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WPS Cardiac Rehabilitation Coverage Review

23 Feb 2011 2:13 PM | Julie Feirer (Administrator)

Clarification on coverage from questions asked of John Wrynn, Outreach Analyst for WPS Medicare on teleconference held 02/23/11. Mary Sue Gardner, RN, BSN, Medicare Outreach Nurse Analyst (Omaha office) was also on the call and this includes her feedback. 

  1. Cardiac Rehab is covered for 36 sessions or 36 weeks, which ever comes first.

  2. If you are billing beyond 36 sessions, be sure to bill using the KX modifier. An ABN is not necessary, but in the absence of an ABN the provider is liable for the bill if the modifier is not used. Services beyond 36 sessions are subject to medical review, and no pre-authorization is required.
  3. Although cardiac rehab is covered up to 36 sessions, it still must be medically necessary for the patient to continue. Patients are not entitled to 36 sessions; that what is allowed based on medical necessity. It is the physician’s responsibility to document medical necessity. He/she must be fully involved and aware of patient status and condition. Please note that CMS makes specific reference to outcomes. If a patient has not progressed in a reasonable amount of time, they should be discharged from the program.
  4. Physician supervision: CMS changed physician supervision rules for 2011 by removing any reference to any particular physical boundary and removing the reference to ‘on the same campus’ or ‘in the off-campus provider-based department’ (italics are CMS’ exact words on pg 72008, Fed Reg, 11-24-10).
  5. Per CMS, MI is the only diagnosis with the 12 month time limit from event. For the other diagnoses, WPS will not enforce a time limit. However, physician documentation must still support medical necessity in order to participate.
  6. If a patient has another event during cardiac rehab participation, you have two choices for continued participation:
    1. Discharge the patient from the current service and readmit with new diagnosis. Even if this is the same diagnosis (i.e., PCI), the onset date will be different.
    2. Continue with current service, and if medically necessary, continue treating patient up to 72 sessions using the KX modifier as described above. Duration of participation is always based on medical necessity.
  7. If services beyond 72 sessions are ordered, medical necessity and appropriate diagnosis must exist. It is essential to get an ABN in these rare instances or the provider will be liable for the bill. The patient should also be aware that coverage beyond 72 sessions will undergo medical review and they will be liable for the bill if CMS determines services do not meet criteria for medical necessity.
  8. Patients cannot switch back and forth between CR and ICR.

Submitted by Candy Steele

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