Doug Doorn, CEO of Spencer Municipal Hospital, related his facility’s experience with the OIG audit of their cardiac rehabilitation program. Much of what was found was consistent with findings of other hospitals that also had OIG visits:

1. Stable angina. Referenced the definition as stated on the Spencer report. Their hospital will no longer be seeing patients who are post PTCA/stent as stable angina patients. Only stable angina patients who are still having anginal symptoms will now admitted to their program. They have provided education to their referring physicians on the criteria for the diagnosis of stable angina, and have had excellent compliance from the physicians.

2. "Incident to." Stressed the importance of documentation of physician visits, encouraging patients to see their physicians during the course of treatment, and even having the staff call and make appointments for the patients while in the program.

3. Physician supervision. They are still relying on the Emergency Department physicians for coverage. They were not cited for this. 

Other considerations: Considering the implementation of a non-Medicare program that is strictly self-pay. This would include both Phase II and Phase III patients. A crucial issue will be whether or not they need to pay a physician to provide supervision.

CMS Regional Office Representatives (Kansas City) were available via speakerphone. They are well aware that programs have concerns about financial viability. Their belief is that the issues uncovered in the OIG audits are issues that need to be addressed at the national level, so they have asked the CMS central office for assistance with this. Their current recommendation is that hospitals make no sweeping changes to programs until the CMS central office issues guidelines for change.

Therese Canaday, manager of medical review at Cahaba (Fiscal Intermediary for most of Iowa) explained the importance of correct diagnosis codes (410.12-410.92, V45.81, and 413.9) and limiting number of visits to 36 sessions to avoid a “SuperOp” edit that will automatically deny a claim (100 % of these claims are automatic edits). The time frame of 12 weeks is not as crucial as the 36 sessions. If a patient comes more than 36 sessions, the documentation in the chart and the documentation submitted with the ADR must support the medical necessity for continued services. This should also include a physician’s order. ADR’s that are returned, or appeals that are filed often result in paid claims. Ms. Canaday stated that they are not looking for evidence of physician supervision when conducting medical review. To meet the "incident to" requirement as defined by Cahaba, there must be an evaluation by a physician and an order for cardiac rehab. If the claim does not contain a covered diagnosis, it will be automatically denied but can be appealed with additional documentation. 

Ms. Canaday relayed the definition of stable angina as stated by Dr. John Olds, FI Medical Director of Cahaba: “Angina that is relatively predictable as to frequency or inciting factors, does not become more severe or frequent, and/or has not been cured by surgery or medication.”

Her final recommendation to the group was to maintain “status quo” until we have guidance from the CMS Central Office.