Pulmonary Rehabilitation Education Services
Issue: #397 NOV2017
The Blue Cross Blue Shield of North Dakota (BCBSND) benefit for pulmonary rehabilitation education consists of three outpatient and/or office-based educational sessions per lifetime for chronic obstructive pulmonary disease (COPD) for the diagnoses listed below. This benefit only applies to the educational sessions. BCBSND does not cover pulmonary rehabilitation services.
These educational sessions should last approximately 60 to 90 minutes and should include the following topics:
- Basic cardiopulmonary anatomy and physiology, with emphasis on the symptoms of pulmonary disease
- Techniques of breathing control
- Respiratory irritants and other aggravators of COPD
- Bronchial hygiene
- Exercise and COPD
- Medications for COPD
The following services are included in a pulmonary rehabilitation education program and should not be billed separately:
- Any evaluation and management (E&M) service
- Physical performance test or measurement
- Therapeutic exercise
- Self-care/home management training
If pulse oximetry is performed as part of any of these programs, it is also considered included in the program and should not be billed separately. Any physical therapy services must meet the benefit information outlined in the physical therapy medical policy. E&M services are not in the scope of services reimbursable by BCBSND for physical, occupational, speech or respiratory therapy.
If a patient chooses to continue with additional sessions beyond the three included in their benefit plan, additional sessions will be their responsibility.
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.
The Federal Employee Program (FEP) does not reimburse for the pulmonary rehabilitation education program; however, pulmonary rehabilitation may be eligible for reimbursement based on medical necessity.
Coding and billing information
|S9473||Pulmonary rehabilitation program, non-physician provider, per diem||Allow three educational sessions/lifetime; do not bill as 99199|
|G0237||Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring)||Non-covered as pulmonary rehab|
|G0238||Therapeutic procedures to improve respiratory function, other than described by G0237, one-on-one, face-to-face, per 15 minutes (includes monitoring)||Non-covered as pulmonary rehab|
|G0239||Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)||Non-covered as pulmonary rehab|
|G0424||Pulmonary rehabilitation, including exercise (includes monitoring) one hour, per session, up to two sessions per day||Non-covered as pulmonary rehab|
Claims for pulmonary rehab and education services must be billed with the above HCPCS codes and revenue code 0948. Claims without the correct HCPCS code and revenue code will be returned to the provider for correction.
|0948||Pulmonary rehabilitation||Per visit|
The following diagnosis codes are appropriate for pulmonary rehabilitation services.
|J43.0||Unilateral pulmonary emphysema (MacLeod’s syndrome)|
|J44.0||Chronic obstructive pulmonary disease with acute lower respiratory infection|
|J44.1||Chronic obstructive pulmonary disease with (acute) exacerbation|
|J44.9||Chronic obstructive pulmonary disease, unspecified|
|J67.2||Bird fancier’s lung|
|J67.7||Air-conditioner and humidifier lung|
|J67.8||Hypersensitivity pneumonitis due to other organic dusts|
|J67.9||Hypersensitivity pneumonitis due to unspecified organic dust|
|J68.4||Chronic respiratory conditions due to chemicals, gases, fumes and vapors|
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