IACPR CR PR 2018 Knipper and Pulmonary Rehab... · W v o } µ o u Z Ç u W : ð ï X í v ] o } µ o u Z Ç u W : ð ï X î K Z u Z Ç u W : ð ï X ô u Z Ç u U µ v ] ( ] W :

2/18/2018

1

Cardiac and Pulmonary RehabUpdate 2018

Janie Knipper, RN, MA, AE-C, MAACVPRAACVPR MAC Liaison, J5 & J8

IACPRMarch 23 and 24, 2018

[email protected]

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).

3

AACVPR MAC Liaison Task Forceand

AACVPR MAC Resource Group - MRG

J5 MAC Liaison: Janie Knipper, RN, MA Phone: (319) [email protected]

J5 MRG Member:Susan Flack, RN-BC, BSN Phone: (515) [email protected]

4

How to Stay Informed and Stay in Compliance with CMS Regulations

Be a member of AACVPRBe a member of IACPRUse your MAC Liaison and MRG as a resourceIf you don’t know if you are in compliance with

regulations – ASK:Your hospital Compliance OfficeMAC LiaisonMRG MemberEmail AACVPR – Members Only

Medicare Conditions for Coverage: Code of Federal Regulations

Pulmonary Rehab: 42 CFR 410.47Cardiac Rehab: 42 CFR 410.49 “Provision” is 1.5 pages in length - broadly written

intentionally MACs are allowed some degree of interpretation in

compliance with these regulations

6

2/18/2018

2

Pulmonary Rehab: 42 CFR 410.47

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)”

7

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.

www.atsjournals.org/doi/pdf/10.1164/rccm.201204-0596PP.

GOLD Classification of COPD

8

Stage 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

GOLD = Global Strategy for the Diagnosis, Management, and Prevention of COPD – GOLD Update 2017

*Post-bronchodilator

8

Timeframe for PFTs prior to PR

42 CFR 410.47 – No timelineWPS: “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.

9

*If you have a policy that states otherwise, change it!It is not based on any regulations.

COPD Diagnoses with ICD-10 Codes

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: J43.9

1010

Cardiac Rehab: 42 CFR 410.49

93797: Physician services for outpatient CR without continuous ECG monitoring (per session)

93798: Physician services for outpatient CR with continuous ECG monitoring (per session)

11

CR - Covered Diagnoses

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%

12

Supervised Exercise Therapy for PAD is NOT Cardiac Rehab

2/18/2018

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 93798 code

and one 93797 code are used Does not apply to PR

Modifier 59 does NOT apply when: Two sessions of CR in one day where two 93798 codes

are used Two sessions of CR in one day where two 93797 codes

are used

1414

15

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: www.wpsgha.com Requires authorization for use

16

Individualized Treatment Plan

The ITP is the only form of documentation discussed in the Medicare provision.

The ITP should tell the patient’s story.

17

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

18

2/18/2018

4

CMS Requirements for the ITPIndividualized 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

19

42 CFR 410.49 & 42 CFR 410.47

CMS Requirements for the ITP:

MUST be signed by the cardiac rehab or pulmonary rehab “physician” prior to the initiation of services

Despite some MACs originally allowinga day or two for the physician signature –

the 2017 CMS audit of CR programsdid not allow this.

20

42 CFR 410.49 & 42 CFR 410.47CMS Medicare Benefit Policy Pub 100-02, Transmittal 124

Clarification from WPS (J5MAC) on Physician Signature on the ITP:

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 100-02, Transmittal 124 (and 2017 CR Audit)

“The initial assessment is for evaluation, and should not be a treatment session as well”

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.”

21

Pulmonary Rehab ONLY

Supervising physician must have initial, direct contact w/patient prior to subsequent treatment

22

CMS Medicare Benefit Policy Pub 100-02, Transmittal 124

The Issue:Billing the Initial Assessment

CMS Rules bundled all PR-related CPT codes into G0424; and all CR-related CPT codes into 93797 & 93798

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 0928 93797 and 93798 are submitted under Revenue Code 0943

23

The Issue:Billing the Initial Assessment

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.

If a CR program submits a bill for the initial evaluation with any CPT code other than 97397 or 97398 with Revenue Code 0943, it will likely be denied.

24

2/18/2018

5

Medicare ComplianceClarification 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”

25

NOTE: MD cannot bill for direct patient contact as part of a PR encounter (visit)

26

Referral is generated by physician(or PA/NP generates referral w/physician cosign)

PR Initial EvaluationIncluding exercise evaluation

Next PR visit: Medical Director has direct contact w/patient and signs the ITP

NO PR charge of G0424

Physician has direct contact w/patient every 30 days

27

Patient is seen by a physician (PCP, Pulmonologist, etc.)

Referral is generated by physician(or PA/NP generates referral w/physician cosign)

Initial EvaluationIncluding exercise evaluation

Medical Director signs the ITP

Charge is generated

Physician has direct contact w/patient every 30 days

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 recordfor each day of service”

28

Respiratory Services

For Chronic Lung disease other than COPD

29

Respiratory Services (non-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 ServicesNO list of approved diagnosesNo PFT guidelines

30

2/18/2018

6

Determine medical necessity for participation in Respiratory Services:

1. Review PFTs for presence of chronic lung disease2. 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?

31

Respiratory Services:

32

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, 2001

Medicare ComplianceClarification from WPS (J5MAC)

Use of 1:1 codes, G0237 and G0238WPS: 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.

33

Current Issues Facing CR and PR

3434

Nonphysician ProvidersClarification from CMS & WPS (J5MAC)

Can Nonphysician Providers (NPPs) independently order CR & PR? NOT AT THIS TIMEMD 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 availableNo reference to time, distance, or location

35

Non-physician ProvidersHR1155 and S.1381

HR 1155 / S.1361 Included in the ACCESS Act Legislation allows qualified NPPs (PA, NP, CNS) to

supervise CR and PR programs on a day-to-day basisNot effective until January 2024 d/t CBO score –

had to be delayed to reduce costAACVPR – working on strategy to move this date up

- legislatively

36

2/18/2018

7

Non-physician ProvidersHR1155 and S.1381

DOTH 2018 - 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

37

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 11-2-15 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

38

Off Campus Provider-Based Departments (PBDs)

Campus: defined in 42 CFR 413.65:“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.”

39

Off Campus Provider-Based Departments (PBDs)

Unintended consequences: Inability to enlarge or re-locate CR, PR, SET PAD

programsLimited access for patients!

40

Medicare Replacement Plans, Private Insurance and

State Medicaid Programs

41

Medicare Replacement Plans

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

42 42

2/18/2018

8

Medicare Replacement Plan Co-payments

AACVPR/GRQ have been collaborating with CMS Medicare Replacement Plans Office since December 2014CMS 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

43 43

Medicare Replacement PlanCo-payments

Patients should call Medicare to report any co-payment that is a barrier to participation in CR or PR

1-800-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

45 45

State Medicaid Plans

Often have session limits, e.g. 25 visits/yearMay not pay for all codes Iowa Medicaid discussing whether to add G0237

and G0238 for paymentMay require prior authorization after an initial

visitMust contact the Plan regarding each patient

46 46

Pre-Authorization for Services

Use a Pre-Auth template for all patients who aren’t traditional Medicare (you can’t pre-authorize with Medicare)

Also found on AACVPR website:https://www.aacvpr.org/ - public documents

47

Supervised Exercise Therapy for Peripheral Artery Disease

SET PAD

48

2/18/2018

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)

49

SET PAD: Program Requirements

Program Duration: Up to 36 sessions over 12 week periodSession Duration: 30-60 minutesService: Therapeutic exercise training for PAD in

patients with claudicationSetting: Hospital outpatient or physician office

50


Staff: Qualified auxiliary personnelNecessary to ensure benefits exceed harmsTrained in exercise therapy for PAD

What does that mean?

51


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 410.27 Federal Register, Vol 74, No. 223, 2009, pg 60580-88

52


Local MAC Discretion May cover beyond 36 sessions over 12 weeks May cover additional 36 sessions over extended period 2nd referral required for additional sessions 72 session limit – assume this is lifetime

Be AwareTraditional Medicare does not pre-authorize, i.e. it is a

retrospective reimbursement or denial of paymentFee-for-service beneficiaries will need to sign ABN

(Advance Notice of Non-Coverage) >12 weeks or 36 visits

53

SET PAD: Enrollment Requirements

Face-to-face visit with physician responsible for PAD treatment and referral for SET

NPP may not independently order SETAt this visit, patient must receive information on cv

disease & PAD risk factor reduction Education, counseling, behavioral interventions,

outcome assessments

54

2/18/2018

10

SET PAD-Medicare Coding/Billing

Procedure code: CPT 93668 Reimbursement amounts Hospital outpatient on-campus: Proposed $55 MD office or hospital off-campus: % (20-40) of

OPPS payment rate

55

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)

56

SET PAD-Medicare Coding/BillingExamples 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

57

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:

10.1161/CIR.0000000000000471AACVPR PAD Tool Kit “How to” posted on AACVPR web site (public)

58


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

59

CMS Medicare Benefit Policy, Pub 100-04, Transmittal 3969


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

60

CMS Medicare Benefit Policy, Pub 100-04, Transmittal 3969

2/18/2018

11

SET PAD must have one of the following ICD-10 codes:

I70.211 –right legI70.212 – left leg I70.213 – bilateral legs I70.218 – other extremity I70.311 – right leg I70.312 – left leg I70.313 – bilateral legs I70.318 – other extremity

I70.611 – right leg I70.612 – left leg I70.613 – bilateral legsI70.618 – other extremityI70.711 – right leg I70.712 – left leg I70.713 – bilateral legsI70.718 – other extremity

61

References1.Centers for Medicare and Medicaid Services: www.cms.gov2.Code of Federal Regulations, 42 CFR 410.493.Code of Federal Regulations, 42 CFR 410.474.CMS Medicare Benefit Policy, Pub 100-02, Transmittal 124,

Change Request 6823: Pulmonary Rehabilitation Services.

5.Federal Register, Vol. 74, No. 226, Wednesday, November 25, 2009, Rules and Regulations. Section 144.

6.Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report. www.atsjournals.org/doi/pdf/10.1164/rccm.201204-0596PP.

7.CMS National Coverage Determination (NCD): Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease (CAG-00449N), May 25, 2017.

8.Gerhard-Herman et al. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease. Circulation2017;135:e726–e779. DOI: 10.1161/CIR.0000000000000471

62

References9. CMS Medicare Benefit Policy, Pub 100-04, Transmittal 3969,

Change Request 10295: Supervised Exercise Therapy for Peripheral Artery Disease.

63

Questions?

Thank [email protected]

64

IACPR CR PR 2018 Knipper and Pulmonary Rehab... · W v o } µ o u Z Ç u W : ð ï X í v ] o } µ o u Z Ç u W : ð ï X î K Z u Z Ç u W : ð ï X ô u Z Ç u U µ v ] ( ] W :

Documents