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
Comments / Questions: