health regulation & reimbursement update for mac j15€¦ · [email protected] go to: aacvpr...

Health Regulation & Reimbursement

Update for MAC J15

Richard Sukeena MS, MBA, FAACVPR

Kentucky Cardiovascular Rehabilitation Association

March 1, 2018

No Financial Disclosures

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Objectives

1. Provide an overview & communication from AACVPR MAC

Liaison Task Force

2. Provide an update on proposed cardiovascular & pulmonary

rehabilitation reimbursement for 2018

3. Review CMS audit questions & concerns for past and

present related reviews

4. What’s your BEST defense for an audit?

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AACVPR MAC Task Force & Resource Group

GRQ/AACVPR MAC Liaison Task Force –Resource Group Structure

AACVPR Task Force: To coordinate, establish, renew, or improve

communication with Medicare Administrative Contractors (MACs)

• MAC: J15 (Kentucky and Ohio) CIGNA (Nashville, TN.)

• Medical Directors: Drs. Berman & Sandler

• MAC Liaison Role & Contact: Task Force liaison to have “quick access”

to your MAC; this will provide consistent interaction with the MAC MD. If

questions and concerns that are not institution-specific are channeled

through this line of communication, dialogue and consistent responses

• MAC Resource Group: Each Task Force member has identified a

member of a small support group, titled “MAC Resource Group” or

MRG, to assist with this goal.

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MAC Communication & Updates

The AACVPR “What’s New in my MAC” web page is for AACVPR

members to access MAC regulations, articles, publications and up-to-date

MAC-specific information.

AACVPR Task Force Chair: Karen Lui

MAC Liaison for J15: Richard Sukeena

MAC Resource Group: Peggy Cox, Stephane Tucker & Tammy Garwick

[email protected] / [email protected]

[email protected]

Go to: AACVPR > Advocacy > What’s new in my MAC > Updates and link

to Cigna (CGS)

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https://www.aacvpr.org/Advocacy/Whats-new-in-my-MAC

mailto:[email protected]



Recent Updates

1. Physician Referral Orders for Cardiac, Pulmonary & Vascular:

On 1/2016, our MAC J15 agreed to allow advance practitioners (NP

PA) to refer patients to CR/PR! BUT

• Overturned - Coverage & Analysis Group (CAG) Office at CMS,

CR/PR services must be ordered and supervised by an MD or DO!

2. Use of NPP’s in cardiac and Pulmonary Rehabilitation Supervision

• Programs MUST have MD or DO immediately and physically

available

• No reference to distance, location and time to respond –Tracking

options

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Recent Updates

3. Payment for off-campus hospital departments will be based on the

Physician Fee Schedule (PFS) rather than the Hospital Outpatient

Prospective Payment System (OPPS), as CMS had proposed.

• This will have serious negative financial consequences for any future

CR/PR services considering an off-campus location.

• Reduced Reimbursement by about 30% estimated $15 per visit

• Only off-campus departments that were operational prior to passage of

the Bipartisan Budget Act of 2015 on 11-2-15 will be grandfathered and

allowed to continue with payment based on the OPPS.

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Recent Updates

4. Change in 2018 to Procedure Code for 6 MWT :

• For 2018, CMS has provided new codes (94617 and 94618) to better

differentiate between the various pulmonary-related tests

• 94618 – Pulmonary stress testing (e.g., 6-minute walk test), including

measurement of heart rate, oximetry and oxygen titration, when

performed (describes the typical simple pulmonary stress test)

• Performance of a 6MWT outside of pulmonary rehab or respiratory

services would be billed with 94618 (Not part of PR service), BUT

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Final Update

Thanks to our Kentucky Members Efforts (letter writing/e-mail)

By now you’ve seen that our bill got into the ACCESS Act (2/8/2018)

BUT, NOT effective until January, 2024. That was due to the CBO

score, so it had to be delayed to reduce cost. ( Typical move)

• Per Task force - We are working on the best strategy to move this

date up.

This technical correction would allow non-physician practitioners to

meet CMS direct supervision requirements of daily supervision for

cardiac rehabilitation (CR) and pulmonary rehabilitation (PR).

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March 5-6 2018 - DOTH This year, AACVPR’s message to our U.S. Congress is

two-fold:

YOU’RE GOING TO WANT TO BE PART OF THIS EVENT

• To offer a solution that would remove the financial barrier of

locating hospital cardiac and pulmonary rehabilitation (CR, PR)

programs to an off-campus location, thus improving access to CR

and PR services for our patients.

• To thank your US Congressional Members who sponsored the NPP

bill, making it possible for nonphysician practitioners to meet the

CMS definition of “direct physician supervision.” The effective date

for our bill is January 1, 2024.

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Supervised Exercise Therapy (SET) Peripheral Artery

Disease

CMS (NCD) for Supervised Exercise Therapy for SYMPTOMATIC PAD

(CAG-00449N). Effective: 5/25/2017 Eligible Criteria: intermittent

claudication

• Duration: Up to 36 sessions – for 12 weeks

• Session/Service: 30-60 minutes – Therapeutic exercise training for PAD

patients WITH INTERMITTENT CLAUDICATION (IC)

• Setting: Hospital based (OPPS) or physician office (Effects

reimbursement)**

• Staffing: Qualified personnel – trained in exercise therapy (competent)

• Supervision: “direct physician supervision” present & immediately

available (BLS/ACLS)

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(SET) Peripheral Artery Disease Requirements

• Physician referral for SET PAD (NP/PA may not refer patient)

• Prior to referral – patient must have a face-to-face visit with the

physician responsible for PAD treatment – patients must receive

information regarding cardiovascular disease and PAD risk factor

reduction (education, counseling, behavioral intervention & outcome

assessments).

• 2nd referral needed beyond 36 sessions over 12 weeks per MAC

• Documentation is key

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(SET) Peripheral Artery Coding/Billing/Reimbursement

• ICD-10: 173.9 unspecified, I70.211 (right), I70.212 (left) or I70.213

(bilateral) atherosclerosis of arteries of extremities with IC

• Reimbursement: Hospital based (on campus) $55.96 – unadjusted

copay amount $11.20

• The revenue code for this service is 943 & procedure code is CPT

93668 . One session per day is billable with no restriction or

requirement on the number of sessions per week.

• A PAD program that is established in an excepted (grandfathered) off-

campus location will use the modifier “PO.” A PAD program in an off-

campus location that is not excepted will need the modifier “PN.”

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CMS Update: February 2, 2018 Transmittal 204

Change Request 10295

• MACs have the discretion to cover SET beyond 36 sessions over

12 weeks and may cover an additional 36 sessions over an

extended period of time (use a KX modifier on the claim)

• Coverage has been extended up to 72 sessions. MACs will

deny/reject claim lines for SET exceeding 73 sessions

• I70.211 – right leg, I70.212 – left leg, I70.213 – bilateral legs,

I70.218 – other extremity, I70.311 – right leg, I70.312 – left leg,

I70.313 – bilateral legs, I70.318 – other extremity, I70.611 – right

leg, I70.612 – left leg, I70.613 – bilateral legs, I70.618 – other

extremity, I70.711 – right leg, I70.712 – left leg, I70.713 – bilateral

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SET PAD RESOURCES & CHARGES

Resources:

• 2016 AHA/ACC Guideline on the Management of Patients with

Lower Extremity Peripheral Artery Disease; Gerhard-Herman et

al.Circulation. 2017;135:e726–e779.

• AACVPR PAD Exercise Training Tool Kit. Programmatic

Implementation; on AACVPR website.

• Charges: what does it cost per session to deliver the service(pre

assessment/testing to post outcomes) monitor versus no monitor

• CHARGE PER SESSION: $85.00 to $225.00 per session ?

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Update on proposed Cardiovascular &

Pulmonary Rehabilitation reimbursement for

2018

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CMS Proposed (estimated) 2018 OPPS Payment

Rates

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Provider Based Departments (PBD) & Fee for Service

Per section “603 of the Bipartisan Budget Act of 2015”

Hospital PBD off campus could continue to bill for services under the

outpatient prospective payment system (OPPS), IF they are:

• grandfathered in (services offered prior to 11/2/15)

• Anytime changes the departments physical address

Payment (as of 1/1/2017) is based on Physician fee Schedule (PFS), not

OPPS

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Provider Based Departments (PBD) & Fee for Service

CMS definition of Campus (42 CFR 413.65)

Physical area immediately adjacent to provider’s main buildings….but

located with 250 yards of the main buildings, and any other areas

determined on an individual case basis, by CMS regional office, to be part of

the providers campus.

Consequences:

• Limited access for patients

• Inability to re-locate CRPRVR services

• Reduced reimbursement when it falls under PFS

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Cigna MAC J15 Pulmonary Rehabilitation

G0237 — Therapeutic procedures to increase strength or endurance of

respiratory muscles, face to face, one on one, each 15 minutes

(includes monitoring)

G0238 — Therapeutic procedures to improve respiratory function, other

than described by G0237, one on one, face to face, per 15 minutes

(includes monitoring)

G0239 — Therapeutic procedures to improve respiratory function or

increase strength or endurance of respiratory muscles, two or more

individuals (includes monitoring)

G0424 — Pulmonary Rehabilitation, including exercise (includes

monitoring), one hour, per session, up to two sessions per day

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Pulmonary Rehabilitation Charges & Reimbursement

Overview & History PR Charges

• 2010 CMS used HCPCs code G0424 for COPD covered diagnoses

• CMS uses Medicare claims data from 2011 to develop payment rates for

2013.

The goal/purpose: To increase reimbursement for G0424 COPD code!

• In early September – AACVPR sent out a letter outlining the need to

review each programs charge master related to COPD G0424 code

charge and the need to increase the charge based on the data outlined

Refer to the Pulmonary Rehabilitation Toolkit – AACVPR website under

Advocacy

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Check Charges? Are You Covering expenses?

Consider expenses associated with the complexity of patients with COPD

Checklist:

• Review your charge master (who determines the charge, how and how

often is it reviewed)?

• Consider the expenses associated with the following per session:

salary/wages/benefits (time unit), overhead, fixed expenses (rent,

depreciation), variable expenses (patient supplies, education materials)

Refer to the Pulmonary Rehabilitation Toolkit – AACVPR website under

Advocacy

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PR: Procedure Code G0424CMS Change Request 6823, May 7, 2010

Patient must have some exercise every session.

• Differs from CR regulation

• One session must be at least 31 minutes in duration.

• Two sessions must be at least 91 minutes in duration.

• KX modifier MUST be used for any PR sessions beyond 36 in

patient’s Medicare lifetime.

• This indicates to Medicare that additional documentation should be

requested to determine medical necessity

• PR services exceeding 72 session will be denied!

• No time limit to complete PR sessions

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Pulmonary Rehabilitation Charges & Reimbursement

PR Programs in KY (Specific programs with > 250 claims & Charges< $400)CMS Number Claims # Charges ($)

180130 1097 309180012 1145 184180040 865 255180009 526 128180088 694 212180036 819 187180038 700 209180011 399 95180035 317 186180017 318 73

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Average Claim Charges Frequency of Claims Providers

$300-349 1,097 1

$250-299 865 1

$200-249 1,394 2

$150-199 1,964 2

$100-149 1,671 1

<$99 472 2

Totals 1654 9

Review of Past & Present Audits of

Cardiac & Pulmonary Rehabilitation

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Past Reviews: Pulmonary Rehabilitation

CGS expects that the physician's prescription (part of

the ITP) for exercise will include:

• Mode of exercise (typically aerobic)

• Target intensity (e.g., a specified percentage of the maximum

predicted heart rate, or number of METs)

• Duration of each session (e.g., "20 minutes")

• Frequency (number of sessions per week)

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Past Reviews: Pulmonary Rehabilitation

• Identifiable timeline for the PR iITP

1st MD orders PR

2nd PR staff assists MD (referring or Medical Director) in the

development of initial ITP

3rd PR Medical Director signs iITP “prior to initiation of PR”

4th The patient is charged for the 1st session

• Can you charge/bill for group education using G0424

The patient must exercise at every session in order for that session to

be legitimately billable to Medicare.

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Pulmonary Rehabilitation (HCPCS Code G0424):

Complex Medical Review – Kentucky

Kentucky Service-Specific Complex Results:

Charges Claims

Reviewed $141,952.22 101

Denied $46,653.63 35

Charge Denial Rate 32.9%

The top denial reasons associated with this review:

1 or more of the following components were missing

• Physician-prescribed exercise

• Cardiac risk factor modification

• Psychosocial assessment

• Outcomes assessment

• An individualized treatment plan

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The top denial reasons


• Condition for coverage was NOT submitted or was NOT covered as

defined as GOLD classification II, III & IV

• ITP was NOT established, reviewed and signed at least every 30

days by a physician

• Requested records NOT submitted in the required timeframe of the

ADR

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Cardiac Rehabilitation (HCPCS Code 93798): Complex

Medical Review – Kentucky

Kentucky Service-Specific Complex Results: 2/2017Charges Claims

Reviewed $1,682,317.21 123

Denied $937,072.28 67



1 or more of the following components were missing






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The top denial reasons


• Documentation did NOT support that the program was under the

direct supervision of a physician

• Missing or unlegable signature to support physician referral and

orders

• Unable to determine medical necessity

• Requested records NOT submitted in the required timeframe of the

ADR

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Cardiac Rehabilitation (HCPCS Code 93798): Complex

Medical Review – Kentucky and Ohio--

Kentucky Service-Specific Complex Edit Results: 8/2017

Charges Claims

Reviewed $3,837,754.27 398

Denied $1,732,392.50 226


The top denial reasons associated with this review are:






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Follow-up to Audits

Cardiac Rehabilitation

2013 CGS has shown a denial rate 44% for 386 claims

2016 has shown a denial rate 39% for 96 claims

2017 has shown a denial rate 56% for 123 claims

Pulmonary Rehabilitation

April 2013 CGS has shown a denial rate 84% for 139 claims

October 2013 has shown a denial rate 56% for 133 claims

March 2014 has shown a denial rate 22% for 44 claims

• Claims can be overturned – address with your claims or compliance

office – can file an appeal

• Denials have been linked to MISINTERPRETATION

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Present Audit: Cardiac Rehabilitation

(HCPCS Code 93798)

Why & What to Expect:

• Up to 20-40 claims would be selected per round & Up to 3 rounds

can occur

• Targeted Probe -Based on past reviews and denial rates (< 30%)

Results Thus Far:

• Not adding the KX modifier for visits that are over the 36 visit limit

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What’s Your BEST Defense for an

Audit?

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General Recommendations

• Refer to the most recent Cigna regulations (MAC)

Cigna website or billing department

Cardiac Rehabilitation: Coverage and Documentation

Requirements (cgsmedicare.com)

• Identify a liaison within the billing or compliance department

(tracking audits, Cigna updates and ADRs)

• Highlight past denial information in the patients chart related to

coverage requirements, especially when sending large amounts of

documentation

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The Importance of DOCUMENTATION

• Make sure all the DETAILS tell the story from the physicians referral to

the discharge summary

• Clear & Concise Documentation is KEY

• Lack of medical necessity documentation is the culprit with most audits

Documentation is most frequently missing in the following areas:

• Physician Referral

• Missing documentation the required components (physician prescribed

exercise, risk factor modification, psychosocial assessment, outcomes

assessment, established ITP)

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The Importance of DOCUMENTATION

Continue Missing Documentation in the following areas:

• ITP reviewed, signed by a physician every 30 days – no signature

or unrecognizable

• Documentation for place of service (hospital based or non-hospital

based)

• Identify the supervising physician – Hospital based versus MOB?

• Goals and outcomes (for each required component)

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Good Offense is your BEST Defense

1. Process of continuous monitoring of regulation requirements

Do regulation requirements crosswalk to the patients chart, iITP, 30 ITP,

daily session reports and discharge summary

Create an internal checklist and audit process

Great QA indicator

2. Continuous education of frontline staff, charge entry and

coders

Update all frontline and ancillary staff on latest requirements, ICD-10

codes

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Good Offense is your BEST Defense

3. Manage the Request/ADR

Align with internal department processing the requests and track

(spreadsheet)

4. Manage the Appeal Cycle

Success and denial rates

Look at trends <30%

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THANK YOU

QUESTIONS

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health regulation & reimbursement update for mac j15€¦ · [email protected] go to: aacvpr...

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