Does 94626 require prior authorization?

No, 94626 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 94626?

Medicare facility rate: $24.38. Non-facility rate: $109.22. Work RVU: 0.56.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.56

Facility

$24.38

Non-Facility

$109.22

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).

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

A56152 — Billing and Coding: Pulmonary Rehabilitation Services

A52770 — Billing and Coding: Pulmonary Rehabilitation Services

ANTHEM-CG-REHAB-03 — CG-REHAB-03 Pulmonary Rehabilitation

Ask Verity about documentation requirements, denial risks, or coverage in your state.