AACVPR REIMBURSEMENT UPDATE
NOVEMBER 5 , 2007

CMS Final Rule on Cardiac Rehabilitation Codes is Announced

This Reimbursement Update comes to you as a member of AACVPR. As many of you know, CMS recently posted a proposed change to the current process for billing cardiac rehabilitation services. CMS proposed replacing the current CPT codes, 93797 and 93798, with new G codes. In addition, they proposed that the new codes would be time sensitive and be focused on a one-hour duration. As always, AACVPR monitors CMS updates and responded to the call for public comments. AACVPR, along with the American College of Cardiology and the American Hospital Association, submitted comments in opposition to these proposed changes.

On November 1, 2007, the Centers for Medicare & Medicaid Services (CMS) published the 2008 final rules for the Hospital Outpatient Prospective Payment System (OPPS) and the Physician Fee Schedule. The important message for the new CMS posting is:

• The CPT codes 93798 and 93797 remain intact and will not be replaced by G codes, as was proposed by CMS earlier this year.
• Because there are no G codes, there will also be no shift from sessions to hours.

To fully understand the decisions, AACVPR members need to distinguish between decisions affecting the physician fee schedule and the hospital outpatient rules. Most notably, some commenters, responding to the physician fee schedule, requested that certain intensive cardiac rehabilitation services should be allowed to bill for multiple sessions of cardiac rehabilitation on the same date of service when modifier 59 is reported. CMS responded that the National Coverage Determination (NCD) does not distinguish between different approaches to the delivery of cardiac rehabilitation services, whether the program is two sessions per week or several sessions per day. This allows for flexibility and tailoring based on patient needs. “Regarding intensity, we expect the intensity of cardiac rehabilitation programs to vary by patient and by program.” Importantly, however, CMS has opened the door, using a modifier, for physicians billing the cardiac rehab codes “under some circumstances.” Those circumstances have yet to be defined by CMS or its contractors.

In the corollary regulation, beginning in 2008:

• Hospitals will be allowed to report more than one unit of service per day if more than one cardiac rehabilitation session lasting at least one hour is provided on the same day.
• Specific coding and payment instructions for multiple billing will be included in program instructions that accompany the January 2008 OPPS update.
• Claims data will be monitored to ensure that utilization of cardiac rehabilitation services remains appropriate.
• As in the physician fee schedule, the precise rules for distinguishing between traditional cardiac rehabilitation programs “intensive” programs have yet to be announced by CMS or its contractors.

As always, AACVPR members can rely on AACVPR to continue to provide you with the timely and important updates that affect billing and reimbursement for Cardiac and Pulmonary Rehabilitation services.

Karen Lui, R.N., M.S.
(FL phn) 239-768-6412
(DC phn) 703-752-4353
Karen@GRQConsulting.com