Pulmonary Rehabilitation: A Budget Impact Model To Evaluate How Policy Changes Will Impact Reimbursement From A
Managed Care Perspective
Erin Henlyshyn, Pharm.D. Candidate., Khalid M. Kamal, Ph.D., Duquesne University Mylan School of Pharmacy, Pittsburgh, PA, USA
BACKGROUND
 Pulmonary rehabilitation (PR) has already been studied for clinical effectiveness and cost
effectiveness in Chronic Obstructive Pulmonary Disease (COPD).
-10%
Introduction
 PR is recommended as a non-pharmacotherapy option as per the Global initiative for chronic
Obstructive Lung Disease (GOLD) guidelines.
OBJECTIVE

To assess how proposed coding changes will impact reimbursement and subsequent budget impact for PR in
patients with COPD.
-$6.00
Population
Reimbursement
Cost of PR Program
Policy Impact
Budget Impact
$0.00
$1.00
$2.00
$3.00
Number of Hours/session
 The policy changes in coding established by DHHS may result in cost savings for
Managed Care Organizations reimbursing for PR services.
 Patients received 2.5 PR sessions/week at 60 minutes per session for a total of 6 weeks.
 Reimbursement rate for HCPCS GXX30 is 0.37 per minute at 60 minutes per claim ($22.50/claim).
Code
# of Claims
Mean Reimbursement Cost Per Claim
Weighted Reimbursement Cost
HCPCS G0237
656
$27.82
$16.71
HCPCS G0238
428
$38.03
$14.91
CPT 93797
1
$13.70
$0.01
CPT 93798
7
$95.44
$0.61
Previous Weighted Average Reimbursement Per Claim
 Perspective: Payer
LIMITATIONS
 Dataset provided by IMS Life Link is commercial; however, the typical COPD patient
is a Medicare patient.
 The four procedural codes included in the previous reimbursement strategy may not
truly capture PR services delivered prior to the generation of the new HCPCS code
specific for PR.
$32.24
$2.55
$23
$20.00
$15.00
$10.00
$5.00
Previous
Current
$250.00
$2.00
$1.69
$150.00
$1.00
$100.00
$0.50
$50.00
$0.00
$0.00
Previous
Current
$225.00
$200.00
$1.50
 Reimbursement cost data was utilized as a means of calculating cost PMPM for the
previous reimbursement strategy. The allotted reimbursement amount from the claims
data may not be similar or equal to true direct cost.
$324.71
$300.00
$2.50
$25.00
Treated PMPM Costs
$350.00
$3.00
$32
$30.00
$0.00
PMPM Costs
 The retrospective database analysis revealed that only 69 out of 33,448 patients with
ICD-9 codes for COPD may have received PR services. The generation of a new code
for reimbursement may significantly increase utilization for PR services.
 The definition of the new code HCPCS GXX30 at 60 minutes per claim may increase
the amount of treatment time provided for patients who receive PR services.
RESULTS
$35.00
 Outcome Measure: Primary and secondary outcomes were cost savings Per Member Per Month
(PMPM) and cost savings per Treated PMPM, respectively.
-$1.00
DISCUSSION
 Prevalence of COPD is 6%.
Avg. Reimbursement per Claim
 Cost Data: Based on reimbursement cost from the claims data in IMS Life Link Health Plans
Claims Database. A weighted average was calculated to obtain reimbursement cost per claim.
-$2.00
Prevalence
Model Assumptions
 Budget Impact Model: Built using Microsoft Excel
 Comparators: Previous Reimbursement Strategy vs. Current Reimbursement Strategy
-$3.00
Proposed reimbursement rate
Model Characteristics
 Reference Population: A 10 % sample from IMS Life Link Health Plans Claims Database was
used to identify patients who were potential recipients of PR services based on ICD-9 codes for
COPD (491.20, 491.21, 491.22, and 496), CPT codes (93797, 93798) and HCPCS codes (G0237,
G0238).
-$4.00
Proposed # weeks
METHODS
 Timeframe: 1-year time horizon
-$5.00
Proposed sessions/week
 The Department of Health and Human Services (DHHS) hypothesizes that Current Procedural
Terminology (CPT) codes for cardiovascular rehabilitation (93797, 93798) and Healthcare
Common Procedure Coding System (HCPCS) codes for respiratory therapy (G0237, G0238) may
be utilized to reimburse for PR services, since the services are similar in labor and resource
utilization.
 PR Program Definition – “Pulmonary rehabilitation (PR) is an evidence-based,
multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases
who are symptomatic and often have decreased daily life activities. Integrated into the
individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms,
optimize functional status, increase participation, and reduce health care costs through stabilizing
or reversing systemic manifestations of the disease.”
PMPM Costs
10%
Previous sessions/week
 Before January 1, 2010 there was no procedural code for PR.
 Effective January 1, 2010, Centers for Medicare & Medicaid Services (CMS) generated a new
HCPCS code (GXX30) for PR and is defined as “Pulmonary Rehabilitation including aerobic
exercise (includes monitoring), per session, per day at minimum of 60 minutes”
Univariate Sensitivity Analysis
Model Overview
CONCLUSION
The changes in coding and reimbursement proposed by DHHS for 2010 will likely result
in cost savings for reimbursement for PR services for Managed Care Organizations;
however, generation of HCPCS code GXX30 may drive utilization for PR services.
Previous
Current
 A total of 69 patients out of 33,448 patients with COPD were identified as recipients of PR services.
 PR services were reimbursed at a weighted average of $32.24/claim for an average of 15.33
minutes/claim.
 The new HCPCS code (GXX30) will be reimbursed for $22.20 for a minimum of 60 minutes.
 A PR program lasting 6 weeks (2.5 sessions/ week), results in a cost savings of $0.86 PMPM and
$99.71 Treated PMPM based on the new HCPCS code for PR.
REFERENCES
1. Casaburi R, ZuWallack R. Pulmonary Rehabilitation for Management of Chronic Obstructive Pulmonary Disease. N Engl J Med.
2009;360:1329-1335.
2. Coultas D, McKinley J. Update on Pulmonary Rehabilitation for COPD. Clin Pulm Med. 2009;16:183-188.
3. Department of Health and Human Services. Centers for Medicare & Medicaid Services Federal Register. July 13, 2009. http://www.aacvpr.org
Portals/0/policy/resources/2010%20 Proposed%20Physician%20Fee%20Sched%20for%20CRPR% 20pp%2033606-33614_7-09.pdf. Accessed
September 28, 2009.
4. Department of Health and Human Services. Centers for Medicare & Medicaid Services Federal Register. July 20, 2009. http://www.aacvpr.org
Portals/0/policy/resources/2010%20Proposed%20Hospital%20Outpatient%20Regs%20for %20CRPR%20pp%2035360-35370_7-09.pdf. Accessed
September 28, 2009.
5. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive
Pulmonary Disease Updated 2009. http://www.goldcopd.com/download.asp?intId=552. Accessed September 20, 2009.
6. Goldstein RS, Gort EH, Guyatt GH, et al. Economic analysis of respiratory rehabilitation. Chest. 1997;112(2):370-379.
7. Rasekaba T, Williams E, Hsu-Hage B. Can a chronic disease management pulmonary rehabilitation program for COPD reduce acute rural hospital
utilization? Chronic Respiratory Disease. 2009;6:157-164.
8. Ries A, Bauldoff G, Carlin B, et al. Pulmonary Rehabilitation Executive Summary. Chest. 2007;131(5):1S-3S.
ACKNOWLEDGEMENT - Special thanks to Xcenda, AmerisourceBergen Specialty Group