Cardiac and Pulmonary Rehab Update I have no disclosures. 2/18/2018. AACVPR MAC Liaison Task Force and AACVPR MAC Resource Group - MRG

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1 Cardiac and Pulmonary Rehab Update 2018 Janie Knipper, RN, MA, AE-C, MAACVPR AACVPR MAC Liaison, J5 & J8 IACPR March 23 and 24, 2018 I have no disclosures. Any opinions expressed are my own. 2 Objectives Attendees will be familiar with: 1. Current Medicare regulations for Cardiac and Pulmonary Rehab programs. 2. Medicare expectations for cardiac and pulmonary rehab documentation, including specific expectations of the J5 Medicare Contractor, Wisconsin Physician Services (WPS). 3. Current issues related to cardiac and pulmonary rehab, including non-physician provider supervision and reimbursement for off-campus provider-based departments. 4. CMS National Coverage Decision for Supervised Exercise Therapy for Peripheral Artery Disease (SET PAD). AACVPR MAC Liaison Task Force and AACVPR MAC Resource Group - MRG J5 MAC Liaison: Janie Knipper, RN, MA Phone: (319) jane-knipper@uiowa.edu J5 MRG Member: Susan Flack, RN-BC, BSN Phone: (515) susan.flack@unitypoint.org 3 4 How to Stay Informed and Stay in Compliance with CMS Regulations Be a member of AACVPR Be a member of IACPR Use your MAC Liaison and MRG as a resource If you don t know if you are in compliance with regulations ASK: Your hospital Compliance Office MAC Liaison MRG Member AACVPR Members Only Medicare Conditions for Coverage: Code of Federal Regulations Pulmonary Rehab: 42 CFR Cardiac Rehab: 42 CFR Provision is 1.5 pages in length - broadly written intentionally MACs are allowed some degree of interpretation in compliance with these regulations 6 1

2 2/18/2018 GOLD Classification of COPD Pulmonary Rehab: 42 CFR Stage G0424: Pulmonary rehabilitation for moderate to very severe COPD GOLD moderate to very severe COPD Defined as chronic bronchitis and/or emphysema in Federal Register, November 25, 2009 GOLD 2017: COPD is caused by a mixture of small airways disease (e.g., obstructive bronchiolitis) and parenchymal destruction (emphysema) Federal Register, Vol. 74, No. 226, Wednesday, November 25, 2009, Rules and Regulations. Section 144. Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report. 7 Timeframe for PFTs prior to PR FEV1/FVC* FEV1* I - Mild COPD < 0.70 FEV1 >80% predicted II - Moderate COPD < 0.70 FEV1 50% -79% predicted III - Severe COPD < 0.70 FEV1 30% - 49% IV - Very Severe COPD < 0.70 FEV1 <30% OR <50% with signs of chronic respiratory failure *Post-bronchodilator GOLD = Global Strategy for the Diagnosis, Management, and Prevention of COPD GOLD Update COPD Diagnoses with ICD-10 Codes 42 CFR No timeline WPS: No timeline requirements to complete PFTs prior to starting a PR program, only that the GOLD classification requirements must be met. WPS: No regulation that state PFTs need to continue on a yearly basis. WPS: Will only cover services that are reasonable & necessary for the treatment of a patient at the time of service. *If you have a policy that states otherwise, change it! It is not based on any regulations. Bronchitis, not specified as acute or chronic: J40 Simple chronic bronchitis: J41.0 Mucopurulent chronic bronchitis: J41.1 Mixed simple and mucopurulent chronic bronchitis: J41.8 Unspecified chronic bronchitis: J42 Chronic obstructive pulmonary disease, unspecified: J44.9 Unilateral pulmonary emphysema: J43.0 Panlobular emphysema: J43.1 Centrilobular emphysema: J43.2 Other emphysema: J43.8 Emphysema, unspecified: J CR - Covered Diagnoses Cardiac Rehab: 42 CFR : Physician services for outpatient CR without continuous ECG monitoring (per session) 93798: Physician services for outpatient CR with continuous ECG monitoring (per session) Acute myocardial infarction within the preceding 12 months Coronary artery bypass surgery Current stable angina pectoris Heart valve repair or replacement Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting Heart or heart-lung transplant Systolic heart failure EF <35% Supervised Exercise Therapy for PAD is NOT Cardiac Rehab

3 Billing for CR and/or PR: Exercise: PR (G0424): Patient must have some exercise every session. CR (93797 and/or 93798): Patient must have some exercise every day. Session duration (BOTH CR and PR): One session must be at least 31 minutes in duration. Two sessions must be at least 91 minutes in duration. Not required to bill for two sessions if > 91 min. KX modifier: MUST be used for any CR and/or PR sessions beyond 36 in patient s Medicare lifetime. This indicates to Medicare that additional documentation should be requested to determine medical necessity PR services exceeding 72 session will be denied! 13 Billing for CR and/or PR: Time limit: PR: No time limit to complete PR sessions CR: 36 weeks to complete up to 36 sessions Modifier 59 applies when: Two sessions of CR in one day where one code and one code are used Does not apply to PR Modifier 59 does NOT apply when: Two sessions of CR in one day where two codes are used Two sessions of CR in one day where two codes are used 14 HIPAA Eligibility Transaction System (HETS) HETS indicates the # of sessions of PR remaining for that patient s lifetime, but indicates the # of CR sessions used: HIPAA Eligibility Transaction System Sessions were not tracked prior to 2010 Any sessions completed prior to January 1, 2010 do not count as part of the PR 72 session limit HETS is ONLY for traditional Medicare patients Private insurance companies and Medicare replacement programs may or may not have session limits Access to HETS: Requires authorization for use Individualized Treatment Plan The ITP is the only form of documentation discussed in the Medicare provision. The ITP should tell the patient s story. Documentation of Education/Training in the ITP Brief narrative description of what was done & patient s response Check box is not sufficient Copious narrative and repetitive data/ documentation not required or necessary Avoid detail in daily progress note Include the detail in the ITP

4 2/18/2018 CMS Requirements for the ITP CMS Requirements for the ITP: Individualized treatment plan = a written plan tailored to each individual patient must include the following: Goals set for the individual under the plan Exercise prescription NO need for other exercise prescription form Emotional functioning as it relates to the individual s rehab Outcomes assessment = evaluation of progress as it relates to the individual s rehab CR: Cardiac risk factor modification ITP details how components are utilized for each patient tells the patient s story 42 CFR & 42 CFR MUST be signed by the cardiac rehab or pulmonary rehab physician prior to the initiation of services 42 CFR & 42 CFR CMS Medicare Benefit Policy Pub , Transmittal 124 Despite some MACs originally allowing a day or two for the physician signature the 2017 CMS audit of CR programs did not allow this. 19 Clarification from WPS (J5MAC) on Physician Signature on the ITP: 20 Pulmonary Rehab ONLY ITP must be signed prior to or on (no later) patient s first CR or PR exercise rehab treatment session per CMS Medicare Benefit Policy Pub , Transmittal 124 (and 2017 CR Audit) The initial assessment is for evaluation, and should not be a treatment session as well Supervising physician must have initial, direct contact w/patient prior to subsequent treatment CMS Medicare Benefit Policy Pub , Transmittal 124 MD signature comes after the evaluation, but prior to the first treatment session. If the plan is developed by the referring physician or the PR physician PR physician must also review and sign the plan prior to initiation of the PR program The Issue: Billing the Initial Assessment The Issue: Billing the Initial Assessment CMS Rules bundled all PR-related CPT codes into G0424; and all CR-related CPT codes into & If a PR program submits a bill for the initial evaluation with any CPT code other than G0424 with Revenue Code 0928, it will likely be denied. PR & CR charges are submitted with their own revenue codes indicates to the payer the charge is coming from PR or CR G0424 is submitted under Revenue Code and are submitted under Revenue Code If a CR program submits a bill for the initial evaluation with any CPT code other than or with Revenue Code 0943, it will likely be denied. 24 4

5 Medicare Compliance Clarification from WPS (J5MAC) PR supervising physician must have at least one direct contact in each 30-day period. WPS: If a patient is not present on the day the physician is present, it is necessary to reschedule the day for the direct contact with-in that 30 days NOTE: MD cannot bill for direct patient contact as part of a PR encounter (visit) 25 Referral is generated by physician (or PA/NP generates referral w/physician cosign) PR Initial Evaluation Including exercise evaluation NO PR charge of G0424 Next PR visit: Medical Director has direct contact w/patient and signs the ITP Physician has direct contact w/patient every 30 days 26 Patient is seen by a physician (PCP, Pulmonologist, etc.) Referral is generated by physician (or PA/NP generates referral w/physician cosign) Initial Evaluation Including exercise evaluation Medical Director signs the ITP Charge is generated Physician has direct contact w/patient every 30 days 27 Clarification from WPS Documentation of Physician Supervision WPS 2011: Daily physician supervision log/record is acceptable Log MUST accompany medical record documentation if audited WPS 2016: Documentation of physician supervision should be somewhere in the patient s medical record for each day of service 28 Respiratory Services (non-copd) Respiratory Services For Chronic Lung disease other than COPD J5 MAC does NOT have a Local Coverage Decision (LCD) for Respiratory Services WPS: There is no plan to develop an LCD for Respiratory Services NO list of approved diagnoses No PFT guidelines

6 2/18/2018 Determine medical necessity for participation in Respiratory Services: 1. Review PFTs for presence of chronic lung disease 2. Does the patient have persistent symptoms despite medical therapy? 3. Does the patient have functional limitations related to chronic lung disease symptoms? 4. Does the patient perceive impaired quality of life? 5. Has the patient had increased health care utilization? Respiratory Services: G0237: Respiratory therapeutic procedure to increase strength & endurance of the respiratory muscles, each 15 minutes, 1:1, includes monitoring VS & Oximetry; NOT ECG (1:1 instruction/supervision in regards to aerobic & resistance training) G0238: Respiratory therapeutic procedure to improve respiratory function other than described by G0237, each 15 minutes, 1:1, includes monitoring (1:1 instruction/supervision in use of airway clearance techniques, paced breathing) G0239: Respiratory therapeutic procedure, group (2 or more individuals), includes monitoring billed once per session Plus other pertinent services provided with Respiratory Services 94664: Initial Aerosol/Inhaler training billed once per session Federal Register, Vol. 66, No. 212, November 1, Medicare Compliance Clarification from WPS (J5MAC) Use of 1:1 codes, G0237 and G0238 WPS: 1:1 supervision must be medically necessary, or indicated or it should not be billed to Medicare. WPS: The same is true with a group session (G0239) or class if only one patient attends, this may not be billed as individual or 1:1 care unless medically necessary. Current Issues Facing CR and PR Nonphysician Providers Clarification from CMS & WPS (J5MAC) Non-physician Providers HR1155 and S.1381 Can Nonphysician Providers (NPPs) independently order CR & PR? NOT AT THIS TIME HR 1155 / S.1361 Included in the ACCESS Act MD or DO must order or co-sign referral orders for CR/PR services CMS rationale: both are categorized as physician services in Social Security Act Program must have MD or DO immediately & physically available No reference to time, distance, or location 35 Legislation allows qualified NPPs (PA, NP, CNS) to supervise CR and PR programs on a day-to-day basis Not effective until January 2024 d/t CBO score had to be delayed to reduce cost AACVPR working on strategy to move this date up - legislatively 36 6

7 Non-physician Providers HR1155 and S.1381 DOTH Karie Martin & Janie Knipper Iowa Cosponsors: Senator Grassley Congressman Loebsack District 2 Congressman Young District 3 Congressman King District 4 Did not cosponsor: Senator Ernst Congressman Blum District 1 Off Campus Provider-Based Departments (PBDs) Per Section 603 of Bipartisan Budget Act of 2015 Provider-Based Departments (PBD) moved to off-campus location now paid under Physician Fee Schedule (PFS) Hospital PBD established off-campus after are not grandfathered if the program (dept) fits within the footprint of the exempted location, it will be grandfathered If a grandfathered off-campus department changes physical address, it loses grandfathered status Bottom Line: Payment based on PFS is fraction of hospital outpatient (OPPS) payment Reimbursement is about 50% less for PR; about 2/3 less for CR Off Campus Provider-Based Departments (PBDs) Campus: defined in 42 CFR : Physical area immediately adjacent to provider s main buildings that are not strictly contiguous to main buildings but are located within 250 yards of main buildings, and any other areas determined on an individual case basis, by CMS regional office, to be part of provider s campus. Off Campus Provider-Based Departments (PBDs) Unintended consequences: Inability to enlarge or re-locate CR, PR, SET PAD programs Limited access for patients! Medicare Replacement Plans Medicare Replacement Plans, Private Insurance and State Medicaid Programs All Plans don t necessarily follow traditional Medicare rules A plan may or may not have a 72 session lifetime limit for PR Plans don t track sessions in the HETS file contact each plan directly Contact individual Plan to determine their rules

8 Medicare Replacement Plan Co-payments AACVPR/GRQ have been collaborating with CMS Medicare Replacement Plans Office since December 2014 CMS established a cap on co-payment in 2017 (with a few exceptions) $50 for CR $30 for PR on average $20 copay but some higher Report excessive co-pays (higher than CMS cap) to J5 MRG or MAC Liaison Co-pay may be a result of the hospital s insurance contract negotiator w/the plan Medicare Replacement Plan Co-payments Patients should call Medicare to report any copayment that is a barrier to participation in CR or PR Medicare Educate your hospital administration AND Insurance Negotiator AND physicians AND patients on the value of CR and PR 44 Private Insurance May or may not have session limits for PR May only pay for 1:1 services, or only group but not both Must contact each insurance company for each patient SET PAD: Must contact private payer to ask about pre-authorization requirements and to confirm eligibility and coverage State Medicaid Plans Often have session limits, e.g. 25 visits/year May not pay for all codes Iowa Medicaid discussing whether to add G0237 and G0238 for payment May require prior authorization after an initial visit Must contact the Plan regarding each patient Pre-Authorization for Services Use a Pre-Auth template for all patients who aren t traditional Medicare (you can t preauthorize with Medicare) Also found on AACVPR website: - public documents Supervised Exercise Therapy for Peripheral Artery Disease SET PAD

9 Supervised Exercise Therapy- Peripheral Artery Disease (SET PAD) CMS National Coverage Determination (NCD): Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease (CAG-00449N) Eligibility Criteria: Intermittent claudication (IC) SET PAD: Program Requirements Program Duration: Up to 36 sessions over 12 week period Session Duration: minutes Service: Therapeutic exercise training for PAD in patients with claudication Setting: Hospital outpatient or physician office SET PAD: Program Requirements Staff: Qualified auxiliary personnel Necessary to ensure benefits exceed harms Trained in exercise therapy for PAD What does that mean? SET PAD: Program Requirements Level of supervision: Under direct supervision of physician, PA, or NP/CNS trained in both basic & advanced life support techniques CMS definition of direct physician supervision : Physically present and immediately available Not defined by response time or distance Regulation: 42 CFR Federal Register, Vol 74, No. 223, 2009, pg SET PAD: Program Requirements Local MAC Discretion May cover beyond 36 sessions over 12 weeks May cover additional 36 sessions over extended period 2 nd referral required for additional sessions 72 session limit assume this is lifetime Be Aware Traditional Medicare does not pre-authorize, i.e. it is a retrospective reimbursement or denial of payment Fee-for-service beneficiaries will need to sign ABN (Advance Notice of Non-Coverage) >12 weeks or 36 visits SET PAD: Enrollment Requirements Face-to-face visit with physician responsible for PAD treatment and referral for SET NPP may not independently order SET At this visit, patient must receive information on cv disease & PAD risk factor reduction Education, counseling, behavioral interventions, outcome assessments

10 SET PAD-Medicare Coding/Billing Procedure code: CPT Reimbursement amounts Hospital outpatient on-campus: Proposed $55 MD office or hospital off-campus: % (20-40) of OPPS payment rate SET PAD-Medicare Coding/Billing Consider what charges (what it costs your institution to deliver) will be submitted to Medicare on claims ( UB04 ) This is used to calculate your cost, reported on hospital FY Medicare Cost Report This is the data CMS will use to determine payment for all SET PAD services, based on total geometric mean (all SET PAD programs) SET PAD-Medicare Coding/Billing Examples of some typical charges that comprise SET: Clinical staff ECG cardiac monitoring capability available if needed (NOT required) ECG electrodes, swabs, etc., supplies Physical space for exercise area, changing/waiting area for patients, & staff space Exercise equipment SET PAD - Guidelines & Delivery 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease; Gerhard-Herman et al. Circulation. 2017;135:e726 e779. DOI: /CIR AACVPR PAD Tool Kit How to posted on AACVPR web site (public) SET PAD - Guidelines & Delivery Day 1 Assess intermittent claudication typically with a treadmill walking protocol Charge for the initial assessment currently appears to be no contraindication to billing Medicare for a 6MWT pre and post SET PAD CMS Medicare Benefit Policy, Pub , Transmittal SET PAD - Guidelines & Delivery KX modifier Must be on the claim as an attestation by the provider of the services that documentation is on file verifying that further treatment beyond the 36 sessions of SET over a 12 week period meets the requirements of the medical policy Common Working File (CWF) should track visits for Medicare beneficiaries CMS Medicare Benefit Policy, Pub , Transmittal

11 SET PAD must have one of the following ICD-10 codes: I right leg I left leg I bilateral legs I other extremity I right leg I left leg I bilateral legs I other extremity I right leg I left leg I bilateral legs I other extremity I right leg I left leg I bilateral legs I other extremity 61 References 1.Centers for Medicare and Medicaid Services: 2.Code of Federal Regulations, 42 CFR Code of Federal Regulations, 42 CFR CMS Medicare Benefit Policy, Pub , Transmittal 124, Change Request 6823: Pulmonary Rehabilitation Services. 5.Federal Register, Vol. 74, No. 226, Wednesday, November 25, 2009, Rules and Regulations. Section Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report. 7.CMS National Coverage Determination (NCD): Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease (CAG-00449N), May 25, Gerhard-Herman et al AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease. Circulation 2017;135:e726 e779. DOI: /CIR References 9. CMS Medicare Benefit Policy, Pub , Transmittal 3969, Change Request 10295: Supervised Exercise Therapy for Peripheral Artery Disease. Questions? Thank you!