Cardiac & Pulmonary Rehabilitation Under Medicare….Mark D
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Transcript Cardiac & Pulmonary Rehabilitation Under Medicare….Mark D
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 errorfree 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
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
36 sessions
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
Provider Outreach & Education
Identify billing errors
Meet Documentation Requirements
Reduce the error rate
LCD
Indications & Limitations of Coverage
Reduce the error rate
Thank You
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