The Science Journal of the American Association for Respiratory Care

1997 OPEN FORUM Abstracts

Reimbursement In Pulmonary Rehabilitation

Julien M. Roy, BA, RTT

Medicare coverage of Respiratory Care Services furnished by the Hospital

- Section 3101.10 - Definition: Respiratory Therapy (respiratory care) is defined as those services that are prescribed by a physician for the assessment, diagnostic evaluation, treatment, management, and monitoring (as defined in 3101.10E.6.) of patients with deficiency and abnormalities of cardiopulmonary function.

Respiratory Care services include but are not limited to:

1. The therapeutic use and monitoring of medical gases (especially oxygen). 2. Bronchial hygiene therapy, including deep breathing and coughing exercises, postural drainage, chest percussion. 3. Diagnostic tests for evaluation by a physician, e.g., pulmonary function tests, spirometry, and blood gas analyses; 4. Pulmonary Rehabilitation techniques which include: a. exercise conditioning b. breathing retraining; and c. patient education regarding the management of the patient's respiratory problems; and d. periodic assessment and monitoring of the acute and chronically ill patients for indications for, and the effectiveness of, respiratory care services.

Such services are performed by respiratory therapists, physical therapists, nurses and other qualified personnel. If such services are reasonable and necessary, they are covered irrespective of where they are furnished in the Hospital; e.g., emergency room, ICU, etc.

To qualify for reimbursement under Medicare, such therapy 1. must qualify as a covered services, and 2. must be reasonable and necessary for the diagnosis or treatment of an illness.

ICD 9 Disease codes for Pulmonary Rehabilitation:

- 492.8 = Emphysema - 496.0 = COPD - 493.90 = Asthma - 494 = Bronchiectasis

Remember, pulmonary rehabilitation is not a reimbursable item by Medicare, but many components are! Respiratory evaluations, specific individualized training sessions from breathing retraining to supervised exercise are bilabial items. Component charges for pulmonary rehabilitation need to be placed under a specific Revenue Code and have CPT codes assigned to each item to be billed.

How to charge for your Program:

Hospital based: use Revenue Code 940 (other unlisted pulmonary services)

- CPT Codes:

- 94761 (continuous pulse oxymetry determination) - 94760 (single pulse oxymetry determination) - 94010 (bedside spirometry) - 82803 (arterial blood gas) - 94160 (peak flow monitoring) - 94667 (chest physiotherapy, mucus clearance) - 94620 (pulmonary stress testing)

Services provided under direction of Physical Therapy or physician's office Pulmonary Rehabilitation:

- CPT Codes:

- 97540 (ADL evaluation) - 97541 (each additional 15 " of ADL) - 97530 (functional activities, kinetic activity) - 97116 (gait training)


- 94799: unlisted procedure under pulmonary therapeutic.

* Red flagged code at Medicare requiring daily documentation sent to Medicare. This code is often used outside Hospital setting. Should not be used in Florida but is widely used in some Pulmonary Rehabilitation programs in USA.

AARC 50th Anniversary, December 6 - 9, 1997, New Orleans, Louisiana.

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