cardiac & pulmonary rehabilitation under medicare mark d pilley, md faafp, abqaurp, faadep...

Cardiac & Pulmonary Rehabilitation

Under Medicare

Mark D Pilley, MD

FAAFP, ABQAURP, FAADEP

Palmetto GBA/CGS

J11/J15 AB MAC

DisclaimerThis presentation was current at the time it was delivered. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

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Medicare Improvements for Providers & Patients Act of 2008 (MIPPA)

 Effective January 1, 2010 Single Pulmonary Rehabilitation (PR)

program – COPD 42 CFR 410.47

Cardiac/Intensive Cardiac Rehabilitation (CR/ICR) 42 CFR 410.49

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CR/ICR/PR  

Physician-prescribed exercise series Physician-supervised

Physician’s office 42 CFR §410.26

Outpatient Hospital 42 CFR §410.27

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CR/ICR/PR Direct Physician Supervision

  Requirement for Medicare coverage Physician must be:

In exercise program area, & Immediately available & accessible for all

emergencies Does not require physical presence in

exercise room itself

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CR/ICR/PR Direct Physician Supervision

 Physician office setting Physician must be present in the office suite

and immediately available to furnish assistance and direction throughout the performance of the procedure. [42 CFR 410.26(a)(2) and 410.32(b)(3)(ii)]

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CR/ICR  

Cardiac risk factor modification

Psychosocial assessment

Outcomes assessment

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CR/ICR Individualized treatment plan

  Individual & tailored written plan

Established, reviewed & signed by the physician every 30 days

Includes all of the following: DX Type, amount, frequency, & duration

Items & services furnished under the plan Individual patient goals under the plan

ICR Peer Reviewed – Published Research  

Physician-supervised CR program

Demonstrates improving CVD

Specific outcome measurements

ICR Peer Reviewed – Published Research 

Accomplished 1 or more: Positively affected progression of CAD

Reduced need for CABG

Reduced need for PCI

ICR Peer Reviewed – Published Research 

Statistically significant reduction - 5 or more LDL Triglycerides BMI SBP DBP Need for cholesterol, B/P, & DM medications.

(See 42 CFR Section 410.49)

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CR/ICR - Indications 

An acute myocardial infarction within the preceding 12 months;

A coronary artery bypass surgery;

Current stable angina pectoris;

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CR/ICR - Indications 

Heart valve repair or replacement;

Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;

A heart or heart-lung transplant; or,

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CR/ICR - Indications 

Other cardiac conditions as specified through a national coverage determination (NCD) (CR only)

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CR/ICRPhysician Requirements

  Expertise in managing of cardiac

pathophysiology CPR (AHA) trained - BLS or ACLS State Medical Licensure for state in which

the CR/ICR program is offered (See 42 CFR Section 410.49)

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CR/ICRFacility Requirements

  “Code Blue” Capabilities Trained / Experienced staff – BLS, ACLS,

CR Exercise Non-physician staff

Employees of physician, hospital, or clinic Direct Supervision Requirements Met

PR - Indications 

42 CFR 410.47 Moderate - Severe COPD

GOLD classification II, III, and IV Referred - physician treating the chronic

respiratory disease Additional medical indications

May be established through NCD

PR Program 

Multidisciplinary program Patient Specific

Individually tailored & designed Optimize physical & social performance &

autonomy

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PR - Main Goal  

Empowerment – Independent Exercise

Exercise (+) training & support mechanisms Encourage Behavioral Change Long-term adherence treatment plan

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PR - Program Setting  

Physician Office – Outpatient Hospital

Emergency Preparedness

PRPhysician Requirements

  Expertise - managing respiratory

pathophysiology

State Medical License

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PRPhysician Requirements

  Responsible & accountable

Involved substantially Consultation with staff Directing patient progress

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Mandatory Components  

Physician-prescribed exercise

Education or training

Psychosocial assessment

Mandatory Components  

Outcomes assessment Outcomes measures

An individualized treatment plan Established, reviewed & signed by the physician every

30 days

Benefit Policy Manual (BPM), Pub. 100-02, chapter 15, section 231

Claims Processing Manual (CPM), Pub. 100-04, chapter 32, section 140

Outcomes Measurements

AACVPR Outcomes Committee (December 1995):

Integrated - routine clinical practice Little - No cost Tools - relevant & meaningful results

Outcomes Measurements

AACVPR: Testing protocols

Easy to administer Easy to understand

Tools – consistent reproducible results

Outcomes Measurements

AACVPR: Tools - valid measures

desired characteristics

Tools – able to measure changes Results of program intervention

Tools

SF-36V2™ Health Survey Written Knowledge Test

Gold Standard – Exercise Stress Test

6-Minute Walk

Tools

Quality of Life

Patient self reporting

Clinical Documentation Lab testing

Outcome Domains

Copyright © 1997- 2008 Indiana Society of Cardiovascular and Pulmonary Rehabilitation

Last Updated August 2008

Risk Stratification

Copyright © 1997- 2008 Indiana Society of Cardiovascular and Pulmonary Rehabilitation

Last Updated August 2008

CR/PR Limitations 

42 CFR 410.47 & 410.49 TWO 1-hour sessions / day 36 sessions

Option (+) Additional 36 sessions Medically necessary KX modifier

Total of 72 sessions

ICR Limitations 

42 CFR 410.49 Maximum of 6-hour sessions / day

Over 18 weeks

Total of 72 sessions

Cardiac Rehabilitation (CR) CR 6850 Acute myocardial infarction within 12 months CABG Stable angina Heart valve repair / replacement PTCA / coronary stenting Heart / heart-lung transplant Other cardiac conditions - specified through NCD

(CR only)

Cardiac Rehabilitation (CR) CR 6850

Top CERT denials Cardiac Rehab Increased Review Denial Rates

NC – 98% SC – 85%

Cardiac Rehabilitation (CR)Audit Findings

Deficiencies in Confirming: Direct Physician Supervision Immediate Availability Compliance with CR Program Physician

Requirements Compliance with Signature Requirements

CR - targeted medical review

Higher % claim review Identify billing errors

Provider Outreach & Education Meet Documentation Requirements Reduce the error rate

LCD Indications & Limitations of Coverage Reduce the error rate

Thank You

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