Dcumentatin Guidance N. DG1011 Cardiac Rehabilitatin Services Revisin Letter A 1.0 Purpse The Centers fr Medicare and Medicaid Services (CMS) has detailed specific dcumentatin requirements fr Cardiac Rehabilitatin Services. Nn-cmpliance with CMS Cardiac Rehabilitatin Services dcumentatin requirements can affect UNM Medical Grup Inc. s (UNMMG) ability t bill Medicare and Medicaid. This dcument prvides guidelines fr apprved Cardiac Rehabilitatin Services. 2.0 Scpe This Guidance/prcedure applies t UNM Health System Prviders. 3.0 Plicy 3.1 Each UNMMG Facility shall ensure that its CR services fr Medicare and Medicaid patients meet the requirements set frth in this plicy, which are the minimum requirements applicable. In additin, the UNMMG shall ensure that its CR prgram meets the requirements f any applicable state law, Jint Cmmissin, r ther licensing r accreditatin authrities. 4.0 Prcedure Per CMS 100-04 Chapter32 Sectin 140: Cardiac rehabilitatin prgrams must include the fllwing cmpnents: Physician-prescribed exercise each day cardiac rehabilitatin items and services are furnished; Cardiac risk factr mdificatin, including educatin, cunseling, and behaviral interventin at least nce during the prgram, tailred t patients' individual needs; Psychscial assessment; Outcmes assessment; and An individualized treatment plan detailing hw cmpnents are utilized fr each patient. Page 1 f 6
4.1 There are three key cmpnents t dcument cardiac rehabilitatin services: 1. Initial plan f care (treatment plan) 2. Prgress ntes 3. Discharge nte with utcmes assessment An initial treatment plan frm the treating physician, dne at the time f admissin t the cardiac rehabilitatin prgram, explaining the fllwing per 100-02 Chapter 15, Sectin232: Individualized treatment plan. This plan shuld be written and tailred t each individual patient and include (i) a descriptin f the individual's diagnsis; (ii) the type, amunt, frequency, and duratin f the CR items/services furnished; and (iii) the gals set fr the individual under the plan. The dcumentatin must include: The patient s clinical histry, Reasn fr the prescriptin f cardiac rehabilitatin A discussin f the individual patient s needs and hw they wuld be met by an exercise prgram A descriptin f the exercise prgram including type, amunt, frequency, and duratin A descriptin f the risk factr mdificatin prgram detailing which risk factrs need t be mdified fr a particular patient sedentary life style, tbacc use, besity, dyslipidemia, etc. Psych-Scial Assessment and Gal(s) fr the psychscial assessment 4.2 A Prgress nte supprting review f the Individualized Treatment Plan every 30 days: Further dcumentatin is required frm the treating physician, n later than 30 days int treatment, describing: The utcmes assessment specifying any mdificatins needed in the plan f care previusly prescribed, r Reasn(s) t cntinue the present plan 4.3 Discharge nte: Outcmes assessment: This refers t the need fr the prgram t shw the interventins/services and whether the patient did r did nt result in sme benefit t the patient. All ntes must be signed and dated by the persn ding the assessment, with his r her credentials, n the day the assessment is dne. Page 2 f 6
5.0 General Requirements CMS LCD #L32688 Guidelines 5.1 Indicatins fr CR Patients wh begin the prgram within 12 mnths f an acute Mycardial Infarctin (MI). Patients with stable, chrnic heart failure defined as patients with left ventricular ejectin fractin f 35% r less and New Yrk Heart Assciatin (NYHA) class II t IV symptms despite being n ptimal heart failure therapy fr at least 6 weeks. Stable patients are defined as patients wh have nt had (< 6 weeks) r planned (< 6 mnths) majr cardivascular hspitalizatins r prcedures. Patients wh have had Crnary Artery Bypass Graft (CABG) surgery within 12 mnths. Patients with stable angina class I, II, III pectris Patients wh have had heart valve repair/replacement. Patients wh have had Percutaneus Interventin. Patients wh have had a heart r heart-lung transplant. Fr cardiac rehabilitatin nly, ther cardiac cnditins as specified thrugh a natinal cverage determinatin. 5.2 Facility fr CR CR prgrams may be prvided by either the utpatient department f a hspital r a physician-directed clinic. Cverage fr either prgram is subject t the fllwing cnditins: The facility meets the definitin f a hspital utpatient department r a physiciandirected clinic, i.e., a physician is n the premises available t perfrm medical duties at all times the facility is pen and each patient is under the care f a hspital r clinic physician. The facility has available fr immediate use all the necessary cardipulmnary emergency diagnstic and therapeutic life-saving equipment accepted by the medical cmmunity as medically necessary, e.g., xygen, cardipulmnary resuscitatin equipment r defibrillatr. The prgram is staffed by persnnel necessary t cnduct the prgram safely and effectively and wh are trained in bth basic and advanced life supprt techniques and in exercise therapy fr crnary disease. When cnducted in a hspital, an identified physician must be immediately available. This des nt require that a physician be physically present in the exercise rm itself but must be immediately available (withut the passage f time) and accessible at all times in case f emergency. When cnducted in the hspital, the nn-physician persnnel are emplyees f the hspital cnducting the prgram. When cnducted in a clinic r physician s ffice, the services furnished by nnphysician persnnel are under the physician s direct supervisin. Page 3 f 6
5.3 Frequency and Duratin fr CR CR Prgram: -The frequency and duratin f the prgram is generally a ttal f 36 sessins ver a maximum f 36 weeks. -A single sessin must last at least 31 minutes in rder t be billable. If tw sessins are billed fr a single day, then the ttal cmbined time must be at least 91 minutes (60 minutes fr the first sessin and at least 31 minutes fr the secnd sessin) in duratin. -N mre than tw ne-hur sessins, utilizing any cmbinatin f the CPT cdes (93797 and 93798) will be allwed per day fr up t 36 sessins ver a maximum f 36 weeks (Phase IIA). -An additinal 36 sessins may be allwed if a significant intercurrent illness r cmrbidity ccurred during the first 36 sessins and the exit criteria have nt been met (Phase IIB). Inclusin f the KX mdifier n the claim line(s) will be accepted as an attestatin by the prvider f the service that dcumentatin is n file verifying that further treatment beynd 36 sessins f CR up t a ttal f 72 sessins meets the CR cverage requirements. -An additinal series f 36 sessins may be allwed as a new series f CR initiated after an intervening event described as an indicatin fr CR in CMS LCD #L32688. Inclusin f the KX mdifier n the claim line(s) will be accepted as an attestatin by the prvider f the service that dcumentatin is n file verifying that an additinal series f CR meets the CR cverage requirements. Exit Criteria fr Bth CR -Minimally, assessments frm the cmmencement and cnclusin f CR, based n patient-centered utcmes, which must be measured by the physician immediately at the beginning and end f the prgram. -Objective clinical measures f the effectiveness f the CR prgram fr the individual patient, including exercise perfrmance and self-reprted measures f exertin and behavir. Nn-Cvered Diagnses fr Bth CR As a resurce use f ICD-9-CM diagnsis cde nt in the ICD-9-CM Diagnsis Cdes That Supprt Medical Necessity sectin f Retired LCD #L32688 culd be cause fr denial f claims. A patient with unstable angina r a patient status pst-nn-cardiac surgery will nt qualify fr CR services. Page 4 f 6
Heart failure in the absence f ther cvered cnditins is nt included as a cvered cnditin f CR in the CMS Claims Prcessing Manual. IOM Pub. 100-04, Chapter 32, Sectin 140. Other Services Evaluatin and Management (E/M) services, Electrcardigrams (ECGs) and ther diagnstic services may be cvered n the day f CR if these services are separate and distinct frm the CR prgram and are reasnable and necessary, but wuld nt be cvered if prvided rutinely as part f the CR prgram. Frms f cunseling, such as dietary cunseling, psychscial interventin, lipid management and stress management, are cmpnents f the CR prgram and are nt separately reimbursed. 6.0 Definitins 6.1 Cardiac Rehabilitatin (CR) is a cmprehensive prgram f medical evaluatin, prescribed exercise, cardiac risk factr mdificatin, educatin and cunseling (psychscial assessment) designed t restre certain patients with crnary r valvular disease t active and prductive lives (utcme assessment). 6.1.1 Phases f Cardiac Rehabilitatin Phase I: Acute in-hspital phase f CR. This is included in the hspital care fr the acute illness and is nt included under the CR benefit. Phase IIA: Is the initial utpatient CR, cnsisting f 36 r fewer sessins, ccurring up t tw sessins per day. Phase IIB: Cnsists f up t an additinal 36 sessins and will nly be allwed if determined medically necessary. Phase IIB benefits must meet additinal medical necessity criteria. Specifically, there must be clear demnstratin that the patient is benefiting frm CR and that the exit criteria belw frm phase IIA have nt been met. The maximum number f allwable sessins under Phase IIA and IIB is 72. Phase III: CR prgrams that are self-directed r self-cntrlled/mnitred exercise prgrams. Phase IV: CR prgrams r maintenance therapy that may be safely carried ut withut medical supervisin. NOTE: Only Phase II CR prgrams meet the supervisry requirements f the benefit and are cvered under Medicare. 6.2 Individualized treatment plan - A written plan tailred t each individual patient that includes all f the fllwing: A descriptin f the individual s diagnsis. The type, amunt, frequency and duratin f the items and services furnished under the plan. Page 5 f 6
The gals set fr the individual under the plan. 6.3 Medical Directr - Physicians wh versee r supervise the CR prgram at a particular site. In cnsultatin with the staff, is invlved in directing the prgress f individuals in the prgram The Medical Directr, as well as physicians acting as the supervising physician must pssess all f the fllwing. Expertise in the management f individuals with cardiac pathphysilgy. Cardipulmnary training in basic life supprt r advanced cardiac life supprt. Licensed t practice medicine in the state in which the CR prgram is ffered. 6.4 Outcmes Assessment Evaluatin f prgress as it relates t the individuals rehabilitatin which includes all f the fllwing: Assessments frm the cmmencement and cnclusin f CR, based n patient-centered utcmes which must be measured by the physician immediately at the beginning f the prgram and at the end f the prgram. Objective clinical measures f exercise perfrmance and self-reprted measures f exertin and behavir. 6.5 Physician-prescribed Exercise Aerbic exercise cmbined with ther types f exercise (that is, strengthening, stretching) as determined t be apprpriate fr the individual patients by a physician. 6.6 Psychscial Assessment An evaluatin f an individual s mental and emtinal functining as it relates t the individual s rehabilitatin which includes an assessment f thse aspects f an individual s rehabilitatin treatment, and psychscial evaluatin f the individual s respnse t and rate f prgress under the treatment plan. CMS Publicatin, LCD #L32688 (retired) - (Directin frm Nvitas is t fllw last LCD in use) http://www.cgsmedicare.cm/parta/pubs/news/2012/0912/cpe19971.html 7.0 Revisin Histry Effective Date Rev Letter Dcument Authr Descriptin f Change March 2014 A Jan Perea Initial Release. Page 6 f 6