medicare policy for cardiac and pulmonary rehabilitation- what’s ahead karen lui, rn, ms, faacvpr...

MEDICARE POLICY FOR CARDIAC AND MEDICARE POLICY FOR CARDIAC AND PULMONARY REHABILITATION-PULMONARY REHABILITATION-WHAT’S AHEAD WHAT’S AHEAD

Karen Lui, RN, MS, FAACVPRGRQ Consulting, [email protected] 23, 2009

Today we will cover:Today we will cover:• Legislative actions that led to

regulatory changes for cardiac rehab (CR) and pulmonary rehab (PR)

• Proposed Medicare regulations • AACVPR recommendations made to

CMS on proposed regulations• AACVPR recent and future actions

regarding proposed rule changes• Recommended next steps for your

program

DEFINITIONSDEFINITIONS

• CMS-Centers for Medicare & Medicaid Services

• NCD-National Coverage Determination-Medicare coverage policy• LCD-Local Coverage Determination-Local Medicare Contractor coverage policy

• MAC-Medicare Administrative Contractor -Formerly Fiscal Intermediaries & Carriers


APCAmbulatory Patient Classification• -Outpatient equivalent of DRGs

for in-patients• -Grouping of services/procedures

based on diagnosis• -APC 0095 includes both (all)

cardiac rehabilitation codes 93798 and 93797


ICD-9-CM CodeInternational Classification of Diseases• -Diagnosis and procedure codes• -Used to code and classify morbidity

data from the inpatient, outpatient records, & physician offices

• -ICD-10 to replace ICD-9 in US by 10-1-2013

• (currently used in Europe)


CPT CodeoCommon Procedure Technology• -#s assigned to MD services• -Codes are owned by AMA• -Codes are determined by CPT

Editorial Panel of AMA

DEFINITIONSDEFINITIONSHCPCS Codes

Healthcare Common Procedure Coding System -CMS creates procedures/professional services codes used by hospitals

-Not all CPT codes are available for hospitals to use

Today we will cover:Today we will cover:

• Legislative actions that led to regulatory changes for CR and PR

• Proposed Medicare regulations for CR and PR

• AACVPR recommendations made to CMS on proposed regulations

• AACVPR recent and future actions regarding proposed rule changes

• Recommended next steps for your program

LEGISLATIVE ACTIONSLEGISLATIVE ACTIONS

Purposes of Public Law 110-275 (MIPPA) To create statutory coverage policies

and payment categories for CR & PRThis was the recommendation of CMSExamples of services covered by statutory regulations: OT/ PT, CORFs

To assure that both CR & PR remain “physician-supervised” programs


• Proposed Medicare regulations for CR and PR




REGULATORY ACTIONSREGULATORY ACTIONS

After passage of MIPPA (7-08)◦11/08, 1/09: Face-to-face CR and PR

meetings between professional societies and CMS policy writers to discuss interpretation of legislative language into clinically-appropriate policy

◦Follow-up written recommendations with evidence-based references were then submitted to CMS

REGULATORY ACTIONSREGULATORY ACTIONS• Release of proposed regulations July,

2009–Physician Fee Schedule (PFS)-MDs–Outpatient Prospective Payment System (OPPS)-hospitals• Posted on AACVPR web site

• Public comment period closed 8-31-09• Final regulations will be published

November, 2009 with effective date 1-1-2010.

PROPOSEDPROPOSED CARDIAC & PULMONARY CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISIONREHAB RULES-PHYSICIAN SUPERVISION

From MIPPA (Pulmonary and Cardiac Rehabilitation Act of 2008) legislative language:

“A physician is immediately available and accessible for medical consultation and medical emergencies at all times items and services are being furnished under such a program in a hospital, such availability shall be presumed…”


Definition of hospital campus• “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 C.F.R. 413.65

PROPOSEDPROPOSED CARDIAC & PULMONARY CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISIONREHAB RULES-PHYSICIAN SUPERVISION• Medical Director required– “Physician who oversees or supervises …involved

substantially in directing the progress of individuals in the program.”

• Physician Supervision based on program location according to definition in OPPS proposed rule:– In hospital or in on-campus department:• MD “…must be present on the same campus, in

the hospital or the on-campus PBD (provider-based department) of the hospital…” (pg 35361, OPPS)

• No change from current rule

PROPOSEDPROPOSED CARDIAC & PULMONARY REHAB CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISIONRULES-PHYSICIAN SUPERVISION

For programs located in an off-campus PBD (provider-based department): MD “must be in the off-campus PBD

and immediately…” (pg 35361, OPPS)Current wording: “on the premises of the location” for off-campus programs may change

PROPOSEDPROPOSED CARDIAC & PULMONARY REHAB CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISIONRULES-PHYSICIAN SUPERVISION

For on-campus and off-campus CR programs:“It does not mean that the physician

must be present in the room when the procedure is performed.”

PROPOSEDPROPOSED CARDIAC & PULMONARY CARDIAC & PULMONARY REHAB RULES-PHYSICIAN REHAB RULES-PHYSICIAN SUPERVISIONSUPERVISION• On-campus CR/PR program that has access

to a code team would meet “immediately available” requirement

• For all programs, use of 911 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 assigned to be “immediately available”.

PROPOSEDPROPOSED CARDIAC & PULMONARY CARDIAC & PULMONARY REHAB RULES-PHYSICIAN REHAB RULES-PHYSICIAN SUPERVISIONSUPERVISION

Larger issue of CMS’ current and proposed definition of direct physician supervision for hospital outpatient therapeutic services (examples include infusion therapy, partial hospitalization, wound care) is being challenged by professional societies.

CMS final decision on this issue, effective January 1, 2010, will be known in November.


• NPPs (NP, PA,CNS) may directly supervise all hospital outpatient therapeutic services…in accordance with State law and scope of practice and hospital-granted privileges EXCEPT FOR CR/ICR/PR

• CR/ICR/PR must be furnished by a doctor of medicine or osteopathy


• AACVPR recommendations made to CMS on proposed CR and PR MD regulations



AACVPR RECOMMENDATIONS TO CMSAACVPR RECOMMENDATIONS TO CMS

Physician Supervision1. Clarify that definition in OPPS, not PFS,

is rule for CR/PR◦“…same campus, in the hospital or the

on-campus department.” NO CHANGE FROM CURRENT RULE

◦PFS rules are confusing as stated, “…for services provided in PBD of hospitals…must be on the premises of the location (meaning the PBD) and immediately…”

AACVPR RECOMMENDATIONS TO CMSAACVPR RECOMMENDATIONS TO CMS

Physician Supervision2. Allow CR/PR to use NPPs as other

hospital outpatient services will be allowed as of 1-1-2010◦This does not replace the need for

a physician to be immediately available.


• Proposed Medicare regulations for CR




PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULESWHAT’S THE SAME?WHAT’S THE SAME?

Same diagnoses qualify patient for early outpatient CR

Comparable reimbursement amounts

2010 = $ 38.40 (co-pay=$13.86) Reimbursement rate varies

regionallyPhysician supervision

“immediately available”

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULESWHAT’S THE SAME?WHAT’S THE SAME?

Two appropriate settings: hospital outpatient or MD office

Maximum of 36 sessions within 18 weeks

Same two CPT (HCPCS) codes:93798 and 93797

PROPOSEDPROPOSED CARDIAC REHAB RULES CARDIAC REHAB RULESWHAT’S NEW? WHAT’S NEW? • Each session must be minimum of 60

minutes–No CMS requirement re: minutes of

exercise• 36 one-hour sessions allowed within 18

weeks• Maximum of two sessions per day

•Minimum of two sessions per week•Patient must exercise aerobically

every day he/she receives rehab

PROPOSEDPROPOSED CARDIAC REHAB RULES CARDIAC REHAB RULESNEW REQUIRED COMPONENTSNEW REQUIRED COMPONENTS

Program must include:◦Initial assessment by CR staff◦Psychosocial assessment◦Individualized Treatment Plan (ITP) Frequency, intensity, modality,

duration Measurable and expected outcomes Estimated timetables to achieve

outcomes

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULESINDIVIDUALIZED TREATMENT PLANINDIVIDUALIZED TREATMENT PLAN

Established by a physician◦Referring or “CR” (supervising) MD◦CR MD must review and sign all plans

prior to initiation of CR◦From proposed regulation, “If the plan

is developed by the referring physician who is not the CR physician, the CR physician must also review and sign the plan prior to initiation of CR.” (pg 33608, PFS)

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULESINDIVIDUALIZED TREATMENT PLANINDIVIDUALIZED TREATMENT PLAN• CR staff provides outcomes and

psychosocial assessments and recommendations to supervising MD prior to 30-day deadline

• Plan is reviewed and signed by “the” physician every 30 days (refers to Medical Director)

• For CR, direct physician contact is not required to meet 30-day review standards (different for PR) unless patient needs such contact

• Outcomes should be consistent with current clinical practice standards

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULESOUTCOMES ASSESSMENTOUTCOMES ASSESSMENT• Part of treatment plan and not

billed separately• Outcomes measured at beginning,

prior to each 30-day review, and at end of patient’s CR program

• Measures are determined by patient’s individual plan–“Alternate or additional measures

may be appropriate.”• Measures should include:–BP, weight, BMI, medication

dosages, QOL, exercise progress, behavioral measures (smoking, etc)

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULESINTENSIVE CARDIAC INTENSIVE CARDIAC REHABILITATIONREHABILITATIONICRNew model of CR formerly known

as a “lifestyle modification” program◦Must apply annually to CMS to receive

ICR designation demonstrating that program has: Positively affected progression of CHD Reduced need for CABG Reduced need for PCI

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULES INTENSIVE CARDIAC INTENSIVE CARDIAC REHABILITATIONREHABILITATIONICR Program Criteria• “Each program must submit peer-

reviewed published research specific to the actual program applying for approval.”

• All designated programs must demonstrate continued compliance with MIPPA standards every year to maintain qualified status.

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULES INTENSIVE CARDIAC INTENSIVE CARDIAC REHABILITATIONREHABILITATIONICR Program Criteria (cont.)• Must demonstrate statistically

significant reduction (pre vs. post) in at least 5 of the following:–LDLs–Trigs–BMI–Systolic BP–Diastolic BP–Need for cholesterol, BP, and DM meds

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULES INTENSIVE CARDIAC INTENSIVE CARDIAC REHABILITATIONREHABILITATIONICR Program Criteria (cont.)• Must submit specific outcomes

assessment information for all patients who initiated and completed the full ICR program during the initial year-long CMS designation

• Must submit average beginning and ending levels of at least 5 of those measures for the program as a whole

• CMS will determine whether program continues to meet payment standards–Further details about the designation process

will be published with final regulation.

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULES INTENSIVE CARDIAC INTENSIVE CARDIAC REHABILITATIONREHABILITATIONICR Program Criteria (cont.)Program Delivery

◦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◦Equivalent reimbursement per

session to “general” CR

PROPOSEDPROPOSED CARDIAC REHAB CARDIAC REHAB RULESRULES

What about expanded CR coverage for heart failure diagnosis?

• HF-ACTION trial: initial findings published fall, 2008

• Await publication of secondary data analysis– spring 2009 through fall, 2009–Addition of diagnosis coverage is at

HHS Secretary’s discretion


• AACVPR recommendations made to CMS on proposed CR regulations



AACVPR RECOMMENDATIONS TO AACVPR RECOMMENDATIONS TO CMSCMSCorrect the flawed payment calculation

software that determines payment for CR so that accurate payment data can begin to be collected in 2010

Support CMS proposed Medical Director qualifications:◦ Training and proficiency in CV disease

management and exercise training of heart patients

◦ This is in agreement with AACVPR Position Statement on Medical Direction for CR Progrmas

AACVPR RECOMMENDATIONS TO AACVPR RECOMMENDATIONS TO CMSCMS• CR staff qualifications should follow

AACVPR Core Competencies regardless of specific academic discipline or legal credentials=multi-disciplinary service

• CR programs should have the flexibility to deliver services based on individual patient need–No minimum on sessions/wk –36 week window should be allowed for

maximum of 36 sessions


• Proposed Medicare regulations for PR


• AACVPR recent and future actions regarding proposed CR rule changes


PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESPAYMENTPAYMENTCurrent billing codes

– Three G Codes (G0237, 0238, 0239) for education and exercise (PT/OT codes 97001-97004)

– CPT codes for inhalation therapy, 6MWT, nebulizer instruction

– PFT codesCurrent payment amounts– $18/15 minute increments for G Codes– 6MWT=$ 55.00, etc.; billable as separate

services– $70/four “G Code services” in a day

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESPAYMENTPAYMENT

New G code replaces G0237-39

Code bundled, precluding billing for services 94620 (6MWT), 94664 (MDI, IPPB,neb), 94667 (vibration)

New payment rate=$ 15/hour@one hour limit /day

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESPAYMENTPAYMENT

This would be a 78% payment reduction

Where did CMS go wrong?Program costs miscalculatedStaffing assumptions not validStandard of care=up to 72 hours

◦LVRS mandates 44-66 hours in 2-hr sessions

Assumed MD work comparable to CR CPT 93797

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESDIAGNOSESDIAGNOSES

Will cover only:◦Moderate COPD (GOLD classification II)

◦Severe COPD (GOLD classification III)Any other conditions will be

considered through NCD process with evidence that supports significantly improved outcomes

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESDIAGNOSESDIAGNOSES

This eliminates 2/3rds of currently covered patients in PR under local Medicare policies.

Where did CMS go wrong?Misread the GOLD Guidelines

◦Should include very severe COPD classification

Didn’t look at numerous local Medicare policies that include non-COPD dx

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESREQUIRED COMPONENTSREQUIRED COMPONENTS

PhysicianPhysician-prescribed exerciseIndividualized Treatment Plan (ITP)

Outcomes AssessmentPsychosocial AssessmentEducation and training

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESPHYSICIAN REQUIREMENTSPHYSICIAN REQUIREMENTSProgram must have a Medical Director

◦Substantial involvement in monitoring and direction of individuals’ progress

Physician qualifications ◦Doctor of medicine or osteopathy◦Must have training and proficiency in: Chronic respiratory disease

management Exercise training of chronic

respiratory disease patients

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESPHYSICIAN REQUIREMENTSPHYSICIAN REQUIREMENTS• A physician must be immediately

available and accessible for medical consultation and medical emergencies at all times when PR service is being provided=“Supervising Physician”–Daily Supervising MD does not have to be

the Medical Director or the same physician every day

• Physician-prescribed exercise–Physical activity, including aerobic

exercise, prescribed and supervised by a physician that improves or maintains an individual’s pulmonary functional level

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESINDIVIDUALIZED TREATMENT PLANINDIVIDUALIZED TREATMENT PLAN

ITP• Written treatment plan to describe pt’s

dx, F.I.T.T., specific educational & training needs, goals set with patient

• Medical Director must sign ITP prior to program entry, every 30 days, and at program completion

• PR staff provides outcome and psychosocial assessments to Medical Director, but MD is responsible for reviewing, modifying, and signing plan

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESINDIVIDUALIZED TREATMENT PLANINDIVIDUALIZED TREATMENT PLAN

• Individualized plan should specify mix of services necessary for that individual patient

• CMS expects at least one direct MD contact with individual in each 30-day period–This is NOT a requirement for CR programs

• Even if referring MD develops and signs initial ITP, Medical Director must review and sign plan prior to initiation of PR

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESOUTCOMES ASSESSMENTOUTCOMES ASSESSMENT

A physician’s evaluation of the patient’s progress as it relates to his/her rehab◦This term NOT used in CR rules

Includes:◦Pre & post assessments, based on

patient-centered outcomes, conducted by the physician

◦Objective clinical measures of exercise performance, dyspnea, & behavior

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESOUTCOMES ASSESSMENTOUTCOMES ASSESSMENT

• Assessments are part of ITP (plan of care)• Considered part of PR program and may

not be billed separately• Measures should include clinical

measures such as:–6MWT–Exercise performance–Weight–QOL–Self-reported dyspnea–Behavioral measures

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESPSYCHOSOCIAL ASSESSMENTPSYCHOSOCIAL ASSESSMENT

• Written assessment and intervention plan by program staff

• Part of 30-day review for ITP• All the usual:–Family & home situation (support group?)–Depression & anxiety (referral for tx?)–Smoking cessation

• No changes to NCD 210.4 for “Smoking & tobacco use cessation counseling”, i.e., separately billable service

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESEDUCATION & TRAININGEDUCATION & TRAINING

Physician should evaluate and include only education & training that addresses particular needs of patient

Primary objective is understanding and self-management of chronic respiratory disease

All the usual educational components of PR

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESEDUCATION & TRAININGEDUCATION & TRAINING

CMS examples• Respiratory techniques for physical

energy conservation, work simplification and relaxation techniques

• Skills training and education that encourage behavioral changes by the patient which lead to improved health and long term adherence

• Brief smoking cessation• Proper use of medications, nutrition

counseling

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESPROGRAM DELIVERYPROGRAM DELIVERY

Max sessions=36 Limit 1 session (hour) per dayPatient must have some aerobic exercise

each day he/she attends rehabSuggested minimum 2x/wk for

combination of endurance and strength tx◦“Patients should generally receive 2-3

sessions per week which are a minimum of 60 minutes each.”

◦That means a 60-minute session-not 60 minutes of exercise

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESPROGRAM DELIVERYPROGRAM DELIVERY

Settings: MD office or hospital outpatient

CORFs (Comprehensive Outpatient Rehabilitation Facility) will not be held to these rules because they have their own statutory language

“Respiratory therapy services performed in a CORF are part of a CORF and not part of a PR program.”

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULES

Four primary areas of concern:1. Payment2. Qualifying Diagnoses3. Program Delivery

Restrictions4. Physician Supervision


• AACVPR recommendations made to CMS on proposed PR regulations



PROPOSEDPROPOSED PULMONARY PULMONARY REHAB RULESREHAB RULESPAYMENTPAYMENTAACVPR recommendations• Continue current G codes (0237-39)• Continue use of component billing for

related services (94620, 94664, 94667)

• Permit MD to submit Evaluation and Management code (“E & M”) when medically necessary

• Re-calculate staffing assumptions based on more accurate staffing mix (part of payment calculation)

• Re-calculate equipment assumptions to be more inclusive of real costs

PROPOSEDPROPOSED PULMONARY REHAB RULES PULMONARY REHAB RULESDIAGNOSESDIAGNOSES

AACVPR recommendationsAppropriate diagnoses for PR based on

evidence & current LCDs:• Very severe COPD (GOLD IV)• Cystic Fibrosis• Interstitial Lung Disease (ILD)• Restrictive Chest Wall Disease• Pulmonary Hypertension• Lung Ca• Neuromuscular Disease

PROPOSEDPROPOSED PULMONARY REHAB PULMONARY REHAB RULESRULESPROGRAM REQUIREMENTSPROGRAM REQUIREMENTS

AACVPR RecommendationsAllow 72 hours maximum for PR

program, based on current standard of care and science behind that standard

Allow and pay for 2-3 hours per day, the typical duration for PR paradigm

AACVPR ACTIONSAACVPR ACTIONSPulmonaryCollaboration with ATS, ACCP, AARC, NAMDRC,

ALA, NECA, NHOPAFly-in of leaders for three face-to-face

meetings with CMS policy and payment staff between Oct, 2008 and present

Letter sent to Congressional staff alerting of implications of these rules in contrast to intent of Public Law 110-275

Written request to meet with Secretary or Deputy Secretary of HHS (Bill Core) asap

27 page document of comments to CMS (including 101 scientific references)

AACVPR ACTIONSAACVPR ACTIONS

CardiacCollaboration with ACC, AHA,

AHospA, PCNA, CEPA on issues of concern

AACVPR recommendations submitted to CMS on proposed CR rules

AACVPR FUTURE ACTIONSAACVPR FUTURE ACTIONS• AACVPR Webinar November 10th (10

am PST) to present CMS 2010 final rules

• AACVPR will develop ITP for its members that is a collaborative effort of:–Reimbursement Committee (Medicare

compliant)–Outcomes Committee (which outcomes

and which tools)–Program Certification and Re-certification

Committees (will include future criteria)–Guidelines Committee (will include future

program recommendations)

AACVPR FUTURE ACTIONSAACVPR FUTURE ACTIONS

• Work with state affiliates for clinically-appropriate interpretation of CMS rules by local Medicare contractors–15 regional AACVPR MAC committees

• This will happen through your AACVPR MAC Committee working collaboratively with your MAC for Jurisdiction 2 - “J-2”–Susan P (AACVPR Reim Comm), Aaron H,

Angie G, Chris W

NEXT STEPSNEXT STEPSWait for final CMS regulations to be

published in November.Get ready to help with advocacy

efforts if CMS doesn’t “do the right thing” for programs and patients, particularly for pulmonary rehab.

Stay informed through AACVPR, your local affiliate, and your MAC Committee. Check out the “What’s New” section of

AACVPR web site.

NEXT STEPSNEXT STEPSPrepare for implementation of new

rules on 1-1-2010. Seek answers to your questions first

from your MAC committee.Share what you know with your

billing department, compliance department, and administration.◦YOU are the expert on CR/PR

services!

medicare policy for cardiac and pulmonary rehabilitation- what’s ahead karen lui, rn, ms, faacvpr...

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