Pulmonary Rehabilitation Reimbursement Challenges and Strategies for Survival by Chris Garvey NP, Phil Porte and Richard Casaburi PhD, MD
The decline in PR reimbursement in the US is at least in part tied to a Medicare change in PR reimbursement in 2010, when a new ‘bundled’ payment code ‘G0424’ for COPD was introduced. This code pays for one hour of PR including all costs of staff, medical director, rehabilitation facilities, overhead, etc. Initially in 2010, Medicare arbitrarily established a payment rate of $50 for one unit of G0424. Medicare acknowledged in 2011 that “failure to carefully construct the charge for G0424 that reports a combination of services previously reported separately under-represents the cost of providing the service described by G0424 and can have significant adverse impact on future payments” [Federal Register 11/30/11].
Historically, PR had been paid for in 15 minute increments for most services. The majority of PR providers and hospitals have never adequately modified PR charges to reflect the increase in time and resources used for the ‘bundled’ G0424 billing code. The impact on reimbursement is due to Medicare’s use of PR charges (as well as information from the hospital cost report) to calculate annual changes in PR reimbursement. A recent review of charges for PR for COPD patients submitted to Medicare in 2015 from claims billed by 1350 US hospitals indicates that lower charges for the PR bundled code continue to persist. This practice has likely contributed to the reality that, as indicated below, cardiac rehabilitation reimbursement is now double that of PR.
CMS Final CY 2017 Outpatient Services Payment Rates:
HCPCS Code Short Descriptor APC Payment Rate
93798 Monitored cardiac rehabilitation 5771 $110.18
G0424 Pulmonary rehabilitation w/ exercise 5733 $54.53
It is possible that PR clinicians are not aware that the amount actually paid for services is often a small fraction of submitted charges. Below is an example of amount charged for services vs. what Medicare pays.
Summary for Medicare Outpatient Prospective Payment System Hospitals for 2015
Ambulatory Payment Classifications (APC) Average Estimated Submitted Charges Average Total Payments
0269 - Level I Echocardiogram Without Contrast $2,386.36 $409.22
0369 - Level II Pulmonary Function Test $1,354.23 $229.25
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient2015.html accessed 10/1/17
What can be done? Hospital administrators set charge rates for all their services, including PR services. These administrators need to be aware of the concerns regarding G0424 billing and the impact of undervalued charges on Medicare payment. A Pulmonary Rehabilitation Toolkit is available that details resources for PR billing at https://www.aacvpr.org/Advocacy/Pulmonary-Rehabilitation-Toolkit.
It is time for the pulmonary medicine and scientific community to bring these concerns to hospital administration. It is also time for practitioners and scientists to partner with PR clinicians and administrators to determine if charges for their PR program reasonably represent the complexity of the intervention, the acuity of the target population, and the value of this evidence based intervention.