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Medicare Reimbursement

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Medicare Reimbursement New Rules New Game Relating Public Policy Changes to Program Evolution KCRA Annual Meeting March 15, 2012 Jim Rosneck RN, MS FAACVPR – PowerPoint PPT presentation

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Title: Medicare Reimbursement


1
Medicare Reimbursement New RulesNew
Game Relating Public Policy Changes to Program
Evolution
KCRA Annual Meeting March 15, 2012
  • Jim Rosneck RN, MS FAACVPR

2
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

3
Next Weeks Objectives
  • Ohio High School State Championship Tournament

4
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.

5
Section 911, Medicare Prescription Drug,
Improvement and Modernization Act of 2003
  • 15 MAC Geographic Regions

J-15 CIGNA CGS
6
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 CMS statutory rules 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

7
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)

8
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 KCRA
    leadership to insure that member and non-member
    programs are aware of HPP issues.

9
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 and/or
    statutory rules interpretation

10
MAC J-15 CGS Strategy
  • Watchful Waiting
  • Announcement of CGS - LCD writing group
  • J-15 action committee will directly contact CGS
    medical director Gary Oakes MD.
  • Educate
  • Petition for adherence to Medicare NCD statute
  • Involve AACVPR national officers PRN

11
CMS 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)

11
12
CMS 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
  • Physician Supervision

12
13
CMS 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
13
14
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
14
15
How About Cardiac Rehab!
15
16
NGS CGS Cardiac Rehab Coverage Similarities
  • 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
17
Cardiac Rehab Performance Measures
18
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

19
NGS vs. CGS 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. unless
  • 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
  • CGS Medical necessity proactively documented
    by the referring / supervising physician

20
CGS - Recent Developments
21
CGS Bulletin (February 10, 2012)
  • Probe Medical Review of Outpatient Pulmonary
    Rehabilitation, Including Exercise (includes
    monitoring), One Hour, Therapeutic, Prophylactic
    or Diagnostic (G0424)
  • Probe Medical Review of Outpatient Cardiac
    Rehabilitation with Continuous ECG Monitoring
    (93798)
  • CGS J15 Part A Medical Review Mail Code
    AG-256 2300 Springdale Drive, Building
    One Camden, SC 29020

Recovery Account Contractor RAC
22
Pulmonary Probe Medical Review
  • Physician's orders for all services billed
  • UB-04
  • Any documentation that supports medical necessity
    for pulmonary rehabilitation
  • Documentation that the physician was immediately
    available for each monitored session billed
  • Documentation of the actual in/out times for each
    session billed
  • Nurse's notes
  • Progress notes
  • Lab reports
  • X-ray reports (if applicable)
  • Radiology test results
  • Therapy notes (if applicable)
  • Any other diagnostic reports
  • Itemized supply or medication lists for all items
    billed for these dates of service
  • Please submit all documentation as required in
    the LCD or NCD (if applicable)

Schedule of physician coverage or class times not
sufficient!
23
Cardiac Probe Medical Review
  • Physician's orders for all services billed
  • UB-04
  • Any documentation that supports medical necessity
    for continuous ECG monitoring
  • Documentation that the physician was immediately
    available for each ECG monitored session billed
  • Nurse's notes
  • Progress notes
  • Lab reports
  • X-ray reports (if applicable)
  • Radiology test results
  • Therapy notes (if applicable)
  • Any other diagnostic reports
  • Itemized supply or medication lists for all items
    billed for these dates of service
  • Please submit all documentation as required in
    the Local Coverage Determination (LCD) or
    National Coverage Determination (NCD) (if
    applicable)

Schedule of physician coverage not sufficient!
24
Documentation Example
25
Pulmonary Rehab Cost Accounting Tool Kit
  • Problem CMS accounting methodology has reduced
    G024 reimbursement to 37.43/session
  • Solution To use non-standard methodology to
    appropriately calculate G024 charges.
  • The Tool Kit primer for pulmonary rehab
    clinicians to approach their finance depts with
    a step-by-step process for cost calculations.
  • Will be released March 29th with instructions via
    AACVPR state affiliate conference call.

26
AACVPR Day On The Hill DOTH
26
27
Day On The Hill DOTH
27
28
DOTH AACVPR Gang of Four J- 15 Representatives
28
29
Talking PointsThe Pitch
29
30
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.

31
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.

32
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

33
Thank youquestions
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