightest (Cigna 9.00 - 9.00 = 0.00; Medicare 12.00 - 11.00 = 1.00). The table and chart below present the full breakdown.