Medicare Reimbursement“New Rules…New Game”

Relating Public Policy Changes to Program Evolution

Jim Rosneck RN, MS FAACVPR

KCRA Annual Meeting March 15, 2012

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Presentation Objectives

Describe Medicare Account Contractors (MACs) Describe AACVPR Health & Public Policy

Committee Functions Report on current AACVPR national & local public

policy initiatives Discuss programming opportunities given the new

rules Describe national lobbying strategies and 2012

DOTH activities

Next Week’s Objectives

Ohio High School State Championship Tournament

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CMS MAC-15 Update “What is a MAC”?

CMS Medicare Account Contractor (MAC) ‘Integrate & centralize information and create efficient processes for delivery of comprehensive care to Medicare beneficiaries’.

Goals: $ Full and open competitions to replace existing system of

Fiscal Intermediary (FI) contractors$ Increased efficiencies Consistent approach to medical coverage across the

service area Competition among current MACs to encourage quality

cost efficient service to health providers.$ Focus on financial management to achieve more accurate

claims payments and greater consistency in payment decisions.

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Section 911, Medicare Prescription Drug, Improvement and Modernization Act of 2003 15 MAC Geographic Regions

J-15 CIGNA “CGS”

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CIGNA Government Services (CGS) Functions

CMS will ensure its MAC contracts focus on three critical areas: 1. Customer service

2. Operational excellence

3. Financial management.

Medicare coverage and billing requirements, and the receipt, processing, and payment of Medicare fee-for service core claims processing operations for both Part A and Part B. .

Interpret CMS statutory rules & national coverage determination “NCD” language and intent in the development of MAC-LCD’s

Maintain a staff of experts knowledgeable of all aspects of the fee-for-service program

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AACVPR MAC J-15 Committee

Dalynn Badenhop, OH Mike Bichsel, OH Elaine Bohman, OH Sherri Bradley, KY Peggy Cox, KY Tammy Garwick, OH Jim Rosneck, OH Rich Sukeena, OH Stephanie Tucker, KY (Physician Liaison: Rich Josephson, OH)

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AACVPR J-15 Committee Functions

Maintain Communication Insure that CGS Cardiac & Pulmonary Rehab local

coverage determination (LCD) represents the letter and intent of the recent national coverage determination.

Coordinate activities with AACVPR national H&PP committee members & leadership.

Communicate issues effectively with OACVPR & KCRA leadership to insure that member and non-member programs are aware of H&PP issues.

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MAC J-15 Current History

CGS “Cutover” from NGS (Fiscal Intermediary) management October 17, 2011

LCD Postings at least by September 1st 2011

October 2012 CGS decision to adhere to the National Coverage Determination NCD and/or statutory rules interpretation

MAC J-15 “CGS Strategy”

“Watchful Waiting” Announcement of CGS - LCD writing group J-15… action committee will directly contact

CGS medical director Gary Oakes MD.• Educate • Petition for adherence to Medicare NCD

statute• Involve AACVPR national officers PRN

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CMS: Components of Pulmonary Rehab

Physician prescribed exercise: Patient centered Some aerobic training included in each session

Education Tailored to individual needs Tailored to behavioral change Brief smoking cessation Nutrition Proper medication use & adherence

Psychosocial Assessment Include assessment of home support Objective measure of progress (Pre & Post Testing)

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CMS: Components of Pulmonary Rehab

Outcomes assessment: Baseline assessment & patient centered goals Individual progress via objective measurements. Pretesting - Goal Setting – Post testing

Individualized Treatment Plan Diagnosis Type, amount, frequency and duration of the items and services Patient centered goals Established reviewed and signed by a physician Reviewed & signed by the medical director

Physician Supervision

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CMS: Components of Pulmonary Rehab - Diagnosis

COPD Moderate, severe and very severe COPD (GOLD guidelines) Billing code = G0424

Non-COPD All other previously recognized diagnoses Billing code = G0239 “Group Exercise” Billing code = G0238 “Individual Exercise q15min” Billing code = G0237 “Individual Education q15min”

LCD will eventually determine the status of Non-COPD diagnosis

Require the “59”

modifier

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Pulmonary Program Evolution

Necessity of ECG monitoring?

Aerobic exercise requirement (PR/session - CR/day)

Two daily sessions

36 sessions / 36 weeks (PR limited 72 lifetime)

Sessions in excess of 36

No restrictions re: program crossover

Educational & Psychosocial requirements

GOLD standard = increased PR patient eligibility

Program individualization per patient focused needs

Knowledge translated to behavioral change

Require the “KX”

modifier

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How About Cardiac Rehab!

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NGS & CGS Cardiac Rehab Coverage: “Similarities”

Physician directed & *supervised Components include:

exercise prescription risk factor modification psychosocial assessment outcome assessment

Individual treatment plan diagnosis individual goals type, amount, frequency and duration of items and services provided. Reviewed and signed by “a physician” every 30 days

Non-physician practitioner (NPP) may order the Cardiac Rehabilitation if it is within his/her scope of state practice under licensure

*DOTH 2012 issue

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Cardiac Rehab Performance Measures

NGS vs. CGS Cardiac Rehab Coverage

NGS: heart valve surgery, PTCA or stenting and stable angina must begin a program within “6mths”

CGS: accepted diagnosis can begin a program within 12mths of procedure or diagnosis

• NGS: clause re: angina assessment via angiographic changes during GXT.

• CGS: angina diagnosis is determined by the referring physician

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NGS vs. CGS Medical justification for extended participation

“Once a patient has reached the exit criteria (i.e. 36 sessions), further CR will not be considered reasonable and necessary”…. unless Proof of ischemia or dysrhythmia per GXT Achievement of 7< METs “a stable level of exercise

tolerance” (AHA Class I or normal FWC) 6< minutes on a Bruce Protocol (or equivalent) Significant ischemia or dysrhythmia > 6 minutes GXT Heart Transplant < 90% predicted VO2 peak

CGS: Medical necessity proactively documented by the referring / supervising physician

CGS - Recent Developments

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CGS Bulletin (Februar:y 10, 2012)

Probe Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (includes monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424)

Probe Medical Review of Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (93798)

CGSJ15 Part A Medical ReviewMail Code: AG-2562300 Springdale Drive, Building OneCamden, SC 29020

Recovery Account Contractor “RAC”

Pulmonary “Probe” Medical Review Physician's orders for all services billed UB-04 Any documentation that supports medical necessity for pulmonary

rehabilitation Documentation that the physician was immediately available for each

monitored session billed Documentation of the actual in/out times for each session billed Nurse's notes Progress notes Lab reports X-ray reports (if applicable) Radiology test results Therapy notes (if applicable) Any other diagnostic reports Itemized supply or medication lists for all items billed for these dates of

service Please submit all documentation as required in the LCD or NCD (if

applicable)

Schedule of physician coverage or class times

not sufficient!

Cardiac “Probe” Medical Review Physician's orders for all services billed UB-04 Any documentation that supports medical necessity for continuous ECG

monitoring Documentation that the physician was immediately available for each ECG

monitored session billed Nurse's notes Progress notes Lab reports X-ray reports (if applicable) Radiology test results Therapy notes (if applicable) Any other diagnostic reports Itemized supply or medication lists for all items billed for these dates of

service Please submit all documentation as required in the Local Coverage

Determination (LCD) or National Coverage Determination (NCD) (if applicable)

Schedule of physician coverage not sufficient!

Documentation Example

Cardiac Rehabilitation Daily Report

Name: Charles E Example Date: 9/1/2011 Session#: 8 Diagnosis: Stent

Time in: 6:57:01 AM Time out: 8:30:46 AM

Health Problem: N/A Med. Change: N/C Pain Status: N/C ECG Monitored: Yes

Home Glucose:125 Home Trng. Min. 60

Staff Evaluator: KLK

BP HR/Pulse Rhythm

Entrance 122/78 73 SR

Exit 110/64 83 SR

Daily Exercise Data

Exercise Device METs RPE BP

Airdyne 1.47

Nu-Step 3

Treadmill 3.14

Airdyne 1.47 13 138/68

Treadmill 3.14 15

Daily Exercise HR Data

Target HR 95-115

Peak HR 109

Trough HR 91

Daily Estimated Work

Mean METs=

2.44 Kcal= Kcal=280.09

Program Work Goals

Init Goal= 2.05 -to- 2.46 METs

Train Goal=

2.46 -to- 2.87 METs

Comments: Pt wanted to try some interval training on TM , similar to what he does at the gym.KK

Signatures

Staff:

Supervising Physician:

Pulmonary Rehab Cost Accounting Tool Kit:

Problem: CMS accounting methodology has reduced G024 reimbursement to $37.43/session

Solution: To use “non-standard” methodology to appropriately calculate G024 charges.

The “Tool Kit” = primer for pulmonary rehab clinicians to approach their finance depts with a step-by-step process for cost calculations.

Will be released March 29th with instructions via AACVPR state affiliate conference call.

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AACVPR “Day On The Hill” DOTH

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Day On The Hill: DOTH

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DOTH AACVPR “Gang of Four” J- 15 Representatives

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Talking Points…The “Pitch”

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1st Talking Point: NPP Supervision of CAH - C&P Programs

1. Issue: Critical Access Hospitals (CAH) programs in jeopardy due to physician supervision language in current statute. (Imposes strict requirements, describing the direct physician supervision standard for PR, CR services)

2. “Technical Correction” to existing 2008 legislation codifying Cardiac & Pulmonary rehab.

3. Bi-partisan co-sponsors

4. No additional $ involved.

5. Prevents use of Medicare services by constituents served by CAHs.

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2nd Talking Point: Cost Reporting

2009 CMS commissioned Research Triangle Institute (RTI) to investigate HOPPS rate setting processes.

RTI data indicated a reimbursement of > $100/session (Current CR = $69.50…PR = $37.43)

RTI found the CMS processes mapping cost-to-charge relationships in C&P programs was flawed and easily corrected. CMS chose to not heed this advise.

HOPPS final rule page 101:CMS-1504-FC 101 (2011 rule changes this process & allows for the use of the “non-standard” methodology)

CRUCIAL all programs should contact their reimbursement depts. to insure they use this method of reporting costs to CMS.

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3rd Talking Point: Excessive Medicare “Advantage” Co-pays

Medicare “Advantage” = Pulmonary & Cardiac Rehab “Disadvantage” !!!

Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans.

Mandated to follow rules set by Medicare. Each Medicare Advantage Plan however has the

freedom to require per-session co-pays greatly in excess of the typical 20% ($7.49) per session fee.

High co-payments = denial of services

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Thank you…questions