New Opportunities for Cardiac & Pulmonary Rehabilitation While Meeting Regulatory & Certification Requirements

1. Karen Lui, RN, MS GRQ, LLC karen@grqconsulting.com NCCRA March 2, 1012 Chapel Hill, NC New Opportunities for Cardiac & Pulmonary Rehabilitation While Meeting Regulatory & Certification Requirements

2. Statement of Disclosure • I have no disclosures. • The opinions expressed are my own.

3. Today’s Talk-Part 1New Opportunities • 2012 Medicare pulmonary rehabilitation payment • Cardiac (CR) and pulmonary (PR) rehabilitation: • Medical direction & physician supervision • Coding and billing • Appropriate use of KX modifier • Individualized Treatment Plan • CMS and performance measures • Adoption of CR referral measures • Request for pulmonary rehab measures GRQ, LLC

4. Today’s Talk-Part 2Meeting Regulatory and Certification Requirements • Disclaimer: I am not on the AACVPR program certification committee. • AACVPR Program Certification follows Medicare requirements, but is not equivalent. • Local Medicare contractors (MACs) have the authority to interpret and enforce Federal Medicare regulations. • This presentation will review current Federal coverage policies for CR and PR. GRQ, LLC

5. 2012 PR Medicare Payment-Why the reduction in reimbursement? • January, 2010: Medicare established PR as a covered service • New bundled procedure code G0424 was created with payment based on review of G0237-39 (unbundled) history • Spring, 2011: CMS reviews G0424 claims data • Median charge of $150 submitted by hospitals calculates to reimbursement rate of $37 GRQ, LLC

6. 2012 PR Medicare Payment-Why the reduction in reimbursement? • Hospitals did not make adjustment from 1:1 15-minute codes to a 1-hr bundled service • CMS “…assumed hospitals would include charges for these additional services in CY 2010 charges…because the services are included in the definition of comprehensive pulmonary rehabilitation.” • Federal Register, 8-19-11, pg 42240 GRQ, LLC

7. 2012 PR Medicare Payment-Why the reduction in reimbursement? • CMS used PR as example to all services for new codes using single code to report multiple services previously reported by multiple codes • CMS advice: • Be careful to construct charge that reports a complete combination of services • To under-represent full cost of providing the service can have significant adverse impact on future payments for individual service described by the new code GRQ, LLC

8. 2012 PR Medicare Payment-How do we correct it? PULMONARY REHABILITATION TOOLKIT • 20-page document that provides guidance in calculating appropriate charges for G0424 • Developed by AACVPR, AARC, ATS, NAMDRC GRQ, LLC

9. 2012 PR Medicare Payment-How do we correct it? PULMONARY REHABILITATION TOOLKIT • CMS reviews 2011 claims data now for CY 2013 • If hospitals correct PR charges immediately, programs could see fiscal correction in 2014 • Toolkit will be available to all programs in the very near future GRQ, LLC

10. Medical Direction-CR & PR • Medical Director is the physician(s) who oversees or supervises CR/PR program • Medicare standards for this position: • Responsible for the program and staff • Involved substantially, in consultation with staff, in directing progress of individuals in the program • Expertise in management of individuals with (cardiac/respiratory) disease • BLS training • License to practice medicine in state where program is located GRQ, LLC

11. Medical Direction-CR & PR • Medical director is involved with: • Outcomes assessment, i.e., pre and post evaluations based on patient-centered outcomes • Physician-prescribed exercise • Physician review and signature required on all Individualized Treatment Plans (ITP) • entry, every 30 days, program completion GRQ, LLC

12. Medical Direction-CR & PR Distinction between CR & PR: • PR-requires medical director to provide direct patient contact related to the periodic review of ITP • CR-no direct contact required for review of ITP GRQ, LLC

13. Physician Supervision-CR & PR • A physician (MD or DO) must be physically immediately available and accessible for medical emergencies at all times the program is being furnished • The supervising physician must at all times be “interruptible” to physically respond immediately • CMS does not differentiate between on or off campus • CMS does not define “immediately” by time, location, or distance GRQ, LLC

14. Physician Supervision-CR & PR • Standards for physician qualifications of the supervising MD or DO are: • Expertise in management of (cardiovascular or respiratory) disease • Cardiopulmonary training or certification in BLS or ACLS (for CR programs) • Licensed to practice medicine in the State where the CR or PR program is located GRQ, LLC

15. Physician Supervision-CR & PR • CMS does not dictate beyond these requirements which physician(s) may provide the supervision for hospital outpatient services • Many programs utilize a physician-run code team or emergency dept physicians (must be interruptible) • Medical director and supervising physician do not have to be the same person(s) • The Medicare regulation for all hospital services requiring physician supervision is found in 42 CFR 410.27 • posted under AACVPR Regulatory & Legislative Resources GRQ, LLC

16. Physician Supervision-CR & PR • Nonphysician Practitioners (NP, PA, CNS) may NOT provide direct supervision for CR or PR services • May not serve as supervising MD for the day • May not sign ITPs • Some MACs allow NPPs to independently order CR/PR services, but Palmetto does NOT • US Senate bill # 2057 and US House bill # ___ , when passed, will allow NPPs to provide aspects of physician supervision GRQ, LLC

17. PR-Eligibility GOLD Guidelines - 2011 revision • No change in classifications of COPD • GOLD 2-Moderate 50% < FEV1<80% predicted • GOLD 3-Severe 30% < FEV1<50% predicted • GOLD 4-Very Severe FEV1<30% predicted • GOLD classifications are based on post-bronchodilator FEV1 GRQ, LLC

18. PR – Coding and Billing • Medicare maximum: up to 36 sessions, with option for additional 36 sessions if medically necessary • 72 lifetime maximum • Up to two 1-hour sessions per day allowed, not required • 1 session > 31 minutes • 2 sessions > 91 minutes • Some exercise is required in every session GRQ, LLC

19. Use of KX Modifier in PR • CMS Change Request 6823 (5-7-10) • Contractors shall pay PR claims which exceed 36 sessions when a KX modifier is included on claim line • Contractors shall deny G0424 when submitted for more than 72 sessions (with or without KX modifier) • Common Working File (CWF) displays remaining PR sessions • Hospital billing office uses CWF for capped Medicare services GRQ, LLC

20. CR - Coding & Billing • 36 weeks to complete up to 36 sessions • Up to maximum of two sessions per day (not new) • One per day remains acceptable • No maximum # of days per week-every day OK (not new) • Minimum of one session per week • 1x/wk might be due to patient barriers (travel, expense, etc) • Understood that patients may miss a week for various reasons (sickness, family need, vacation) • Documentation of such absences would be prudent GRQ, LLC

21. CR - Coding & Billing 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)” • Education/counseling (non-exercise required components) • Non-ECG monitored exercise GRQ, LLC

22. CR - Coding & Billing • Up to two sessions per day • Every session counts toward total of 36 • Co-payment for each session • CMS: Some exercise “every day”, not every session • To bill for 2 sessions, duration (not exercise minutes) must be > 91 minutes GRQ, LLC

23. CR – Coding & Billing Examples of typical options for multiple CR services/day based on individual patient needs: • One 93798 session and one 93797 session • 1st day assessment and “exercise orientation” • One session ECG-monitored ex and one session education • Two 93798 sessions • 95 minutes of ECG-monitored aerobic & resistance tx • Two 93797 sessions • One non-ECG ex session & one counseling session • 95 minutes of non-monitored aerobic & resistance tx GRQ, LLC

24. Use of KX Modifier in CR • KX modifier is required for any CR sessions beyond first 36 received as a Medicare beneficiary • Extension of one course (rare) • New course of CR for eligible diagnosis in later months/years (not uncommon) • CMS has instructed local Medicare contractors of this • Change Request 6850, 5-21-2010 • CMS does NOT limit the total # of CR sessions over the lifetime of a Medicare beneficiary, i.e., new qualifying event provides medical necessity for a new CR course GRQ, LLC

25. Individualized Treatment Plan • Written plan tailored to individual patient=opportunity • ITP Components: • Diagnosis • Plan for exercise frequency, intensity, modality, & duration • Measureable and expected outcomes • Individualized goals • Estimated timetables to achieve identified outcomes goals • *Each of these components should be part of the ITP, i.e., one document, but obviously not one page GRQ, LLC

26. Individualized Treatment Plan • Every 30 days=Calendar Days • Example: 1x/wk for one month=30 calendar days • Palmetto does not allow flexibility in “30-day” rule • CMS: “…not intended to be a rigid protocol.” GRQ, LLC

27. CR Referral Performance Measures CR referral in the outpatient setting (MD office) performance measure is 1 of 6 new chart-abstracted measures (5 DM measures) for CY 2014 MD payment • CMS says included because: • CR is beneficial (mortality & morbidity, QOL, reduces risk factors, enhances adherence to preventable meds), yet CR remains underutilized • Valuable in care coordination • Improved enrollment rates are the critical and desired outcome GRQ, LLC

28. CR Referral Performance Measures • CR referral in the outpatient setting will be included as an individual measure in 2012 PQRS (Physician Quality Reporting System) • Reporting via claims and/or registry • CMS is evaluating the CR referral performance measure for the inpatient setting as a future hospital quality measure. • AACVPR & ACC pursuing next steps on this GRQ, LLC

29. PR Performance Measures • Two time-endorsed PR measures: • QOL • Functional improvement (6MWT) • CMS is seeking a Pulmonary Rehabilitation measures group for PQRS • AACVPR will pursue this opportunity GRQ, LLC

31. The 2010 World Heart Games Included: • 66 athletes, 20 volunteers, the spirit of competition, 1 World Heart Games • Olympic-style competition for those with cardiovascular disease or with risk factors • The event will feature a wide variety of challenging – yet safe and monitored – competitions for patients, from table tennis to golf to volleyball to bowling • If you have interest in participating or supporting future World Heart Games, please visit our website at www.acsm.org/worldheartgames

32. “Must Have” Research • Cardiac rehabilitation 2012-advancing the field through emerging science. Kwan G, Balady GJ, Circ 2012;125:e369-e373. • Core competencies for CR/secondary prevention professionals:2010 update. Hamm LF, Sanderson BK, Ades PA et al. JCRP 2011;31:2-10. • Clinical research in CR and secondary prevention. Savage PD, Sanderson BK, Brown TM, et al. JCRP 2011;31:333-341. • High-calorie expenditure exercise: a new approach to CR for overweight coronary patients. Ades PA, Savage PD, Toth MJ, et al. Circ 2009;119;2671-2678. GRQ, LLC

33. References • 42 CFR 410.49: CR & ICR Conditions of Coverage* • 42 CFR 410.47: PR Conditions for Coverage* • CMS Change Request 6850,CR & ICR,5-21-10* • CMS Change Request 6823, 5-7-10* *Posted on AACVPR web site GRQ, LLC

34. QUESTIONS?