Pulmonary rehab billing is changing fast as 2026 rules take shape, so clear, up‑to‑date standards matter for every clinic. This guide tells you core medical codes, coverage rules, and workflow steps in plain, professional language.
What Pulmonary Rehab Billing Covers
Pulmonary rehab, or PR, is a planned program for people with lung disease. It often serves those with COPD, a lung injury after COVID, or other long-term lung disease. PR includes
- Guided exercise
- Breathing practice
- Patient teaching
- Food advice and group support
Care is given in a hospital, clinic, and rehab center. For billing, PR is viewed as one bundled service. It is not billed as single tasks, such as one walk test or one class. Charges should reflect the full level of care, staff time, equipment use, and patient risk.
Core PR CPT and G‑codes
Medicare and many payers rely on a strict set of codes for out‑patient PR. The main fee schedule medical codes are:
- 94625: out‑patient pulmonary rehab without continuous oximetry, per session.
- 94626: out‑patient pulmonary rehab with continuous oximetry, per session.
- G0424 (in some policies) or related G‑codes when billed under hospital out‑patient rules.
Group therapy codes like G0239 can apply when payers do not follow the newer PR codes or when local policy requires them. In every case, your charge sheet should tie each session note to one clear primary code
Medicare Coverage Rules Through 2026
- Medicare usually covers up to 36 PR sessions.
- Occasionally, there are two sessions per week for about 18 weeks, to detect any lung disease.
- Coverage may reach 72 sessions if the doctor shows medical need, poor baseline status, or slow progress with benefits.
- A valid referral and healthcare plan from a qualified physician is required before billing the first session.
- Supervision rules state that a physician or qualified practitioner must be immediately available in the unit during each PR session
Key elements of compliant documentation
Clean PR billing starts with clear paperwork that shows medical need, risk, and progress. Each PR chart should have:
- Primary evaluation: diagnosis, lung function values, six-minute walk test, symptom scales, and risk factors.
- Custom plan: exercise targets, education goals, and safety steps. These must be signed by the physician before treatment.
Many payers also expect formal progress reports every 30 days. These should summarize changes in walk distance, symptom scores, and quality of life scales.
Typical Billing Workflow for PR
A repeatable workflow keeps PR billing smooth and lowers denial rates. Here’s a simple six-step process:
Pre-authorization and Insurance Check
- Confirm PR coverage, prior-auth rules, co-pays, and allowed session counts.
- Log approval numbers and limits in the EHR. This helps staff avoid exceeding covered visits.
Intake and Scheduling
- Gather history, testing, and referrals. Build a complete care plan that aligns with payer policy.
- Schedule sessions within the covered time frame. Flag any planned extension requests early.
Coding and Charge Entry
- Select the correct primary PR code (94625 vs. 94626) based on monitoring. Ensure notes match clearly.
- Avoid mixing PR codes with unrelated respiratory therapy codes on the same date unless allowed.
Claim Submission
- Send claims with diagnosis codes that match medical requirements.
- Keep the plan of care, initial testing, and progress notes ready for audits, even if not sent with the claim.
Payment Posting and Denial Clean-up
- Track common denial reasons, such as missing physician signatures or exceeding session limits.
- Use standardized appeal templates that highlight guideline-based indications and measurable gains from PR.
Ongoing Monitoring
- Monitor clean claim rates, denial rates, and days in accounts receivable for PR codes.
- Update regularly to ensure accuracy.
By strict codes, paper work, and tracking around these points, clinics can keep pulmonary rehab programs compliant, sustainable, and ready for the updated 2026 billing standards.
Conclusion
A solid pulmonary rehab billing plan for 2026 begins with clear rules, tidy notes, and teamwork. The front desk, clinicians, and billing team must work closely together. Careful checks on eligibility, supervision, and outcomes create a solid record for payer reviews or audits.
This is where a partner like Wisconsin Medical Billing Services adds real value. Their team can help set up charge sheets, scrub PR claims, track denial trends, and adjust workflows. Working with Wisconsin Medical Billing Services gives your PR program a revenue expert. This way, you can bill confidently and support better breathing and lives for every patient in your program.
FAQS
What does pulmonary rehab billing actually cover?
Pulmonary rehab billing covers a full, structured program of exercise, breathing training, teaching, nutrition support, and risk review for people with chronic lung disease, not single tests or classes billed alone.
Which diagnoses usually qualify for PR under Medicare and most payers?
Common covered conditions include moderate to very severe COPD, post‑COVID lung disease, interstitial lung disease, and other long‑term respiratory disorders that limit daily activity.
What are the main CPT and HCPCS codes for pulmonary rehab in 2026?
Most PR programs use CPT 94625 (outpatient PR without continuous oximetry, per session) and CPT 94626 (outpatient PR with continuous oximetry, per session) for physician or qualified provider services.