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New RulesNew GameRelating Public Policy
Changes to Program Evolution in Cardiac
Pulmonary Rehab

• Jim Rosneck RN, MS

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Presentation Objectives

• Describe Medicare Account Contractors (MACs)
• Describe AACVPR Health Public Policy Committee
  Functions
• Report on current AACVPR national local public
  policy initiatives
• Discuss programming opportunities given the new
  rules
• Describe national lobbying strategies and 2012
  DOTH activities

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CMS MAC-15 Update What is a MAC?

• CMS Medicare Account Contractor (MAC) ?
  Integrate centralize information and create
  efficient processes for delivery of comprehensive
  care to Medicare beneficiaries.
• Goals
• Full and open competitions to replace existing
  system of Fiscal Intermediary (FI) contractors
• Increased efficiencies
• Consistent approach to medical coverage across
  the service area
• Competition among current MACs to encourage
  quality cost efficient service to health
  providers.
• Focus on financial management to achieve more
  accurate claims payments and greater consistency
  in payment decisions.

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Section 911, Medicare Prescription Drug,
Improvement and Modernization Act of 2003

• 15 MAC Geographic Regions

J-15 CIGNA CGS
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CIGNA Government Services (CGS) Functions

• CMS will ensure its MAC contracts focus on three
  critical areas
• Customer service
• Operational excellence
• Financial management.
• Medicare coverage and billing requirements, and
  the receipt, processing, and payment of Medicare
  fee-for service core claims processing operations
  for both Part A and Part B. .
• Interpret national coverage determination NCD
  language and intent in the development of
  MAC-LCDs
• Maintain a staff of experts knowledgeable of all
  aspects of the fee-for-service program

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AACVPR MAC J-15 Committee

• Dalynn Badenhop, OH
• Mike Bichsel, OH
• Elaine Bohman, OH
• Sherri Bradley, KY
• Peggy Cox, KY
• Tammy Garwick, OH
• Jim Rosneck, OH
• Rich Sukeena, OH
• Stephanie Tucker, KY
• (Physician Liaison Rich Josephson, OH)

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AACVPR J-15 Committee Functions

• Maintain Communication
• Insure that CGS ? Cardiac Pulmonary Rehab local
  coverage determination (LCD) represents the
  letter and intent of the recent national coverage
  determination.
• Coordinate activities with AACVPR national HPP
  committee members leadership.
• Communicate issues effectively with OACVPR
  KACVPR leadership to insure that member and
  nonmember programs are aware of HPP issues.

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MAC J-15 Current History

• CGS Cutover from NGS (Fiscal Intermediary)
  management October 17, 2011
• LCD Postings at least by September 1st 2011
• October 2012 CGS decision to adhere to the
  National Coverage Determination NCD for Pulmonary
  Cardiac rehab rules coverage interpretation.

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MAC J-15 CGS Strategy

• Watchful Waiting
• Announcement of CGS LCD writing group
• J-15 action committee will directly contact CGS
  medical directtor Gary Oakes MD.
• Educate
• Petition for adherence to Medicare NCD statute
• Involve AACVPR national officers PRN

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Current PR LCD?
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NCD Components of Pulmonary Rehab

• Physician prescribed exercise
• Patient centered
• Some aerobic training included in each session
• Education
• Tailored to individual needs
• Tailored to behavioral change
• Brief smoking cessation
• Nutrition
• Proper medication use adherence
• Psychosocial Assessment
• Include assessment of home support
• Objective measure of progress (Pre Post Testing)

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NCD Components of Pulmonary Rehab

• Outcomes assessment
• Baseline assessment patient centered goals
• Individual progress via objective measurements.
• Pretesting - Goal Setting Post testing
• Individualized Treatment Plan
• Diagnosis
• Type, amount, frequency and duration of the items
  and services
• Patient centered goals
• Established reviewed and signed by a physician
• Reviewed signed by the medical director

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NCD Components of Pulmonary Rehab - Diagnosis

• COPD
• Moderate, severe and very severe COPD (GOLD
  guidelines)
• Billing code G0424
• Non-COPD
• All other previously recognized diagnoses
• Billing code G0239 Group Exercise
• Billing code G0238 Individual Exercise q15min
• Billing code G0237 Individual Education
  q15min
• LCD will eventually determine the status of
  Non-COPD diagnosis

Require the 59 modifier
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Pulmonary Program Evolution

• Necessity of ECG monitoring?
• Aerobic exercise requirement (PR/session -
  CR/day)
• Two daily sessions
• 36 sessions / 36 weeks (PR limited 72 lifetime)
• Sessions in excess of 36
• No restrictions re program crossover
• Educational Psychosocial requirements
• GOLD standard increased PR patient eligibility
• Program individualization per patient focused
  needs
• Knowledge translated to behavioral change

Require the KX modifier
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NGS CGS Cardiac Rehab Coverage

• Physician directed supervised
• Components include
• exercise prescription
• risk factor modification
• psychosocial assessment
• outcome assessment
• Individual treatment plan
• diagnosis
• individual goals
• type, amount, frequency and duration of items and
  services provided.
• Reviewed and signed by a physician every 30
  days
• Non-physician practitioner (NPP) may order the
  Cardiac Rehabilitation if it is within his/her
  scope of state practice under licensure

DOTH 2012 issue
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Pulmonary Rehab Coverage Scenarios
T. B. A.
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Cardiac Rehab Performance Measures
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NGS vs. CGS Cardiac Rehab Coverage

• NGS heart valve surgery, PTCA or stenting and
  stable angina must begin a program within 6mths
  
• CGS accepted diagnosis can begin a program
  within 12mths of procedure or diagnosis

• NGS clause re angina assessment via
  angiographic changes during GXT.
• CGS angina diagnosis is determined by the
  referring physician

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Medical justification for extended participation

• Once a patient has reached the exit criteria
  (i.e. 36 sessions), further CR will not be
  considered reasonable and necessary.
• Proof of ischemia or dysrhythmia per GXT
• Achievement of 7lt METs a stable level of
  exercise tolerance (AHA Class I or normal FWC)
• 6lt minutes on a Bruce Protocol (or equivalent)
• Significant ischemia or dysrhythmia gt 6 minutes
  GXT
• Heart Transplant lt 90 predicted VO2 peak

.unless

• CGS Medical necessity proactively documented by
  the referring / supervising physician

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1st Talking Point NPP Supervision of CAH - CP
Programs

1. Issue Critical Access Hospitals (CAH) programs
   in jeopardy due to physician supervision language
   in current statute. (Imposes strict requirements,
   describing the direct physician supervision
   standard for PR, CR services)
2. Technical Correction to existing 2008
   legislation codifying Cardiac Pulmonary rehab.
3. Bi-partisan co-sponsors
4. No additional involved.
5. Prevents use of Medicare services by constituents
   served by CAHs.

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2nd Talking Point Cost Reporting

• 2009 CMS commissioned Research Triangle Institute
  (RTI) to investigate HOPPS rate setting
  processes.
• RTI data indicated a reimbursement of gt
  100/session (Current CR 69.50PR 37.43)
• RTI found the CMS processes mapping
  cost-to-charge relationships in CP programs was
  flawed and easily corrected. CMS chose to not
  heed this advise.
• HOPPS final rule page 101CMS-1504-FC 101 (2011
  rule changes this process allows for the use of
  the non-standard methodology)
• CRUCIAL all programs should contact their
  reimbursement depts. to insure they use this
  method of reporting costs to CMS.

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3rd Talking Point Excessive Medicare Advantage
Co-pays

• Medicare Advantage Pulmonary Cardiac Rehab
  Disadvantage !!!
• Medicare pays a fixed amount every month to the
  companies offering Medicare Advantage Plans.
• Mandated to follow rules set by Medicare.
• Each Medicare Advantage Plan however has the
  freedom to require per-session co-pays greatly in
  excess of the typical 20 (7.49) per session
  fee.
• High co-payments denial of services

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Thank youquestions