By Anna Horner | News & Views

With 2026 on the horizon, it’s important for cardiopulmonary rehabilitation (CR/PR) providers to be aware of upcoming changes to Medicare rules and regulations. To ensure they appropriately bill for services and avoid audits and payment denials, CR and PR practitioners should understand how regulatory changes by the Centers for Medicare & Medicaid Services (CMS) will affect CR, Intensive CR (ICR), Supervised Exercise Therapy for Peripheral Artery Disease (SET PAD), PR, and Outpatient Respiratory Services (ORS) programs. They also should be informed about AACVPR’s regulatory agenda and what they can do to advocate for changes to benefit both patients and providers.

Final Rules for CR, ICR, and PR

CMS implemented two final rule changes that apply to CR, ICR, and PR for 2026, according to Lorri Lee, MHA, BS, CCRP, CEP, FAACVPR, cardiopulmonary rehabilitation supervisor at CHRISTUS Santa Rosa-New Braunfels, Texas. First, virtual direct supervision of CR, ICR, and PR by a physician or non-physician practitioner is now permanent for both hospital outpatient provider department (HOPD) and physician office-based programs, applying to both in-person delivery of care or telehealth delivery that should only be conducted from a physician office-based program. “This means physicians and non-physician providers are allowed to virtually supervise CR, ICR, and PR programs,” Lee says.

Under the second rule change, CR/ICR/PR codes are now permanently listed on the Medicare telehealth services list. “These codes only apply to physician office-based programs, which still have to provide real-time, continuous, audio-visual communication technology,” explains Lee, who emphasizes that phone-only and audio-only communication are not acceptable. “Hospital outpatient provider departments, however, still cannot provide these services virtually. That would require a statutory fix.” As for 2026 reimbursement rates, Lee says there will be a small increase across all service lines and locations — except for ORS Code G0239, which will decline slightly across all locations.

Lee notes that non-physician practitioners — defined as nurse practitioners, physician assistants, and clinical nurse specialists — can provide direct supervision of CR, IR, SET PAD, and PR services but cannot order these services, sign treatment plans, or serve as medical directors. “They can use their eyes to supervise and their brains to counsel your programs under direct supervision, but they may not use their pens or computers to sign orders or treatment plans. They can use their eyes and brains but not their fingers to sign and order electronically,” she cautions. “That’s because in the statutes for CR and PR, there is a line that states programs furnish physician-prescribed exercise as part of an individualized treatment plan, which must be established, reviewed, and signed by a physician. CMS has interpreted that to mean only a physician can order those services and sign the treatment plans.” However, Lee adds that the Department of Veterans Affairs and possibly some commercial payers make their own rules, potentially allowing non-physician practitioners to send referrals.

CR vs. PR Billing

PR is allowed two diagnoses by Medicare: COPD and post-COVID-19, says Susan Flack, MS, BSN, RN, FAACVPR, CR and PR program manager for Unity Point Health in Des Moines, Iowa. She explains there are some similarities between CR and PR with Medicare patients. “Up to two sessions may be billed per day. The Medicare beneficiary is responsible for only one copay, even if two are billed. For CR, if they're billed for two, some form of exercise must be performed in one of those sessions, but exercise must be performed in each session that they are billed in PR. Both allow 36 sessions over 36 weeks and an additional 36 if medically necessary,” Flack says. “For CR, Medicare allows 36 sessions with each referral, with up to 72 if medically necessary, and no lifetime limit on number of sessions. PR, however, has a lifetime limit of 72 since January 1, 2010, including all the codes that have ever been used for PR and for both diagnoses, COPD and post-COVID-19.”

AACVPR’s Regulatory Agenda

There are several regulatory changes AACVPR is pushing CMS to make, according to Todd Brown, MD, MSPH, FACC, FAHA, MAACVPR, professor of medicine at the University of Alabama at Birmingham. “We are really trying hard to convince CMS to allow non-physician practitioners to refer or order CR, ICR, and PR services,” says Dr. Brown. “We’ve also been advocating for a regulatory fix for virtual delivery for hospital-based programs. We are trying to work with CMS to restore virtual delivery for CR, ICR, and PR by HOPD programs.”

Further, Dr. Brown says AACVPR is recommending changes to reimbursement for CR services on the physician fee schedule, noting that “CR is reimbursed at a level that’s exceedingly low relative to the hospital outpatient department.” He also pointed to a disparity in payment for PR services. “PR services are reimbursed at a higher level on the physician fee schedule than on the HOPD, but then when they implement what they call the physician fee schedule equivalent rate for an off-campus HOPD, they cut the reimbursement by 60%. In addition to requesting some relief on that, we’re calling for an elimination of the 72-session lifetime limit for PR and for an expanded list of covered diagnoses for CR, ICR, and PR,” Dr. Brown explains.

To achieve these goals, Dr. Brown calls on AACVPR members to attend Day on the Hill in March 2026. He emphasizes, “This is democracy in action, and we need you to advocate on behalf of your patients and on behalf of the profession.”