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

1. MEDICARE POLICY FOR CARDIAC AND PULMONARY REHABILITATION-WHAT’S AHEAD Karen Lui, RN, MS, FAACVPR GRQ Consulting, LLC karen@GRQConsulting.com 770-531-9298 OSCVPR October 23, 2009

2. 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

3. DEFINITIONS • 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

4. DEFINITIONS APC Ambulatory 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

5. DEFINITIONS ICD-9-CM Code International 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)

6. DEFINITIONS CPT Code • Common Procedure Technology • -#s assigned to MD services • -Codes are owned by AMA • -Codes are determined by CPT Editorial Panel of AMA

7. DEFINITIONS HCPCS 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

8. 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

9. LEGISLATIVE ACTIONS Purposes of Public Law 110-275 (MIPPA) • To create statutory coverage policies and payment categories for CR & PR • This was the recommendation of CMS • Examples of services covered by statutory regulations: OT/ PT, CORFs • To assure that both CR & PR remain “physician-supervised” programs

10. Today we will cover: • 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

11. REGULATORY 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

12. REGULATORY 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.

13. PROPOSED CARDIAC & PULMONARY REHAB 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…”

14. PROPOSED CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISION 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

15. PROPOSED CARDIAC & PULMONARY REHAB 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

16. PROPOSED CARDIAC & PULMONARY REHAB RULES-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

17. PROPOSED CARDIAC & PULMONARY REHAB RULES-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.”

18. PROPOSED CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISION • 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”.

19. PROPOSED CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISION • 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.

20. PROPOSED CARDIAC & PULMONARY REHAB RULES-PHYSICIAN SUPERVISION • 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

21. Today we will cover: • AACVPR recommendations made to CMS on proposed CR and PR MD regulations • AACVPR recent and future actions regarding proposed rule changes • Recommended next steps for your program

22. AACVPR RECOMMENDATIONS TO CMS Physician Supervision 1. 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…”

23. AACVPR RECOMMENDATIONS TO CMS Physician Supervision 2. 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.

24. Today we will cover: • Proposed Medicare regulations for CR • AACVPR recommendations made to CMS on proposed regulations • AACVPR recent and future actions regarding proposed rule changes • Recommended next steps for your program

25. PROPOSED CARDIAC REHAB RULESWHAT’S THE SAME? • Same diagnoses qualify patient for early outpatient CR • Comparable reimbursement amounts • 2010 = $ 38.40 (co-pay=$13.86) • Reimbursement rate varies regionally • Physician supervision “immediately available”

26. PROPOSED CARDIAC REHAB RULESWHAT’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

27. PROPOSED CARDIAC REHAB RULESWHAT’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

28. PROPOSED CARDIAC REHAB RULESNEW 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

29. PROPOSED CARDIAC REHAB RULESINDIVIDUALIZED 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)

30. PROPOSED CARDIAC REHAB RULESINDIVIDUALIZED 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

31. PROPOSED CARDIAC REHAB RULESOUTCOMES 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)

32. PROPOSED CARDIAC REHAB RULESINTENSIVE CARDIAC REHABILITATION ICR • New 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

33. PROPOSED CARDIAC REHAB RULES INTENSIVE CARDIAC REHABILITATION ICR 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.

34. PROPOSED CARDIAC REHAB RULES INTENSIVE CARDIAC REHABILITATION ICR 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

35. PROPOSED CARDIAC REHAB RULES INTENSIVE CARDIAC REHABILITATION ICR 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.

36. PROPOSED CARDIAC REHAB RULES INTENSIVE CARDIAC REHABILITATION ICR 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

37. PROPOSED CARDIAC REHAB RULES 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

38. Today we will cover: • AACVPR recommendations made to CMS on proposed CR regulations • AACVPR recent and future actions regarding proposed rule changes • Recommended next steps for your program

39. AACVPR RECOMMENDATIONS TO CMS • Correct 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

40. AACVPR RECOMMENDATIONS TO CMS • 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

41. Today we will cover: • Proposed Medicare regulations for PR • AACVPR recommendations made to CMS on proposed regulations • AACVPR recent and future actions regarding proposed CR rule changes • Recommended next steps for your program

42. PROPOSED PULMONARY REHAB RULESPAYMENT Current 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 codes Current 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

43. PROPOSED PULMONARY REHAB RULESPAYMENT • 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

44. PROPOSED PULMONARY REHAB RULESPAYMENT This would be a 78% payment reduction Where did CMS go wrong? • Program costs miscalculated • Staffing assumptions not valid • Standard of care=up to 72 hours • LVRS mandates 44-66 hours in 2-hr sessions • Assumed MD work comparable to CR CPT 93797

45. PROPOSED PULMONARY REHAB RULESDIAGNOSES • 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

46. PROPOSED PULMONARY REHAB RULESDIAGNOSES • 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

47. PROPOSED PULMONARY REHAB RULESREQUIRED COMPONENTS • Physician • Physician-prescribed exercise • Individualized Treatment Plan (ITP) • Outcomes Assessment • Psychosocial Assessment • Education and training

48. PROPOSED PULMONARY REHAB RULESPHYSICIAN REQUIREMENTS • Program 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

49. PROPOSED PULMONARY REHAB RULESPHYSICIAN 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

50. PROPOSED PULMONARY REHAB RULESINDIVIDUALIZED 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