Transcript Document

MEDICARE POLICY FOR CARDIAC AND
PULMONARY REHABILITATIONWHAT’S AHEAD
Karen Lui, RN, MS, FAACVPR
GRQ Consulting, LLC
[email protected]
770-531-9298
OSCVPR
October 23, 2009
Today we will cover:
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•
•
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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
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
DEFINITIONS
APC
Ambulatory Patient Classification
• -Outpatient equivalent of DRGs for inpatients
• -Grouping of services/procedures based on
diagnosis
• -APC 0095 includes both (all) cardiac
rehabilitation codes 93798 and 93797
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)
DEFINITIONS
CPT Code
o Common Procedure Technology
• -#s assigned to MD services
• -Codes are owned by AMA
• -Codes are determined by CPT Editorial
Panel of AMA
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
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 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 “physiciansupervised” programs
Today we will cover:
•
•
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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
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 clinicallyappropriate policy
◦ Follow-up written recommendations with
evidence-based references were then
submitted to CMS
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 1-12010.
•
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…”
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
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
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
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.”
PROPOSED CARDIAC & PULMONARY
REHAB RULES-PHYSICIAN SUPERVISION
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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”.
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.

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
•
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
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…”
AACVPR RECOMMENDATIONS TO CMS
Physician Supervision
2. Allow CR/PR to use NPPs as other hospital
outpatient services will be allowed as of 1-12010
◦ This does not replace the need for a
physician to be immediately available.
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
PROPOSED CARDIAC REHAB RULES
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 regionally

Physician supervision “immediately
available”
PROPOSED CARDIAC REHAB RULES
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

PROPOSED CARDIAC REHAB RULES
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
•
PROPOSED CARDIAC REHAB RULES
NEW 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
PROPOSED CARDIAC REHAB RULES
INDIVIDUALIZED 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)
PROPOSED CARDIAC REHAB RULES
INDIVIDUALIZED TREATMENT PLAN
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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
PROPOSED CARDIAC REHAB RULES
OUTCOMES ASSESSMENT
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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)
PROPOSED CARDIAC REHAB RULES
INTENSIVE 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
PROPOSED CARDIAC REHAB RULES
INTENSIVE CARDIAC REHABILITATION
ICR Program Criteria
• “Each program must submit peerreviewed 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.
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
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.
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
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
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
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
AACVPR RECOMMENDATIONS TO CMS
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•
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
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
PROPOSED PULMONARY REHAB RULES
PAYMENT
Current billing codes
– Three G Codes (G0237, 0238, 0239) for
education
and exercise (PT/OT codes 9700197004)
– 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
– $70/four “G Code services” in a day
PROPOSED PULMONARY REHAB RULES
PAYMENT
 New
G code replaces G0237-39
 Code bundled, precluding billing for
services 94620 (6MWT), 94664 (MDI,
IPPB,neb), 94667 (vibration)
 New payment rate=$ 15/hour@one
hour limit /day
PROPOSED PULMONARY REHAB RULES
PAYMENT
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
PROPOSED PULMONARY REHAB RULES
DIAGNOSES

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
PROPOSED PULMONARY REHAB RULES
DIAGNOSES
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
PROPOSED PULMONARY REHAB
RULES
REQUIRED COMPONENTS
 Physician
 Physician-prescribed
exercise
 Individualized Treatment Plan (ITP)
 Outcomes Assessment
 Psychosocial Assessment
 Education and training
PROPOSED PULMONARY REHAB
RULES
PHYSICIAN 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

PROPOSED PULMONARY REHAB
RULES
PHYSICIAN 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
PROPOSED PULMONARY REHAB RULES
INDIVIDUALIZED 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
PROPOSED PULMONARY REHAB
RULES
INDIVIDUALIZED 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
PROPOSED PULMONARY REHAB RULES
OUTCOMES 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 patientcentered outcomes, conducted by the
physician
◦ Objective clinical measures of exercise
performance, dyspnea, & behavior

PROPOSED PULMONARY REHAB RULES
OUTCOMES 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
•
PROPOSED PULMONARY REHAB
RULES
PSYCHOSOCIAL ASSESSMENT
•
•
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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
PROPOSED PULMONARY REHAB
RULES
EDUCATION & TRAINING
Physician should evaluate and include only
education & training that addresses
particular needs of patient
 Primary objective is understanding and selfmanagement of chronic respiratory disease
 All the usual educational components of PR

PROPOSED PULMONARY REHAB
RULES
EDUCATION & 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
PROPOSED PULMONARY REHAB RULES
PROGRAM DELIVERY



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Max sessions=36
Limit 1 session (hour) per day
Patient must have some aerobic exercise each day
he/she attends rehab
Suggested 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
PROPOSED PULMONARY REHAB RULES
PROGRAM 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.”

PROPOSED PULMONARY REHAB RULES
Four primary areas of concern:
1. Payment
2. Qualifying Diagnoses
3. Program Delivery Restrictions
4. Physician Supervision
Today we will cover:
•
•
•
AACVPR recommendations made to
CMS on proposed PR regulations
AACVPR recent and future actions
regarding proposed rule changes
Recommended next steps for your program
PROPOSED PULMONARY REHAB
RULES
PAYMENT
AACVPR 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
PROPOSED PULMONARY REHAB RULES
DIAGNOSES
AACVPR recommendations
Appropriate 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
PROPOSED PULMONARY REHAB RULES
PROGRAM REQUIREMENTS
AACVPR Recommendations
 Allow 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
Today we will cover:
•
•
AACVPR recent and future actions
regarding proposed rule changes
Recommended next steps for your program
AACVPR ACTIONS
Pulmonary
 Collaboration with ATS, ACCP, AARC, NAMDRC, ALA,
NECA, NHOPA
 Fly-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 ACTIONS
Cardiac
 Collaboration with ACC, AHA, AHospA,
PCNA, CEPA on issues of concern
 AACVPR recommendations submitted
to CMS on proposed CR rules
AACVPR FUTURE ACTIONS
•
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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 ACTIONS
•
Work with state affiliates for clinicallyappropriate 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
Today we will cover:
•
Recommended next steps for your
program
NEXT STEPS
Wait 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 STEPS
Prepare for implementation of new rules on 11-2010.
 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!
