CMS SPECIALTY DESIGNATION CODE for ADVANCED HEART
FAILURE/TRANSPLANT CARDIOLOGISTS
The Heart Failure Society of America (HFSA) successfully petitioned the American
Board of Internal Medicine (ABIM) Subspecialty Board on Cardiology for approval
of Advanced Heart Failure and Transplant Cardiology as a secondary sub-specialty
in 2008. The certification was first awarded in 2010. Advances in clinical
outcomes in patients with heart failure have resulted in a growing complexity of
care, supporting the need for special expertise to optimize the effective utilization
of appropriate interventions and strategies.
In a joint effort with the American College of Cardiology (ACC), HFSA has
proposed that Advanced Heart Failure and Transplant Cardiology be recognized
by the Centers for Medicare and Medicaid Services (CMS) as a separately
identified Medicare specialty.
REASONS FOR A MEDICARE SPECIALTY DESIGNATION
Using the Medicare directory called Physician Compare, patients will be able to
quickly identify physicians who are specialists in Advanced Heart Failure and
Transplant Cardiology. Second, for performance measurement and value-based
purchasing, it will be important to compare Advanced Heart Failure and
Transplant specialists to each other rather than to all cardiologists. Third, patients
with advanced heart failure are often candidates for highly specialized therapies
such as mechanical circulatory support devices or cardiac transplantation.
Appropriate selection and management of these complex patients requires highly
specific skills and expertise that are unique to Advanced Heart Failure and
Transplant Cardiology specialists.
The typical cardiologist’s practice pattern consists of a diverse mix of evaluation
and management, imaging, and interventions in patients with a variety of
illnesses, especially coronary artery disease. The practice pattern of Advanced
Heart Failure and Transplant Cardiology specialists is much more focused on
office and hospital visits, and those visits are much more likely to be at a higher
acuity and coding level. Advanced Heart Failure and Transplant Cardiology
specialists play a critical role in the appropriate use of advanced therapies
through evaluation and management of high risk, complex patients. However,
they are unlikely to have a significant number of procedures or interventions as
part of their billing record, because there are no significant surgical or procedural
interventions for heart failure outside of those performed by cardiothoracic
surgeons (cardiac transplants, ventricular assist devices) or electrophysiology
specialists (cardiac resynchronization therapy devices, implantable
cardiodefibrillators). Many Advanced Heart Failure and Transplant Cardiology
specialists provide longitudinal care to patients who receive these therapies,
providing long-term care and medical management of patients in the advanced
stages of this syndrome.
BOARD TRAINING AND CERTIFICATION
Physicians who are specialists in cardiovascular medicine are trained in a threeyear residency in internal medicine followed by a three-year cardiology
fellowship. Heart failure specialists receive this same training. However, in
recent years, we have seen development of a number of training programs
focusing specifically on Advanced Heart Failure and Transplant Cardiology. This
additional yearlong program provides additional intensive training in the care of
these very sick patients.
In 2012, specific accreditation for these fellowship programs was established by
the Accreditation Council for Graduate Medical Education (ACGME). There are
currently 60 accredited programs. Candidates who are certified by the ACGME in
Advanced Heart Failure and Transplant Cardiology must have a comprehensive
understanding of indications, contraindications, limitations, complications,
techniques, and interpretation of results of those diagnostic and therapeutic
procedures integral to the discipline of Advanced Heart Failure and Transplant
Cardiology. A body of knowledge and experience must be acquired for evaluating
and optimally managing patients with heart failure, particularly those with
advanced heart failure, those with devices, including ventricular assist devices,
and those who have undergone or are awaiting transplantation.
There are two pathways that would allow physicians to qualify for board
certification. The first requires the fellowship training. The second, which is only
available for the first three examinations (2010, 2012, 2014) is based on a practice
pathway and demonstration of significant practical experience in advanced heart
failure (including showing that at least 40% of clinical time is spent managing
patients with advanced heart failure). After the 2014 exam is completed, the
practice pathway will no longer be available, and all those who apply for the exam
must have completed a fellowship in advanced heart failure.
MEDICARE VOLUME
The vast majority of patients seen by Advanced Heart Failure and Transplant
specialists are covered by Medicare. Because heart failure is a progressive
syndrome, caused by cumulative insults to the heart (e.g. myocardial infarction,
hypertension), it is most prevalent in the elderly population. While current billing
data make it difficult to differentiate the severity of heart failure, the diagnosis
code family for heart failure is among the most prevalent for both hospital
admissions and outpatient visits. Also, the population seen by Advanced Heart
Failure and Transplant Cardiology specialists is among the most complex of these
patients. Although these patients represent only a subset of those diagnosed with
heart failure, they are the most severely affected and among the most costly for
Medicare, as many are candidates for advanced therapies, such as mechanical
circulatory support, transplantation, or end-of-life care.
PROCESS
Last year, HFSA and ACC submitted a request to CMS for a specialty designation
code for advanced heart failure and transplant cardiologists. This request was
denied by CMS. After a meeting with senior CMS personnel this summer, HFSA
will convene a meeting with ACC to strategize regarding the submission of a
revised application. It is important for patients and providers alike to have the
services of advanced heart failure and transplant cardiologists recognized and
attributed to this unique subset of providers.