Fall Regional Meetings

Coastal Regional Meeting  Friday, October 25th
1001 Newman Rd.  New Bern, NC  28561
for more information contact Coastal VP Kelly Forrest (KForrest@carolinaeasthealth.com)
Agenda:  NCCRA Coastal REgion 2019 Agenda

Coastal Presentations:  Whited Slides

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)
Agenda: NCCRA Mountain Region 2019 Symposium

Mountain Presentations:  NCCRA 2019 Soukup


Reimbursement Updates

by Susanne Bice (Piedmont VP)

CMS (Centers for Medicare & Medicaid Services) released hospital outpatient and physician proposed regulations on July 30, 2019. There is now a 60-day public comment period followed by the publication of the final 2020 regulations with CMS responses to public comments, typically released in early to mid-November and effective January 1, 2020. AACVPR will be submitting comments on issues that do or could potentially impact cardiac and pulmonary rehabilitation (CR/PR). Those comments when submitted are posted on the AACVPR Regulatory & Legislative Actions web page.

The following is a breakdown of the proposed regulation which can be found in entirety at  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1717-P.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Proposed Physician Fee Services (PFS)

Intensive Cardiac Rehab will include Heart Failure Diagnosis as part of the Balanced Budget Act of 2018. The “proposed rule” will be finalized with an amendment to the Medicare Provision, 42 CFR 410.49

Proposed coverage through ICR and CR for additional cardiac conditions that would be as specified through future rule-making. Programs must be able to provide clinical evidence that supports the diagnosis and coverage. CMS notes that, “…conditions that may be considered for expanded coverage are limited to cardiac conditions and may not include other conditions (for example, cancer, metabolic syndrome, diabetes, peripheral artery disease, etc.)”

2020 Proposed Payment Rates

The following chart reflects proposed payment rates for hospital outpatient services in 2020 that are on-campus or were granted off-campus accepted status. The reimbursement amounts below are estimates that are subject to change after additional data are collected prior to publication of the final regulation in November.

CR/PR services that are off-campus and not excepted will receive roughly 40% of the payment listed here. Also, CR/PR services that are billed (i.e., owned) by physician practices are paid according to a complex formula that uses a conversion factor ($36.09 for 2020). This is unchanged from 2019, so payment will be virtually the same.

Note that the respiratory care procedure codes, G0237 & G0238, have been moved to a new APC (Ambulatory Payment Classification), causing the reduction in the payment amount for these services in 2020. The APC and procedure code, G0239, remains unchanged.

CPT/HCPCS Code APC Payment Co-Pay Revenue Code
93668 Peripheral Vascular Rehab 5733 55.87 11.18 943
93798 Cardiac rehab/monitor 5771 110.60 22.12 943
93797 Cardiac rehab 5771 110.60 22.12 943
G0422 Intensive cardiac rehab/w exercise 5771 110.60 22.12 943
G0423 Intensive cardiac rehab/no exercise 5771 110.60 22.12 943
G0424 Pulmonary rehab/w exercise 5733 55.87 11.18 948
G0237 Therapeutic procedures/ strength, endurance 5731 23.57 4.72 410
G0238 Other respiratory proc, individual 5731 23.57 4.72 410
G0239 Other respiratory proc, group 5732 34.33 6.87 410


Great news: American Heart Association with partner professional organizations has successfully introduced a bill in the U.S. House of Representatives.  HR 3911-Increasing Access to Quality Cardiac Rehabilitation Care Act of 2019 Building on the BBA of 2018, this bill will potentially move the implementation date of NNP supervision in CR AND PR to 2020 instead of starting in 2024. Also additional language will allow NNPs to independently order CR/PR services as well as establish, sign and review treatment plans.

AACVPR Site of Service Bill

This bill addresses the payment schedule for the off campus locations for CR/PR. The bill is asking for access to patients off campus without the 40% reduction in reimbursement.  AACVPR has this bill being finalized by the Rules Committee Chairman and a Representative from Nebraska. Expectation is that there are US Senators who will be willing to introduce a companion bill in the US Senate once there is a House Bill.

Please contact your local representatives and ask for support for Site of Service as well as HR 3911 mentioned above.

AACVPR meets with CMS Regarding Regulatory Issues

The meeting was held at CMS headquarters in Baltimore, led by AACVPR President Kate Traynor, Director of Cardiac Rehabilitation at Mass General Hospital, and Dr. Jonathan Whiteson, Medical Director for the Pulmonary Rehabilitation Program at NYU Langone Medical Center in New York City along with Phil Porte and Karen Lui, GRQ Consultants.

Flexibility was requested on the timing of physician review & signature on ITPs, clarification sought for MACs and auditors on the definition of session duration, and there was discussion about the direct patient contact requirement for pulmonary rehabilitation.

AACVPR is optimistic that the recommendations taken to the CMS team were heard and would be considered. All changes/recommendations must first be vetted through the CMS legal department. Then as usual, go through public posting, comments period and final draft. We will watch for and share any updates and changes as they develop.

Updates for the week of July 29th

New Legislation Proposes Expanded Access to Cardiovascular Rehab Services
New legislation introduced yesterday in Congress – a result of joint efforts between the ACC, the American Heart Association, and others – will take an important step towards addressing heart disease in the United States. The Increasing Access to Quality Cardiac Rehabilitation Care Act of 2019, introduced by Representatives John Lewis (D-GA) and Adrian Smith (R-NE), expands patient access to important cardiovascular rehabilitation services, which have been shown to reduce cardiovascular disease related death and hospital readmissions.  https://www.acc.org/latest-in-cardiology/articles/2019/07/23/17/32/new-legislation-proposes-expanded-access-to-cardiovascular-rehab-services?utm_campaign=advocate&utm_medium=email_newsletter&utm_source=advocate&utm_content=20190725
We encourage our membership to contact your legislators and ask them to support this effort!

Congratulations to Nash Cardiopulmonary Rehab opens their new facility
We are excited for Nash on their brand new facility.  It’s beautiful – we know your patients will enjoy it!



Week of May 20th Updates

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).

News this week of April 15th – NCCRA Program directory and a retired LCD

The program directory on the website is slowly being updated with the information that was shared at the symposium. Thank you to everyone who participated! If you were not in attendance or did not complete the program directory updates form we still would love to hear from you. Please complete the form and email it to info@nccraonline.org. CR-PR program directory information

On 4/5/2019 Palmetto retired the Cardiac rehab LCD “due to existing NCD, statutes, and extensive manual coverage definitions.” https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34412&ContrId=378&ver=50&ContrVer=1&CntrctrSelected=378*1&Cntrctr=378&name=&DocType=3&LCntrctr=378*1%7c379*1%7c380*1%7c381*1&bc=AgACAAQAAAAA&

The Respiratory therapy LCD has not changed.

Discipline Meeting notes from the symposium

Nursing discipline meeting
Chair: Lisa Warren
NCCRA Nursing Discipline 2019

Exercise discipline meeting
Chair: Angela Lanier
NCCRA Exercise Discipline Meeting 2019

Nutrition Discipline Meeting
Chair: Judith Hinderliter
Nutrition Discipline Meeting 2019

Slides for the Symposium

We are adding slides as we receive them. We can’t wait to see you!

So You Think You Can Dance? Empowering the Patient to Take the Lead empowering the vascular patient k smith final 2018

Practical Business Knowledge in CP Rehab NCCRA Financial Presentation – 04 05 19

Creating a Culture of Patient Voice North Carolna CVPR April 2019 4-3

ACSM Heart Games

Generational Differences Generational Differences. 2 hr. Webinar (002)

AACVPR Value Based Care Update
2019 VBC for Affiliates

Program Spotlight

Chatham Hospital Cardiac and Pulmonary Rehabilitation

Chatham Hospital Cardiac and Pulmonary Rehabilitation
163 Medical Park Dr, Suite 120
Siler City, NC 27344

Contact: Debbie Scotten
Email: Debbie.Scotten@chathamhospital.org
Phone: (919) -799-4650
Fax: (919) 799-4651

Our program is located in  rural NC  and operate through a critical access hospital (25 bed facility).  Our hospital does not provide invasive cardiac procedures therefore very few heart patients are served in the inpatient setting.  Our Cardiac Rehab referrals are 99% from the surrounding Medical Centers such as UNC Chapel Hill, Moses Cone, and Pinehurst.  We are located  in the a Medical Office Building behind Chatham Hospital.  We are limited in the number of classes due to MD supervision so we only operate on Monday, Wednesday, and Thursdays from 7:30 AM to 12 Noon.  We see an average of 30 patients per day and have 1 FTE- program director which also serves as the program EP and FT nurse,  3 part time nurses, 1 RD 12 hours per month , and a Social Worker who works 4 hours per month.    We have 2 staff that are CCRP and we currently are AACVPR certified. 

LCD draft for Cardiac Rehab effective 2/5/2019

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

LCD for cardiac rehab effective 2-2019

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