Knowledge Base Article

We all know the benefits of a healthy diet and exercise. You can hardly go a day without seeing or hearing information on how eating right and exercising will lead to a longer, healthier, and happier life. Unfortunately, not all of us are proactive when it comes to our health. We wait until an episode or condition has occurred before changing our ways. Better late than never, so it is lucky for many that Medicare covers cardiac and pulmonary rehabilitation. For the providers that furnish these services, it is also wise to be proactive to ensure you meet the Medicare requirements of coverage and billing. Better late than never is not a wise option for providers since your facility could lose valuable reimbursement if you fail to follow the Medicare rules.

In May 2018, the Office of Inspector General added review of outpatient cardiac and pulmonary rehabilitation services to their Work Plan. The OIG notice reminds providers, “For these services to be covered, however, they must be medically necessary and comply with certain documentation requirements. Previous OIG work identified outpatient cardiac and pulmonary rehabilitation service claims that did not comply with Federal requirements.” In addition to prior OIG reviews, some Medicare Administrative Contractors (MACs) have also reviewed cardiac and pulmonary rehab services. The MAC reviews found significant error rates for these services.

If your facility provides one or both of these services, what should you do to ensure you comply with Federal requirements? The obvious first step is being familiar with Medicare’s requirements. The  Medicare Benefits Policy manual, chapter 15 discusses the coverage of pulmonary rehab in section 231 and cardiac rehab in section 232. Chapter 32 of the Medicare Claims Processing Manual provides instructions on these programs in section 140.

If you do provide these services, it is likely you know the covered conditions and required components of each. So, in this article, let’s focus on the areas that are most prone to be deficient.

Pulmonary rehab is covered for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease. Cardiac rehab is covered for patients with

• 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;
• Heart or heart-lung transplant.
• Stable, chronic heart failure 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 6 weeks.

In the case of a medical review, the patient’s diagnosis should be stated as part of the treatment plan but in addition, your record must substantiate the covered diagnosis with documentation from physicians’ office notes, hospital records, findings of diagnostic testing, and/or operative notes. Also verify timeframes (AMI within the last 12 months, optimal heart failure therapy for at least 6 weeks for CHF) and the inclusion of specific measures when required (GOLD class II, III, or IV; VEF of 35% of less; NYHA class II – IV symptoms) are addressed with supporting documentation.

Denials of pulmonary and cardiac rehab from prior MAC reviews were often cited as due to lack of all the required components. Both pulmonary and cardiac rehab require the following components.

• Physician-prescribed exercise,
• Education or training (for cardiac risk factor modification in the case of cardiac rehab)
• Psychosocial assessment
• Outcomes assessment
• Individualized treatment plan

It is unknown how strict a particular Medicare reviewer will be, so best practice is to address each of these elements with the following strategy – 1) what does the patient need, 2) what is the plan for addressing that need, 3) what was done for the patient based on the plan, 4) how did the patient respond and 5) modifications based on patient failure to progress. Years ago, CGS published an article that described the requirements for cardiac rehab. That article is no longer available, but MMP provided details from that publication in a prior Wednesday@One article that you might find helpful.

Cardiac and pulmonary rehabilitation program sessions are limited to a maximum of two (2) 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary. MMP sees Medicare denials of cardiac and pulmonary rehab services with Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached. This could occur when:

• Cardiac/pulmonary rehab services exceed two (2) units for a single day of service
• Cardiac/pulmonary rehab services exceed 36 sessions without a –KX modifier included on the claim line
• Cardiac/pulmonary rehab services exceed 72 sessions

Medicare will assign liability for these services to the provider unless an Advance Beneficiary Notice (ABN) was obtained.

If a patient requires medically necessary cardiac/pulmonary rehab services beyond 36 sessions (up to a maximum of 72 sessions), a –KX modifier should be appended to the claim line. The –KX modifier indicates the services provided meet the medical necessity requirements of the applicable medical policy/regulation and there is supporting the rehab services beyond 36 sessions. For example, a patient may be benefiting from rehab but may not meet exit criteria after the initial 36 sessions. This is an example when use of the –KX modifier would be appropriate.

Also, be sure your documentation specifies the amount of time the patient is participating in cardiac or pulmonary rehab. In order to report one session of cardiac/pulmonary rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Two sessions may only be reported in the same day if the duration of treatment is at least 91 minutes. If several shorter periods of cardiac/pulmonary rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.

Now is a good time to look at your own cardiac or pulmonary rehab records to verify they meet all the Federal requirements before the OIG, a MAC, or another Medicare reviewer comes calling for those records. Be proactive before it is too late.