Knowledge Base Article

We all learned our ABCs in kindergarten, but now we have to know Medicare’s version of the alphabet. For example this article looks at LCDs by the MACs and a new CMS NCD for coverage of CHF for CR for certain NYHA classes. And don’t forget to add the KX modifier when needed.

Cahaba, Palmetto, and First Coast - Medicare Administrative Contractors (MACs) for Jurisdictions 10, 11 and N respectively - did not have any new, retired or draft Local Coverage Determinations (LCDs) last month, but Novitas, the MAC for Jurisdictions H and L, retired a number of policies and replaced most of them with new policies. It appears Novitas is working toward having one policy on a topic for both of their jurisdictions and for both Part A and B. This will ensure consistency in coverage criteria for all providers handled by Novitas. See the table at the conclusion of this article for the list of this month’s new and retired policies.

On the national front, CMS manualized the National Coverage Determination (NCD) for coverage of congestive heart failure (CHF) for cardiac rehabilitation (CR) (see MLN Matters Article MM8758). The transmittals, to be implemented August 18, 2014, allow Medicare coverage, effective for dates of service on and after February 18, 2014, of cardiac rehabilitation services for patients with stable, chronic heart failure.

Stable, chronic heart failure is defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks. Stable patients are defined as patients who have not had recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures.

In addition to CHF, Medicare covers cardiac rehab for the following conditions:

• Acute myocardial infarction within the preceding 12 months
• Coronary artery bypass surgery
• Current stable angina pectoris
• Heart valve repair or replacement
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting or
• Heart or heart-lung transplant

This is a good time to remind CR providers about the maximum number of sessions for CR and appropriate billing. MMP, as part of our 835 reviews for the HIQUP reports, consistently sees some cardiac rehab services denied with claim adjustment reason code (CARC) 151 (Payment adjusted because the payer deems the information submitted does not support this many services). This appears to be denials for cardiac rehab services exceeding the allowed maximum sessions.

Cardiac rehabilitation program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. For medically necessary CR sessions beyond 36, the provider should append a KX modifier on the claim lines as an attestation that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary. The Medicare contractor will accept the KX modifier and allow payment. Medicare will not cover CR sessions beyond 72 sessions, with or without the inclusion of a modifier.

The CARC for these maximum benefit denials may be changing as the Claims Processing Manual update included the following instructions:

The following messages shall be used when contractors deny CR claims that exceed 36 sessions, when a KX modifier is not included on the claim line:

Claim Adjustment Reason Code (CARC) 119 – Benefit maximum for this period or occurrences has been reached

Regardless of the denial reason code, providers need to carefully monitor their CR patients’ number of sessions and use the KX modifier when appropriate to assure proper payment. This will be even more important now that the volume of cardiac rehab will likely increase due to the inclusion of CHF as a covered indication.