(Medicare Claims Processing Manual)

140.4  PR Program Services Effective for Dates of Service On or After January 1, 2024  (Rev.  12497; Issued: 02- 08-24; Effective: 01 -01-24; Implementation: 03 -12-24)  As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:    With moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease;   Who have had confirmed or suspected COVID -19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective January 1, 2022);   Additional medical indications for coverage for PR may be established through an NCD.   PR must include all of the following components:    Physician prescribed exercise during each pulmonary rehabilitation session.   Education or training that is closely and clearly related to the individuals care and treatment which is tailored to the individuals needs and assists in achievement of goals toward independence in activities of daily living, adaptation to limitations and improved quality of life. Education must include information on respiratory problem management and, if appropriate, brief smoking cessation counseling.   Psychosocial assessment.  Outcomes assessment.   An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.   Medicare Part B pays for PR in a physicians office or a hospital outpatient setting. All settings must have the following: (i) A physician or nonphysician practitioner immediately available and accessible for medical consultations and emergencies at all t imes when items and services are being furnished under the program. This provision is satisfied if the physician or nonphysician practitioner meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42 CFR 410.27, and, (ii) The necessary cardio- pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and defibrillator) to treat chronic respiratory disease.  Note: Nonphysician practitioners are eligible to supervise PR effective January 1, 2024.   As specified at 42 CFR 410.47(e), the number of PR sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the MAC s.   140.4.1  Coding Requirements for PR Services Furnished On or After January 1, 2010  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  The following are the applicable HCPCS codes for PR:   Effective January 1, 2010 through December 31, 2021  G0424 (Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per  session)   Effective January 1, 2022  94625 (Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session))   94626 (Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session)   Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1 -hour sessions per day. In order to report one session of PR in a day, the duration of treatment must be at least 31 minutes. Two sessions of  PR may only be reported in the same day if the duration of treatment is at least 91 minutes. In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes, if two sessions are reported. If seve ral shorter periods of PR are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.  Example : If the patient receives 20 minutes of PR in the day, no PR session may be reported because less than 31 minutes of services were furnished.  Example : If a patient receives 20 minutes of PR in the morning and 35 minutes of PR in the afternoon of a single day, the hospital or practitioner would report 1 session of PR under 1 unit of HCPCS code/CPT code for the total duration of 55 minutes of PR on that day.  Example : If the patient receives 70 minutes of pulmonary rehabilitation services in the morning and 25 minutes of pulmonary rehabilitation services in the afternoon of a single day, the hospital or practitioner would report two sessions of pulmonary rehabilitation services under the HCPCS G -code/CPT codes because the total duration of pulmonary rehabilitation services on that day of 95 minutes exceeds 90 minutes.  Example : If the patient receives 70 minutes of pulmonary rehabilitation services in the morning and 85 minutes of pulmonary rehabilitation services in the afternoon of a single day, the hospital or practitioner would report two sessions of pulmonary rehabilitation services under the HCPCS G -code/CPT codes for the total duration of pulmonary rehabilitation services of 155 minutes. A maximum of two sessions per day may be reported, regardless of the total duration of pulmonary rehabilitation services.   140.4.2  Claims Processing Requirements for Pulmonary Rehabilitation (PR) Services Furnished On or After January 1, 2010  (Rev. 1966, Issued: 05- 07-10, Effective: 01 -01-10, Implementation: 10- 04-10)  140.4.2.1  Correct Place of Service (POS) Code for PR Services on Professional Claims  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Effective for claims with dates of service on and after January 1, 2010, place of service (POS) code 11 shall be used for pulmonary rehabilitation (PR) services provided in a physicians office and POS 22 shall be used for services provided in a hospital outpatient setting. All other POS codes shall be denied. Medicare contractors shall adjust their prepayment procedure edits as appropriate.   The following messages shall be used when Medicare contractors deny PR claims for POS:  CARC 96: Non- covered charge(s).   RARC N428: Service/procedure not covered when performed in this place of service.   Medicare Summary Notice (MSN) 21.25: This service was denied because Medicare only covers this service in certain settings.   Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   NOTE: This is a new MSN message.   Contractors shall use Group Code PR (Patient `Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  140.4.2.2  Requirements for PR Services on Institutional Claims  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Effective for claims with dates of service on and after January 1, 2010, Medicare contractors shall pay for PR services when submitted on a type of bill (TOB) 13X and 85X only, along with revenue code 0948. All other TOBs shall be denied.   The following messages shall be used when Medicare contractors deny PR claims for TOB:    CARC 96: Non- covered charge(s).   RARC N428: Service/procedure not covered when performed in this place of service.   Medicare Summary Notice (MSN) 21.25: This service was denied because Medicare only covers this service in certain settings.   Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   NOTE: This is a new MSN message.   Contractors shall use Group Code PR (Patient `Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   140.4.2.3  Daily Frequency Edits for PR Claims  (Rev. 1966, Issued: 05- 07-10, Effective: 01 -01-10, Implementation: 10- 04-10)  Effective for claims with dates of service on or after January 1, 2010, Medicare contractors shall deny all PR claims (both professional and institutional claims) that exceed two units on the same date of service.   The following messages shall be used when Medicare contractors deny PR claims for exceeding the daily frequency limit:   CARC 119: Benefit maximum for this time period or occurrence has been reached.   RARC N362: The number of days or units of service exceeds our acceptable maximum.   MSN 20.5:  These services cannot be paid because your benefits are exhausted at this time.  Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   140.4.2.4  Edits for PR Services Exceeding 36 Sessions  (Rev. 1966, Issued: 05- 07-10, Effective: 01 -01-10, Implementation: 10- 04-10)  When a beneficiary has reached 37 PR sessions, CWF shall reject the claims to the contractors if the KX modifier is not included on the claim line.  Effective for claims with dates of service on or after January 1, 2010, Medicare contractors shall deny all  claims (both professional and institutional claims) that exceed 36 PR sessions without a KX modifier included on the claim line.    The following messages shall be used when Medicare contractors deny PR claims that exceed 36 sessions, without the KX modifier on the claim line:   CARC 151: Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.   MSN 23.17: Medicare wont cover these services because they are not considered medically necessary .  Spanish Version: M edicare no cubrir estos servicios porque no son considerados necesarios por razones mdicas.   Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   140.4.2.5  Edits for PR Services Exceeding 72 Sessions  (Rev. 12497; Issued: 02- 08-24; Effective: 01 -01-24; Implementation: 03 -12-24)  Effective for claims with dates of service on and after January 1, 2010, through December 31, 2021, CWF shall reject PR claims that exceed 72 sessions. Medicare contractors shall deny PR claims that exceed 72 sessions regardless of whether the - KX modifier is submitted on the claim line.   The following messages shall be used when Medicare contractors deny PR claims that exceed 72 sessions:   CARC 119: Benefit maximum for this time period or occurrence has been reached.   RARC N362: The number of days or units of service exceeds our acceptable maximum.    MSN 20.5: These services cannot be paid because your benefits are exhausted at this time.   Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Contractors shall use Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Contractors shall use Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  Effective for claims with dates of service on and after January 1, 2022, Medicare Contractors shall deny PR claims that exceed 72 sessions only when the - KX modifier is not submitted on the claim line.   150 - Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity  (Rev. 931, Issued:  04- 28-06, Effective:  02 -21-06, Implementation:  05- 30-06 Carrier/10-02-06 FI)   150.1 - General  (Rev. 2841, Issued: 12- 23-13, Effective: 09 -24-13, Implementation: 12- 17-13)