J5/J8 Reimbursement Update June 29, 2016
Wisconsin Physician Services (WPS), the Medicare Administrative Contractor for Jurisdiction 5 and Jurisdiction 8 finally agreed to a conference call with Susan Flack and Janie Knipper, IACPR, to discuss cardiac rehab (CR) and pulmonary rehab (PR) reimbursement. The call was held on June 2, 2016. Questions related to reimbursement were submitted to WPS prior to the call; however the representatives from WPS chose to not respond to any questions during the call, but rather provide written feedback.
The AACVPR MAC Liaison Task Force created a PowerPoint presentation on CR and PR for the purpose of educating MACs about these services. Janie presented the PowerPoint during the call. The WPS representatives on the call commented that none of the presentation was a surprise to them; they found the information to be consistent with their understanding of CR and PR. WPS representatives included Mary Sue Gardner, RN/BSN, WPS Provider and Outreach Education (POE) Specialist, Dr. Cheryl Ray, WPS J5 Medical Director, and 2 people from the claims department. Dr. Noel, J8 Medical Director was invited to attend but declined. We asked the claims representatives if they had noticed anything in CR and PR billing practices that raised a red flag, and they denied seeing any red flags.
The written responses from WPS were received on June 24, 2016, and are summarized below with comments from Janie. The answers pertain primarily to pulmonary rehab. There were no issues related to cardiac rehab, other than the question of Nonphysician Providers independently ordering CR & PR, and clarification for WPH about # of CR session/week.
1. Nonphysician Provider (NPP) – Can NPPs independently order CR/PR?
a. No – the regulation wording states “physician” referral.
2. Number of CR Sessions per Week:
a. WPS is aware of and in agreement with the removal of the requirement for CR patients to participate in a minimum of 2 CR sessions each week. Public Law 110-275, effective 1-1-2010, allows up to 36 sessions of CR over 36 weeks.
3. The Individualized Treatment Plan (ITP):
a. Must be signed prior to the patient’s first exercise rehab treatment session
b. WPS views the first visit to be the “initial assessment” for evaluation of the patient, and not a treatment session. In my opinion, the initial assessment has to include some type of exercise evaluation to allow us to write the exercise prescription. However, there is no way to charge for that initial evaluation, unless you charge for a 6-‐Minute Walk Test (6MWT), which you could do if you are not charging for a “treatment” session.
c. WPS did include cardiac rehab in their response regarding the ITP being signed prior tothe patient’s first treatment session. We will be seeking further clarification on this, as this is not in the CR regulations. I would not change your practice at this point; but wait for further clarification.
4. Pulmonary Rehab- Direct Patient Contact by the Physician:
a. Must be done during each 30-day period. The regulation is not at 30 days, but within that 30 day period.
b. In the event a patient is not present in rehab on the day the physician will be establishing or re-evaluating the ITP, it is necessary to reschedule the day for the direct contact within that 30 days. Note: the regs do not state the ITP needs to be signed the same day the physician sees the patient. We will be requesting clarification on this.
5. Log of Supervising Physician:
a. CMS does not dictate the format of the log for documenting physician supervision. However, the documentation regarding the supervising physician should be documented somewhere in the medical record for that day of service. Logs are acceptable, however, this information could be contained anywhere in your documentation, so long as it is reproducible if selected for medical review. This differs from a 2011 response stating it did not need to be in the medical record; we will seek clarification.
6. PFT Requirements for COPD Diagnosis for Participation in PR:
a. There are NO timeline requirements for completing the PFTs prior to starting a PR program, only that the GOLD classification requirements must be met (moderate to very severe COPD). In other words, if you require new patients to have PFTs within 6 or 12 months prior to starting PR, this is not correct. There is no such requirement anymore.
b. There are NO regulations that state PFTs need to continue on a yearly basis. Medicare would only cover services that are reasonable and necessary for the treatment of a patient at the time of service. Janie recommends changing your practice/policies if you still require PFTs within a year prior to enrollment in PR.
7. Billing for 1:1 Respiratory Therapeutic Services:
a. If 1:1 supervision of the patient is not medically necessary or indicated, it should not be billed to Medicare. The situation is the same with a group session or class and only one patient shows up for the session – this may not be billed as individual or 1:1 care.
8. Documentation of Daily Sessions:
a. All items must be documented in the ITP or an updated treatment plan. It must be ordered and signed by the physician prior to the session. This was in response to our question that arose from the audit done by the Office of Inspector General (OIG) in October 2015. The OIG seemed to want all documentation to be done in the ITP, and didn’t care about other documentation. WPS seems to agree. We will seek clarification on this since the ITP requirements are for a “reassessment of progress made toward goal achievement”, not details from every session. However, we should all review our ITPs and make sure there is adequate documentation of the services provided.
March 2016 Summary - Janie Knipper and Susan Flack
Prior to DOTH, Senators Grassley and Ernst were already co-sponsors of S.488, and Representative Loebsack (District 2) was a cosponsor of HR3355. Janie and Susan personally met with Representative Young from District 3, and he was very receptive to our “ask”. So much so that he signed on as a co-sponsor later that day! The meetings with Legislative Aids in the offices of Representative Blum (District 1) and Representative King (District 4) were also well-received, and we are continuing dialogue with them. We are hopeful that they, too, will sign on as co-sponsors. Thank you to all who sent letters to the Congressmen. The letters were hand-delivered to the offices by Janie and Susan.
Medicare Regulations for Cardiac & Pulmonary Rehabilitation: Meeting Compliance in 2016
The Individualized Treatment Plan
March 23, 2016
There have been several audits of cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs over the last few years. The audits have helped provide clarification in some areas, but also raise questions regarding Medicare regulations for CR and PR. The information included in this summary will highlight the recommendations as discussed at the AACVPR conference held in conjunction with AACVPR Day on the Hill in Washington, D.C., March 23, 2016. The conference also addressed the individualized treatment plan (ITP), as a Medicare requirement as well as the ITP requirements for AACVPR program certification. This information is also summarized below.
The most recent audit of CR and PR was not requested by the Centers for Medicare and Medicaid Services (CMS), but rather was conducted by the Office of Inspector General (OIG). The OIG is under Congressional mandate to audit and investigate numerous government branches. The OIG Audit Report, published in December 2015, reviewed 100 random claims for CR and PR in one hospital in New Jersey over a 2-year period. There were 46 claims found to be out of compliance with Medicare requirements, many of which were related to the individualized treatment plan (ITP). In fact, the only CR/PR document the OIG seemed to be interested in was the ITP.
Click here to learn what must be in the ITP for either PR or CR to meet Medicare regulations in 2016.
Contributions to the IACPR: Becky Paxton
Becky has served on the IACPR Board of Directors since 2006, and has served as the IACPR Treasurer since 2007, which also includes serving as Chair of the Budget and Finance Committee. Becky’s responsibilities as Treasurer are vital in overseeing how money is spent, and in making recommendations to the BOD regarding the financial ability of the organization to carry out their stated aims and objectives. She has consistently provided the BOD and the general membership with organized reports regarding the financial status of the organization.
Becky’s accurate records and supporting documentation has been kept with a reasonable level of detail that provides a clear audit trail.
Becky has guided the organization through difficult financial times, and her leadership in this position has helped keep the IACPR viable as an organization. Becky is always very prompt in her communication with the BOD and members in need of her service, as well as in providing members with authorized reimbursement.
I commend Becky for her long and continued service to the IACPR BOD.
Nomination submitted by:
Janie Knipper, University of Iowa Hospitals and Clinics, Pulmonary Rehabilitation Clinical Supervisor
Recent OIG audits of cardiac and pulmonary rehabilitation programs, in New Jersey, have provided some clarification on CMS rules and expectations of programs. The key findings were related to the individual treatment plan (ITP). We must be diligent in creating thorough ITPs for our patients, and making sure our medical directors or supervising physicians have direct contact with the patient prior to the initiation of services, and every 30 days thereafter. In the past we had been told that some MACs acknowledged the challenge of being able to always obtain a signed ITP at exactly 30 days, and allowed flexibility. However, the AACVPR recommends moving forward with a strict 30-day protocol. The AACVPR Program Certification requirements are in line with the recommendations made by the OIG, therefore there are no changes in the requirements for the ITP for 2016.
Cardiac Rehab Week: February 14-20, 2016
Pulmonary Rehab Week: March 13-19th, 2016
Southwest Regional Meeting
When: 1/7/16, 9:30-1:00
Where: Clarinda Regional Health Center
823 S. 17th ST
Clarinda, IA 51632
Please contact Karie Martin with questions
2015 IACPR Fall Regional Meeting Schedule
Northeast Regional Meeting
Where: Okoboji Grill
1749 Golf Course Blvd
Independence, IA 50644
When: Tuesday, October 27th, 12-2pm
Please contact Aleshia Bloker with questions.
**Information about other regional meetings will be posted as available**
Winner: Peg King, Boone County Hospital
Peg is one of those quiet behind the scenes people that keeps IACPR running smoothly. She is incredibly knowledgeable about the workings of our organization and offers guidance based on her long history as secretary. I have always appreciated her questions which I think she often posed as gentle reminders of tasks or meetings that needed to be scheduled. We are blessed to have someone who meticulously records our meeting minutes. It cannot be easy to determine what is imperative to record from our teleconferences, but Peg manages to do an outstanding job.
Claire Shannon, IACPR Past-President
The Lung Transplant Program at the University of Iowa Hospitals and Clinics (UIHC) is almost 8 years old! There have been 110 lung transplants performed in that time. Many of you have cared for these patients in your pulmonary rehabilitation programs, both before and after transplant. Thank you for that! I often receive emails with questions about the care of these patients, so would like to take this opportunity to review the care of these patients in pulmonary rehab.
Patients seeking lung transplant at the UIHC must participate in pulmonary rehab (PR) prior to being listed for transplant. This assists the patient in achieving a more optimal level of physical function, with improved surgical outcomes; and also shows motivation on the part of the patient. The UIHC Lung Transplant Medical Director requires that all patients seeking lung transplant be able to complete a minimum of 30 minutes of aerobic exercise, preferably on a treadmill. Ideally, this should be 30 minutes of continuous exercise at a minimum speed of 1.0 mph. Of course, not all patients can accomplish this initially, but with close supervision and support from the PR staff, most patients are able to achieve this goal. However, if it is not physically possible for the patient, then 30 minutes of continuous exercise on the NuStep may be acceptable. Keep in mind that some patients may require titration of supplemental oxygen to a level that maintains their SpO2 >88% while exercising. Please make sure your program’s policy allows you to titrate oxygen as needed.
Pre-lung transplant patients are billed for these services with the same codes as any other PR patient, based on diagnosis. Patients with a diagnosis of moderate to very severe COPD are billed with CPT code G0424. Patients with a diagnosis of chronic respiratory disease other than COPD are billed with Respiratory Therapeutic Services codes, G0237, G0238 and/or G0239. Pre-lung transplant patients should be discharged from the program within 36 sessions or less (for COPD patients), or in a similarly reasonable time period for patients with a diagnosis of chronic respiratory disease other than COPD. They must then transition into a maintenance exercise program, or be able to provide documentation of daily aerobic exercise to the UIHC Lung Transplant Team. It is important to keep in mind that patients with a diagnosis of COPD tend to remain on the lung transplant list longer than patients with some other chronic respiratory diagnosis. Therefore, use caution in the number of pulmonary rehab sessions provided these patients. Pre-lung transplant patients are end-stage and are at high risk for exacerbation and hospitalization. Each hospitalization may require a few sessions of PR to help the patient get back on track with exercise. That won’t be possible if they have used all of their “lifetime” sessions. Please find a way for these patients to participate in your maintenance programs, assisting them in any way possible if the patient has financial constraints or transportation issues.
Note: Patients who are noncompliant with attendance at PR will likely not be considered for lung transplantation, as this suggests a lack of interest in taking responsibility for their health.
All post-lung transplant patients are required to participate in PR following discharge from the hospital. They spend the first 4 weeks post-transplant in the Iowa City area, staying in a hotel after discharge. They attend PR 5 days per week at the UIHC Pulmonary Rehab Program. When the Lung Transplant Team determines the patient is ready to be discharged to home, they will be referred to a pulmonary rehab program in their local community. The UIHC Pulmonary Rehab Team will provide a detailed treatment plan for that patient. Please follow it! The following is a list of the key points to remember when working with a post-lung transplant patient:
1. Protect the patient from potential infection: Do NOT mainstream these patients into your regular PR classes. These patients are very immunocompromised from their transplant medications. The patient is required to wear a mask at all times when in public places, but it is difficult to exercise wearing a mask. Ideally, attempt to schedule a time when the patient can exercise alone or far enough away from other patients that they can remove the mask. Do not allow a staff member to work with the patient if they are or have been ill recently. Make sure all exercise and monitoring equipment has been cleaned prior to use by the post-transplant patient. Remind the patient and all staff to use good hand hygiene.
2. Education: The patient and their support person(s) have received extensive education from the Lung Transplant Team. This can be reinforced by the PR staff if it is consistent with what has been taught. Each patient has a notebook containing the education material, as well as medication, vital sign, and exercise diaries. The UIHC PR Program staff has outlined the key education to reinforce in the individualized treatment plan for the patient. Post-lung transplant patients no longer have lung disease; therefore, teaching them about chronic lung disease is NOT appropriate. Even if the patient receives only a single lung transplant, the new lung typically takes over the majority of function, overshadowing the remaining diseased lung.
3. Exercise: Post-lung transplant patients must not have an interruption in their pulmonary rehab. They are often discharged from the UIHC PR Program on a Wednesday and should begin PR in your program by Friday, or Monday at the latest. The UIHC PR Program staff will fax the information you need to allow smooth transition into your program. This patient does not need a complete PR evaluation prior to beginning the program. If this must be done, please complete the evaluation when the patient attends exercise sessions, rather than delaying their start date until there is an opening in your new evaluation schedule. Post-lung transplant patients have 6-12 months to achieve maximal function from their new lungs. The best way to achieve maximal function is to challenge the new lungs with the deep breathing that occurs with exercise!
a. PR Frequency: Minimum of 3 times/week for 24-36 sessions. However, the patient will travel to Iowa City every Wednesday for first few months for an appointment in the Lung Transplant Clinic. Many of them choose to exercise in the UIHC PR Program that day. Therefore, they should participate in at least 2 sessions of PR/week in the local program. The patient should exercise independently the other days of the week.
b. Exercise Prescription: The UIHC PR Program will provide the local PR program with the most current exercise prescription for the patient. Please begin the patient’s exercise according to that prescription; however do progress the exercise program on a regular basis, using the guidelines provided in the Exercise section of the ITP provided you. There should be no reason to exercise the patient at a lower workload, unless the patient has had a change in physical health. In that situation, the UIHC Lung Transplant Team should be notified immediately.
c. A lifelong commitment to exercise should be encouraged in all transplant patients.
4. Billing: This patient no longer has lung disease; therefore their therapy should be billed with the Respiratory Therapeutic Services codes (G0237, G0238, or G0239) using the Lung Transplant ICD-9 code V42.6.
The European Respiratory Society and American Thoracic Society have recently published new standards for field walking tests, including the six minute walk test (6MWT). The 6MWT is a standardized test therefore, specific guidelines should be followed when administering the test. Find this new important information here: Holland AE, Spruit MA, Troosters T, Puhan MA, et.al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J 2014; 44:1428-1446. Click on this link to find the article: http://www.thoracic.org/statements/pages/copd.php