Articles
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
Washington, D.C.
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.
Pre-Lung Transplant
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.
Post-Lung Transplant
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
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.