Pulmonary Rehabilitation Reimbursement Challenges

Abstract

Pulmonary rehabilitation (PR) is a highly effective intervention for persons with chronic respiratory diseases, resulting in improvement in exercise capacity, dyspnea, health-related quality of life, mood, reduced hospitalization, and improved survival and cost savings post-COPD hospitalization. Despite demonstrated effectiveness, PR is underutilized in part due to lack of awareness, limited access, and inadequate PR reimbursement. Poor payment is a long-standing barrier to PR’s financial stability and access. Addressing PR payment, access, and utilization is a complex challenge and requires strategic, collaborative long-term approaches to meaningful solutions. Strategies to overcome payment disparities begin with legislative approaches to address limitations of Centers for Medicare and Medicaid Services coverage. Additional priorities include permanent approval for remote physician and advanced practice provider (APP) PR supervision, PR referrals by APPs, telerehabilitation using two-way audio/video technology, and elimination of the PR lifetime maximum limit of 72 h or units/patient. Methods are needed to effectively link appropriate PR prescribing and encouragement with primary care providers, hospitalists, case managers, and hospital navigators to optimize PR referrals. There is an important need to address inadequate PR access in rural settings. Potential opportunities to improve PR referrals and access include exploration of PR synergies with value-based care models that emphasize high-quality care and cost savings. Development and use of effective PR provider tools and resources may help address the above challenges as well as financially benefit PR programs.

Introduction

Pulmonary rehabilitation (PR) is a highly effective treatment for persons with chronic respiratory diseases.^1-4 Benefits of PR in persons with COPD include improvement in exercise capacity, dyspnea, fatigue, depression, health-related quality of life, reduction in hospitalization,^5-7 improved survival following COPD hospitalizations,⁸ and substantial cost savings when administered after a COPD hospitalization.⁹ The magnitude of evidence of PR effectiveness led a 2015 Cochrane review to note that additional randomized controlled trials comparing the effects on exercise tolerance improvement and dyspnea reduction of PR as compared to conventional care in COPD were not warranted.⁵

Despite the substantial improvement in clinical outcomes and cost savings, United States PR payment, access, and utilization are chronically inadequate with a long-standing barrier to PR financial stability and access. Strategies to address inadequate payment and access begin with legislative and regulatory approaches to improve insufficient PR coverage and payment by the Centers for Medicare and Medicaid Services (CMS). These approaches to address gaps in PR coverage and operations include permanently allowing remote physician and advanced practice provider (APP) PR supervision, PR referrals by APPs, telerehabilitation using two-way audio/video communications technology, and eliminating the lifetime maximum limit for PR of up to 72 one-h units/patient. Addressing PR payment, access, utilization, and awareness requires collaborative long-term, strategic approaches. Importantly, payment for virtual PR provided by hospital out-patient programs was terminated by CMS in May 2023 as part of the end of the pandemic-related public health emergency. Importantly, virtual PR models in general are an emerging model of PR delivery in the United States. Early analysis suggests substantial heterogeneity among virtual PR programs, leading to concerns about program content, efficacy, safety, and selection of optimal candidates in these programs.

Review of the Literature

PR is a comprehensive, multidisciplinary approach that includes supervised exercise training, self-management education targeting long-term behavior change, and support from peers. PR outcomes include multidimensional improvement in physical function, dyspnea, depression, health-related quality of life, reduction in hospitalization,^2-7 improved survival⁸ and significant cost savings when timely PR follows COPD discharge.⁹ Despite clear effectiveness of PR, its poor uptake, access, and reimbursement have resulted in widespread challenges and barriers including CMS payment of < 50% of that for cardiac rehabilitation (CR) (Table 1).

Table 1.

Cardiac and Pulmonary Rehabilitation Billing Codes and Medicare Payment

This dichotomy between CR and PR payment rates by Medicare persists despite strong evidence of PR effectiveness and arguably higher complexity of the pulmonary patient. One study that compared PR to CR subjects found that PR subjects had more comorbidities, older age, smoked more, had markedly poorer functional status, greater polypharmacy, and were less likely to be employed versus CR counterparts.¹⁰

PR is underutilized in the United States, with < 4% of Medicare members with COPD attending PR¹¹ and < 10% receiving PR following discharge for exacerbation of COPD.¹² Additional barriers to PR utilization include inadequate awareness of PR among health care professionals and caregivers,¹³ lack of transportation and related challenges,¹³ geographic disparities particularly in rural settings,^14,15 and limited training opportunities for PR professionals.^12,14

COPD impacts an estimated 24 million Americans,¹⁶ with many remaining undiagnosed and untreated. COPD health costs are estimated at $800 billion during the next 20 years.¹⁷ PR is a highly effective treatment for COPD¹⁸ with significant increase in 1-y survival when occurring within 90 d following COPD discharge,⁸ with a cost savings of $171/session,⁹ which is many times the Medicare reimbursement rate (Table 1), as well as incremental cost-effectiveness ratio of $884/session for $50,000/quality-adjusted life year (QALY) and $1,597/session for $100,000/QALY.⁹

How Did We Get Here?

United States PR reimbursement challenges are complex and long-standing. This is at least in part tied to a change in Medicare PR payment in 2010 to reflect changes in the Medicare statute that, for the first time, identified PR as a specific Medicare benefit. CMS established a Healthcare Common Procedure Coding System (HCPCS) billing code in the absence of a Current Procedural Terminology (CPT) billing code. The new PR HCPCS code, G0424, was created to provide a payment pathway authorized by the change in statute. CMS invariably establishes HCPCS codes to address such a vacuum. G0424 was defined as a bundled billing code for PR, including exercise (which includes monitoring), 1 h/session, ≤ 2 sessions/d. In addition to supervised exercise and education, the code also encompasses payment for staff salary and benefits, physician work, and overhead charges for the PR facility among other costs. G0424’s bundled, comprehensive design differed from older billing codes G0237 and G0238 that paid for each 15-min increment of service including exercise (G0237) and education (G0238). The new code covered PR for patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD stages 2–4 and was limited to a maximum of 72 one-h sessions or units/lifetime. Due to the absence of any billing data for the new PR code, Medicare assigned a temporary charge of $50/unit for G0424. To determine subsequent payment for PR, CMS has collected data from both annual Medicare hospital cost reports as well as hospital PR billing charges. PR payment by CMS has stagnated since the early days of coverage primarily due to chronically inadequate PR charges by hospitals that underrepresent the complexity of both PR services and patients and the use of a bundled charge code that represents the amount of time for G0424—a 1-h bundled code versus previous billing 15-min codes G0237 and G0238. CMS specifically identified G0424 as an example of a new code where hospitals need to review their charges to reflect the shift from 15-min billing codes to a 60-min bundled code framework. Most hospitals have yet to adjust their charges despite urging from CMS and the broad PR community.

To understand the undervaluing of PR charges, a review of 2015 Medicare data examined the genesis of low hospital charges for PR services.¹⁹ As noted above, PR payment by CMS is calculated from two key data sources provided by hospitals: the amount submitted to CMS for payment of PR billing codes and information from the hospital annual Medicare hospital cost report. The amount charged by hospitals for G0424 has historically been more consistent with older 15-min billing codes G0237 and G0238 units versus the 1-h bundled code G0424. To better understand these barriers to equitable payment, the 2015 review of CMS data assessed approximately 1,350 United States hospitals billing out-patient PR code G0424. The review demonstrated significant variability in G0424 charges ranging from $44–1,981/unit, with a mean charge of $247. Hospital annual cost report data ranged from $4–1,265/unit. Approximately 750 hospitals submitted data to CMS reflecting PR costs/h at ≤ $50. These findings led to the development of the original PR Reimbursement Toolkit developed by representatives from several national PR societies including American Association for Cardiovascular and PR (AACVPR), American Thoracic Society (ATS), and American Association for Respiratory Care (AARC) to inform PR staff, billing leads, and hospital administration of strategies to make PR charges more representative of the cost of PR services. The toolkit recently underwent a comprehensive update: https://www.aacvpr.org/Learn/PR-Reimbursement-Toolkit (Table 2). Effective January 1, 2022, G0424 was retired and replaced by 2 CPT codes intended to represent the complexity of PR and similarity of services to CR: CPT code 94625, out-patient PR, without continuous oximetry monitoring (per session); and CPT 94626, out-patient PR, with continuous oximetry monitoring (per session). This change was intended to provide a more accurate description of PR and its related services and similarities to CR. Significant impact of modification of billing codes on payment for PR has not yet been established. This may be multifactorial including hospital PR charges that do not reflect the complexity of PR services and patients.

Table 2.

Pulmonary Rehabilitation Reimbursement Resources

Actions to Address PR Payment Disparities and Billing Challenges

An important yet complex payment challenge is identifying and using appropriate PR charges because of CMS reliance on the data provided by hospitals. This process should include regular interfacing with PR management, hospital billing leads, and administration to collaboratively review and assure use of appropriate PR charges. Resources to support skills for reasonable charges and billing competency have been developed by the AACVPR with support of by the ATS, AARC, and other pulmonary organizations. Helpful resources include the ATS Pulmonary Rehabilitation US Reimbursement Update: 2024 (https://www.thoracic.org/members/assemblies/assemblies/pr/quarterly-bite/pulmonary-rehabilitation-us-reimbursement-update-2024.php) which provides essential details of CMS billing and coverage updates on a regular basis. To optimize understanding of billing and PR program operations, PR programs should consider identifying at least one staff member to become an AACVPR member to optimize PR billing skills, regulatory practice, program operations, and opportunities to interface with experts and colleagues with similar interests in PR reimbursement.

Medicare Rules and Regulatory Approaches

The past several years has brought heightened awareness, collaboration, and strategies targeting understanding and improving PR reimbursement, access, awareness, and resources. Central to this expansion of PR priorities is knowledge and utilization of appropriate PR billing. This requires effective tools, training, and support targeting PR providers and managers, billing leads, and hospital administration, as well as focused updates for prescribing clinicians.

A pair of key annual regulatory publications that outline updated CMS rules, payment, and related information includes the Medicare Hospital Out-Patient Prospective Payment System (HOPPS) Calendar Year (CY) 2023 and Ambulatory Surgical Center Payment System Final Rule With Comment Period (CMS 1772-FC); and physician fee schedule (PFS) changes and updates: American Hospital Association (AHA) Summary of Physician Fee Schedule Final Rule for CY 2024, AHA reflecting changes in the PFS. HOPPS is used to reimburse hospital out-patient services including hospital out-patient PR, and PFS includes physician’s professional services such as office-based PR. Proposed rules are normally published in July with an opportunity for public comment. Final rules are normally available the first week of November to potentially give providers time to adjust billing practices for the following CY. Pulmonary societies regularly submit comments to respond to CMS’ proposed rules, particularly if they raise concerns about payment and/or services.

The 2024 proposed rules are identified as CMS-1784-P: Medicare and Medicaid Programs, CY 2024, payment policies under the PFS addressing payment for medical doctor (MD) office–based PR and other changes to Part B payment policies CMS proposed rules 2(b)(3)(ii). These rules allow for the direct virtual supervision requirement for PR to include virtual presence of the physician through audio/video real-time communications technology through December 31, 2024. CMS has extended this policy to APPs who are eligible to supervise PR services in 2024 (Table 3). In the proposed rules for 2024, CMS had sought comments on whether there are safety and/or quality-of-care concerns regarding this policy beyond the current or proposed extensions and what policies CMS could adopt to address those concerns if the policy were extended beyond its current 2023 expiration date. Major pulmonary societies submitted formal comments to support the above proposed policies and the efficacy and safety of these approaches as well as urging CMS to make virtual direct supervision a permanent option in meeting this requirement, with the goal of increasing accessibility of these services. They also have asked CMS to allow the same coverage and PR codes to the Out-Patient Prospective Payment System as well so that PR programs based in hospital out-patient departments will have the same opportunity as MD office practices to increase access.

Table 3.

Medicare Rules for 2024 That Impact Pulmonary Rehabilitation

Legislative Efforts

Recent advocacy efforts have focused on permanent virtual direct physician and APP PR supervision, face-to-face real-time virtual delivery of PR, and allowing expansion of PR and improvement in accessibility to PR without payment reduction based on the location of the service via the Sustaining Out-Patient Services (SOS) Act. AACVPR along with ATS, AARC, the COPD Foundation, and other national organizations are actively pursuing legislative avenues to allow for permanent PR telerehabilitation access via House Bill (HR) 1406 and Senate Bill (SB) 3021 entitled the Sustainable Cardiopulmonary Rehabilitation Services in the Home Act. This bipartisan bill would allow hospital-based PR programs to provide virtual, real-time audiovisual services in the patient’s home on a permanent basis (Table 4). The passage of this bill would help address some of the barriers to PR participation, eg, reducing delayed PR due to space constraints, excessive travel expense, and long distance to a center-based PR program, and would lead to improved adherence and health outcomes. AACVPR and other societies have supported APPs including nurse practitioners, physician assistants, and clinical nurse specialists independently ordering and providing direct supervision for PR services.

Table 4.

Pulmonary Rehabilitation Legislative Summary of High-Priority Bills

AACVPR sponsors an annual Day on the Hill that recently championed out-patient services as part of SB S1849, the SOS Act introduced on June 8, 2023. It is the companion bill to HR 955. If passed, the bill would exempt certain hospital out-patient services, including PR, from significant CMS payment reduction based solely on the location of the hospital out-patient service. The bill mandates that Medicare payment for hospital-based PR services remains under the out-patient payment rate. The current 40–50% reduction in PR reimbursement for off-campus services dramatically reduces an already grossly inadequate reimbursement. The bipartisan bill would allow PR programs to expand to rural, larger, and more accessible off-campus locations and potentially improve access to PR.

HR 2583, the Increasing Access to Quality CR Act, would allow both CR and PR to expand the role of APPs to allow their independent referral to and ordering of PR services, operate PR programs in the APP’s office, review and sign individualized treatment plans, prescribe exercise, and provide PR program oversight. CMS currently requires a physician or group of physicians to serve as PR medical director(s). This Act raises some potential concerns: It is unclear if eliminating the physician oversight requirement of PR supports all safety and efficacy needs of PR and whether there is a possible risk of negative impact on PR reimbursement.

What About PR Telerehabilitation?

A recent challenge for both PR services and patient access is CMS’ termination of payment for center-based virtual PR at the end of the public health emergency in May 2023. Prior to its termination, Medicare allowed PR under the “hospital at home” waiver, paying for virtual (synchronous, real-time audio/video) delivery of PR by out-patient hospital PR departments for patients with GOLD COPD 2–4. Ending virtual PR has further deepened an important disparity. Note that virtual PR (synchronous, real-time audio/video) programs currently may be provided exclusively by PR programs that are owned and billed by physicians under the telehealth professional codes. This applies to patients with GOLD COPD 2–4 and confirmed or suspected COVID–19 with persistent symptoms, effective through 2024. Note that asynchronous (not real-time, such as recorded) services for PR are not paid for by Medicare. Programs may use such adjuncts to enhance a patient’s rehabilitation course, eg, digital health tracking (steps, medication adherence, etc; electronic educational resources; or telephone calls), but these are not paid for by CMS. An important resource for understanding telerehabilitation and its potential role can be found in the ATS Workshop Report Defining Modern PR.²⁰

Addressing PR Access, Awareness, and Payment

Strategies to improve PR awareness, access, and payment include an annual multisociety social media campaign led by the ATS Reimbursement Working Group in collaboration with approximately 20 pulmonary and patient organizations whose missions support addressing the needs of persons with chronic lung disease including a national social media campaign with infographics describing PR efficacy and challenges (Fig. 1 and Fig. 2).

Fig. 1.

Infographic for national social media campaign. Pulmonary rehab and cost savings. From the American Thoracic Society, with permission.

Fig. 2.

Infographic for national social media campaign. Pulmonary rehab and mortality. From the American Thoracic Society, with permission.

Efforts to improve PR access led to a recent full update of the ATS Livebetter.org PR program directory database. The update included calls to over 1,700 United States PR programs to verify current program information including current provision of center-based PR, virtual PR, and maintenance exercise. The recent update included combining the Livebetter.org database with the Moscovice et al¹⁵ PR program database, which was developed in part to address PR disparities in rural settings.

Understanding Value-Based Care Models and a Potential for PR Interface

Medicare has an increasing alignment with value-based care (VBC) models, thus impacting a growing number of CMS beneficiaries as outlined in the publication The Medicare VBC Strategy: Alignment, Growth, and Equity.²¹ A subgroup of the ATS PR Reimbursement Working Group has met with VBC experts and leadership to explore potential synergies that may ultimately enhance PR referrals and access. VBC models including Medicare Advantage (MA) and accountable care organizations (ACOs) generally focus on improved quality of care and cost savings that may lead to opportunities to recognize the value and importance of PR. A recent editorial in the Annals of the ATS²² described the potential alignment of PR outcomes and VBC goals. Timing is particularly important for this interface. In 2021, CMS established a goal to have 100% of original Medicare beneficiaries in accountable care relationships by 2030 as part of Medicare’s Innovation Center Strategy.²¹

PR Provider Training and Resources

AACVPR has recently provided several sold-out comprehensive PR reimbursement and coding workshops to help advance PR provider skills and provide tools and resources to enhance understanding and use of effective and accurate PR billing practices. AACVPR, along with ATS and AARC, recently led a complete update of the PR Reimbursement Toolkit (https://www.aacvpr.org/Learn/PR-Reimbursement-Toolkit). The toolkit is a comprehensive guide and resource supplement that supports understanding and optimizing PR charges and payment. The toolkit targets PR clinicians, hospital billing leads, and administrators and includes focused resources for providers and hospital administration. AACVPR’s annual national meeting provides reimbursement education and opportunities to interface with national experts and PR colleagues.

What Can We Learn From Cardiac Rehabilitation’s Successes?

CMS has acknowledged similarities in CR and PR. Lower PR reimbursement despite recognized CR similarities and patient complexity led a multisociety group led by ATS and American College of Chest Physicians to propose new CPT billing codes that have clear similarities to CR procedure codes. A multisociety effort led to the successful establishment of CMS PR American Medical Association CPT codes 94625 and 94626 to replace G0424. The new codes became effective January 1, 2022.

1. 94625: Physician or other qualified health care professional services for out-patient PR, without continuous oximetry monitoring (per session).

2. 94626: Physician or other qualified health care professional services for out-patient PR, with continuous oximetry monitoring (per session).

The above PR codes are used to bill PR for patients with GOLD COPD 2–4 or confirmed or suspected COVID-19 with persistent symptoms that include respiratory dysfunction for at least 4 weeks. The codes have a maximum lifetime limit of 72 one-h units/patient. Normally this is for an initial 36 units and potential coverage for an additional 36 using if medically necessary.

Medicare Payment for PR and Out-Patient Respiratory Services

Medicare has 2 general models of coverage related to PR type services: (1) PR and (2) out-patient respiratory services (ORSs). Use of each service is primarily based on the patient’s diagnosis and oversight of administration and payment. For patients with COPD GOLD stages 2–4 or confirmed or suspected COVID-19 as described earlier, PR services are typically used and billed using CPT codes 94625 and 94626 for bundled or comprehensive PR services. These CPT codes are used to bill for each 1-h unit (2 maximum units/d) and include 36 maximum lifetime visits/patient (with eligibility for an additional 36 lifetime PR visits if medically necessary). To bill for one session of PR/d, the duration of treatment must be at least 31 min. Two sessions of PR on the same day must be at least 91 min in length. Each billed unit must include exercise although there is no specific definition of the amount or type of exercise required.

In contrast to Medicare payment and oversight of PR, ORSs are overseen by one of 12 regional Medicare administrative contractors (MACs) comprised of private insurance companies that contract with CMS to interpret CMS rules and pay for services on behalf of CMS for Medicare A and B (Fig. 3).

Fig. 3.

Map of Medicare Part A and B Medicare administrative contractors.

In contrast to the bundled or comprehensive billing codes used for PR services, MACs require the HCPCS codes below for billing for ORS services (Table 5) including:

1. G0237: Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, 1:1, each 15 min.

2. G0238: Therapeutic procedures to improve respiratory function, other than that in G0237, face to face, 1:1, each 15 min.

3. G0239: Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, 2 or more individuals.

Table 5.

G Codes for Billing Out-Patient Respiratory Services

MACs are an essential entity given their role in coverage of many diagnoses not covered under traditional PR. Covered services, diagnoses, and International Classification of Diseases, Tenth Revision codes may be described in individual MAC’s local coverage determination (LCD) for respiratory services. However, not all MACs have current LCDs to guide providers regarding covered diagnoses and requirements. Understanding regional MACs and their rules is necessary for understanding covered diagnoses and for successful billing of services. Note that a MAC may cover more than but not less than coverage rules established by CMS. Given the complexity and diversity of MAC coverage, providers should refer to the AACVPR MAC resources for guidance including MAC (https://www.aacvpr.org/MAC-Medicare-Administrative-Contractor) and MAC publications (https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?articleid=52770). AACVPR provides a MAC resource page, a list of MAC task force member(s), as well as regulatory updates, webinars, workshops, and courses held at their national conference (see AACVPR.org).

In contrast to traditional Medicare, MA insurance is provided by private insurance health plans and is paid for by CMS, subscriber premiums, and co-payments. MA providers include physicians and, in some cases, hospitals. In general, MA should provide the same coverage as traditional Medicare although this may vary by state regulations and plans. Additionally, MA may offer additional coverage, eg, medication, hearing aids, gym membership. Under the broader umbrella of VBC organizations, MA and ACOs focus on high-value services and cost containment. MA clinician providers are incentivized to control costs as part of a risk model that rewards control of costs within a predetermined amount and penalizes VBC providers when costs exceed these amounts. Individual plans may require preauthorization for PR. PR providers need to establish which codes the MA plan will cover as well as the number of authorized visits and co-payments and written evidence of this information from the insurer. Appeals can be made to the patient’s insurer in the event services have been declined.

For ORSs, 15-min billing codes, the minimum and maximum time increments per unit billed, are given above (Table 6).

Table 6.

Out-Patient Respiratory Services Billing and Time Increments for G0237 and G0238 Coding

Approaches That May Favorably Impact PR Payment

Approaches that have potential to favorably impact PR payment and access include:

1. Develop a collaborative strategic plan to define priorities, mechanisms, responsibilities, and follow-up regarding legislative approaches to improving PR payment and access including permanent allowance by Medicare of:

   1. Remote physician and APP PR supervision
   2. PR referrals by APPs as part of Medicare services
   3. Telerehabilitation using synchronous two-way real-time audio/video technology
   4. Allowing expansion of PR including off-site provision and improved accessibility to PR without payment reduction due to the location of the service via the SOS Act
   5. Eliminating the PR lifetime maximum limit of 72 one-h units/patient.

2. Determine pathways to facilitate appropriate clinician referrals to PR including developing approaches that effectively target primary care physicians, hospitalists, and case managers.

3. Develop methods to address PR needs in rural settings where services are routinely inadequate.

4. Develop and promote tools and resources to optimize clinician understanding and practice of PR billing that represent the complexity of both PR patients and PR services. Target communication and interface with hospital billing staff and administration.

5. Explore interfacing with VBC entities to assess potential synergies of PR and VBC goals of improved quality of care and cost savings.

6. Importantly, adjusting PR payment upward is not as simple as addressing the above-identified variables. Because all out-patient services are paid under a specific payment formula, the primary PR payment challenge is the lack of hospitals adjusting PR charges to an equitable level. There is a risk that even if CMS addressed items A–E above, low payment could remain.

Monitoring and Auditing PR Financial Operations

PR providers should collaborate with management and billing leads to develop, enlist, and monitor a system for tracking and analyzing PR billing including accounts receivable. At a minimum, information tracked and audited should include monthly total visits and amount billed and paid per patient unit of service. Any concerns or shortfalls should be addressed with management and billing at least monthly and as needed. Tools for navigating these processes are included in the updated PR Reimbursement Toolkit (see Table 2.).

Considerations for PR Charges

Understanding PR charges versus payment is neither simple nor transparent. Potential challenges include that hospital charges rarely reflect the amount paid for a service by private insurance or federal programs such as Medicare. The United States health care system is complicated, and many health care costs are market driven. Increased charges may reflect the growing costs of care, including drug costs (often high and unregulated), medical and staff salaries, growing charges of health care centers, and other factors. Many of these factors do not exist at the same magnitude for countries whose health systems are based on socialized medicine models and/or health care services are less driven by a market economy. Understanding a hospital’s charges and the amount paid for PR services are important, as well as how PR charges compare to similar services, eg, CR, pulmonary function testing, electrocardiogram, and echocardiogram.

Staff may assume that a charge should only reflect the time a patient spends exercising. This undervalues the complexity of both PR services and PR patients, as well as the multidimensional improvement and cost savings that PR yields.⁹ The PR Reimbursement Toolkit (https://www.aacvpr.org/Learn/PR-Reimbursement-Toolkit) offers detailed information on construing fair charges for PR.

PR Reimbursement Resources

National, state, and local resources may add clarity and support to navigating PR billing and payment. AACVPR has a daily listserv called Pulse Digest that allows members to submit questions and comments and review frequently asked question and expert responses. Many states have a state society (often combined with CR) that may provide local support. A brief list of PR reimbursement resources is included in Table 2.

Summary

PR is well established as the standard of care in persons with chronic lung disease including COPD. Despite the clear effectiveness of all major relevant outcomes, PR reimbursement, access, and awareness continue to stagnate at marginal levels. Addressing these disparities should be a priority for pulmonary societies and patient organizations. Strategies should include a strategic methodology to address Medicare coverage inequities including legislative approaches to address barriers to care. In addition, improving clinician awareness and providing resources and tools to improve PR services, referrals, and staff training should be a priority. Telerehabilitation models potentially offer a valuable option for improving PR access. This important service is not currently paid for by CMS payment when provided by out-patient hospital departments. Additionally, there are currently no standards of care including quality metrics to assess effectiveness and safety of these interventions that are somewhat rare in the United States.

Panel Discussion

Garvey: I don’t know about questions, but I’d like some answers if you have any.

Bhatt: Chris, can you tell us more about HR 1406.¹ What does that involve? Can you tell us more about it?

Garvey: This is in response to Medicare terminating virtual pulmonary rehab as part of the end of the public health emergency. HR 1406 and SB 3021 would impact both cardiac and pulmonary rehab. AACVPR has led the multi-society campaign to pass these bills. I’m trying to get clarification if this is just for GOLD COPD II–IV and post COVID-19 with persistent respiratory symptoms, or is there going to be opportunity for coverage by Medicare administrative contractors as well, which could mean other non-COPD and non-COVID pulmonary diagnoses may be eligible. We don’t know yet. That’s it in a nutshell. It’s important, but there are potential risks. We just have to accept that. I think it’s such an ethical challenge to not support providing services to people in rural settings that it outweighs whatever risk we will need to face.

Yohannes: Thank you for that excellent presentation, I really enjoyed it. In your presentation, you mentioned about how to defend center-based PR. If the legislation in the United States about telerehabiliation reimbursement has been approved as a model of PR program, how do we defend it? Just wondering what are your initial thoughts on how are we going to go about it?

Garvey: Evidence-based outcomes. The studies like Marilyn [Moy] presented, randomized controlled trials. But it’s not going to be easy because in this day and age I personally feel it would be unethical to not offer somebody that has advanced disease pulmonary rehab. Scholarly publications, societal support, and possibly more legislation are potential ways to support center-based PR. We have to find the right avenues, and it’s probably going to require several different approaches because we can’t easily predict the approaches that are going to take hold. If we’re going to change things, it probably has to be legislative because Medicare is not always fully transparent. An important part of advocacy is getting the word out to patients. We can do that, but what it takes is for ATS, AARC, AACVPR, and ACCP to make this a priority when they have so many priorities that we’re competing with. It will be the most labor-intensive part, but I think the most important component. I would say that ATS, AACVPR, ACCP, and AARC are taking pulmonary rehab more seriously. I mean, we’re here. But we’re probably going to have to push harder. So, more to come, but I think that’s going to be valuable to have the pulmonary societies behind this.

Rochester: Thanks, Chris, for your great presentation. It’s always difficult to wade through all these different Medicare options and plans, and it’s helpful to have a focused review of them. I think my question builds on what Abebaw [Yohannes] was asking of what specific actions do we need to take immediately to convincingly assure that center-based pulmonary rehab will not be eradicated by HR 1406 if it passes? It’s not that we don’t have evidence to show center-based rehab works. We can write editorials about all the reasons why we need center-based rehab programs, and some of this was articulated very clearly in the ATS defining modern pulmonary rehab workshop² as to the different components and spectrums of models, and there’s been a lot of written about this already, but what beyond that can we do perhaps legislatively or otherwise to ensure that center-based programs don’t disappear?

Garvey: I really think this requires a strategic approach where leaders, many people in this room, have a call and talk about what and where the priorities and opportunities are; it should involve Gary Ewart of ATS, Miriam O’Day of AARC, and other legislative leads. A plan much like you were talking about with a pulmonary rehab action plan or plan of care, and we need to talk about each component. I think there’s a publication component where Respiratory Care, prominent ATS publications, and Chest all commit to valuing publication of scholarly content that talks about the evidence. Rich [Casaburi] and Surya [Bhatt] have a really good handle on this. Even if you’re a very strong proponent of virtual PR, you don’t want to see center-based PR go away. It’s getting all of the evidence together in a state-of-the-art manuscript in each scholarly journal to start the process. Potentially everybody should have a background on how to argue for legislative change. We rely on guidance from the legislative leads because this is a totally different world and we really find out what should we be thinking in order to navigate the legislative process and passage of bills. We have been talking to Gary Ewart about meeting with Medicare. He thinks we should, because of better evidence, but we haven’t really come up with a concrete plan. I think a strategic planning meeting starting with the pulmonary rehab assembly and then inviting experts to be part of it would be helpful. I think the more organized, and more careful, and the more we’re keeping our eyes on goals, the better.

Mosher: Chris, that was a great talk. Thank you so much. Two clarifying questions. The HR bill that you mentioned, am I correct in understanding that if that gets approved that would only cover virtual services that are done in a tele rehabilitation face-to-face synchronous fashion, correct? These models that use apps and even occasional telephone calls to check in would still not be covered.

Garvey: Correct, my understanding is that they would not be included as part of HR 1406.

Mosher: And then my second question is separate to that. You had a slide where you were showing the historical context of the billing codes for PR and it looked to me, maybe I didn’t understand it correctly, but even when it was revised in 2022, the PR reimbursement is still extremely poor. Is that correct even though they’ve changed the coding?

Garvey: That is the key message. Whether the change in coding is going to help or not, we don’t know. It may not, but we have never recovered from not modifying our charges to reflect the complexity of the bundled comprehensive billing code established in 2010, so payment continues to stagnate. At the last Respiratory Care Journal Conference³ we had a conversation about this, and my opinion is we just weren’t looking at the books for a decade following the introduction of the new bundled code in 2010. People weren’t looking at what we were getting paid, and 10 years later we start to notice, wow, we have a problem. AACVPR has been strongly supportive for several years. My opinion is that we are ethically bound to make sure that the payment is equitable.

Criner: I think the current lack of definition creates an opportunity for the structured center-based pulmonary rehab programs to define the narrative of what a complementary virtual hybrid program should look like. I think one of the best examples is home versus in-lab sleep studies where, same thing, was it just going to leach out all the center-based sleep studies until the center-based sleep studies embraced integrated home studies with their in-lab centers. It solidified the nature and the viability of the in-based centers. So, I think the same thing could be done with this.

Garvey: That’s a great analogy. And it’s established and successful, so that’s a good thing to include.

Moy: Thank you for the talk. I learned so much. Two questions. One is about the HR bill, who actually proposed it and who created the language?

Garvey: It came from AACVPR, and I believe the American College of Cardiology was involved. It’s had a lot of buy in, so we’ll see how this evolves. The focus right now is to get the word out. I believe it is on the ATS pulmonary rehab reimbursement webpage (https://www.thoracic.org/members/assemblies/assemblies/pr/reimbursement-updates-and-tools.php. Accessed January 19, 2024). And the COPD Foundation has it on their web page (https://www.copdfoundation.org/Take-Action/Get-Involved/Join-our-Advocacy-Action-Center.aspx?vvsrc=%2fCampaigns%2f104240%2fRespond. Accessed January 19, 2024). And I believe AARC does as well (https://mstr.app/ca1c65af-93aa-489d-81de-7dddeca395e7 and https://mstr.app/28035830-ef85-4b68-aaea-97554a8319b9 Accessed March 26, 2024).

Moy: My second question is, is there a limit to the ratio of patients to PR staff that we need to abide by in virtual PR as we do with our in-person centers? For the virtual PR, we thought we could have 50 people on the screen and it would be fine. But is there some definition of that ratio at this point for the virtual programs?

Garvey: I am not aware of any limit at this time, but effectiveness and safety should be important principles. I should probably note that with the exception of Surya and Marilyn, some VA programs, and a few other small programs, virtual pulmonary rehabilitation for the most part did not exist in the United States until COVID-19. And then programs were not really supported in starting virtual pulmonary rehabilitation because, as you know, the public health emergency got extended every 3 months during the pandemic. So how are you going to build a financial model when you don’t know if it’s going to be paid for or exist in 3 months? It was really a challenge. Some programs provide one-to-one PR. I know of at least one program that provides more than one patient per virtual PR session. This is an area that is prime for better understanding and guidance because of the heterogeneity of the practice. My opinion is that we may need to tighten things up. I think that several of the speakers at this meeting could help prevent some of the challenges with “pop-up” virtual programs. I contact them; nobody contacts me back. It’s unclear if they want me to know what they’re doing. Nonetheless, we plan to survey United States virtual PR programs to better understand their services and impact.

Bhatt: There are plenty of experts in this room, so I’d like to ask you all, do you think a position statement for how to define telerehab and what the components should be, and some recommendations for standardization would help?

Garvey: I think as Carly [Rochester] said Anne Holland and several others participated in that as part of the ATS Defining Modern Pulmonary Rehabilitation workshop. That was an outstanding start. But we need to go to the next step. We need to get more guidance on who is a candidate for center-based PR versus virtual PR and what are the minimum standards for virtual pulmonary rehabilitation. For me, a bit like Rich but not quite as adamant, I’m a strong believer in a 6-min walk test before and after virtual and center-based pulmonary rehabilitation because, except for what Surya and Marilyn have done, we’re in the infancy of virtual pulmonary rehab models in the United States. We know very little. I think at this stage we need to be doing an in-person assessment before and after virtual PR unless the patient lives in a remote and/or inaccessible location. We need to have more scholarly publication on this topic so we can impact it when the opportunity arises.

Rochester: Just to build on what Surya asked about the possibility of a position paper, I think it could and should be highlighted that as it stands now we have data relating to things like the 6-min walk, but there are several outcomes of relevance for which we really don’t have data for non-center–based PR as of yet. It is important to articulate clearly that there are things that telerehabilitation perhaps can and can’t do and there are aspects that we just don’t know about yet.

Garvey: I think in addition to that, patient education may need assessment and resources such as the the ATS Patient Fact Sheets (https://www.thoracic.org/patients/patient-resources/fact-sheets-az.php Accessed April 15, 2024). An area of potential challenge is physicians and patients who want a virtual option but the patient may be clinically very complex and/or unstable (eg, advanced pulmonary hypertension and need for high-flow oxygen) and they want to have rehab at home. And physicians may not be aware of the merit of assessment prior to virtual PR. I’ve had patients referred to virtual pulmonary rehab that, for example, had signed themselves out against medical advice following recent extubation in the ER because they wanted to go home. Virtual PR was prescribed because the patient declined center-based PR. The pulmonary rehab program has to do the digging to find out if a patient is an appropriate candidate for center-based PR vs virtual PR. I think if we’re more clear about who is an appropriate candidate that the physicians and patients may have guidance and get a better sense of how we can best support them.