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 (https://oig.hhs.gov/oas/reports/region2/21401013.pdf). 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.