1. Karen Lui, RN, MS GRQ, LLC karen@grqconsulting.com NCCRA March 2, 1012 Chapel Hill, NC

2. Statement of Disclosure  I have no disclosures.  The opinions expressed are my own.

3. Today’s Talk-Part 1 New Opportunities 1. 2012 Medicare pulmonary rehabilitation payment 2. Cardiac (CR) and pulmonary (PR) rehabilitation: Medical direction & physician supervision Coding and billing Appropriate use of KX modifier Individualized Treatment Plan 3. CMS and performance measures Adoption of CR referral measures Request for pulmonary rehab measures GRQ, LLC

4. Today’s Talk-Part 2 Meeting Regulatory and Certification Requirements  Disclaimer: I am not on the AACVPR program certification committee.  AACVPR Program Certification follows Medicare requirements, but is not equivalent.  Local Medicare contractors (MACs) have the authority to interpret and enforce Federal Medicare regulations.  This presentation will review current Federal coverage policies for CR and PR. GRQ, LLC

5. 2012 PR Medicare Payment- Why the reduction in reimbursement?  January, 2010: Medicare established PR as a covered service  New bundled procedure code G0424 was created with payment based on review of G0237-39 (unbundled) history  Spring, 2011: CMS reviews G0424 claims data  Median charge of $150 submitted by hospitals calculates to reimbursement rate of $37 GRQ, LLC

6. 2012 PR Medicare Payment- Why the reduction in reimbursement?  Hospitals did not make adjustment from 1:1 15-minute codes to a 1-hr bundled service  CMS “…assumed hospitals would include charges for these additional services in CY 2010 charges…because the services are included in the definition of comprehensive pulmonary rehabilitation.” Federal Register, 8-19-11, pg 42240 GRQ, LLC

7. 2012 PR Medicare Payment- Why the reduction in reimbursement?  CMS used PR as example to all services for new codes using single code to report multiple services previously reported by multiple codes  CMS advice: Be careful to construct charge that reports a complete combination of services To under-represent full cost of providing the service can have significant adverse impact on future payments for individual service described by the new code GRQ, LLC

8. 2012 PR Medicare Payment- How do we correct it? PULMONARY REHABILITATION TOOLKIT  20-page document that provides guidance in calculating appropriate charges for G0424  Developed by AACVPR, AARC, ATS, NAMDRC GRQ, LLC

9. 2012 PR Medicare Payment- How do we correct it? PULMONARY REHABILITATION TOOLKIT  CMS reviews 2011 claims data now for CY 2013  If hospitals correct PR charges immediately, programs could see fiscal correction in 2014  Toolkit will be available to all programs in the very near future GRQ, LLC

10. Medical Direction-CR & PR  Medical Director is the physician(s) who oversees or supervises CR/PR program  Medicare standards for this position: Responsible for the program and staff Involved substantially, in consultation with staff, in directing progress of individuals in the program Expertise in management of individuals with (cardiac/respiratory) disease BLS training License to practice medicine in state where program is located GRQ, LLC

11. Medical Direction-CR & PR  Medical director is involved with: Outcomes assessment, i.e., pre and post evaluations based on patient-centered outcomes Physician-prescribed exercise  Physician review and signature required on all Individualized Treatment Plans (ITP) entry, every 30 days, program completion GRQ, LLC

12. Medical Direction-CR & PR Distinction between CR & PR:  PR-requires medical director to provide direct patient contact related to the periodic review of ITP  CR-no direct contact required for review of ITP GRQ, LLC

13. Physician Supervision-CR & PR  A physician (MD or DO) must be physically immediately available and accessible for medical emergencies at all times the program is being furnished  The supervising physician must at all times be “interruptible” to physically respond immediately  CMS does not differentiate between on or off campus  CMS does not define “immediately” by time, location, or distance GRQ, LLC

14. Physician Supervision-CR & PR  Standards for physician qualifications of the supervising MD or DO are: Expertise in management of (cardiovascular or respiratory) disease Cardiopulmonary training or certification in BLS or ACLS (for CR programs) Licensed to practice medicine in the State where the CR or PR program is located GRQ, LLC

15. Physician Supervision-CR & PR  CMS does not dictate beyond these requirements which physician(s) may provide the supervision for hospital outpatient services Many programs utilize a physician-run code team or emergency dept physicians (must be interruptible)  Medical director and supervising physician do not have to be the same person(s)  The Medicare regulation for all hospital services requiring physician supervision is found in 42 CFR 410.27 posted under AACVPR Regulatory & Legislative Resources GRQ, LLC

16. Physician Supervision-CR & PR  Nonphysician Practitioners (NP, PA, CNS) may NOT provide direct supervision for CR or PR services May not serve as supervising MD for the day May not sign ITPs  Some MACs allow NPPs to independently order CR/PR services, but Palmetto does NOT  US Senate bill # 2057 and US House bill # ___, when passed, will allow NPPs to provide aspects of physician supervision GRQ, LLC

17. PR-Eligibility GOLD Guidelines - 2011 revision  No change in classifications of COPD GOLD 2-Moderate50% < FEV1<80% predicted GOLD 3-Severe30% < FEV1<50% predicted GOLD 4-Very SevereFEV1<30% predicted  GOLD classifications are based on post- bronchodilator FEV1 GRQ, LLC

18. PR – Coding and Billing  Medicare maximum: up to 36 sessions, with option for additional 36 sessions if medically necessary  72 lifetime maximum  Up to two 1-hour sessions per day allowed, not required 1 session > 31 minutes 2 sessions > 91 minutes  Some exercise is required in every session GRQ, LLC

19. Use of KX Modifier in PR  CMS Change Request 6823 (5-7-10) Contractors shall pay PR claims which exceed 36 sessions when a KX modifier is included on claim line Contractors shall deny G0424 when submitted for more than 72 sessions (with or without KX modifier) Common Working File (CWF) displays remaining PR sessions GRQ, LLC ○ Hospital billing office uses CWF for capped Medicare services GRQ, LLC

20. CR - Coding & Billing  36 weeks to complete up to 36 sessions  Up to maximum of two sessions per day (not new) One per day remains acceptable No maximum # of days per week-every day OK (not new)  Minimum of one session per week 1x/wk might be due to patient barriers (travel, expense, etc) Understood that patients may miss a week for various reasons (sickness, family need, vacation) Documentation of such absences would be prudent GRQ, LLC

21. CR - Coding & Billing HCPCS Code 93798 “Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)” HCPCS Code 93797 “Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)” Education/counseling (non-exercise required components) Non-ECG monitored exercise GRQ, LLC

22. CR - Coding & Billing  Up to two sessions per day  Every session counts toward total of 36 Co-payment for each session  CMS: Some exercise “every day”, not every session  To bill for 2 sessions, duration (not exercise minutes) must be > 91 minutes GRQ, LLC

23. CR – Coding & Billing Examples of typical options for multiple CR services/day based on individual patient needs:  One 93798 session and one 93797 session 1 st day assessment and “exercise orientation” One session ECG-monitored ex and one session education  Two 93798 sessions 95 minutes of ECG-monitored aerobic & resistance tx  Two 93797 sessions One non-ECG ex session & one counseling session 95 minutes of non-monitored aerobic & resistance tx GRQ, LLC

24. Use of KX Modifier in CR  KX modifier is required for any CR sessions beyond first 36 received as a Medicare beneficiary Extension of one course (rare) New course of CR for eligible diagnosis in later months/years (not uncommon)  CMS has instructed local Medicare contractors of this Change Request 6850, 5-21-2010  CMS does NOT limit the total # of CR sessions over the lifetime of a Medicare beneficiary, i.e., new qualifying event provides medical necessity for a new CR course GRQ, LLC

25. Individualized Treatment Plan  Written plan tailored to individual patient=opportunity  ITP Components: Diagnosis Plan for exercise frequency, intensity, modality, & duration Measureable and expected outcomes Individualized goals Estimated timetables to achieve identified outcomes goals  *Each of these components should be part of the ITP, i.e., one document, but obviously not one page GRQ, LLC

26. Individualized Treatment Plan  Every 30 days=Calendar Days Example: 1x/wk for one month=30 calendar days ○ Palmetto does not allow flexibility in “30- day” rule CMS: “…not intended to be a rigid protocol.” GRQ, LLC

27. CR Referral Performance Measures CR referral in the outpatient setting (MD office) performance measure is 1 of 6 new chart- abstracted measures (5 DM measures) for CY 2014 MD payment CMS says included because: ○ CR is beneficial (mortality & morbidity, QOL, reduces risk factors, enhances adherence to preventable meds), yet CR remains underutilized ○ Valuable in care coordination Improved enrollment rates are the critical and desired outcome GRQ, LLC

28. CR Referral Performance Measures  CR referral in the outpatient setting will be included as an individual measure in 2012 PQRS (Physician Quality Reporting System) Reporting via claims and/or registry  CMS is evaluating the CR referral performance measure for the inpatient setting as a future hospital quality measure. AACVPR & ACC pursuing next steps on this GRQ, LLC

29. PR Performance Measures  Two time-endorsed PR measures: QOL Functional improvement (6MWT)  CMS is seeking a Pulmonary Rehabilitation measures group for PQRS AACVPR will pursue this opportunity GRQ, LLC

31. The 2010 World Heart Games Included: - 66 athletes, 20 volunteers, the spirit of competition, 1 World Heart Games - Olympic-style competition for those with cardiovascular disease or with risk factors - The event will feature a wide variety of challenging – yet safe and monitored – competitions for patients, from table tennis to golf to volleyball to bowling  If you have interest in participating or supporting future World Heart Games, please visit our website at www.acsm.org/worldheartgames

32. “Must Have” Research  Cardiac rehabilitation 2012-advancing the field through emerging science. Kwan G, Balady GJ, Circ 2012;125:e369-e373.  Core competencies for CR/secondary prevention professionals:2010 update. Hamm LF, Sanderson BK, Ades PA et al. JCRP 2011;31:2-10.  Clinical research in CR and secondary prevention. Savage PD, Sanderson BK, Brown TM, et al. JCRP 2011;31:333- 341.  High-calorie expenditure exercise: a new approach to CR for overweight coronary patients. Ades PA, Savage PD, Toth MJ, et al. Circ 2009;119;2671-2678. GRQ, LLC

33. References  42 CFR 410.49: CR & ICR Conditions of Coverage*  42 CFR 410.47: PR Conditions for Coverage*  CMS Change Request 6850,CR & ICR,5-21-10*  CMS Change Request 6823, 5-7-10* *Posted on AACVPR web site GRQ, LLC

34. QUESTIONS?