G0238 — Therapeutic procedures to improve respiratory function, other than described by g0237, one on one, face to face, per 15 minutes (includes monitoring)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$11.36
Non-Facility
$11.36
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.
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Therapeutic respiratory procedures (HCPCS G0237, G0238, G0239) using an individualized physical conditioning and exercise program with breathing techniques are covered for patients with documented activity limitations.
11 Active Policies
A52770 — Billing and Coding: Pulmonary Rehabilitation Services
A57225 — Billing and Coding: Respiratory Care
AETNA-CPB-0067 — Chest Physiotherapy and Airway Clearance Devices
AETNA-CPB-0004 — Obstructive Sleep Apnea in Adults
ANTHEM-CG-REHAB-03 — CG-REHAB-03 Pulmonary Rehabilitation
Related Codes
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