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Date Printed: December 18, 2017: 03:31 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-94010-07

Original Effective Date: 10/15/02

Reviewed: 07/28/16

Revised: 08/15/16

Subject: Outpatient Pulmonary Rehabilitation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Pulmonary rehabilitation (PR) is a multidisciplinary approach to reducing symptoms and improving quality of life in patients with compromised lung function. A pulmonary rehabilitation outpatient program is a comprehensive program that generally includes team assessment, patient training, psychosocial intervention, exercise training, and follow-up. Team assessment includes input from a physician, respiratory care practitioner, nurse, and psychologist, among others. Psychosocial intervention addresses support system and dependency issues. Patient training includes breathing retraining, bronchial hygiene, medications, and proper nutrition.The overall length of the program and the total number of visits for each component may vary from program to program.

Exercise training includes strengthening and conditioning, and may include stair climbing, inspiratory muscle training, treadmill walking, cycle training (with or without ergometer), and supported and unsupported arm exercise training. Exercise conditioning is an essential component of pulmonary rehabilitation. Education in disease management techniques without exercise conditioning does not improve health outcomes of patients who have chronic obstructive pulmonary disease.

Candidates for pulmonary rehabilitation should be medically stable and not limited by another serious or unstable medical condition. Contraindications to pulmonary rehabilitation include severe psychiatric disturbance (eg, dementia, organic brain syndrome), and significant or unstable medical conditions (eg, heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, disabling stroke).

Pulmonary rehabilitation is routinely offered to patients awaiting lung transplantation and lung volume reduction surgery. PR before lung surgery may stabilize or improve patients’ exercise tolerance, teach patients techniques that will help them recover after the procedure, and allow health care providers to identify individuals who might be suboptimal surgical candidates due to noncompliance, poor health, or other reasons.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Outpatient Pulmonary Rehabilitation Services - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: The following services are covered according to the member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to pulmonary rehabilitation therapy services.

A single course of pulmonary rehabilitation in the outpatient ambulatory care setting meets the definition of medical necessity for the following:

Treatment of chronic pulmonary disease for individuals with moderate-to-severe pulmonary disease, when ALL of the following are met:

A team assessment has been completed (generally includes a physician, respiratory care practitioner, nurse, and psychologist)

Candidate does not have a severe psychiatric disturbance (eg, dementia, organic brain syndrome)

Candidate does not have an unstable medical condition (eg, heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, renal failure, disabling stroke)

FEV1 or FVC is less than 80% of predicted value

Candidate is experiencing disabling symptoms and significantly diminished quality of life*, despite optimal medical management (eg, increased exertional dyspnea, decreased endurance, increased fatigue, increased anxiety, and reduced ability to carry out activities of daily living), OR

As pre-operative conditioning for those considered appropriate candidates for lung volume reduction surgery or for lung transplantation, OR

As post-operative conditioning following lung transplantation

Pulmonary rehabilitation programs are considered experimental or investigational in all other situations including, but not limited to, the following:

Pulmonary rehabilitation for mild chronic pulmonary disease

Multiple courses of pulmonary rehabilitation, including:

As maintenance therapy in patients who initially responded to a rehabilitation program

In patients who failed to respond to an initial rehabilitation program

In patients whose response to an initial rehabilitation program has diminished over time

Home based pulmonary rehabilitation programs

Following other types of lung surgery, included but not limited to lung volume reduction surgery and surgical resection of lung cancer

Data in published medical literature are inadequate to permit scientific conclusions on long-term and net health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to report pulmonary rehabilitation:

HCPCS Coding:

G0237

Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes

G0238

Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, each 15 minutes (includes monitoring)

G0239

Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, 2 or more individuals (includes monitoring)

G0424

Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day

S9473

Pulmonary rehabilitation program, non-physician provider, per diem

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

D38.1

Neoplasm of uncertain behavior of trachea, bronchus and lung

D84.1

Defects in the complement system

D86.0

Sarcoidosis of lung

D86.2

Sarcoidosis of lung with sarcoidosis of lymph nodes

E84.0

I11.9

Hypertensive heart disease without heart failure

I26.90

Septic pulmonary embolism without acute cor pulmonale

I26.99

Other pulmonary embolism without acute cor pulmonale

I27.0

Primary pulmonary hypertension

J41.8

Mixed simple and mucopurulent chronic bronchitis

J42

Unspecified chronic bronchitis

J43.0 – J43.9

Emphysema

J44.9

Chronic obstructive pulmonary disease, unspecified

J47.0 – J47.9

Bronchiectasis

M34.0 – M34.9

Systematic sclerosis [scleroderma]

P27.0 – P27.9

Chronic respiratory disease originating in the prenatal period

Q21.0

Ventricular septal defect

Q33.4

Congenital bronchiectasis

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date: Pulmonary Rehabilitation Services (240.8) and Heat Treatment, Including the Use of Diathermy and Ultrasound for Pulmonary Conditions (240.3) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Respiratory Therapeutic Services (L33745) located at fcso.com.

DEFINITIONS:

FEV 1: timed forced expiratory volume; volume of air expired in a specified time (one second) in the course of the forced vital capacity maneuver of the spirometry test.

FVC: forced vital capacity; vital capacity measured with the subject exhaling as rapidly as possible; data relating to volume, expiratory flow, and time form the basis of other pulmonary function tests (e.g., flow-volume curve, forced expiratory volume, forced expiratory time, forced expiratory flow).

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. AHRQ National Guideline Clearing House. Guideline 00985: British Thoracic Society guideline on pulmonary rehabilitation in adults. British Thoracic Society Pulmonary Rehabilitation Guideline Development Group, British Thoracic Society Standards of Care Committee. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax. 2013 Sep;68(Suppl 2):ii1-30.
  2. American Association of Respiratory Care (AARC) Clinical Practice Guideline, Pulmonary Rehabilitation (Respir Care 2002; 47(5): 617-625).
  3. American College of Chest Physicians Patient Education Guides “Pulmonary Rehabilitation, a Team Approach to Improving Quality of Life”, (accessed 07/29/09).
  4. American College of Chest Physicians/ American Association of Cardiovascular and Pulmonary Rehabilitation (ACCP/AACVPR) Pulmonary Rehabilitation Guidelines Panel. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines. Chest 1997; 112(5): 1363-96.
  5. American College of Chest Physicians/American College of Cardiovascular and Pulmonary Rehabilitation. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest 2008; 131; 1-3 (accessed 07/28/09).
  6. American College of Chest Physicians. Family-Based Psychosocial Support and Education as Part of Pulmonary Rehabilitation in COPD: A Randomized Controlled Trial. Chest. 2015;147(3):662-672.
  7. American Medical Association CPT (current edition).
  8. American Thoracic Society. Patient Information Series: Exacerbation of COPD. Am J Respir Crit Care Med Vol. 189, P11-P12, 2014. Accessed at https://www.thoracic.org/patients/patient-resources/resources/copd-exacerbations-ecopd.pdf.
  9. Blue Cross Blue Shield Association Medical Policy Reference Manual. 8.03.05, Outpatient Pulmonary Rehabilitation. (March 2016)
  10. Blue Cross Blue Shield Association TEC Assessments, (1996, Tab 4).
  11. Centers for Medicare & Medicaid Services (CMS), CMS Manual system. Pub 100-04 Medicare Claims Processing, 05/07/10.
  12. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions (240.3).
  13. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Pulmonary Rehabilitation Services (240.8).
  14. ClinicalTrials.gov, Beneficial Effects of Pulmonary Rehabilitation for Idiopathic Pulmonary Fibrosis, sponsored by National Jewish Health, accessed 05/19/11.
  15. ClinicalTrials.gov, Effect of Pulmonary Rehabilitation in Lung Cancer Survivors, sponsored by Imperial college Healthcare NHS Trust, accessed 05/19/11.
  16. ClinicalTrials.gov, Effect of Pulmonary Rehabilitation on Surgical Outcomes in the Cancer Setting, sponsored by M.D. Anderson Cancer Center, accessed 05/19/11.
  17. Florida Medicare Part A Medical Policy # A94799. Pulmonary Rehabilitation Services (10/01/00); retired 01/01/04.
  18. Florida Medicare Part B Medical Policy # 94799. Pulmonary Rehabilitation Services (10/01/00); retired 01/01/04.
  19. First Coast Service Options, Inc. (FCSO). Local Coverage Determination (LCD) Respiratory Therapeutic Services (L29268), 02/02/09. Retired 09/30/15.
  20. First Coast Service Options, Inc. (FCSO). Local Coverage Determination (LCD) Respiratory Therapeutic Services (L33745). (10/01/15)
  21. Gaunaurd IA, Gomez-Marin OW, Ramos CF, et al. Physical activity and quality of life improvements of patients with idiopathic pulmonary fibrosis completing a pulmonary rehabilitation program. Respir Care. Dec 2014;59(12):1872-1879.
  22. HAYES Medical Technology Directory; “Pulmonary Rehabilitation” PULM0301.20, (04/02 updated 04/12/07).
  23. Institute for Clinical Systems Improvement (ICSI), Health Care Guideline: Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD), Eighth Edition March 2011.
  24. Lacasse Y, Brosseau L, Milne S, Martin S, Wong E, Guyatt GH, Goldstein RS, White J. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003793. DOI: 10.1002/14651858.CD003793.
  25. Mador MJ, Deniz O, Aggarwal A, Shaffer M, Kufel TJ, Spengler CM. Effect of respiratory muscle endurance training in patients with COPD undergoing pulmonary rehabilitation. Chest. 2005 Sep; 128(3): 1216-24.
  26. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2:CD003793.
  27. National Institute for Clinical Excellence (NICE). Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 101. June 2010.
  28. National Institute for Health and Care Excellence (NICE). Quality Standard 79 (QS79): Idiopathic pulmonary fibrosis in adults. January 2015. Accessed at https://www.nice.org.uk/guidance/QS79/chapter/Quality-statement-5-Palliative-care.
  29. Norweg AM, Whiteson J, Malgady R, Mola A, Rey M. The effectiveness of different combinations of pulmonary rehabilitation program components: a randomized controlled trial. Chest. 2005 Aug; 128(2): 663-72.
  30. Ries AL, et al, Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines, Chest 2007; 131;4-42.
  31. Ries AL, Make BJ, Lee SM, Krasna MJ, Bartels M, Crouch R, Fishman AP. National Emphysema Treatment Trial Research Group. The effects of pulmonary rehabilitation in the national emphysema treatment trial. Chest. 2005 Dec; 128(6): 3799-809morbidity in patients with severe COPD. Chest. 2006 Apr; 129(4): 899-904.
  32. Roman M, Larraz C, Gomez A, et al. Efficacy of pulmonary rehabilitation in patients with moderate chronic obstructive pulmonary disease: a randomized controlled trial. BMC Fam Pract. 2013;14:21.
  33. Rugbjerg M, Iepsen UW, Jorgensen KJ, et al. Effectiveness of pulmonary rehabilitation in COPD with mild symptoms: a systematic review with meta-analyses. Int J Chron Obstruct Pulmon Dis. 2015;10:791-801.
  34. Salhi B, et al, Effects of Pulmonary Rehabilitation in Patients with Restrictive Lung Diseases, Chest 09-0241.
  35. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. Oct 15 2013;188(8):e13-64.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/28/16.

GUIDELINE UPDATE INFORMATION:

10/15/02

New Medical Coverage Guideline.

07/15/04

Scheduled review; no changes.

09/15/06

Scheduled review; added lung volume reduction and lung transplants as covered indications for coverage; removed Medicare Advantage Program Exception information.

08/15/07

Reviewed; reformatted guideline; updated references.

09/15/09

Scheduled review; update position statement. Update ICD 9 coding. Update HCPCS coding. Update references.

01/01/10

Annual HCPCS coding update: add HCPCS code G0424.

10/15/10

Revision; related ICD-10 codes added.

12/15/10

Revision; deleted ICD-9 codes 415.1 and 494; added ICD-9 codes 415.11, 415.12, 415.19, 494.0 and 494.1.

07/15/11

Scheduled review; position statements maintained and references updated.

10/01/11

Revision; added ICD9 codes 415.13, 516.31 and 516.34.

04/01/12

Revision; updated ICD10 coding with new and revised codes.

02/15/14

Revision; Program Exceptions section and references updated.

10/01/15

Revision; updated ICD9 and ICD10 coding sections.

11/01/15

Revision: ICD-9 Codes deleted.

08/15/16

Scheduled review. Revised MCG title and Position Statement section. Updated references.

Date Printed: December 18, 2017: 03:31 PM