CPT® Code 94625

Official Description

Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)

Common Language Description

Pulmonary rehabilitation (PR) is a comprehensive program designed to assist patients suffering from chronic lung diseases in understanding and managing their conditions effectively. The primary goal of PR is to improve the patient's overall function, enhance their quality of life, and reduce the frequency of hospital visits. Typically lasting between 4 to 12 weeks, a PR program encompasses a variety of components, including thorough evaluation, education, and exercise. This multidisciplinary approach involves collaboration among healthcare professionals such as pulmonologists, respiratory therapists, physical and occupational therapists, nutritionists, and social workers, all working together to provide holistic care tailored to the patient's needs.

PR is particularly beneficial for patients with a range of respiratory conditions, including asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, muscular dystrophy, lung diseases resulting from occupational or environmental exposures, sarcoidosis, pulmonary fibrosis, and pulmonary hypertension. Additionally, pulmonary rehabilitation may be prescribed for lung transplant patients, either as a preparatory measure before surgery or as part of the recovery process afterward.

The program typically commences with exercise and lung function testing, which includes an initial assessment of the patient's oxygen saturation levels both at rest and during physical activity. This assessment is crucial for determining the appropriate level of rehabilitation required and identifying any supplemental oxygen needs. Based on the individual assessment, a personalized exercise regimen is developed, which may include strength training using weights and endurance exercises performed on a bike or treadmill. Furthermore, patients may receive training in various breathing strategies aimed at increasing oxygen levels and strengthening the airway.

Education is a key component of the program, where patients learn about their specific lung disease, effective medication management, and the use of medical equipment. They are also taught techniques to enhance their efficiency in daily activities, thereby conserving energy. In addition to physical training, nutritional guidance and psychological counseling may be integrated into the program to support the patient's overall well-being. It is important to note that while continuous oximetry monitoring is a part of the pulmonary rehabilitation process, it is specifically associated with CPT® Code 94626, whereas CPT® Code 94625 refers to outpatient pulmonary rehabilitation services without such monitoring.

1. Indications

The following conditions and symptoms indicate the need for outpatient pulmonary rehabilitation services as described by CPT® Code 94625:

Chronic Lung Diseases Patients with chronic lung diseases such as asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, and pulmonary fibrosis may benefit from pulmonary rehabilitation to manage their conditions effectively.
Muscular Dystrophy Individuals diagnosed with muscular dystrophy may require pulmonary rehabilitation to improve respiratory function and overall physical capabilities.
Lung Diseases of Occupational or Environmental Origin Patients suffering from lung diseases caused by occupational or environmental factors can utilize pulmonary rehabilitation to enhance their lung function and quality of life.
Sarcoidosis Patients with sarcoidosis may be referred for pulmonary rehabilitation to help manage their symptoms and improve lung capacity.
Pulmonary Hypertension Individuals diagnosed with pulmonary hypertension may benefit from a structured rehabilitation program to improve their exercise tolerance and overall health.
Lung Transplant Patients Pulmonary rehabilitation may be prescribed for patients before and after lung transplant surgery to prepare for the procedure and aid in recovery.

2. Procedure

The procedure for outpatient pulmonary rehabilitation as outlined in CPT® Code 94625 involves several key steps that are essential for the effective management of chronic lung diseases:

Initial Evaluation The process begins with a comprehensive evaluation of the patient’s medical history, current health status, and specific respiratory conditions. This evaluation helps healthcare professionals understand the patient's unique needs and tailor the rehabilitation program accordingly.
Lung Function Testing Following the initial evaluation, lung function testing is conducted to assess the patient's respiratory capacity. This includes measuring oxygen saturation levels at rest and during exercise to determine the appropriate level of rehabilitation and any need for supplemental oxygen.
Development of a Personalized Program Based on the results of the evaluation and lung function tests, a personalized rehabilitation program is developed. This program typically includes a combination of exercises aimed at improving muscle strength and endurance, which may involve the use of weights, stationary bikes, or treadmills.
Education and Training Patients receive education on their specific lung conditions, medication management, and the use of medical equipment. Training in breathing techniques is also provided to help increase oxygen levels and strengthen the airway, which is crucial for effective respiratory management.
Implementation of Exercise Regimen The rehabilitation program is implemented with a focus on regular exercise sessions designed to enhance physical fitness and respiratory function. These sessions are conducted under the supervision of qualified healthcare professionals to ensure safety and effectiveness.

3. Post-Procedure

After completing the outpatient pulmonary rehabilitation sessions, patients are expected to experience improvements in their lung function and overall quality of life. Post-procedure care may include follow-up evaluations to monitor progress and adjust the rehabilitation program as necessary. Patients are encouraged to continue practicing the techniques learned during rehabilitation, including exercise routines and breathing strategies, to maintain their health gains. Additionally, ongoing education about disease management, medication adherence, and lifestyle modifications may be provided to support long-term health outcomes.

Short Descr	PHY/QHP OP PULM RHB W/O MNTR
Medium Descr	PHYS/QHP SVCS OP PULM REHAB WO CONT OXIMTRY MNTR
Long Descr	Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)
Status Code	Active Code
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Procedure or Service, Not Discounted when Multiple
Berenson-Eggers TOS (BETOS)	none
MUE	2

95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
KX	Requirements specified in the medical policy have been met
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
CR	Catastrophe/disaster related
GZ	Item or service expected to be denied as not reasonable and necessary
K0	Lower extremity prosthesis functional level 0 - does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter
KK	Dmepos item subject to dmepos competitive bidding program number 2
GC	This service has been performed in part by a resident under the direction of a teaching physician
GW	Service not related to the hospice patient's terminal condition
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
KC	Replacement of special power wheelchair interface
KS	Glucose monitor supply for diabetic beneficiary not treated with insulin
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
TR	School-based individualized education program (iep) services provided outside the public school district responsible for the student