Cardiac & Pulmonary Rehabilitation Under Medicare Mark D Pilley, MD FAAFP, ABQAURP, FAADEP Palmetto GBA/CGS J11/J15 AB MAC

Disclaimer This 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.

. 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

. CR/ICR/PR Physician-prescribed exercise series Physician-supervised Physician’s office 42 CFR §410.26 Outpatient Hospital 42 CFR §410.27

. 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

. 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)]

. CR/ICR Cardiac risk factor modification Psychosocial assessment Outcomes assessment

. 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)

. CR/ICR - Indications   An acute myocardial infarction within the preceding 12 months; A coronary artery bypass surgery; Current stable angina pectoris;

. CR/ICR - Indications Heart valve repair or replacement; Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; A heart or heart-lung transplant; or,

. CR/ICR - Indications   Other cardiac conditions as specified through a national coverage determination (NCD) (CR only)

. CR/ICR Physician 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)

. CR/ICR Facility 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

. PR - Main Goal Empowerment – Independent Exercise Exercise (+) training & support mechanisms Encourage Behavioral Change Long-term adherence treatment plan

. PR - Program Setting Physician Office – Outpatient Hospital Emergency Preparedness

PR Physician Requirements Expertise - managing respiratory pathophysiology State Medical License

. PR Physician Requirements Responsible & accountable Involved substantially Consultation with staff Directing patient progress

. 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 Gold Standard – Exercise Stress Test 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 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

Thank You

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