Note:
Cigna Government Services (CGS) assumed MAC J15 governance responsibilities as of Monday
10/17/12. I have been able to recently contact representatives of CGS regarding their organizational
policy regarding Cardiac Rehab coverage in their geographic area (Kentucky & Ohio).
CGS has decided to adhere to the national coverage determination (NCD) of January 1, 2010
regarding CMS coverage of Cardiac Rehab (rather than “crossing over” to our previous provider
NGS’s LCD). This is good news! It allows for more flexibility in providing our services. Below I listed
the program requirements contained within the NCD. (Billing practices should not be effected by this
change in MAC provider).
There is the possibility that in the future CGS may decide to develop a specific LCD for Cardiac
Rehab. If so the AACVPR MAC J-15 committee as well as national governance colleagues will be
actively involved in the process to insure equitable coverage rules for our service.
Warm Regards,
Jim Rosneck RN, MS
MAC J-15 Committee Chairman
.
Required Program Components Cardiac Rehab
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Physician-Prescribed Exercise
CMS Definition: “… aerobic exercise combined with other types of exercise (strengthening,
stretching) as determined appropriate for individual patients by a physician.” (Physician
reviewed exercise RX i.e. developed by CR staff)JR
Psychosocial Assessment
• Evaluation of individual’s mental and emotional functioning related to individual’s rehab,
including aspects of family/home situation that affect that patient’s rehab treatment
– Examples: SF-36 or depression screening tools
• Part of treatment plan and not billed separately
Outcomes Assessment
CMS Definition: Evaluation of progress as it relates to individual’s rehabilitation, including:
– Pre & post CR based on patient-centered outcomes measured by the physician
– Objective clinical measures of exercise performance and self-reported measures of exertion
and behavior
• Similar to what is required for AACVPR Program Certification
• CMS allows flexibility in determining which outcomes are measured every 30 days (ITP) vs.
which outcomes are measured at beginning and at end of patient’s CR program
• Outcome measures are determined by patient’s individual plan; none specifically required by
CMS
– Examples: BP, weight, BMI, medication dosages, QOL, behavioral measures (smoking, etc)
– Alternate or additional measures may be appropriate
• Part of treatment plan and not billed separately
Individualized Treatment Plan (ITP)
CMS Definition: Written plan tailored to each individual patient, including:
– Description of diagnosis
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– Type, amount, frequency, and duration of items and services furnished under the plan
– Goals set for the individual under the plan (Should include the exercise Rx for ease of
documentation physician signature)JR
ITP Components:
• Plan for exercise frequency, intensity, modality, & duration
• Measureable and expected outcomes
• Estimated timetables to achieve identified outcomes goals
• Established, reviewed, signed by a physician every 30 days (Physician “prescribed” can
be interpreted as the physician reviewing and approving the Initial Treatment Plan (ITP) which
should include the exercise Rx and individualized care plan “developed PR staff”) JR
– Does NOT require that it must be the Medical Director
– MD is involved in directing the progress of individuals “in consultation with CR staff”
Physician Supervision
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A physician must be immediately available and accessible at all times program is operating
A physician must be present and immediately available where the services are being furnished
For CR programs located in hospital or on campus department, “Physician availability shall be
presumed.” (per Public Law 110-275)
Hospital Campus Definition: “Campus means the physical area immediately adjacent to the
provider’s main buildings, other areas and structures that are not strictly contiguous to the
main buildings but are located within 250 yards of the main buildings, and any other areas
determined on an individual basis, by the CMS regional office, to be part of the provider’s
campus.” 42 CFR (Code of Federal Regulations) 413.65
CMS Definition of “In the Hospital”: “…areas in the main building(s) of a hospital or CAH that
are under the ownership, financial and administrative control of the hospital or CAH; that are
operated as part of the hospital; and for which the hospital bills the services furnished under
the hospital’s or CAH’s CMS Certification Number (CCN).”
CMS does not define “immediately available” by time parameter
On-campus CR program that has access to a physician-run code team would meet
“immediately available” requirement
For all programs, use of 911 alone does not meet Medicare requirement for physician
“immediacy”
Calling 911 as back-up and for patient transport is appropriate, but doesn’t replace need for an
MD who is identified as the MD “immediately available”
For hospital-owned CR programs located in an off-campus provider-based department (PBD),
MD “must be in the PBD of the hospital or CAH and immediately available…”
This rule applies to other hospital outpatient therapeutic services; is not exclusive to CR/PR
In the hospital outpatient setting, CR/PR is no longer an “incident-to physician” services (due to
new statute), but does remain under CMS “direct physician supervision” rules
The physician does not have to be present in the room when the procedure (CR) is being
performed (on hospital campus, hospital off-campus, or in MD office setting)
For CR program located in physician office (i.e., MD-owned), physician must be “in the suite”,
but does not have to be in the room.
Nonphysician Practitioners (NP, PA, CNS)
– May NOT provide direct supervision for CR services
– May not serve as supervising MD for the day
– May not sign Individualized Treatment Plan
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Can NPPs order CR? Yes in OHIO - ? Kentucky
– Not addressed by CMS
– Scope of practice is determined by state law
– May need clarification via local Medicare contractor process because response may vary
Supervising Physician
Supervising physician definition: “immediately available and accessible…”
• Supervising physician requirements:
– Expertise in the management of individuals with cardiac pathophysiology
– BLS or ACLS training
– Licensed to practice medicine in the state in which the CR program is offered
Medical Director
Medical Director definition: “Physician that oversees or supervises the CR or ICR program at a
particular site.”
• Not required to scrutinize each patient’s medical record…should be aware of patient’s
condition…should at least be knowledgeable of each patient’s progress through CR or ICR.
• Medical Director requirements:
– Responsible for CR program; oversees and supervises the CR program
– Involved in directing progress of individuals in consultation with staff
– Expertise in management of individuals with cardiac pathophysiology
– Licensed to practice medicine in the state where CR program is located
– Training in BLS or ACLS
Medical Director and Supervising Physician
• May be same person
• May be different physicians
• Supervising MD doesn’t have to be same person each day (However documentation of who the
supervising physician is crucial JR)
• CMS allow flexibility on how CR programs provide MD coverage & involvement
Program Paradigm Options
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To report one session in a day the duration of treatment must be at least 31 minutes
– CMS does not address # of minutes of exercise because that is individualized for each
patient
– CMS does not specify how session duration is to be documented in individual patient records
Class schedule would not be adequate documentation
Up to maximum of two sessions per day
Two sessions may be reported in the same day if the duration of treatment is at least 91
minutes
– First session would equal 60 minutes, second session would equal at least 31 minutes if two
sessions are reported
One session per day remains acceptable
No maximum # of days per week (every day OK)
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Minimum of one session per week
– It is understood that patients may miss a week for various reasons (sickness, family need,
vacation)
– Documentation of such absences would be prudent
36 week window to complete 36 sessions
Some aerobic exercise is required every day patient is in CR
Exercise is not required in every CR session
Up to additional 36 sessions (total 72) may be granted by local Medicare contractor
– Based on medical necessity
– Extension is not granted prospectively, but is based on a case-by-case basis
Covered diagnoses for Phase II CR remain unchanged from current NCD
CMS does not require that CR services be exclusive from other services, such as PR
Coding & Billing
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Revenue Code=0943
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)”
– Could be either of following scenarios:
Education/counseling (non-exercise required components)
• Non-ECG monitored exercise
• There are no codes for CR staff to bill for CR initial assessment or six-minute walk test-CMS
considers these part of patient’s treatment plan
– Physician evaluation and management (“E & M”) CPT codes are for physician services as
per E & M CPT code rules
• Multiple sessions per day are allowed, but not required
– Could be any of the following scenarios:
• One 93798 session and one 93797 session
• Two 93798 sessions
• If only one session per day is provided, a session lasting less than 31 minutes would not be
billable.
• No requirements on which disciplines may make up multi-disciplinary CR team
• OTs and RDs may not supervise or bill separately for services furnished during CR/ICR
• CMS does not have required or recommended staff to patient ratio
• PTs may be part of the multidisciplinary team; however, comprehensive CR services should
not be billed separately
• A Medicare 700 or 701 form is NOT required for CR services
2010 CR Medicare Reimbursement
• $ 38.36 in hospital-based program as posted in Hospital Outpatient Payment System (HOPPS)
2010 rules
• Co-payment = $13.86; covered by patient’s secondary or supplemental insurance or by patient
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• Regional variation in Medicare reimbursement rate
• Same reimbursement amount for 93798 and 93797 for hospital outpatient programs because
both are within APC 0095 (Ambulatory Patient Classification) (Potentially allows for risk
stratification…low risk patients non/infrequently monitored.)JR
• Reimbursement for physician-owned (“free-standing”) CR programs is calculated differently, is
posted in Physician Fee Schedule and is less (low $20’s)
• Reimbursement in this setting is roughly half for CPT 93797 than reimbursement for CPT 93798
Intensive Cardiac Rehabilitation
• CMS definition: “A physician-supervised program that furnishes cardiac rehabilitation and has
shown, in peer-reviewed published research, that it improves patients’ cardiovascular disease
through specific outcome measurements.”
• Designation Process:
– ICR program submits application for CMS review
– If ICR program is approved, individual sites then enroll with their local Medicare contractor to
become an ICR program
• Peer-reviewed published research requirement is for ICR program, not individual sites.
• ICR program must show:
– Positively affected progression of CHD
– Reduced need for CABG and PTCA
– Statistically significant reduction in at least 5 of following measures pre to post ICR:
• LDL
• Trigs
• BMI
• SBP
• DBP
• Need for cholesterol, BP, and DM medications
• ICR program delivery components
• ITP signed by MD every 30 days
• Same MD supervision rules
• Psychosocial Assessment
• Outcomes Assessment
• Patients receive 72 one-hour sessions within 18 weeks
• Up to 6 sessions per day
• Patient must exercise aerobically every day he/she receives rehab
• Billing Codes for ICR
• G0422: “Intensive cardiac rehabilitation; with or without continuous ECG monitoring, with exercise,
per hour, per session”
• G0423: “Intensive cardiac rehabilitation; with or without continuous ECG monitoring, without
exercise, per hour, per session”
• To report one session in a day the duration of treatment must be at least 31 minutes
– CMS does not address # of minutes of exercise because that is individualized for each patient
– CMS does not specify how session duration is to be documented in individual patient records
• For both G Codes for ICR, reimbursement is equivalent per session to CR (same APC)
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• MACs (Medicare Administrative Contractor) administrate and process Medicare claims for CR
based on CMS regulations
• MACs may publish instructions in form of LCDs, articles, and/or bulletins for providers
• MACs have authority to “interpret” CMS rules, so there may be variations between MACs
• CMS Rules were effective January 1, 2010 and do not require the publication of an NCD (National
Coverage Determination) to be implemented.
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