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Cardiac & Pulmonary Rehabilitation
Under Medicare
Mark D Pilley, MD
FAAFP, ABQAURP, FAADEP
Palmetto GBA/CGS
J11/J15 AB MAC
DisclaimerThis 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/ICRPhysician 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/ICRFacility 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
PRPhysician Requirements
Expertise - managing respiratory
pathophysiology
State Medical License
.
PRPhysician 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 Identify billing errors
Provider Outreach & Education Meet Documentation Requirements Reduce the error rate
LCD Indications & Limitations of Coverage Reduce the error rate
Thank You
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