CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Outpatient Pulmonary Rehabilitation Coverage Criteria

This policy governs coverage and coding for outpatient pulmonary rehabilitation services for Blue Cross & Blue Shield of Rhode Island members, including Medicare (BlueCHiP) and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOutpatient Pulmonary Rehabilitation Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionConfirm eligibility and benefits with the provider call center before delivering outpatient pulmonary rehabilitation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36typical sessions

up to 72max sessions

GOLD II-IVMedicare COPD severity

S9473, G0424covered HCPCS

25+references

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General coverage and Medicare-specific coverage

Covered when program components and setting requirements are met.

Program components and setting: Pulmonary rehabilitation is covered when the program includes education or training tailored to the individual's needs, physician-prescribed exercise with some aerobic exercise included in each session, psychosocial assessment, outcomes assessment, and an individualized treatment plan detailing how components are utilized for each patient; services must be furnished in a physician's office or a hospital outpatient setting with a physician immediately available and accessible for medical consultations and emergencies while services are being furnished.

Medicare coverage is limited to patients with moderate to very severe COPD (GOLD II–IV) when referred by the treating physician.

Course limits

Limits on number of courses and sessions.

Initial course: A course of outpatient pulmonary rehabilitation typically consists of two 1-hour sessions per day for up to 36 sessions.<=36 sessions

Claims submitted for greater than 36 sessions will suspend for review; up to an additional 36 sessions may be allowed if medically necessary, not to exceed 72 total sessions.

Repeat courses: Outpatient pulmonary rehabilitation beyond one course of treatment is typically not covered/medically necessary for BlueCHiP Medicare and Commercial products because appropriate self-care is expected to have been taught during the initial course.one course

Home-based pulmonary rehabilitation programs are not covered for all Blue Cross & Blue Shield of Rhode Island (BCBSRI) products. Providers should not bill BCBSRI for home-based pulmonary rehabilitation when the member’s coverage is under a BCBSRI product that excludes these services; verify member benefits for program-specific coverage before initiating treatment.

If services are determined to be not medically necessary (or are medically necessary but constitute non‑covered benefits under the member’s subscriber agreement), the provider may not charge the member for those services unless the provider has informed the member and obtained the member’s written agreement in advance to continue treatment at the member’s expense. Benefits and eligibility are determined by the member’s subscriber agreement or certificate; contact the provider call center to verify.

Outpatient pulmonary rehabilitation beyond one course of treatment is typically not covered / not medically necessary for both BlueCHiP for Medicare and Commercial products because self‑care and maintenance training are expected to have been taught during the initial course. A typical course consists of two 1‑hour sessions per day for up to 36 sessions; claims for more than 36 sessions will be suspended for review and, in select cases, an additional 36 sessions (not to exceed 72 total sessions) may be allowed if medically necessary.

Services that are determined to be not medically necessary are subject to claim denial and billing restrictions according to the member’s benefits. Providers should confirm eligibility and benefit details in the member’s subscriber agreement and consult the provider call center before furnishing services that may be excluded or non‑covered.

Coding and Session Information

Covered HCPCS CodesHCPCSCovered

S9473	Pulmonary rehabilitation program, non-physician provider; per diem
G0424	Pulmonary rehabilitation, 1 hour, per session (Medicare)

Codes not to include on claimsHCPCSNot Covered

G0237	Pulmonary rehabilitation, one on one, each 15 minutes (includes monitoring)
G0239	Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)
G0238	Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring)

Typical course sessions — inv-09: Typical course sessions

Typical sessions per dayTwo 1-hour sessions per day

Standard course lengthUp to 36 sessions per course

Additional sessionsAn additional 36 sessions may be allowed if medically necessary (not to exceed 72 total)

Claim review thresholdClaims submitted for greater than 36 sessions will suspend for review

Provider Actions and Billing Rules

Prior Authorization

Prior authorization

Not applicable

Note

Verify benefits/authorization

Benefits and eligibility are determined by the member's subscriber agreement (member certificate). Providers should verify eligibility and benefits, including any authorization requirements, with the member's plan before scheduling services. Contact provider customer service or the provider call center for benefit verification.

Verify eligibility and benefits per the member's certificate/subscriber agreement
Contact provider customer service or provider call center for benefit/authorization details

Denial Risk

Member charge and denial risk

Services determined to be not medically necessary or not covered under the member's benefit plan may result in member financial liability. Providers may not bill the member for non-covered services unless the member has been informed in advance and has agreed in writing to accept financial responsibility. Refer to your participation agreement for applicable provisions.

If a service is denied as not medically necessary or non-covered, the member may be financially responsible
Written advance agreement required before billing member for non-covered services

Billing Rule

Repeat course limitation

Outpatient pulmonary rehabilitation beyond one course of treatment is typically not covered/medically necessary. For BlueCHiP for Medicare and Commercial products, repeat courses are generally not approved because the patient is expected to have been taught appropriate self-care.

BlueCHiP for Medicare: repeat outpatient pulmonary rehabilitation beyond one course typically not covered
Commercial products: repeat outpatient pulmonary rehabilitation beyond one course typically not medically necessary

Billing Rule

Excess sessions trigger review

A typical course consists of up to 36 one-hour sessions (often two 1-hour sessions per week). Claims submitted for greater than 36 sessions will suspend for review; additional sessions (up to a total of 72) may be considered if medically necessary and appropriately documented.

Typical course: up to 36 sessions
Claims > 36 sessions will suspend for review
Additional sessions (up to 72 total) require documentation of medical necessity

Documentation Required

Required program components and setting

Required program components for covered pulmonary rehabilitation include: individualized treatment plan; education/training tailored to the individual's needs (including respiratory management and, if appropriate, brief smoking cessation counseling); physician-prescribed exercise with aerobic exercise included in each session; psychosocial assessment; outcomes assessment; physician prescription/referral; and furnishing in an appropriate setting with physician immediately available for consultations and emergencies.

Individualized treatment plan
Education/training tailored to patient needs
Physician-prescribed exercise including aerobic exercise each session
Psychosocial and outcomes assessments
Physician prescription/referral and appropriate setting with physician immediately available

Note

Provider action highlight

Reserved for additional actionable provider guidance.

Definitions

Pulmonary rehabilitation (PR) — inv-19: Comprehensive intervention definition

DefinitionA comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies including exercise training, education, and behavior change

Primary componentsAssessment followed by therapeutic interventions such as exercise training, education, and behavior change

Intended outcomesImprove functioning and quality of life in patients with compromised pulmonary function

Populations studiedMost research focused on COPD; also used for asthma, fibrosis, bronchiectasis, transplant candidates, and pre/postoperative patients

Medicare-eligible PR patient criteria — inv-20

Medicare-eligible COPD severityModerate to very severe COPD (GOLD II, III, IV)

Referral requirementWhen referred by the physician treating the chronic respiratory disease

Program requirement linkageMedicare limits apply when program components and setting requirements are met

Pulmonary rehabilitation — inv-21: Multidisciplinary exercise and education programs

Multidisciplinary naturePrograms are multidisciplinary, involving assessment, exercise training, education, psychosocial assessment and behavior-change interventions

Exercise and educationExercise training (including aerobic exercise each session) and education/training tailored to individual needs

Timing and use casesApplied pre- or post-operatively, and after exacerbations or hospitalizations, and for transplant or volume reduction surgery candidates

Setting and staffingServices must be furnished in a physician's office or hospital outpatient setting with a physician immediately available

OpenPayer

Outpatient Pulmonary Rehabilitation Coverage Criteria

Coverage Criteria for Outpatient Pulmonary Rehabilitation

Coding and Session Information

Provider Actions and Billing Rules

Background

Definitions