Reversing the Cardiac Effects of Sedentary Aging in Middle Age—A Randomized Controlled Trial Implications For Heart Failure Prevention

Coastal Regional Meeting

We had a great meeting for the Coastal Region on Friday, October 19th.  Attached are some of the power point presentations from that meeting.

AACVPR – National Conference Update 2018


Million Hearts Initiative

AACVPR has teamed up with the CDC and Million Hearts to focus on increasing cardiac rehab referral and participation by eligible patients.  They have developed some wonderful tools that all of us can use.  Check it out!

Reimbursement information

Just a few pieces of information that you might find helpful:

As you may be aware Palmetto released a Draft LCD for Supervised Exercise training.  Both the NCCRA and AACVPR MAC committee gave input on this draft but the future LCD is now available for your review:*1&Cntrctr=381&name=&DocType=Future%7cAllProposed&s=34%7c48%7c53%7c58&bc=AAAAAAQAAAAA&
It is effective for services performed on or after 11/19/2018.

The Office of the Inspector General  (OIG) recently examined appeals and denials of Medicare Advantage  and found that MAOs overturned 75% of their own denials during 2014-2016. Furthermore, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers.   This is highly unusual because beneficiaries and providers rarely use the appeals process, which is designed to ensure access to care and payment. The report recommends that CMS (1) enhance its oversight of MAO contracts including those with extremely high overturn rates and/or low appeal rates and take corrective action as appropriate; (2) address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage; and (3) provide beneficiaries with clear, easily accessible information about serious violations by MAOs. CMS concurred with all three recommendations.  For more information you can go to

Cardiac and Pulmonary rehab also remains on the OIG work plan.  Previous OIG work identified outpatient cardiac and pulmonary rehabilitation service claims that did not comply with Federal requirements. They will assess whether Medicare payments for outpatient cardiac and pulmonary rehabilitation services were allowable in accordance with Medicare requirements. They will also determine whether potential risks in outpatient cardiac and pulmonary rehabilitation programs continue to exist.

If you are not familiar with the previous OIG work here is the report:  OIG audit of Englewood hosp




Piedmont Region Fall Meeting

Thank you to everyone that came out to the Piedmont Region Fall Meeting.  Here are the slides for those that weren’t able to attend:

2018 Introduction
Cardiac Rehabilitation – Jan Wagoner and John Pasquini
PAD – Carl King
Pulmonary CSI – Kim Clark

Mountain Region Meeting

Thank you to all those who made it out to the Mountain region meeting!  We had a great turn out.  Here are the slides for those who were not able to get away to the meeting.

ATRIUM-clinical considerations for OHT and VAD
Unlocking the Secrets Presentation

Legislative/Reimbursement Updates


As you know Palmetto released a draft LCD for Supervised Exercise training on May 17th.  The comment period ran through July 19th and we are now waiting on their final decision.  Responses were provided to Palmetto from many organizations and groups including NCCRA and AACVPR.  We will communicate the final LCD as soon as we know it’s available.

Response to SET draft LCD

Section 603 of BBA of 2015 – impacting movement to off campus locations

Section 603 of the Balanced Budget Act of 2015 mandated that hospitals would no longer be able to bill under the hospital outpatient methodology, i.e., higher reimbursement rate, under certain conditions:

  1. If an existing off campus (beyond 250 yards) service moves to a new location, the hospital is required to bill at the physician fee schedule rate rather than the hospital outpatient rate.
  2. If a hospital opens a NEW hospital outpatient service, that new service must be within 250 yards of the main campus in order to receive hospital outpatient reimbursement; otherwise, the physician fee schedule rate applies.

Impact on Pulmonary/Cardiac Rehabilitation (PR/CR): Hospitals that choose to expand or relocate (beyond the 250 yard threshold) services must bill at the physician fee schedule rate, thereby creating a very strong disincentive for hospitals to improve access to PR/CR services. (A very limited number of exceptions to this exist.)  CMS recognizes this reality as an “unintended consequence” of Section 603, but the Agency states it has no authority to address our problem.

Political considerations: Section 603 received strong support on Capitol Hill, on both sides of the political aisle as it addressed an important issue at one end of the Medicare scale. However, PR/CR are at the other end of the scale, definitively evidenced by Medicare data.

  • Pulmonary rehabilitation billing under the physician fee schedule for all medical specialties for G0424 totaled $535K in 2014, a 22% reduction from 2012. The largest single specialty, pulmonary disease, is under $230K for G0424.
  • Cardiac rehabilitation billing under the physician fee schedule for all medical specialties for CPT 93798 totaled $1.2M in 2014, a 30% reduction from 2012. The largest single specialty, cardiology, is under $1M for 93798.

This clearly documents that that the primary premise of Section 603 does not apply to either PR or CR because hospitals are not purchasing pulmonary or cardiac practices to benefit from the higher reimbursement rate for PR/CR services. Simply stated, these services are NOT being performed in physician offices, nor have they been provided in that setting for years.

Solution: We are seeking sponsors for legislation that would exempt hospitals from Section 603 and the implementing regulations by creating specific thresholds. As long as no physician specialty, nationwide, bills for any CPT or HCPCS code under the Medicare Physician Fee Schedule in an aggregate amount greater than $1million in the previous year for which data are available, that code (or codes) would be exempt from Section 603 requirements.

As noted above, because billing for 93798 and G0424 under the physician fee schedule has no physician specialty billing exceeding $1M, those codes would be exempt from Section 603 requirements.

NCCRA representatives recently met with Representative Butterfield with the hope of gaining his support in introducing legislation that would help this issue.  Although he was able to provide some advice and direction, he has not committed to assisting with this effort at this time.  We appreciate the assistance we received from the programs in his district that wrote letters of support for this work.   AACVPR will hopefully be able to partner with other House and Senate members to get this bill created and moved forward.


Mark Your Calendars for Upcoming Regional meetings

We know how quickly your calendars fill up so please make note of the following upcoming meetings:

Go to for more information on all of these events.

Mountain Region Fall symposium
October 1 from 8:30-1:00pm
For more information please contact Jennifer (

Piedmont Region Meeting
October 5 from 9am to 2pm
For more information please contact Hannah Wofford (

Coastal Region Meeting
October 19th
For more information please contact Kelly Forrest (




Program Updates on the Website

Please make sure that you have a representative from your program review the information on the website.  Let us know if there have been any changes to contact information, location, or contact person.  We have also had a recent request to include fax numbers if possible.  Thank you!!

The OIG (Office of Inspector General) has released a 2019 Work Plan that includes an audit of Cardiac & Pulmonary Rehabilitation (CR/PR) services

Be aware that the OIG does not necessarily follow through on all audits included in the Work Plan but we want you to be aware.

A previous OIG audit of cardiac rehabilitation, mentioned in the above link, was conducted in 2015. It reviewed one hospital in New Jersey ( A significant number of deficiencies in both CR and PR programs in that institution were identified by the OIG.

A weekly subscription entitled Report on Medicare Compliance published by a commercial company, Health Care Compliance Association (HCCA), included an article that discussed Medicare/MAC audits of CR/PR and lessons learned. The content of the article reflects their interpretation and while there is some helpful advice in the article, AACVPR tells us that they offer the following clarification to CR and PR programs on these points from the article:

The PR Medicare provision (42 CFR 410.47) is correctly cited, stating that patients with moderate to very severe COPD (stages II-IV), are eligible for PR. There are inaccurate references to eligibility for patients with “moderate to severe” COPD elsewhere in the article.

Some PR programs document the CMS requirement for direct contact in PR with a physician signature on the monthly ITP that states, “I have seen this patient and I …” The article proposes adding a separate physician note in the chart specific to the initial direct contact and with every 30-day direct contact. This suggests one more form for documentation that is burdensome for programs and for the physician (work not billable by the physician). The ITP is the document CMS requires for documentation that can adequately serve this purpose.

The advice regarding staffing recommendations is concerning to NCCRA and AACVPR. Keep in mind that staffing ratios and personnel credentials may be subject to individual state laws. However, the current Medicare provisions for CR/PR and CMS’ response to public comments were published in the Federal Register in 2009. It is clear that CR/PR are multidisciplinary services.

From Federal Register, Vol. 74, No. 226, November 25, 2009:

pg 61877: “…may be part of the multidisciplinary team working with CR and ICR patients…”

pg 61880: “A PR program is typically a multidisciplinary program…”; “The plan is developed by a physician in conjunction with the interdisciplinary team.”

pg 61884: “Given that various individuals, acting under the supervision of a physician, can make up the PR multidisciplinary team…We believe these evaluations and individualized treatments are part of the PR, CR, or ICR program for those beneficiaries who need them. As such, we believe they should be conducted by one or more members of the multidisciplinary team of the CR, CR, or ICR program with the appropriate expertise.”

From Federal Register, Vol. 74, No. 223, November 20, 2009:

pg 60567: “We believe these evaluations and individualized treatments are part of the PR, CR, or ICR program…should be conducted by one or more members of the multidisciplinary team of the PR, CR, or ICR program with the appropriate expertise.” 

In fact, it is the multidisciplinary nature of CR and PR that strengthens the quality of the service provided to patients with many co-morbidities and educational needs. Each program director should strive to hire staff with the goal of having a well-rounded team. Local and institutional resources are unique to each program.

It is significant to point out that since the 1970’s when CMS (then HCFA) began covering and reimbursing for CR (and PR in 2010), neither CMS nor any MAC or auditor has questioned the qualifications of staff beyond the expectation for “qualified personnel” and CMS provides no further definition beyond that.

With the goal of identifying elements that would constitute “qualified staff”, AACVPR offers a voluntary professional certification (CCRP) for cardiac rehabilitation practitioners and a joint AARC/AACVPR certificate for pulmonary rehabilitation practitioners. There are over 900 CCRPs and this is a “preferred qualification” for CR practitioners, as outlined in the AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs (Human Kinetics, 2013). These certifications were developed from published core competencies and guidelines.

AACVPR also offers a voluntary program certification program that is based on scientific evidence, core program components, and regulatory compliance. CR and PR programs that have achieved and maintained certification status as well as rehabilitation programs that continually strive to incorporate current and best practices should be well prepared to face the rigors of an audit with confidence.