Review of Medicare Outpatient Cardiac Rehabilitation Provided by Hospitals (A-05-03-00102) http://www.oig.hhs.gov/oas/reports/region5/50300102.pdf

This report consolidates the results of the OIG audits of Medicare outpatient cardiac rehabilitation provided by 34 hospitals. The objective was to determine whether hospitals had complied with national Medicare outpatient cardiac rehabilitation coverage requirements for direct physician supervision and "incident to" services. Twenty-nine of the 34 hospitals in the sample relied on emergency physicians or "code" teams in other parts of the hospital to provide physician supervision when the medical directors were not available, while the remaining 5 hospitals designated a particular physician to provide direct physician supervision. Thirty-two of the 34 hospitals considered the patient's referring physician as the physician whose professional services the cardiac rehabilitation was provided "incident to," while the other 2 hospitals relied on the professional services of a hospital physician. Inconsistent guidance was noteed between the Medicare Coverage Issues Manual, Hospital Manual, and Intermediary Manual.

OIG recommended that CMS: (1) clarify national Medicare cardiac rehabilitation coverage requirements on the provision of direct physician supervision and the physician (referring or hospital) whose professional services the cardiac rehabilitation must be "incident to" and (2) direct fiscal intermediaries to educate hospitals on the clarified national Medicare coverage policy for outpatient cardiac rehabilitation services. In its comments on our draft report, CMS agreed to develop and publish provider education materials to clarify the direct physician supervision and "incident to" provisions of the cardiac rehabilitation benefit.

AACVPR has requested a grass-roots effort to endorse legislation that would move cardiac and pulmonary rehabilitation out of the benefit category of “incident to physician services” and into distinct benefit categories of their own. As you may know, the AACVPR and 3 other pulmonary medicine societies (American College of Chest Physicians, the American Thoracic Society and the National Association for Medical Direction of Respiratory Care) funded a cost estimate from a private economic consulting firm to determine the impact such a move would have on Medicare. The cost estimate was favorable, therefore Senator Mike Crapo (R-ID) introduced bill S.1440, with Blanche Lincoln (D-AR) as original co-sponsor, requesting formal legislation to accomplish the above goal.

It is very important that you contact Senators Grassley and Harkin immediately, asking them to sign on as co-sponsors to S.1440. Click on the emails below to send a letter. Do not sent letters via US postal service - they will take several weeks to arrive as the mail in Washington is screened heavily since the anthrax scare.

http://grassley.senate.gov/webform.htm and http://harkin.senate.gov/

If you like, you can fax your letters, preferably on your hospital's letterhead:

Senator Grassley's fax: (202) 224-6020

Senator Harkin's fax: (202) 224-9369

We have provided a sample letter for you to download and use in drafting a letter on your hospital letterhead that is personal and to the point. We want the letters to come from program directors and medical directors. Scripted phone calls and form letters are less meaningful than a note from the heart that is very personal. Please send an email or a fax of your letter promptly. Grassley told reporters that scripted phone calls and form letters are less meaningful than “a handwritten note or a note from the heart…that’s very personal,” so add something that will be personally from you as an Iowa constituent.

Download the sample letter to your senator here: http://www.iacpr.net/uploads/doc/Sample%20letter%20to%20Senators.doc

After you send the email/fax, call your Senator’s office and request a face-to-face meeting with the Senators or their legislative assistant when they are back in Iowa during their break in August.

Please notify Janie Knipper or Candy Steele when you have sent your email or fax to Senators Harkin and Grassley. Please notify us of any face-to-face meetings or phone calls as well. If you are aware of program directors/medical directors that are not IACPR members or do not have email and would not have received our email alert, refer them to this web page.

Thank you for your support of this important issue.
Sincerely,

Janie Knipper, RN, MA, FAACVPR, IACPR Reimbursement Committee Co-Chair jane-knipper@uiowa.edu
319-356-8396 

Candy Steele, RN, MA, FAACVPR, IACPR Reimbursement Committee Co-Chair steelec@covhealth.com
319-272-2269

Updated 07/25/05: Because of recent communications from members, the AACVPR leadership wants to make sure that all members understand the distinctions between two pending issues. 

Legislative Initiative:  This effort focuses on changing the Medicare statute to establish specific benefit categories for both cardiac and pulmonary rehabilitation.  When this is accomplished, the issue of “incident to” basically disappears but it is important to know that our proposed legislation does have specific requirements for physician involvement and supervision that are similar to current requirements.  Critically important is a provision that states the physician supervision requirement is presumed to met when the service is provided by a hospital.  Now that the bill, S.1440 has been introduced by Senator Crapo (R-ID) and sponsored by Blanche Lincoln (D-AR), our grassroots letterwriting campaign has begun. When a companion bill is introduced in the House of Representatives, a parallel letter writing campaign will be triggered.

Regulatory Initiative:  CMS recently announced that it was once again opening its review of cardiac rehab, the expanded diagnoses, the role of the physician, and “incident to” issues.  Apparently CMS has decided that it will not wait for the final OIG report, literally closing the long standing policy review and starting anew.  A coordinated response is involved, with the AACVPR, ACC, and AHA (Amer Hosp Assn) all involved in providing input and review into one final document.  Although the CMS website encourages public comment, the AACVPR is fearful that broad public comment might provide CMS with differing information, particularly as it pertains to the role of a physician in cardiac rehabilitation.  If CMS receives a broad range of comments on that topic alone, they could use it as an argument that there is no consensus regarding physician involvement and, therefore, they could modify (reduce) payment for cardiac rehabilitation.  

AACVPR strongly encourages its members to write letters to members of Congress, now that a bill has been formally introduced in the Senate, and when the bill is formally introduced in the House.   We will notify you when this occurs.  Also AACVPR does NOT encourage individual members to write letters to CMS in response to its website posting to limit the possibility of confusing and contradictory statements regarding clinical indications for cardiac rehab and the role of a physician in cardiac rehabilitation.

Click here to view the contents of S.1440. You will need to enter the bill number in the search box.

We are assisting AACVPR in collecting information on the number of cardiac rehab programs that have closed or are in danger of closing. AACVPR and the American Hospital Association will be meeting with CMS in the very near future. If you know of any programs in Iowa that have closed or are contemplating closing, please email Candy Steele, the Cardiac Reimbursement Contact for IACPR, or call her at (319) 272-2269 no later than November 9. We want AACVPR to have the most accurate information possible.

We have sent emails to all of our members as they are listed in the online directory. If you did not get an email regarding this request, please check your profile and make sure we have your correct email address. Many of them came back as "undeliverable."

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.

The main discussion will center around the OIG reports on cardiac rehabilitation programs. Representatives from CMS regional office in Kansas will be available to provide their perspective on the investigation and CMS requirements with regard to physician supervision and oversight in the cardiac rehab setting. Spencer Municipal Hospital CEO Doug Doorn will be available to discuss his hospital's experiences during their review and their responses to the OIG.

We hope to have a good representation at this meeting from our state's compliance officers, as well as cardiac rehab program managers and your IACPR leaders.

This was an issue for many programs who have AEDs. We contacted Susie Carter, Chair of the AACVPR Certification Committee. She discussed it with her AACVPR Director and the Recertification Committee Chair, Robin Cuffe. Their determination is that the list on Guideline 11.3 (page 202 of the 4th edition of GCR) is a "should" list. They believe that the guidelines say that the "program services are dependent on the particular site at which the care is being delivered". Having a pacemaker with each defibrillator may actually be based on the individual institution's policy as well. As long as the staff is trained to utilize the AED until the code team or the EMS arrives, the AED should be adequate.

With a goal keeping you informed in a more timely fashion, we are looking forward to an entirely web-based newsletter. We will be able to update articles and aouncements throughout the year instead of only twice a year.

We are looking for four energetic regional editors to gather news and write articles to be laced on the website. This will broaden our news base and give a wider forum to all the talented and informed Cardiopulmonary professionals we have in Iowa. Join us in sharing our expertise and improving our profession.

Contact Us to let us know if you're interested in the editor positions.

There will be a printed mini-newletter sent in February and more on this venture at the Annual Meeting in April - we hope to see you in Sioux Falls!

According to the staff at Wellmark Provider Services, Wellmark BC/BS allows up to 36 sessions for Cardiac Rehab. In addition, all diagnosis restrictions have been removed. You should verify with BC/BS that cardiac rehabilitation is a benefit that the patient's group has included in the benefits package. These changes were effective 11/13/01.