94625
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.36
Facility
$16.37
Non-Facility
$87.18
Documentation Required
- A physician order must prescribe exercise including aerobic exercise combined with other appropriate exercise types and must indicate exercise is to be provided at each treatment session.
- An individualized plan of care must be initially established by the physician and reviewed and signed by the physician every 30 days documenting how components are utilized for each patient.
- Medical records must document that individual component services are tailored, require a qualified clinician, and are medically reasonable and necessary to support billing of G0237–G0239 or CPT 97xxx codes.
- Program records must document psychosocial assessment and reassessment at periodic intervals, and significant outcomes assessment with initial and ending objective clinical measures (exercise performance, dyspnea, behavior).
Key Coverage Criteria
- Individual pulmonary rehabilitation components are covered when tailored to the individual patient based on a thorough evaluation, require a qualified clinician due to complexity, and are medically reasonable and necessary for treatment of an acute or exacerbated pulmonary condition.
- Medicare covers Pulmonary Rehabilitation Program services for patients with moderate to very severe COPD (GOLD II-IV) when referred by the physician treating the chronic respiratory disease and when all program requirements are met.
- Medicare covers pulmonary rehabilitation program services for confirmed or suspected COVID-19 patients who experience persistent respiratory symptoms for at least four weeks (effective Jan 1, 2022) when all program requirements are met.
- Pulmonary rehabilitation program services are covered when the program provides a comprehensive, evidence-based multidisciplinary intervention for chronic respiratory impairment and fulfills applicable CMS manual and NCD 240.8 requirements.
- Pulmonary rehabilitation (PR) is consideredmedically necessaryin individuals who meet the following criteria:
- Individual is preparing fororrecovering from surgical interventions such as:Lung transplantation;orLung volume reduction surgery;orPost-operative states; (for example, thoracic or abdominal surgery).or
3 Active Policies
A56152 — Billing and Coding: Pulmonary Rehabilitation Services
A52770 — Billing and Coding: Pulmonary Rehabilitation Services
ANTHEM-CG-REHAB-03 — CG-REHAB-03 Pulmonary Rehabilitation
Related Codes
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