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Cardiac Rehabilitation ADR Checklist

CGS recommends providers organize the medical documentation in the order indicated below. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process. Please ensure the documentation is submitted within 45 days of the Additional Documentation Request (ADR). If the documentation has not been received, the claim will automatically deny on the 46th day for non-receipt of documentation.

Providers should submit all documentation that is pertinent to support the medical necessity of services for the billing period being reviewed. Ensure services billed are coded accurately for the service provided and the documentation supports those services. This may include documentation that is prior to the review period, such as an Individualized Treatment Plan (ITP). Please note that the most common reason for overturned appeals is due to providers submitting new documentation upon the appeal that was omitted with the initial submission of medical records.

*Please include the beneficiary name and date of service on all documentation and include an abbreviation key (if applicable). Documentation must be legible and complete (including signature(s) and date(s)). If you question the legibility of your signature, you may submit a signature log or an attestation statement.

The Checklist below is intended to be utilized by providers as a reference when responding to ADRs to ensure each claim meets the policy requirements prior to the ADR submission. Please submit all documentation as required in the LCD or NCD, if applicable, and in accordance with the Medicare Benefit Policy Manual. It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. Ensure the documentation submitted belongs solely to the intended beneficiary and documentation of another beneficiary is not present within any aspect of the medical record.

Response to an ADR may require you to contact the hospital, physician office and/or the facility where the services were provided and obtain your signed physician orders, history and physical information, progress notes, plan of care, and/or other requested documentation. Please submit a copy of the ADR request and enclosed cover sheet with each appropriate DCN to separate applicable documentation for review. Please ensure you include a designated point of contact (name, email, telephone number) with all records submitted in response to each ADR. CGS may contact this individual for an easily curable error identified during the review process in order to prevent a claim denial for missing documentation.

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Cardiac Rehabilitation ADR Checklist – Preferred Order

 

1. ADR letter and enclosed cover sheet with each DCN

 

2. Physician’s order for cardiac rehabilitation

 

3. History and physical exam information supporting the diagnosis and treatment for cardiac rehabilitation

 

4. Practitioner progress notes, including actual minutes of rehab therapy

 

5. All diagnostic reports (lab, radiology, cardiology, etc.); specifically, ECG tracings

 

6. For diagnosis of Congestive Heart Failure (CHF):  documentation of left ventricular ejection fraction of 35% or less AND documentation of NYHA Class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks

 

7. Documentation should include the following components of a cardiac rehabilitation program:

i. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished (mode of exercise, target intensity, duration of each session, and frequency of sessions)

ii. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patients' individual needs

iii. Psychosocial assessment

iv. Outcomes assessment

v. 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.

 

8. If services are provided in a non-hospital-based rehabilitation facility, please submit documentation to support physician supervision (policy and procedure for physician supervision, a calendar/schedule/call log, or other documentation to verify the immediate availability of a physician during the billed services).

 

9. Other relevant documentation to support medical necessity of all services billed

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How to Prevent Common Denials:

Ensure documentation includes:

  • Individualized Treatment Planned (ITP) established, reviewed, signed and dated by physician every 30 days to cover the DOS billed
  • All Cardiac Rehab (CR) Program Component Requirements
  • Physician-prescribed exercise
  • Cardiac Risk Factor Modification (education or training tailored to meet the pt’s needs)
  • Psychosocial assessment (include screening tool utilized)
  • Outcomes assessment (to determine if the interventions did or did not result in some benefit to the pt)
  • Individualized treatment plan (ITP)

*These 5 components must be signed and dated by the physician every 30 days. Claims must have all 5 components in order to be paid. Components may be separate or compiled together in the ITP.

  • Sessions for each DOS billed inclusive of minutes and an ECG monitoring strip
  • Physician-prescribed exercise plan inclusive of:
    • Mode of exercise (typically aerobic)
    • Target intensity (e.g., a specified percentage of the maximum predicted heart rate or number of METs)
    • Duration of each session (e.g., "31 minutes")
    • Frequency (number of sessions per week)
    • Physician Validated Diagnosis

CHF has 2 components: (ejection fraction of 35% or less and NYHA class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks)

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Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as an index and prove very helpful to provide the location of key documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended as documentation may not be legible.

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Please contact J15AMREDUCATION@cgsadmin.com for further questions, concerns, or educational needs related to this review. Be sure to include the facility name and provider number/PTAN for the inquiry. Ensure CGS is current with provider contact information for any educational outreach opportunity.

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