AACVPR REIMBURSEMENT UPDATE
JANUARY 24, 2008

New CMS Release, Effectively Immediately

AACVPR has learned that CMS has released a transmittal implementing changes in Cardiac Rehabilitation services paid under the Hospital Outpatient Prospective Payment System. As a valued member of AACVPR, we are keeping you informed with the most updated information available.

The Centers for Medicare and Medicaid Services (CMS) has provided its contractors with guidance for implementation of policy changes related to provision of and billing for cardiac rehabilitation services, effective immediately. These changes are related to the hospital outpatient prospective payment final rule, published in the November 27, 2007 Federal Register. The new communication from CMS, Transmittal 1417, dated January 18, 2008, addresses a wide range of policy changes, with one section devoted to the provision of cardiac rehabilitation services.

Background

The November 27th final regulation made two important changes in the provision of cardiac rehabilitation. First, CMS shifted from the concept of “sessions” to the more definitive use of “hours” as a measurement unit, defining one unit of HCPCS 93797 or 93798 as at least one hour (and up to 1 hour, 59 minutes). Secondly, CMS opened the door to permit programs to bill more than one session/hour per day per beneficiary. The new transmittal provides important guidance on those two key issues.

The New Cardiac Rehabilitation Provision

The following language is taken directly from the new Cardiac Rehabilitation Provision within Transmittal 1417:
“The National Coverage Determination for cardiac rehabilitation programs requires that programs must be comprehensive and to be comprehensive they must include a medical evaluation, a program to modify cardiac risk factors (e.g., nutritional counseling), prescribed exercise, education, and counseling. (See the National Coverage Determinations (NCD) Manual, Pub. 100-03, section 20.10.) A cardiac rehabilitation session may include more than one aspect of the comprehensive program. For CY 2008, hospitals will continue to use CPT code 93797 (Physician services for outpatient cardiac rehabilitation, without continuous ECG monitoring (per session)) and CPT code 93798 (Physician services for outpatient cardiac rehabilitation, with continuous ECG monitoring (per session)) to report cardiac rehabilitation services. However, effective with dates of service January 1, 2008 or later, hospitals may report more than one unit of HCPCS codes 93797 or 93798 for a date of service if more than one cardiac rehabilitation session lasting at least 1 hour each is provided on the same day. In order to report more than one session for a given date of service, each session must last a minimum of 60 minutes. For example, if the services provided on a given day total 1 hour and 50 minutes, then only one session should be billed to report the cardiac rehabilitation services provided on that day.”

• Programs should know that some Medicare contractors do not recognize use of code 93797, unmonitored cardiac rehabilitation. CMS has clarified that it is within the authority of each contractor to make that decision. Some programs may determine that their current treatment protocols and business model do not need to be changed, as long as the 60 minute minimum for each session is met. After all, there is nothing in this new rule that mandates change beyond the requirement that each billable “session” be at least 60 minutes in duration.

If your entry and exit ECG strip does not document time, you might consider adding documentation of session duration. This could be as simple as noting the start and finish time of each exercise session.

Example 1: A patient is able to complete only 45 minutes of ECG-monitored exercise in the first visit. This would be non-reimbursable because the patient did not achieve the minimum 60 minute requirement.

Example 2: A patient spends 60 minutes doing ECG-monitored exercise and 30 minutes in a stress management class. This would be reported as one hour of HCPCS 93798 because it does not meet the requirement of the minimum of 120 minutes required for submission of two hours of cardiac rehabilitation services.

Example 3: A patient spends 70 minutes performing ECG-monitored exercise and 50 minutes in a class on risk factor modification. This would be reported as one 93798 hour for that day.

Example 4: A patient spends 60 minutes performing ECG-monitored exercise and 60 minutes in a stress management class. This would be reported as one 93798 and one 93797 service of cardiac rehabilitation. (Keep in mind that many Medicare contractors will not reimburse for the 93797 code.)

• Programs that do decide to shift into a model that will provide more than one billable session (at least 120 minutes) must remember that the total number of sessions is still set at a threshold of 36, as clearly outlined in CMS coverage policy 20.10. That is, 36 sessions of 93798 equals the 36 session threshold, as does 30 sessions of 93798 + 6 sessions of 93797. Program directors should also recognize that multiple sessions per day would likely have the aggregate effect of an actual reduction in exercise therapy time, as a second session would likely focus on components of cardiac rehabilitation other than monitored exercise training.

Example 1: Your program provides three ECG-monitored hours (93798) per week and one hour of dietary education per week (93797). However, once a total of 36 sessions has been reported for a combination of services using the 93797 and 93798 definitions, that patient’s course of cardiac rehabilitation is complete and no further reimbursement will be provided by Medicare, even though the patient did not receive 36 exercise hours (93798). That patient’s course would translate to 4 hours per week over 9 weeks to equal the 36-session limit, as one example.

Example 2: The exercise session lasts anywhere between one and two hours (60-119 minutes), so it is still considered one session. An exercise session would need to be between two and three hours (120 minutes or greater) to be reportable as two units of HCPCS code 93798.

As stated in the CMS Cardiac Rehabilitation NCD 20:10, Medicare contractors have the discretion to cover cardiac rehabilitation services beyond 18 weeks or 36 sessions on a case-by-case basis, not to exceed a total of 72 sessions for 36 weeks. However, the granting of an extension for the cardiac rehab benefit by a contractor is rare.

• As always, programs must ensure that all billable services to Medicare are in accordance with accepted coding practices. The definition of codes 93797 and 93798 are fairly specific

o 93797 -- Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session);
o 93798 -- with continuous ECG monitoring (per session)

Therefore, it is imperative that any services billed under these codes be documented in the medical record be reflective of the actual services provided to the beneficiary.

This important information is sent to you as a valued member of AACVPR. As always, AACVPR will keep members updated with the most current information for billing and reimbursement of cardiac and pulmonary rehabilitation.

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