New Opportunities for Cardiac &
Pulmonary Rehabilitation While
Meeting Regulatory & Certification
Requirements
Karen Lui, RN, MS
GRQ, LLC
karen@grqconsulting.com
NCCRA
March 2, 1012
Chapel Hill, NC
Statement of Disclosure
• I have no disclosures.
• The opinions expressed are my own.
Today’s Talk-Part 1
New Opportunities
1. 2012 Medicare pulmonary rehabilitation payment
2. Cardiac (CR) and pulmonary (PR) rehabilitation:
– Medical direction & physician supervision
– Coding and billing
– Appropriate use of KX modifier
– Individualized Treatment Plan
3. CMS and performance measures
– Adoption of CR referral measures
– Request for pulmonary rehab measures
GRQ, LLC
Today’s Talk-Part 2
Meeting Regulatory and Certification Requirements
• Disclaimer: I am not on the AACVPR program
certification committee.
• AACVPR Program Certification follows Medicare
requirements, but is not equivalent.
• Local Medicare contractors (MACs) have the
authority to interpret and enforce Federal Medicare
regulations.
• This presentation will review current Federal
coverage policies for CR and PR.
GRQ, LLC
2012 PR Medicare PaymentWhy the reduction in reimbursement?
• January, 2010: Medicare established PR as a
covered service
• New bundled procedure code G0424 was
created with payment based on review of
G0237-39 (unbundled) history
• Spring, 2011: CMS reviews G0424 claims data
• Median charge of $150 submitted by hospitals
calculates to reimbursement rate of $37
GRQ, LLC
2012 PR Medicare PaymentWhy the reduction in reimbursement?
• Hospitals did not make adjustment from 1:1
15-minute codes to a 1-hr bundled service
• CMS “…assumed hospitals would include
charges for these additional services in CY
2010 charges…because the services are
included in the definition of comprehensive
pulmonary rehabilitation.”
– Federal Register, 8-19-11, pg 42240
GRQ, LLC
2012 PR Medicare PaymentWhy the reduction in reimbursement?
• CMS used PR as example to all services for new
codes using single code to report multiple services
previously reported by multiple codes
• CMS advice:
– Be careful to construct charge that reports a
complete combination of services
– To under-represent full cost of providing the
service can have significant adverse impact on
future payments for individual service described
by the new code
GRQ, LLC
2012 PR Medicare PaymentHow do we correct it?
PULMONARY REHABILITATION TOOLKIT
• 20-page document that provides
guidance in calculating appropriate
charges for G0424
• Developed by
AACVPR, AARC, ATS, NAMDRC
GRQ, LLC
2012 PR Medicare PaymentHow do we correct it?
PULMONARY REHABILITATION TOOLKIT
• CMS reviews 2011 claims data now for
CY 2013
• If hospitals correct PR charges
immediately, programs could see fiscal
correction in 2014
• Toolkit will be available to all programs in
the very near future
GRQ, LLC
Medical Direction-CR & PR
• Medical Director is the physician(s) who oversees or
supervises CR/PR program
• Medicare standards for this position:
– Responsible for the program and staff
– Involved substantially, in consultation with staff, in
directing progress of individuals in the program
– Expertise in management of individuals with
(cardiac/respiratory) disease
– BLS training
– License to practice medicine in state where program is
located
GRQ, LLC
Medical Direction-CR & PR
• Medical director is involved with:
– Outcomes assessment, i.e., pre and post
evaluations based on patient-centered
outcomes
– Physician-prescribed exercise
• Physician review and signature required on all
Individualized Treatment Plans (ITP)
– entry, every 30 days, program completion
GRQ, LLC
Medical Direction-CR & PR
Distinction between CR & PR:
• PR-requires medical director to provide
direct patient contact related to the
periodic review of ITP
• CR-no direct contact required for review of
ITP
GRQ, LLC
Physician Supervision-CR & PR
• A physician (MD or DO) must be physically
immediately available and accessible for medical
emergencies at all times the program is being
furnished
• The supervising physician must at all times be
“interruptible” to physically respond immediately
• CMS does not differentiate between on or off
campus
• CMS does not define “immediately” by time,
location, or distance
GRQ, LLC
Physician Supervision-CR & PR
• Standards for physician qualifications of the
supervising MD or DO are:
– Expertise in management of (cardiovascular or
respiratory) disease
– Cardiopulmonary training or certification in BLS or
ACLS (for CR programs)
– Licensed to practice medicine in the State where
the CR or PR program is located
GRQ, LLC
Physician Supervision-CR & PR
• CMS does not dictate beyond these requirements which
physician(s) may provide the supervision for hospital
outpatient services
– Many programs utilize a physician-run code team or
emergency dept physicians (must be interruptible)
• Medical director and supervising physician do not have to be
the same person(s)
• The Medicare regulation for all hospital services requiring
physician supervision is found in 42 CFR 410.27
– posted under AACVPR Regulatory & Legislative Resources
GRQ, LLC
Physician Supervision-CR & PR
• Nonphysician Practitioners (NP, PA, CNS) may NOT
provide direct supervision for CR or PR services
– May not serve as supervising MD for the day
– May not sign ITPs
• Some MACs allow NPPs to independently order
CR/PR services, but Palmetto does NOT
• US Senate bill # 2057 and US House bill # ___ ,
when passed, will allow NPPs to provide aspects of
physician supervision
GRQ, LLC
PR-Eligibility
GOLD Guidelines - 2011 revision
• No change in classifications of COPD
– GOLD 2-Moderate 50% < FEV1<80% predicted
– GOLD 3-Severe
30% < FEV1<50% predicted
– GOLD 4-Very Severe
FEV1<30% predicted
• GOLD classifications are based on postbronchodilator FEV1
GRQ, LLC
PR – Coding and Billing
• Medicare maximum: up to 36 sessions, with
option for additional 36 sessions if medically
necessary
• 72 lifetime maximum
• Up to two 1-hour sessions per day allowed,
not required
– 1 session > 31 minutes
– 2 sessions > 91 minutes
• Some exercise is required in every session
GRQ, LLC
Use of KX Modifier in PR
• CMS Change Request 6823 (5-7-10)
– Contractors shall pay PR claims which exceed 36
sessions when a KX modifier is included on claim
line
– Contractors shall deny G0424 when submitted for
more than 72 sessions (with or without KX
modifier)
– Common Working File (CWF) displays remaining
PR sessions
• Hospital billing office uses CWF for capped
Medicare services
GRQ, LLC
CR - Coding & Billing
• 36 weeks to complete up to 36 sessions
• Up to maximum of two sessions per day (not new)
– One per day remains acceptable
– No maximum # of days per week-every day OK (not
new)
• Minimum of one session per week
– 1x/wk might be due to patient barriers (travel,
expense, etc)
– Understood that patients may miss a week for
various reasons (sickness, family need, vacation)
– Documentation of such absences would be prudent
GRQ, LLC
CR - Coding & Billing
HCPCS Code 93798
 “Physician services for outpatient cardiac
rehabilitation; with continuous ECG monitoring
(per session)”
HCPCS Code 93797
 “Physician services for outpatient cardiac
rehabilitation; without continuous ECG
monitoring (per session)”
 Education/counseling (non-exercise
required components)
 Non-ECG monitored exercise
GRQ, LLC
CR - Coding & Billing
• Up to two sessions per day
• Every session counts toward total of 36
– Co-payment for each session
• CMS: Some exercise “every day”, not every
session
• To bill for 2 sessions, duration (not exercise
minutes) must be > 91 minutes
GRQ, LLC
CR – Coding & Billing
Examples of typical options for multiple CR services/day based
on individual patient needs:
• One 93798 session and one 93797 session
– 1st day assessment and “exercise orientation”
– One session ECG-monitored ex and one session education
• Two 93798 sessions
– 95 minutes of ECG-monitored aerobic & resistance tx
• Two 93797 sessions
– One non-ECG ex session & one counseling session
– 95 minutes of non-monitored aerobic & resistance tx
GRQ, LLC
Use of KX Modifier in CR
• KX modifier is required for any CR sessions beyond
first 36 received as a Medicare beneficiary
– Extension of one course (rare)
– New course of CR for eligible diagnosis in later
months/years (not uncommon)
• CMS has instructed local Medicare contractors of this
– Change Request 6850, 5-21-2010
• CMS does NOT limit the total # of CR sessions over
the lifetime of a Medicare beneficiary, i.e., new
qualifying event provides medical necessity for a new
CR course
GRQ, LLC
Individualized Treatment Plan
• Written plan tailored to individual patient=opportunity
• ITP Components:
– Diagnosis
– Plan for exercise frequency, intensity, modality, & duration
– Measureable and expected outcomes
– Individualized goals
– Estimated timetables to achieve identified outcomes goals
• *Each of these components should be part of the ITP, i.e.,
one document, but obviously not one page
GRQ, LLC
Individualized Treatment Plan
• Every 30 days=Calendar Days
– Example: 1x/wk for one month=30 calendar
days
• Palmetto does not allow flexibility in “30day” rule
– CMS: “…not intended to be a rigid protocol.”
GRQ, LLC
CR Referral Performance Measures
CR referral in the outpatient setting (MD office)
performance measure is 1 of 6 new chart-abstracted
measures (5 DM measures) for CY 2014 MD payment
– CMS says included because:
• CR is beneficial (mortality & morbidity, QOL,
reduces risk factors, enhances adherence to
preventable meds), yet CR remains underutilized
• Valuable in care coordination
– Improved enrollment rates are the critical and
desired outcome
GRQ, LLC
CR Referral Performance Measures
• CR referral in the outpatient setting will be
included as an individual measure in 2012
PQRS (Physician Quality Reporting System)
– Reporting via claims and/or registry
• CMS is evaluating the CR referral performance
measure for the inpatient setting as a future
hospital quality measure.
– AACVPR & ACC pursuing next steps on this
GRQ, LLC
PR Performance Measures
• Two time-endorsed PR measures:
– QOL
– Functional improvement (6MWT)
• CMS is seeking a Pulmonary Rehabilitation
measures group for PQRS
– AACVPR will pursue this opportunity
GRQ, LLC
The 2010 World Heart Games Included:
- 66 athletes, 20 volunteers, the spirit of competition, 1 World
Heart Games
-
Olympic-style competition for those with cardiovascular
disease or with risk factors
-
The event will feature a wide variety of challenging – yet safe
and monitored – competitions for patients, from table tennis
to golf to volleyball to bowling
• If you have interest in participating or supporting future
World Heart Games, please visit our website at
www.acsm.org/worldheartgames
“Must Have” Research
• Cardiac rehabilitation 2012-advancing the field through
emerging science. Kwan G, Balady GJ, Circ 2012;125:e369e373.
• Core competencies for CR/secondary prevention
professionals:2010 update. Hamm LF, Sanderson BK, Ades PA
et al. JCRP 2011;31:2-10.
• Clinical research in CR and secondary prevention. Savage PD,
Sanderson BK, Brown TM, et al. JCRP 2011;31:333-341.
• High-calorie expenditure exercise: a new approach to CR for
overweight coronary patients. Ades PA, Savage PD, Toth MJ, et
al. Circ 2009;119;2671-2678.
GRQ, LLC
References
• 42 CFR 410.49: CR & ICR Conditions of
Coverage*
• 42 CFR 410.47: PR Conditions for Coverage*
• CMS Change Request 6850,CR & ICR,5-21-10*
• CMS Change Request 6823, 5-7-10*
*Posted on AACVPR web site
GRQ, LLC
QUESTIONS?