1. Jim Rosneck RN, MS FAACVPR
Medicare Reimbursement “New Rules…New Game” Relating Public Policy Changes to Program Evolution
KCRA Annual Meeting
March 15, 2012
Jim Rosneck RN, MS FAACVPR

2. Presentation Objectives
Describe Medicare Account Contractors (MACs)
Describe AACVPR Health & Public Policy Committee Functions
Report on current AACVPR national & local public policy initiatives
Discuss programming opportunities given the new rules
Describe national lobbying strategies and 2012 DOTH activities

3. Next Week’s Objectives
Ohio High School State Championship Tournament

4. CMS MAC-15 Update “What is a MAC”?
CMS Medicare Account Contractor (MAC)  ‘Integrate & centralize information and create efficient processes for delivery of comprehensive care to Medicare beneficiaries’.
Goals:
Full and open competitions to replace existing system of Fiscal Intermediary (FI) contractors
Increased efficiencies
Consistent approach to medical coverage across the service area
Competition among current MACs to encourage quality cost efficient service to health providers.
Focus on financial management to achieve more accurate claims payments and greater consistency in payment decisions.

5. Section 911, Medicare Prescription Drug, Improvement and Modernization Act of 2003
15 MAC Geographic Regions
J-15 CIGNA “CGS”
The eventual plan is consolidation of the current 15 MACs to 10 in “Several Years” J-15 & J-8 (Wisconsin & Minnesota…NGS) to be consolidated.

6. CIGNA Government Services (CGS) Functions
CMS will ensure its MAC contracts focus on three critical areas:
Customer service
Operational excellence
Financial management.
Medicare coverage and billing requirements, and the receipt, processing, and payment of Medicare fee-for service core claims processing operations for both Part A and Part B. .
Interpret CMS statutory rules & national coverage determination “NCD” language and intent in the development of MAC-LCD’s
Maintain a staff of experts knowledgeable of all aspects of the fee-for-service program

7. AACVPR MAC J-15 Committee
Dalynn Badenhop, OH
Mike Bichsel, OH
Elaine Bohman, OH
Sherri Bradley, KY
Peggy Cox, KY
Tammy Garwick, OH
Jim Rosneck, OH
Rich Sukeena, OH
Stephanie Tucker, KY
(Physician Liaison: Rich Josephson, OH)

8. AACVPR J-15 Committee Functions
Maintain Communication
Insure that CGS  Cardiac & Pulmonary Rehab local coverage determination (LCD) represents the letter and intent of the recent national coverage determination.
Coordinate activities with AACVPR national H&PP committee members & leadership.
Communicate issues effectively with OACVPR & KCRA leadership to insure that member and non-member programs are aware of H&PP issues.

9. MAC J-15 Current History
CGS “Cutover” from NGS (Fiscal Intermediary) management October 17, 2011
LCD Postings at least by September 1st 2011
October 2012 CGS decision to adhere to the National Coverage Determination NCD and/or statutory rules interpretation
Comment period characterized by participation of an advisory committee and/or state & local provider organizations.

10. MAC J-15 “CGS Strategy” “Watchful Waiting”
Announcement of CGS - LCD writing group
J-15… action committee will directly contact CGS medical director Gary Oakes MD.
Educate
Petition for adherence to Medicare NCD statute
Involve AACVPR national officers PRN

11. CMS: Components of Pulmonary Rehab
Physician prescribed exercise:
Patient centered
Some aerobic training included in each session
Education
Tailored to individual needs
Tailored to behavioral change
Brief smoking cessation
Nutrition
Proper medication use & adherence
Psychosocial Assessment
Include assessment of home support
Objective measure of progress (Pre & Post Testing) 11

12. CMS: Components of Pulmonary Rehab
Outcomes assessment:
Baseline assessment & patient centered goals
Individual progress via objective measurements.
Pretesting - Goal Setting – Post testing
Individualized Treatment Plan
Diagnosis
Type, amount, frequency and duration of the items and services
Patient centered goals
Established reviewed and signed by a physician
Reviewed & signed by the medical director
Physician Supervision 12

13. CMS: Components of Pulmonary Rehab - Diagnosis
COPD
Moderate, severe and very severe COPD (GOLD guidelines)
Billing code = G0424
Non-COPD
All other previously recognized diagnoses
Billing code = G0239 “Group Exercise”
Billing code = G0238 “Individual Exercise q15min”
Billing code = G0237 “Individual Education q15min”
LCD will eventually determine the status of Non-COPD diagnosis
Require the “59” modifier
NHLBI/WHO Global Initiative for chronic Obstructive Pulmonary Disease “GOLD” 13 13

14. Pulmonary Program Evolution
Necessity of ECG monitoring?
Aerobic exercise requirement (PR/session - CR/day)
Two daily sessions
36 sessions / 36 weeks (PR limited 72 lifetime)
Sessions in excess of 36
No restrictions re: program crossover
Educational & Psychosocial requirements
GOLD standard = increased PR patient eligibility
Program individualization per patient focused needs
Knowledge translated to behavioral change
Require the “KX” modifier
If you dead everything wrong with you. If you CAD you high risk. In fact the earlier the manifestation of risk the higher your overall risk. Preservation of myocardial contractility EF = low risk 14 14

15. How About Cardiac Rehab!15

16. NGS & CGS Cardiac Rehab Coverage: “Similarities”
Physician directed & *supervised
Components include:
exercise prescription
risk factor modification
psychosocial assessment
outcome assessment
Individual treatment plan
diagnosis
individual goals
type, amount, frequency and duration of items and services provided.
Reviewed and signed by “a physician” every 30 days
Non-physician practitioner (NPP) may order the Cardiac Rehabilitation if it is within his/her scope of state practice under licensure
*DOTH 2012 issue

17. Cardiac Rehab Performance Measures

18. NGS vs. CGS Cardiac Rehab Coverage
NGS: heart valve surgery, PTCA or stenting and stable angina must begin a program within “6mths”
CGS: accepted diagnosis can begin a program within 12mths of procedure or diagnosis
NGS: clause re: angina assessment via angiographic changes during GXT.
CGS: angina diagnosis is determined by the referring physician

19. NGS vs. CGS Medical justification for extended participation
“Once a patient has reached the exit criteria (i.e. 36 sessions), further CR will not be considered reasonable and necessary”…. unless
Proof of ischemia or dysrhythmia per GXT
Achievement of 7< METs “a stable level of exercise tolerance” (AHA Class I or normal FWC)
6< minutes on a Bruce Protocol (or equivalent)
Significant ischemia or dysrhythmia > 6 minutes GXT
Heart Transplant < 90% predicted VO2 peak
6 minutes on a Bruce protocol: Men = 5.7 METs, Women = 6.4 METs ( without demonstrating significant ischemia or dysrhythmia after completion of six minutes of a Bruce protocol, or equivalent,
7 1/2 min: Men & women 6 1/2 min = 7 METs
CGS: Medical necessity proactively documented by the referring / supervising physician

20. CGS - Recent Developments

21. CGS Bulletin (Februar:y 10, 2012)
Probe Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (includes monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424)
Probe Medical Review of Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (93798)
CGS J15 Part A Medical Review Mail Code: AG Springdale Drive, Building One Camden, SC 29020
Recovery Account Contractor “RAC”

22. Pulmonary “Probe” Medical Review
Physician's orders for all services billed
UB-04
Any documentation that supports medical necessity for pulmonary rehabilitation
Documentation that the physician was immediately available for each monitored session billed
Documentation of the actual in/out times for each session billed
Nurse's notes
Progress notes
Lab reports
X-ray reports (if applicable)
Radiology test results
Therapy notes (if applicable)
Any other diagnostic reports
Itemized supply or medication lists for all items billed for these dates of service
Please submit all documentation as required in the LCD or NCD (if applicable)
Schedule of physician coverage or class times not sufficient!

23. Cardiac “Probe” Medical Review
Physician's orders for all services billed
UB-04
Any documentation that supports medical necessity for continuous ECG monitoring
Documentation that the physician was immediately available for each ECG monitored session billed
Nurse's notes
Progress notes
Lab reports
X-ray reports (if applicable)
Radiology test results
Therapy notes (if applicable)
Any other diagnostic reports
Itemized supply or medication lists for all items billed for these dates of service
Please submit all documentation as required in the Local Coverage Determination (LCD) or National Coverage Determination (NCD) (if applicable)
Schedule of physician coverage not sufficient!

24. Documentation Example

25. Pulmonary Rehab Cost Accounting Tool Kit:
Problem: CMS accounting methodology has reduced G024 reimbursement to $37.43/session
Solution: To use “non-standard” methodology to appropriately calculate G024 charges.
The “Tool Kit” = primer for pulmonary rehab clinicians to approach their finance depts with a step-by-step process for cost calculations.
Will be released March 29th with instructions via AACVPR state affiliate conference call.

26. AACVPR “Day On The Hill” DOTH26

27. Day On The Hill: DOTH 27

28. DOTH AACVPR “Gang of Four” J- 15 Representatives
Elaine Bohman RN, Troy; Jim Rosneck RN Summa, Akron, Rich Josephson MD & Rich Sukeena MA, MBA University Hospitals, Honorable Geoff Davis
Taking Picture: Lauren O’Brien “Legislative Director” 28 28

29. Talking Points…The “Pitch”
Allison Rochford Legislative assistant Sherrod Constituents' coffee 3/3/2011 (This technique used repeatedly to engender support for HR552 29 29

30. 1st Talking Point: NPP Supervision of CAH - C&P Programs
Issue: Critical Access Hospitals (CAH) programs in jeopardy due to physician supervision language in current statute. (Imposes strict requirements, describing the direct physician supervision standard for PR, CR services)
“Technical Correction” to existing 2008 legislation codifying Cardiac & Pulmonary rehab.
Bi-partisan co-sponsors
No additional $ involved.
Prevents use of Medicare services by constituents served by CAHs.
CBO = Cost is Zero; Everyone agrees CMS included that the physician on-site requirement for CAHs is onerous.

31. 2nd Talking Point: Cost Reporting
2009 CMS commissioned Research Triangle Institute (RTI) to investigate HOPPS rate setting processes.
RTI data indicated a reimbursement of > $100/session (Current CR = $69.50…PR = $37.43)
RTI found the CMS processes mapping cost-to-charge relationships in C&P programs was flawed and easily corrected. CMS chose to not heed this advise.
HOPPS final rule page 101:CMS-1504-FC 101 (2011 rule changes this process & allows for the use of the “non-standard” methodology)
CRUCIAL all programs should contact their reimbursement depts. to insure they use this method of reporting costs to CMS.
HOPPS = Hospital Outpatient Prospective Payment System

32. 3rd Talking Point: Excessive Medicare “Advantage” Co-pays
Medicare “Advantage” = Pulmonary & Cardiac Rehab “Disadvantage” !!!
Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans.
Mandated to follow rules set by Medicare.
Each Medicare Advantage Plan however has the freedom to require per-session co-pays greatly in excess of the typical 20% ($7.49) per session fee.
High co-payments = denial of services
AKA “MA’ 7 Part c

33. Thank you…questions