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Breaking from AACVPR: CMS Publishes Final Regulation/NCD for Cardiac Rehabilitation

23 Jul 2014 1:50 PM | Julie Feirer (Administrator)

Links to these documents are below and are also posted for members in the AACVPR Regulatory & Legislative Resources section of the AACVPR web site which contains extremely helpful and informative resources.

As the final Medicare policy states, coverage of cardiac rehabilitation for beneficiaries with stable, chronic heart failure was effective for dates of service on and after February 18, 2014. This was previously discussed in the AACVPR Reimbursement Update on February 19, 2014.

The implementation date is August 18, 2014. This means that all WPS must have completed changes to their claims processing software so that appropriate heart failure diagnoses (ICD-9 codes) are not denied. For CR programs that received denials for CR services provided to heart failure patients as of February 18th or later, re-submission after August 18th will most likely be necessary for reimbursement. Please work with your billing departments to be sure inappropriate denials are tracked and corrected. 

Medicare now covers CR services to patients with stable, chronic heart failure defined as: 

1.     Patients with left ventricular ejection fraction of 35% or less, and

2.     NYHA class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

Are an AACVPR member? They have provided members with excellent webinars and FAQs to help programs interpret appropriate HF candidates for CR, based on the above eligibility criteria. This will continue to be discussed in depth at a heart failure session at the AACVPR Annual Conference in Denver: "How to Implement a Heart Failure Rehabilitation Program" - Randal J. Thomas, MD, MS, FAACVPR; Ray Squires, PhD, MAACVPR, Steven Keteyian, PhD, FAACVPR; Karen Lui, RN, MS, MAACVPR, on September 5, 2014 from 8:00 am - 9:30 am. For more information on how to register, please click here. CR Program staff, in conjunction with CR medical directors and referring physicians, should develop department policies that are consistent with the Medicare qualifying criteria with the goal of enrolling patients who will benefit from CR and are appropriately eligible.

Some CR programs have been enrolling HF patients in CR since the effective date with successful Medicare reimbursement using diagnosis (ICD-9) code 428.22 (chronic systolic heart failure). You are advised to work with your billing dept. to find the most descriptive and appropriate ICD-9 code for each patient, given that patient's clinical diagnosis. It would be best practice to utilize the patient's medical record/Plan of Care to clearly document all the elements/conditions that qualify this patient for CR. 

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