Pulmonary Rehabilitation

Section: Therapy
Effective Date: January 01, 2020

Description

Pulmonary rehabilitation (PR) is a multidisciplinary approach to reducing symptoms and improving quality of life (QOL) in individuals with compromised lung function. Outpatient PR programs generally include a patient assessment followed by therapeutic interventions including exercise training, education, and behavior change.

Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up. Individuals should have the ability to perform the exercise training and have a high level of motivation to participate in and complete the program.

Individuals for PR should be medically stable and not limited by another serious or unstable medical condition. Contraindications to PR include but are not limited to:

  • Severe psychiatric disturbance (i.e., dementia, organic brain syndrome); or
  • Significant or unstable medical conditions (i.e., heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, or disabling stroke); or
  • Currently smoking.

The focus of therapy is to educate the individual and establish a program of adaptive changes to a chronic medical illness. The optimal outcome is achieved when the patient continues these adaptive changes on an independent basis after discharge from the program.

Criteria

A single course of PR in the outpatient ambulatory care setting may be considered medically necessary for ANY of the following indications:

  • Treatment of chronic pulmonary disease for individuals with moderate to severe disease see Table 1) who are experiencing disabling symptoms and significantly diminished QOL despite optimal medical management; or
  • Preoperative conditioning component for those considered appropriate candidates for lung volume reduction surgery or for lung transplantation; or
  • Following lung transplantation.

Outpatient PR for any other indication not listed above is considered not medically necessary.

Table 1
Classification of Severity of Airflow Limitation in COPD a,b
GOLD 1 Mild FEV1 ≥ 80% predicted
GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
GOLD 4 Very Severe FEV1 < 30% predicted
a Based on post-bronchodilator FEV1
b In patients with FEV1/FVC < 0.70

Procedure Codes

G0237 G0238 G0239 G0424

The following indications for PR courses or programs are considered not medically necessary:

  • Following other types of lung surgery, included but not limited to lung volume reduction surgery and surgical resection of lung cancer; or
  • Multiple courses of PR either as maintenance therapy in individuals who either:
    • Initially respond to treatment; or
    • Fail to respond to treatment; or
    • Response to treatment has diminished over time; or
  • Maintenance programs may include, but are not limited to, ANY of the following:
    • Continued physical medicine and rehabilitation services beyond the duration of the PR program; or
    • Gym/Health club memberships; or
    • Personal trainer fees; or
    • Informal Counseling; or
    • Educational and self-help materials; or
  • Home-based PR; or
  • Repetitive pulmonary rehabilitation programs.

Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up. PR program length may be considered medically necessary for up to 18 sessions, depending on program and may include the following:

  • Team assessment:
    • May include input from:
      • Physician; and
      • Respiratory care practitioner; and
      • Nurse; and
      • Psychologist; and
      • Others as needed.
  • Individual training:
    • May include:
      • Breathing training; and
      • Bronchial hygiene; and
      • Medications; and
      • Proper Nutrition.
  • Psychosocial intervention:
    • May address:
      • Support system; and
      • Dependency issues.
  • Exercise training:
    • Includes strengthening and conditioning and may utilize the following:
      • Stair climbing; or
      • Inspiratory muscle training; or
      • Treadmill walking; or
      • Cycle training (with or without ergometer); or
      • Supported and unsupported arm exercise training.

Note: Exercise conditioning is an essential component of pulmonary rehabilitation. Education in disease management techniques without exercise conditioning does not improve health outcomes of individuals who have chronic obstructive pulmonary disease.

  • Follow up:
    • May include supervised home exercise conditioning.

Diagnosis Codes

E84.0 J41.0 J41.1 J41.8 J42 J43.0 J43.1
J43.2 J43.8 J43.9 J44.0 J44.1 J44.9 J47.0
J47.1 J47.9 J60 J61 J62.0 J62.8 J63.0
J63.1 J63.2 J63.3 J63.4 J63.5 J63.6 J64
J65 J66.0 J66.1 J66.2 J66.8 J84.10 J84.17
J84.89 J95.1 J95.2 J95.3 J95.821 J95.822 J96.00
J96.20 J96.21 J96.22 J98.2 J98.3 Z48.24 Z48.280
Z90.2 Z94.2 Z94.3

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