HomeWashington Letter2016 ▶ CMS Final OPPS Rule Includes Unwelcomed Surprise for Pulmonary Rehabilitation Payments
CMS Final OPPS Rule Includes Unwelcomed Surprise for Pulmonary Rehabilitation Payments

November 2016

This month, CMS released the final rule for the Hospital Outpatient Prospective Payment System.  As you probably heard, the final rule includes significant (and unexpected) cuts in reimbursement for respiratory therapy/pulmonary rehabilitation codes.  Below is a chart that shows current payment, payment levels listed in the proposed HOPPS rule and what came out in the final rule.

CPT/G code Short Descriptor 2016 payment 2017 proposed payment 2017 final payment
G0237 Therapeutic procd strg endur $91.18 $265.56 $28.37
G0238 Oth resp proc, indiv $55.94 $161.29 $28.37
G0239 Oth resp proc, group $30.51 $95.66 $28.37
G0424 Pulmonary rehab w exer $55.94 $161.29 $54.53

What happened?

What happened was CMS changed the status indicator for the code from Q1 status (which means it is a bundled service and includes all services/supplies related to providing the service and would only be paid, if no other major service is provided on that day) to S status (which means it is an un-bundled service and can be billed and separately payable regardless if other major services are on that claim).

To put it in other terms, when it was Q1 status the payment for pulmonary rehab and supplemental oxygen and six minute walk test and Labs, etc were part of that payment.  With it being changed to S status, it will always be separately paid, as would any other status S such as smoking cessation, and is not automatically packaged if another major service(s) is on that claim.

Why did this happen?

During the public comment process, CMS received a comment (we don't know from who yet, but it was not submitted on behalf of the ATS) saying that Medicare law required pulmonary rehab to be separately paid, therefore changing it to S status. CMS reviewed the law and agreed and made the switch in the final rule.

How bad is this?

For starters, we don't yet know if this is bad, good or neutral.  Clearly, at first look the drop from current payments for G0237, G0238 and G0239 to $28.37 doesn't look good.  But it may work out that separate billing of related services (oxygen, walk tests, etc) will equal or exceed the previous payments for pulmonary rehab.  At this point, we do not yet have the data to understand the short and long-term policy implications of this policy change.

What's next?

The ATS will review Medicare data files to see if switching from Q1 to S status will actually increase, decrease or have minimal total impact on pulmonary rehabilitation programs.  Reviewing this data and developing estimates will take a few weeks.  Once we have collected and analyzed that information, it will provide concrete information about how to respond to CMS and specific advice to ATS members engaged in pulmonary rehabilitation.

The ATS will continue to share information as it becomes available.

Last Reviewed: October 2017