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

2. 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.

3. . Medicare Improvements for Providers & Patients Act of 2008 (MIPPA)
Effective January 1, 2010
Single Pulmonary Rehabilitation (PR) program – COPD
42 CFR
Cardiac/Intensive Cardiac Rehabilitation (CR/ICR)
42 CFR

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

5. . 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

6. . 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 (a)(2) and (b)(3)(ii)]

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

8. . 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

9. ICR Peer Reviewed – Published Research
Physician-supervised CR program
Demonstrates improving CVD
Specific outcome measurements

10. ICR Peer Reviewed – Published Research
Accomplished 1 or more:
Positively affected progression of CAD
Reduced need for CABG
Reduced need for PCI

11. 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 )

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

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

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

15. . 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 )

16. . 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

17. 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

18. PR Program Multidisciplinary program Patient Specific
Individually tailored & designed
Optimize physical & social performance & autonomy

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

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

21. PR Physician Requirements
Expertise - managing respiratory pathophysiology
State Medical License

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

23. . Mandatory Components Physician-prescribed exercise
Education or training
Psychosocial assessment

24. Mandatory Components Outcomes assessment
Outcomes measures
An individualized treatment plan
Established, reviewed & signed by the physician every 30 days
Benefit Policy Manual (BPM), Pub , chapter 15, section 231
Claims Processing Manual (CPM), Pub , chapter 32, section 140

25. Outcomes Measurements
AACVPR Outcomes Committee (December 1995):
Integrated - routine clinical practice
Little - No cost
Tools - relevant & meaningful results

26. Outcomes Measurements
AACVPR:
Testing protocols
Easy to administer
Easy to understand
Tools – consistent reproducible results

27. Outcomes Measurements
AACVPR:
Tools - valid measures
desired characteristics
Tools – able to measure changes
Results of program intervention

28. Tools SF-36V2™ Health Survey Gold Standard – Exercise Stress Test
Written Knowledge Test
Gold Standard – Exercise Stress Test
6-Minute Walk

29. Tools Quality of Life Patient self reporting Clinical Documentation
Lab testing

30. Outcome Domains
Copyright © Indiana Society of Cardiovascular and Pulmonary Rehabilitation
Last Updated August 2008

31. Risk Stratification
Copyright © Indiana Society of Cardiovascular and Pulmonary Rehabilitation
Last Updated August 2008

32. 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

33. ICR Limitations 42 CFR 410.49 Maximum of 6-hour sessions / day
Over 18 weeks
Total of 72 sessions

34. 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)

35. Cardiac Rehabilitation (CR) CR 6850
Top CERT denials
Cardiac Rehab Increased Review
Denial Rates
NC – 98%
SC – 85%

36. Cardiac Rehabilitation (CR) Audit Findings
Deficiencies in Confirming:
Direct Physician Supervision
Immediate Availability
Compliance with CR Program Physician Requirements
Compliance with Signature Requirements

37. 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

38. Thank You

39. Comments / Questions: