Knowledge Base Article

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e. MAC, RAC, OIG, etc.) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month’s focus is on cardiac rehabilitation.

Did You Know?

Cardiac Rehabilitation (CR) and Intensive Cardiac rehabilitation (ICR) Defined

• CR means a physician-supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment.
• ICR program means a physician-supervised program that furnishes CR and has shown, in peer-reviewed published research, that it improves patients’ cardiovascular disease through specific outcome measurements described in 42 CFR 410.49(c).

Timeline to Medicare Coverage of CR and ICR

• 2008: The Medicare Improvements for Patients and Providers Act of 2008 amended the Act to establish coverage for CR, ICR and pulmonary rehabilitation.
• 2010: The CMS implemented provisions for the three rehabilitation services in the CY 2010 Physician Fee Schedule (PFS) final rule.
• 2014: National Coverage Determination (NCD) 20.10.1 expanded CR coverage to beneficiaries with stable, chronic heart failure
• 2018: Bipartisan Budget Act (BBA of 2018) expanded covered indications for ICR to include beneficiaries with stable, chronic heart failure.
• 2020: CY 2020 PFS final rule updated 42 CFR 410.49 to codify the expansion of coverage.
• March 2021: CMS updated sub-regulatory guidance regarding coverage requirements for outpatient CR to reflect the regulatory text more closely and published an MLN Fact Sheet.

Medicare Review Contractor Activities

Recovery Auditors: On January 8, 2019, CMS approved Issue 0135 (Cardiac Rehabilitation: Medical Necessity and Documentation Requirements). By March of 2019, all four RAC regions had added this issue to their list of complex medical record reviews for outpatient hospital claims.

Medicare Administrative Contractors (MACs): In 2021, three MACs have been performing post-payment reviews of CR and includes

• CGS (J15) has published review results for claims from Ohio with dates of service from January through March 2021. The claims error rate was 64.7%.
• NGS (J6) has published review results of claims with dates of service from January 1, 2019, through February 29, 2020. The claims error rate was 51.18%.
• NGS (JK) posted notice of a service specific post payment review of cardiac rehab on May 26, 2021. The primary focus is to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

Office of Inspector General (OIG): In May 2021, the OIG Published a report titled CMS Needs to Strengthen Regulatory Requirements for Medicare Part B Outpatient Cardiac and Pulmonary Rehabilitation Services to Ensure Providers Fully Meet Coverage Requirements (link).

The OIG reviewed the third highest-paid provider in the country in combined Medicare reimbursement for outpatient cardiac and pulmonary rehabilitation services. The audit period was from April 2016 through March 2018 and covered just over $2.7M in Medicare payments representing 26,408 beneficiary days of rehabilitation services.

As the audit progressed, the focus shifted from the provider to CMS. This occurred due to the OIG noting that “we found that although the provider generally complied with Medicare coverage requirements, it did not meet the intent of the requirements. Therefore, we determined that the larger issue was whether CMS’s regulatory requirements were sufficient to ensure providers complied with the intent of the Medicare coverage requirements.”

Based on their findings, the OIG believes that Medicare payments made by CMS to all providers for outpatient cardiac and pulmonary rehabilitation services during the audit period may not have met requirements. They recommended that CMS revise its regulations to provide sufficient guidance to ensure that providers meet coverage requirements for these services.

In their response, CMS noted that in March 2021 they updated sub-regulatory guidance within the Medicare Benefit Policy Manual and Medicare Claims Processing Manual regarding coverage requirements to reflect the regulatory text more closely. CMS also noted they will take the OIG recommendation into consideration when determining next steps regarding the regulations for these rehabilitation services.

P.A.R. Pro Tips: Cardiac Rehabilitation Provider Outreach and Education Efforts )

Both CMS and the MACs have made available several resource documents related to outpatient cardiac rehabilitation services.

CMS

• March 2021 MLN Fact Sheet: Overview of the Conditions of Coverage for Medicare Part B Outpatient Cardiac Rehabilitation Services (link).
• March 24, 2021, Transmittals updating Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Program Manual Sections
• R10573CP (link)
• R10573BP (link)

CGS (J15 MAC)

• CGS Article: Cardiac Rehabilitation: Coverage and Documentation requirements (link)
• Cardiac Rehab with Continuous ECG Monitoring ADR checklist (link)

NGS (J6 and JK MAC))

• NGS Article: Reminder for Billing Cardiac Rehabilitation Session and Session Limitations (link)

Noridian (JE and JF MAC)

• Noridian has published outpatient CR local coverage article (LCA) for JE (A54068) and JF (A54070).
• Noridian has a dedicated webpage on their website titled Cardiac and Pulmonary Rehabilitation Programs (link).

Novitas Solutions (JH and JL MAC)

• Novitas has published LCA A55758.
• Noridian recently published a September 15, 2021 Ask the Contractor (ACT) Q&A document (link). Question four is about cardiac the KX modifier and Cardiac Rehab.

Palmetto GBA (JJ and JM MAC) )

• Palmetto GBA has published LCA A53775.
• On October 28, 2021, Palmetto GBA published a CR: Coverage Criteria & Documentation Requirements Module (link).

What Can You Do?

• Become familiar with indications for CR/ICR & Medicare documentation requirements,
• Submit medical record requests to the Medicare Contractor in a timely manner, and
• Read a related article in this week’s newsletter to learn the temporary direct supervision policy change due to the COVID-19 PHE and paid claims amounts paid to providers by CMS in CY’s 2019 and 2020 for CR/ICR services.