Heart Failure & Cardiac Rehabilitation

Transcription

1 Heart Failure & Cardiac Rehabilitation Karen Lui, RN, MS, MAACVPR SCACVPR Greenville May 3, I have no disclosures. 2 Outline New Professional Certification New AACVPR CR Guidelines New Heart Failure Coverage Recent CMS direction on MD supervision for PR/CR programs Medicaid Coverage CR FAQs 3 1

2 Add CCRP to your résumé and advance your career. 4 What is the CCRP? The only professional certification specific to cardiac rehabilitation. Why should I take the exam? Earning this certification demonstrates mastery of the core competencies essential in providing quality cardiac rehabilitation. 5 Who is eligible to sit for the exam? Professionals with: 1,200 clinical hours in CR/secondary prevention Minimum of a Bachelor s degree or higher in a health related field from an accredited college or university or current RN licensure. Current RN licensure does not necessitate minimum academic requirement. 6 2

3 How does CCRP compare to other certifications? ACSM CCRP is not intended to replace ACSM clinical exercise physiology certifications. In fact, ACSM certification in clinical exercise physiology is a preferred qualification for hiring an exercise specialist or physiologist in an outpatient cardiac rehabilitation setting. AACVPR Guidelines for Cardiac Rehabilitation, 5th edition, How does CCRP compare to other certifications? ACSM CCRP goes beyond testing only clinical exercise physiology knowledge to include a comprehensive examination based on all the identified core competencies of CR. Therefore, individuals with ACSM certification will not be grandfathered in to the CCRP program. 8 How does CCRP compare to other certifications? ANCC American Nursing Credentialing Center (ANCC) retired a cardiac rehabilitation specific certification years before the publication of evidence based core competencies for CR. The focus of the current ANCC examination has shifted to serve nurses practicing in a cardiovascular setting, such as hospital unit or physician practice. 9 3

4 How does CCRP compare to other certifications? ANCC Because it is not based on the published core competencies for cardiac rehabilitation, individuals with the RN C certification previously offered by ANCC will not be grandfathered in to the CCRP program. CCRP goal is to achieve ANCC magnet status asap. 10 How can I prepare? Download the CCRP Exam Blueprint from aacvpr.org View the Candidate Handbook (available spring 2014) Purchase the Study Guide (available spring 2014) 11 AACVPR Blueprint 10 Domains Patient assessment Nutrition management Weight management BP management Blood lipid management Diabetes management Tobacco cessation Psychosocial mngmnt Physical activity counseling Exercise training Duties and Tasks

5 AACVPR Blueprint Example 1. Patient Assessment # of questions= Explain cardiovascular system anatomy and physiology 1.2 Recognize pathophysiology of cardiovascular diseases (e.g., atherosclerosis, valvularheart disease, chronic heart failure) 1.3 Identify risk factors contributing to atherosclerotic heart disease 1.4 Recognize cardiac dysrhythmias and potential implications during physical activity to When is the exam? Wednesday, September 3, 2014 In advance of the AACVPR 29 th Annual Meeting in Denver, CO How much will it cost? The first exam will be discounted: $249 AACVPR members $299 non members

6 5 th Edition CR Guidelines New: Outcomes based programming emphasized No staff to patient ratio recommendations Preferred hiring qualifications added Higher educational level for program director (MS) ACSM certification preferred for clinical exercise specialists/physiologists Mastery of AACVPR Core Competencies for all nucleus staff, as demonstrated through CCRP 16 Heart Failure Medicare Coverage Regulations National Coverage Determination (NCD) 20:10 Medicare Provision 42 CFR Eligibility criteria ICD 9 CM and ICD 10 CM Codes 17 National Coverage Determination NCD 20:10 Effective date: February 18, 2014 CAG # 00437N HF patients are not eligible for Intensive Cardiac Rehab (ICR) Separate benefit (statute) for ICR Evidence of benefit based on CR model, not ICR 15 6

7 Medicare Provision for CR Same regulation for HF: 42 CFR hour sessions/day >91 minutes=2 sessions <90 minutes=1 session Up to 36 sessions per course Up to 36 weeks to complete CR course Required components Physician prescribed exercise (CR team) Cardiac risk factor reduction interventions 19 Eligibility Criteria CMS criteria were derived from HF ACTION Trial for patient eligibility. Research design often differs from real world procedure for valid reasons. 20 Eligibility Criteria Beneficiaries with stable, chronic heart failure meeting all of following: 1. Left ventricular ejection fraction < 35% 2. NYHA class II IV symptoms despite being on optimal heart failure therapy for at least 6 weeks 3. Stable=have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures 21 7

8 Eligibility Criteria: Stable Stable In general, stable means that the patient's symptoms from heart failure are not worsening relatively rapidly, requiring prompt evaluation for medication adjustment or procedures. Although patients with heart failure can have "good days and bad days", progressive declines in functional capacity due to fatigue or dyspnea or rapid increase in edema or weight may be symptoms of medical instability. 22 Eligibility Criteria: Optimal Optimal Medical therapy varies, depending on a patient's tolerance for medications, but in general includes a beta blocker such as carvedolol or metoprolol and an ACEI or ARB. Referring physicians will understand the concepts of stable and optimal medical therapy, as they relate these terms to patients with heart failure. 23 Eligibility Criteria Beneficiaries with stable, chronic heart failure meeting all of following: 1. Left ventricular ejection fraction < 35% Measurement by any method is OK EF >35% not eligible EF is not an exact measurement 24 8

9 Eligibility Criteria Beneficiaries with stable, chronic heart failure meeting all of following: 2. NYHA class II IV symptoms despite being on optimal heart failure therapy for at least 6 weeks Goal for HF patients is not symptom free, but that patients are able to monitor and control their symptoms Similar to stable angina where goal is selfmanagement skills 25 Eligibility Criteria Beneficiaries with stable, chronic heart failure meeting all of following: 3. Stable=have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures Patient does not have to have been hospitalized to be eligible No per year or per lifetime limit, as with all CR dx 26 Eligibility Considerations What constitutes planned and major? LVAD: planned differs from future evaluation for ICD, pacemaker, PCI not typically considered major cardiovascular hospitalizations/procedures EPs increasingly using life vest in CR to assess need for AICD after some weeks of CR 27 9

10 Eligibility Considerations What about patient with AMI who has EF < 35%? What about a patient who begins Phase II and is re hospitalized for HF? What about patient who would benefit from > 36 sessions per course? Similar to stable angina diagnosis 28 Eligibility Considerations Bottom line: Medical necessity, dept policy protocol, CR Medical Director, education & medical judgment of referring MDs will guide these clinical decisions and referral appropriateness. 29 Eligibility Considerations 30 day all cause re admission penalties for HF dx Role for CR to provide or participate in transitional treatment strategies to improve care coordination Start education earlier post DC Plan is that 30 day will move to 60 day to 90 day to 1 year with CMS Episode of Care Program Episode Grouper 30 10

11 Referral Considerations Is it appropriate to obtain referral at hospital discharge? Absolutely EMR/automated + liaison referral (CR team) yields highest rates of enrollment (Sherry Grace et al) Wait times for referral to enrollment (unfortunately) average 20+ days CR initial assessment screens for current stability and appropriateness to begin CR Adds to rationale for CR involvement in transitional care (esp. with ACO model) 31 Billing & Coding Procedure codes There are only two CPT codes available to bill for all Medicare required components of CR services Billing & Coding List of HF ICD 9 and ICD 10 (diagnosis) codes posted on AACVPR HF web page ICD 10 CM codes effective Oct. 1, 2015 CMS web site for ICD 10 instructions ndex.html?redirect=/icd

12 Clinical Considerations for HF & CR Helpful starting points: 1. AACVPR HF Workshop Webinar held March 13th 2. Cardiac Rehabilitation Exercise and Self Care for Chronic Heart Failure. Ades PA, Keteyian SJ, Balady GJ, Houston Miller N, et al. JACC Heart Fail 2013;1: Evidence to support Exercise prescription Self care counseling 34 MD Supervision in CAH Setting 2010: CMS relaxed physician supervision requirement for outpatient services in critical access hospitals, except for cardiac and pulmonary rehab services (Federal Register, Nov 24, 2010, Vol 75, # 226, pg 72000) CAHS allowed to use NPPs except for CR/PR due to statutory language (SSA; Title XVIII, Section 144; i.e., Public Law ) 35 MD Supervision in CAH Setting March 24, 2014 Per CMS: Direct supervision by a physician is required (in CAHs) and will be enforced by CMS for PR/CR/ICR. AACVPR advocacy effort (Day on the Hill) was attempt to obtain use of NPPs for supervision (not medical direction) in all CR/PR programs, regardless of setting 36 12

13 Medicaid Coverage Medicare is under SSA Title XVIII Medicaid is under SSA Title XIX Medicaid is obligated to cover same outpatient services that Medicare covers Coverage and payment are separate issues example PAD exercise 37 Medicaid Coverage Medicaid is state run & state funded program States have some flexibility to impose amount, duration or scope limitations on required benefits as long as most enrollees who need the benefit are fully served. Some enrollees will receive alternate benefit packages modeled after commercial benchmark coverage that includes essential health benefits. States that don t accept federal funding? 38 CR FAQs of 2014 Valve repair/replacement coverage Any technique is acceptable TAVR KX Modifier Needed for every session after 36 as a Medicare beneficiary as of Jan, 2010 CWF/HETS/C SNAP or other CMS tracking system is used by your billing dept to check utilization Referred to as CMS Patient Inquiry Screen 39 13

14 Thank you 40 14