CMS Pub. 100-02, ch. 15, § 231

Dates of Service On Or After January 1, 2024

(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)

Pulmonary rehabilitation (PR) means a physician or nonphysician practitioner supervised

program for chronic obstructive pulmonary disease (COPD) and certain other chronic

respiratory diseases designed to optimize physical and social performance and autonomy.

Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical

nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social

Security Act (the Act).

Effective January 1, 2010, Medicare Part B pays for PR if specific criteria are met by the

Medicare beneficiary, the PR program itself, the setting in which it is administered, and

the physician administering the program, as outlined below.

Covered Conditions:

As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:

• With moderate to very severe COPD (defined as GOLD classification II, III, and

IV), when referred by the physician treating the chronic respiratory disease;

• Who have had confirmed or suspected COVID-19 and experience persistent

symptoms that include respiratory dysfunction for at least four weeks (effective

January 1, 2022);

• Additional medical indications for coverage for PR program services may be

established through a national coverage determination (NCD).

PR must include all of the following components:

Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise

combined with other types of exercise (such as conditioning, breathing retraining, step,

and strengthening) as determined to be appropriate for individual patients by a physician.

Each PR session must include physician prescribed exercise.

Education or training. Education or training that is closely and clearly related to the

individual’s care and treatment which is tailored to the individual’s needs and assists in

achievement of goals toward independence in activities of daily living, adaptation to

limitations and improved quality of life. Education must include information on

respiratory problem management and, if appropriate, brief smoking cessation counseling.

Psychosocial assessment. Psychosocial assessment means an evaluation of an

individual’s mental and emotional functioning as it relates to the individual’s

rehabilitation or respiratory condition which includes an assessment of those aspects of

an individual’s family and home situation that affects the individual’s rehabilitation

treatment, and psychosocial evaluation of the individual’s response to and rate of

progress under the treatment plan.

Outcomes assessment. Outcomes assessment means an evaluation of progress as it relates

to the individual’s rehabilitation which includes the following: (i) Evaluations, based on

patient-centered outcomes, which must be measured by the physician or program staff at

the beginning and end of the program. Evaluations measured by program staff must be

considered by the physician in developing and/or reviewing individualized treatment

plans. (ii) Objective clinical measures of exercise performance and self-reported

measures of shortness of breath and behavior.

Individualized treatment plan. Individualized treatment plan means a written plan tailored

to each individual patient that includes all of the following: (i) A description of the

individual’s diagnosis. (ii) The type, amount, frequency, and duration of the items and

services furnished under the plan. (iii) The goals set for the individual under the plan. The

individualized treatment plan detailing how components are utilized for each patient,

must be established, reviewed, and signed by a physician every 30 days.

As specified at 42 CFR 410.47(e), the number of PR sessions are limited to a maximum

of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for

an additional 36 sessions over an extended period of time if approved by the Medicare

Administrative Contractor (MAC).

PR Settings:

Medicare Part B pays for PR in a physician’s office or a hospital outpatient setting. All

settings must have the following: (i) A physician or nonphysician practitioner

immediately available and accessible for medical consultations and emergencies at all

times when items and services are being furnished under the program. This provision is

satisfied if the physician or nonphysician practitioner meets the requirements for direct

supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient

services at 42 CFR 410.27, and (ii) The necessary cardiopulmonary, emergency,

diagnostic, and therapeutic life-saving equipment accepted by the medical community as

medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and

defibrillator) to treat chronic respiratory disease.

PR Medical Director Standards:

Medical director means the physician who oversees the PR program at a particular site.

The medical director is the physician responsible for a PR program and, in consultation

with staff, is involved in directing the progress of individuals in the program and must

possess all of the following: (1) Expertise in the management of individuals with

respiratory pathophysiology. (2) Cardiopulmonary training in basic life support or

advanced cardiac life support. (3) Be licensed to practice medicine in the State in which

the PR program is offered.

Supervising Practitioner Standards:

Supervising practitioner means a physician or nonphysician practitioner that is

immediately available and accessible for medical consultations and medical emergencies

at all times items and services are being furnished to individuals under PR programs.

Physicians or nonphysician practitioners acting as the supervising practitioner must

possess all of the following: (1) Expertise in the management of individuals with

respiratory pathophysiology. (2) Cardiopulmonary training in basic life support or

advanced cardiac life support.

(See Publication 100-04, Claims Processing Manual, chapter 32, section 140.4, for PR

claims processing, coding, and billing requirements.)