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.