Northwest Association of Cardiovascular
and Pulmonary Rehabilitation

Representing...
Washington, Idaho, Alaska

Affiliate Society of AACVPR
American Association of Cardiovascular
 and Pulmonary Rehabilitation

Reimbursement

CMS/Medicare have notified all MAC Medical Directors that orders for
Cardiac and Pulmonary Rehab MUST be signed by an M.D. or D.O.

Dr. Oakes (our MAC J-F Medical Director) has agreed to support any program that is questioned regarding the NP order for the period April 2016 to August 2017. If you should have denials or audits regarding the NP order for this period please reference Dr. Oakes initial consent in April and let me know. We will connect you with Dr. Oakes for follow up if needed. 

Holly Bright's (partner for MAC J-F) ideas on this situation:

We are ecstatic that the non-physician providers (NPPs) are ordering CR & PR!  Let’s communicate this latest development in a way that does not discourage the NPPS from ordering our services.  Here are some options, you may have additional ones:

      1. Ask the NPPs to write or enter electronically, the name of the attending/supervising physician on the order and we will obtain the physician order.
      2. Once order is received from NPP, call or email the patient’s cardiologist/physician for an order
      3. Ask the NPPs to prompt their supervising/attending physician to write an order for CR & PR.
      4. Add the orders for Outpatient CR or PR to physician discharge orders. (if you haven’t already done this).

      
    DIAGNOSIS and BILLING
     
    Cardiac Rehab: 
        Diagnosis:
           NSTEMI/STEMI
            CABG
            Stable Angina   
            Heart Valve Repair / Replacement
            PTCA / Stent / PCI
            Heart or Heart-Lung Transplant
            Chronic Systolic Heart Failure
            
           
    Billing Codes:
           93798 - ECG monitored Exercise
            98797 - Non-ECG monitored Exercise (Ok for education)


          Modifiers:

           KX - use after 36 visits (after 1/1/2010)
            59 - use if billing both 93797 and 93798

           Rules:
            must exercise every day, not every session billed
            session duration at least 31 minutes if billed one session
            session duration at least 91 minutes if billed two sessions

    Pulmonary Rehab: 
        
    Diagnosis:
            COPD (moderate-very severe)
            Non-COPD
             
            PFT: post bronchodilator
            (in patients with FEV1/FVC <0.70)

             Gold 1: Mild - > or = 80% predicted
             Gold 2: Moderate - 50% -< 80% predicted

             Gold 3: Severe - 30% - <50% predicted
             Gold 4: Very Severe - < 30% predicted


            
    Billing Codes:
             G0424 - COPD only (moderate-very severe)
             G0237 - Non-COPD (per 15 min)
                        - Strength/Endurance of Respiratory Muscles
                        - Breathing Retraining
             G0238 - Non-COPD (per 15 min)
                        -  Respiratory Function Capacity
                        - Stairs, physical activity, 6 MWT
             G0239 - Non- COPD
                        - Group Exercise
     
           Modifiers:

             KX - use after 36 visits (after 1/1/2010)
            
           Rules:
            must exercise some, every session
            session duration at least 31 minutes if billed one session
            session duration at least 91 minutes if billed two sessions
            72 lifetime sessions for G0424


    CMS CHANGES
    EPISODE PAYMENT MODELS
    (EPM-BUNDLED)
    and
    CARDIAC REHAB INCENTIVE

    January 1, 2018


    NEW Cardiac Rehab program coverage for Heart Failure Diagnosis...
     

    New coverage policy effective:
    February 18, 2014
    Implementing the new coverage:
     August 18, 2014

    Eligible Criteria for HF patients...

    1. Left Ventricular EF of ≤ 35% (35-40 not acceptable)
    2. NYHA class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks
    3. Stable (have not had recent ≤ 6 weeks or planned ≤ 6 months major cardiovascular hospitalizations or procedures.

    ALL elements/conditions used to determine coverage MUST be documented in the medical record, preferably in the Plan of Care

    Medicare published documents...
    The National Coverage Determination (NCD)

    A further description of the benefit

    Claims Processing rules


    For more information...
    Presentation at 2014 NWCVPR Conference:
        
    Integrating Heart Failure Patients into CR Programs

    Reimbursement Updates

    Pulmonary Rehabilitation

    This is an important Call to Action for Pulmonary Rehab programs to calculate appropriate charges for G0424

    NWCVPR is sending this Call to Action out to ALL Pulmonary Rehab Programs we know of in our region.  If you know of others who have not received this information, please forward this onto them.


    The ultimate goal is that the charges submitted for PR by hospitals on Medicare claims truly reflect all the important elements (services, supplies and equipment) that occur in PR and that this accuracy is subsequently reflected in appropriate reimbursement of PR services by CMS.

    AACVPR website information: Pulmonary Rehab Toolkit

    Guidance to Calculating Appropriate Charges for G0424

    Outpatient pulmonary rehabilitation (PR) ia facing a significant funding challenge.  Effective 1/1/2012, CMS has dramatically reduced reimbursement by Medicare for PR services delivered to COPD patients.  Five leading national pulmonary societies have worked aggressively to understand and address this change.  Extensive analysis has revealed that the reduction in reimbursement appears to be from inadequate detail and appropriateness of PR changes submitted by many hospitals on their Medicare claims for billing code GO424 (PR for moderate to severe COPD, GOLD II-IV).  AARC, AACVPR, ACCP, ATS, and NAMDRC have developed resources and strategies for improving the accuracy of the charges that are reported to Medicare so that the charges accurately reflect the complexity and depth of PR services.

    The PR Toolkit offers PR providers:

    1.   The detail and resources to understand and calculate all that is entailed in an appropriate charge for PR services integral to bundled code GO424. 

    2.  The guidance to accurately communicate these important aspects of PR to hospital financial personnel.

     

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