Medical Direc1on: CMS Standards

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1 Statement of Disclosure Cardiac Rehab Rules & Regula1ons Update I have no disclosures. The opinions expressed are my own. Candace Steele, RN, MA, FAACVPR Wheaton Franciscan Healthcare Heartland Conference April 2013 Objec1ves Discuss the 2010 changes in Cardiac Rehab reimbursement established by the CMS Discuss the appropriate coding and billing processes for cardiac rehab Medical Direc1on Medical Director is the physician(s) who oversees or supervises CR/PR program Medicare standards for this physician role in cardiac rehab are listed in Medicare provision 42 CFR Medical Direc1on: CMS Standards 1. Responsible for the program and staff 2. Involved substan1ally, in consulta+on with staff, in direc1ng progress of individuals in the program 3. Exper1se in management of individuals with (cardiac/respiratory) disease Medical Direc1on (cont d) 4. BLS training (or ACLS training) 5. License to prac1ce medicine in state where program is located 1

2 Medical Direc1on Medical director is involved with: Outcomes assessment, i.e., pre and post evalua1ons based on pa1ent- centered outcomes Physician- prescribed exercise Physician review and signature required on all Individualized Treatment Plans (ITP) Program entry, every 30 days, program comple1on Medical Direc1on Dis1nc1on between CR & PR: No direct contact required for review/signature of ITP in cardiac rehab programs Same requirements as for Pulmonary Rehab: 42 CFR Medicare regula1on for physician supervision of hospital outpa1ent services Posted on AACVPR web site under Regulatory & Legisla1ve Resources Removal of reference to any par1cular physical boundary in 2011 CMS does not differen1ate between on or off campus CMS does not define immediately by 1me, loca1on, or distance (cont d) Medical director and supervising physician do not have to be the same person(s) CMS does not dictate which physician(s) may provide the supervision for hospital outpa1ent services beyond above standards Many programs u1lize a physician- run code team or emergency department physicians (must be interrup1ble). For WPS (via teleconference communica1on): o Keep log of supervising physician in the department. o Documenta1on in pa1ent chart is not necessary. o If audited, log must go with medical records that are sent. 2

3 However. in the case of items and services furnished under such a program in a hospital, such availability shall be presumed Public Law , Sec1on 144 (July 2008) Discussions with CMS numerous 1mes since this issue was leh out of the CR and PR provisions. Non- physician Prac11oners (NP, PA, CNS) may not provide direct supervision for CR or PR services (per 42 CFR ) May not serve as supervising MD for the day May not sign ITPs or orders in J- 5 CMS needs a technical correc1on from Congress to allow this Be aware of goals of DOTH we need your help! MAC (in our case, WPS) has authority to deny payment based on their interpreta1on of Medicare regula1ons. Keep trail of any discussion with your physicians and compliance department regarding physician supervision. 42 CFR Medicare provision (regula1on) Eligible diagnoses: AMI within preceding 12 months CABG Stable angina Heart valve repair or replacement PTCA and/or stent Heart or heart- lung transplant WPS does NOT enforce 1me limits beyond AMI, i.e., follows federal provision. As such, all services must be reasonable and necessary. Heart valve repair or replacement LVAD only if tricuspid valve annuloplasty also done, or meets other criteria TAVR- transcatheter aor1c valve replacement PTCA and/or stent If procedures are planned sequen1al interven1ons, this would be one diagnosis=one CR course Not as clearly separate events (to payer) as other new dx jus1fying new CR course KX Modifier: Change Request Coding and billing instruc1ons sent to providers in May 2010 Instruc1ons covering use of KX modifier posted on AACVPR web site 3

4 36 weeks to complete up to 36 sessions Why was the program dura1on extended from 18 to 36 weeks? Hamm LF, Kavanagh T et al. Timeline for peak improvements during 52 weeks of outpa?ent cardiac rehabilita?on. JCRP 2004;24: Maximum of two sessions per day This has been allowed since 2008 One session per day remains acceptable No maximum # of days per week OK to exercise the pa?ent every day 1-2x/wk for longer dura1on 4-5x/wk for shorter dura1on Best approach? Both op1ons available to fit what s best for each pa1ent Ask yourself Will CMS/WPS s?ll deem these services medically necessary? CMS has not defined medically necessary with regard to CR Minimum of one session per week 1x/wk might be due to pa1ent barriers (travel, expense, etc) Understood that pa1ents may miss a week for various reasons (sickness, family need, vaca1on) Essen1al to document pa1ent absences. HCPCS Code Physician services for outpa?ent cardiac rehabilita?on; with con?nuous ECG monitoring (per session) HCPCS Code Physician services for outpa?ent cardiac rehabilita?on; without con?nuous ECG monitoring (per session) Educa1on/counseling (non- exercise required components) OR Non- ECG monitored exercise In a hospital outpahent seing, reimbursement for CPT/HCPCS and is the same amount Note: absence of the word exercise The pahent must exercise every day, but not necessarily every session. 4

5 Cardiac rehab is reimbursed in two seungs: Hospital outpa1ent seung (i.e., hospital owned outpa1ent clinics) Physician office (physician- owned) Reimbursement is higher for outpa1ent hospital programs Up to two sessions per day can be billed Every session counts toward total of 36 allowed per event Co- payment for each session CMS: Some exercise every day, but not every session To bill for 1 session, must be 31 minutes To bill for 2 sessions, dura1on of sessions (not exercise minutes) must be 91 minutes Examples of typical op1ons for mul1ple CR services/day based on individual pa?ent needs: One session and one session 1 st day assessment and exercise orienta1on One session ECG- monitored ex and one session educa1on Two sessions 95 minutes of ECG- monitored aerobic & resistance training Two sessions One non- ECG ex session & one counseling session 95 minutes of non- monitored aerobic & resistance training Billing: Use of Modifier 59 When submiung claim for one and one on same day, modifier 59 is required This is NOT required for any other combina1on of these two codes (i.e., two or two 93797) Reference: NCCI edits (Na1onal Correc1ve Coding Ini1a1ve), version 18.1, effec1ve posted at hxp://www.cms/gov/na1onalcorrectcodinited/ncciep/ list.asp#topofpage Billing: Use of KX Modifier (CR) KX modifier is required for any CR sessions beyond first 36 received as a Medicare beneficiary, effec1ve 1/1/10 Extension of one course (rare) Pa1ents are eligible for 36 sessions with each qualifying event. Billing: Use of KX Modifier (CR) Change Request 6850, CMS KX modifier instruc1ons sent to local Medicare contractors and providers CMS does NOT limit the total number of CR sessions over the life?me of a Medicare beneficiary Each new qualifying event provides medical necessity for a new CR course This is different from pulmonary rehab lifehme limit of 72 sessions. 5

6 CMS axempts to correct CR reimbursement All ins1tu1ons are required to submit a yearly Medicare Cost Report (on hospital s FY calendar) In Oct 2009, CMS implemented a non- standard cost center for cardiac rehab cost repor1ng WHY: CR was being reported under other services (standard cost center), so when cost to provide CR was calculated by CMS, underpayment was the result July, 2012: CMS will use CR non- standard cost center to determine reimbursement Non- Standard Cost Center Your responsibility: Communicate with your CFO to ascertain that you are repor1ng Cardiac Rehab services under this new non- standard cost center. References 1. Federal Register, Vol 76, No. 230, November 30, hyp://bit.ly/xtx47q 2. CMS Manual System, Change Request 6850, CR & ICR, hyp://bit.ly/xtx47q 3. Medical Director Responsibili1es for Outpa1ent Cardiac Rehabilita1on/Secondary Preven1on Programs: 2012 Update, Journal of Cardiopulmonary Rehabilita?on and Preven?on 2012;32: References (cont d) 4. Public Law , Sec1on 144 hyp://1.usa.gov/w41wwm MIPPA, July 15,

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