Coastal Regional Meeting  Friday, October 25th
for more information contact Coastal VP Kelly Forrest (KForrest@carolinaeasthealth.com)

Piedmont Regional Meeting:  Saturday, November 16th
For more information contact Piedmont VP Susanne Bice (susannebice@gmail.com)

Mountain Regional Meeting:  Tuesday,  November 5th
Location: Watauga Medical Center auditorium
336 Deerfield Road, Boone, NC  28607
For more information contact Mountain VP Beth Ann Scott (bascott@apprhs.org)

 

More details to follow

Legislative Updates

The AACVPR anticipates having bill language soon that would ensure reimbursement for hospital off-campus cardiac and pulmonary rehabilitation (CR/PR) services remains based on hospital outpatient payment rather than reduced by 40% to Physician Fee Schedule (PFS) payment rates. The next step will then be to obtain a bill number so the bill can be introduced in Congress. Two Members of the US House of Representatives have agreed to be co-leads on the House bill. AACVPR is in discussion with two Senate Members considering co-introduction. As with past Congressional bills, AACVPR expects to have “companion” or identical bills in the House and Senate.

Once a bill is formally introduced and assigned a bill number, it then becomes your time to get involved.   It will be crucial to the success of bill passage that you help to secure support from your two US Senators and your US House Member . With signatures from a majority of members in both the Senate and the House by this fall, this legislation could pass and be effective as soon as 2020.

It also should be noted that the American Heart Association has taken the lead to address the role of nonphysician practitioners (NPP) for CR and PR.  They seek legislation that would move up the effective date allowing NPPs to provide “direct supervision” from the current effective date of 1/1/2024 (per the AACVPR bill that passed in 2018).  This bill would also allow NPPs to order CR/PR services independent of physicians for Medicare beneficiaries. The current statute in the Social Security Act requires that the referral order be signed by an MD or DO. AACVPR is collaborating with partner professional organizations, such as American College of Cardiology and PCNA, on these legislative efforts.

Growing Concern for What “Site of Service” May Mean for Cardiac & Pulmonary Rehabilitation

In the final 2019 hospital outpatient regulation (OPPS), published in the Federal Register (Vol 83, No. 225, 11-21-2018), CMS offered insight into possible changes in the 2020 regulation regarding payment for off-campus hospital outpatient services that would have negative consequences for CR, PR, and supervised exercise therapy (SET) for PAD.

In the final 2019 regulation, CMS said, “…capping the OPPS payment at the Physician Fee Schedule (PFS)-equivalent rate is an effective method to control the volume of the unnecessary increases in certain services because the payment differential that is driving the site-of-service decision will be removed,” (pg. 58821). For example, in 2019, outpatient clinic visits (G0463) delivered in “excepted” (grandfathered) off-campus locations receive a 30% reduction in payment in 2019 and another 30% reduction in 2020 to total a 60% reduction in reimbursement for this service.

AACVPR submitted comments on the proposed 2019 regulation that pointed to the evidence and rationale for CR/PR services not being provided in a physician office setting. This is contrary to CMS’ belief that off-campus services reimbursed at a higher rate could be done in a physician office setting for less payment.

AACVPR’s concern for the need to legislatively ensure adequate payment for off-campus CR/PR, whether excepted or not excepted, remains a high priority, given the current CMS viewpoint.

Bundled Payment Care Improvement-Advanced Considers Cardiac Rehabilitation

The CMS Bundled Payment Care Improvement-Advanced (BPCI-Advanced) has been discussed in a previous Health Policy & Reimbursement Update (10-15-2018). CMS has announced a Request for Applications (RFA) for participation in Model Year 3 which, begins in January of 2020. Read more.

You should be aware if your institution is considering participation. This non-binding application has a deadline of June 24, 2019. Additional cardiac and pulmonary diagnoses have been included in this next version.

AACVPR has held discussions with the CMS Center for Medicare & Medicaid Innovation (CMMI) regarding the value of CR and PR and outcomes these services demonstrate that match the value-based care goals of CMMI. In fact, the RFA states (pgs. 7-8),

CMS is considering whether to modify the Model to incentivize the use of cardiac rehabilitation (CR) and intensive CR services for BPCI Advanced cardiac Clinical Episodes. The intent is to increase utilization of CR and intensive CR services by BPCI Advanced Beneficiaries…CMS is currently evaluating whether adding a CR intervention to this model is feasible…We intend to provide further information regarding the CR incentive prior to the end of the application period. 

CMS Audit Underway

CMS has employed a Recovery Audit Contractor (RAC) to review medical necessity for CR and ICR. Several CR programs have recently received a notice of this audit with request for documentation.

The request for records may go back 3 years from the ADR (Additional Documentation Request). Affected codes are:

• 93797-Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG  monitoring (per session)
• 93798-Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
• G0422-Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
• G0423-Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session

Programs that participated in the 2017 CMS CR audit may relate to a recent CMS blog. It reported numerous complaints from providers, such as lengthy appeals, very time-consuming, high administrative expenses, and inaccurate denials that were overturned when appealed. In response to those concerns, CMS has given RACs new guidance, including:

• Holding RACs accountable to maintain a 95% accuracy score
• Requiring RACs to maintain an overturn rate of less than 10%
• Enhanced provider portals for better transparency on status of claims
• Payment to RACs held until after second level of appeal is completed

It will be important that you are informed if your CR program has received a RAC audit notice. Check regularly with your business/billing office, ask to be contacted if an ADR arrives, and be sure you’re included in the documentation retrieval process. You want to be sure no documentation is inadvertently excluded, which would prompt a denial of that claim(s).

Have you seen the recent draft of the Cardiac Rehab LCD?

LCD for cardiac rehab effective 2-2019

https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.117.030617?fbclid=IwAR3xEfFwooltAReCbjRkXdGv56wgFHtKtduD1IWyGB-YQExq-cCGmrp3m8M