Knowledge Base Article

“Learn from the mistakes of others. You can never live long enough to make them all yourself.”― Groucho Marx

Last month, CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, published results of their ongoing service-specific complex medical review of cardiac rehabilitation services. One J15 state improved their charge denial rate but the other state’s denial rate increased. And overall neither of the charge denial rates are that great, ranging this quarter from 46.8% to 55.7% which means about half of the cardiac rehab charges submitted are being denied. The good news here is that the rest of us can learn from the mistakes of others and proactively address the documentation deficiencies identified in the CGS medical review.

In addition to “requested records not submitted,” the main denial reasons in the CGS review were that the cardiac rehab sessions did not include all the required services and the physician supervision requirements were not met. Specifically for the required cardiac rehab service components, the review findings noted “the following components of the cardiac rehabilitation program were not submitted in the medical record:

• Physician-prescribed exercise
• Cardiac risk factor modification
• Psychosocial assessment
• Outcomes assessment
• An individualized treatment plan”

Years ago, CGS published an article that describes the requirements for cardiac rehab (originally published September 24, 2012, but updated August 24, 2016). Here is information from the article that addresses the components identified as missing in the medical review. Please refer to the entire article at the link above for more complete information.

1. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished.
2. There should be documentation in the chart that the physician prescribed a specific exercise for each day (a note or order from the physician, signed and dated) and a record showing the patient did the exercise.
3. The physician's prescription for exercise should include the mode of exercise (typically aerobic), the target intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs), the duration of each session (e.g., "20 minutes") and the frequency (number of sessions per week).
4. The cardiac rehab professional supervising the patient’s exercise should document the patient's name, date, a description of the exercise showing the doctor's prescription was followed, and their signature and credentials.
5. They should also monitor and record the patient's objective and subjective responses to the exercise therapy.
6. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patient's individual needs.
7. The plan of care prescribed and signed by the physician should include a comment that cardiac risk factor modification will be addressed, which risk factors are important to this particular patient (cholesterol lowering for example, or sedentary life-style, or tobacco use) and directing education, counseling and behavioral intervention.
8. The record must contain documentation demonstrating how such risk factors were addressed with concurrent notes, signed and dated by the appropriate individual at the time these services are delivered.
9. A form signed and dated stating, "tobacco cessation education done” is not adequate documentation. There should also be a progress note discussing what intervention is made and its outcome by the person who does the intervention.
10. Psychosocial assessment documentation should be present.
11. Although a psychologist or psychiatrist may conduct this assessment, recognized tools for depression screening, accompanied by the physician's plan of action based on the results is also acceptable.
12. A note stating a standardized test was done and its score is not sufficient documentation of a psychosocial assessment.
13. Documentation should include the dated signature of the health care professional who conducted the assessment; an interpretation of the results; and the dated signature of the physician who utilized the results of the recognized screening tool to prepare the plan of care.
14. Outcomes assessment
15. The outcomes assessment shows whether services did or did not result in benefit to the patient (such as weight loss, walking distance, etc.).
16. If a goal was not met, it is prudent to include what modifications were made to the care plan to address the failure.
17. The assessment must be signed and dated by the person doing the assessment, with his or her credentials, on the day the assessment is done.
18. An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days
19. A progress note from the treating physician, done at the time of admission to the cardiac rehabilitation program that explains
20. the patient's clinical history,
21. the reason for the prescription of cardiac rehabilitation (covered diagnosis/condition),
22. a discussion of the individual patient's needs and how they would be met by an exercise program, and
23. incorporates components #1-3 above, i.e. description of the exercise program, risk factor modification program, and goals for the psychosocial assessment.
24. Documentation from the treating physician no later than 30 days into treatment that utilizes the outcomes assessment (#4 above) to specify any modifications needed in the plan of care previously prescribed, or reason(s) to continue the present plan.

Direct physician supervision in a hospital department means a physician is immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. Non-physician practitioners may not serve the supervising role for cardiac rehabilitation services.

CGS’s article makes it clear that the required components of cardiac rehab cannot simply be check-boxes that are marked off. Each component serves a purpose in ensuring the patient’s needs are identified, addressed, and met by the cardiac rehab program. By studying the findings of the CGS review and the related education article, providers can learn from the mistakes of others and be better prepared to weather a review themselves.