As highlighted in our 2021 year-end advocacy update article, two new CPT codes for pulmonary rehabilitation services became effective the beginning of the year, replacing G0424 that had been used to bill for services since the inception of the program. To recap, the new CPT codes are:
- CPT 94625 – Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)
- CPT 94626 – with continuous oximetry monitoring (per session)
When CMS proposed setting the payment rates for the new codes, they did so based on their belief that 100% of the utilization for PR services previously billed using G0424 would be billed using CPT 94626, with continuous oximetry monitoring. Although AARC and other pulmonary organizations, such as the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), indicated in comments to CMS that there are times when continuous monitoring would not be required, CMS elected not the change the final rule but did agree to consider stakeholder comments in future rulemaking. This analysis by CMS has caused confusion among programs as to when to bill Medicare using CPT 42625 versus CPT 94626. For example, we understand some insurance companies only pay for continuous oximetry monitoring, even though the payment amount is the same for each code when services are furnished in the hospital outpatient setting.
AARC has developed a resource document available in the Advocacy menu on the AARC website to assist respiratory therapists working with their programs’ medical directors in determining the appropriate use of the codes based on the patient’s clinical need. It includes examples provided by AACVPR as well as a pulse oximetry monitoring algorithm. We encourage respiratory therapists to review the document and to share it with their program medical directors to reduce the chance of inappropriate claims that may result in potential audit issues.
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