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April 18, 2018

Cardiac Rehabilitation: Coverage and Documentation Requirements

Cardiac rehabilitation may be covered under Medicare Part B ("Part B of A") for dates of service on or after January 1, 2010. Coverage was established in Section 144(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and the previous National Coverage Determination (NCD) was rescinded. The Centers for Medicare & Medicaid Services (CMS) published MLN Matters article MM6850, which further describes the guidelines associated with coverage of cardiac rehabilitation under Medicare. The purpose of this article is to provide the criteria for coverage and the documentation required to meet the conditions of coverage.

The rule states the following:

  1. General rule.
    1. Covered beneficiary rehabilitation services. Medicare Part B covers cardiac rehabilitation and intensive cardiac rehabilitation program services for beneficiaries who have experienced one or more of the following:
      1. An acute myocardial infarction within the preceding 12 months
      2. A coronary bypass surgery;
      3. Current stable angina pectoris;
      4. Heart valve repair or replacement;
      5. Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
      6. A heart or heart-lung transplant
      7. For cardiac rehabilitation only, other cardiac conditions as specified through a national coverage determination

Explanation: In the documentation provided, CGS expects to see clinical evidence the patient had one or more of the stated conditions within the stated time frame, if specified. For example, the history, written and signed by the physician managing the case, might state the patient was hospitalized in September 2011 with an acute myocardial infarction.

The rule:

  1. Components of a cardiac rehabilitation program and an intensive cardiac rehabilitation program.

    Cardiac rehabilitation programs and intensive cardiac rehabilitation programs must include all of the following:

    1. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished.
    2. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patients' individual needs.
    3. Psychosocial assessment
    4. Outcomes assessment.
    5. 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.

Explanation: When reviewing these cases, CGS finds this set of requirements is often not documented correctly or sufficiently in the medical records provided. The documentation should clearly show that these parameters are met.

  1. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished.

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. This does not mean a physician must write an order every day, but it means the physician must write an order for what is done, prior to it being done. Remember: documentation requirements include the patient's name, date, a description of the exercise showing the doctor's prescription was followed, and the signature and credentials of the individual who directly supervised that exercise–or supply a reasonable clinical explanation for its not being done. A copy of the clinical record created for the particular patient might provide all of the information. A piece of paper saying, "Elliptical trainer 9:00, July 6, 2011" does not meet these requirements. An order saying, "Treadmill at 2 pm for 30 minutes five times per week for 4 weeks" would meet the requirement for that exercise.

CGS expects that the physician's prescription for exercise will include:

  • 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., "20 minutes")
  • Frequency (number of sessions per week)

CGS also expects that the cardiac rehabilitation professional will use this prescription as a dynamic blueprint and will continuously monitor and record the patient's objective and subjective responses to the exercise therapy. While the supervising physician may not personally orchestrate each change in the exercise program, he or she will certainly rely on recorded data and observations based on the exercise sessions in his or her periodic reviews of the patient's progress.

  1. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patient's individual needs.

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. 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. A piece of paper with the patient's name, and "elliptical" with an attached ECG strip and a physician's signature at the bottom dated on a different day, is an example of inadequate documentation. Another example of inadequate documentation is a form signed and dated stating, "tobacco cessation education done." There could be an order to address education; for example, "please work on tobacco cessation, lipid management and weight control." There should also be a progress note discussing what intervention is made and its outcome by the person who does the intervention.

  1. Psychosocial assessment documentation should be present.

This does not mean that a psychologist or psychiatrist must be on staff and personally conduct the psychosocial assessment. Although a psychologist or psychiatrist may conduct this assessment, other acceptable methods of conducting the assessment include recognized tools for depression screening, accompanied by the physician's plan of action based on the results. Regardless of the method used to conduct the psychosocial assessment, documentation is expected to include the signature and date of the health care professional who conducted the assessment; an interpretation of the results; and the signature and date of the physician who utilized the results of the recognized screening tool to prepare the plan of care. A note stating a standardized test was done and its score is not sufficient documentation of a psychosocial assessment.

  1. Outcomes assessment:

This refers to the need for the program to show the interventions/services did or did not result in some benefit to the patient. For example, if the goal was to lose one pound a week, there should be notation in the file of the beginning weight was 230 pounds and the weight after 4 weeks was 232 pounds and the goal was not met. Or the goal was for the patient to be able to walk for 30 minutes on the treadmill at 2 miles per hour daily without chest pain or undue shortness of breath and the goal was met or not met. If the goal was not met, it is prudent to include what modifications were made to the care plan to address the failure. Like all such notes, it must be signed and dated by the person doing the assessment, with his or her credentials, on the day the assessment is done.

  1. 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.

Explanation: The initial individualized treatment plan (ITP) is completed on 1/1/18 and signed and dated by the physician on 1/1/18. Subsequent ITPs are completed every 30 days and signed and dated by the physician. Please ensure the date is legible.

This requirement uses the information from (iv) above but specifies it must be done every 30 days by a physician. This could be documented by:

  •  A progress note from the treating physician, done at the time of admission to the cardiac rehabilitation program in question, explaining:
    • The patient's clinical history, and
    • Reason for the prescription of cardiac rehabilitation (the first requirement above),
    • A discussion of the individual patient's needs and how they would be met by an exercise program,
    • A description of the exercise program,
    • A description of the risk factor modification program detailing which risk factors need to be modified for a particular patient–sedentary life style, tobacco use, obesity, high cholesterol, etc.–and
    • Goal(s) for the psychosocial assessment.
  • Further documentation is required from the treating physician, no later than 30 days into treatment, that describes:
    • The outcomes assessment specifies any modifications needed in the plan of care previously prescribed, or
    • Reason(s) to continue the present plan.

In the example regarding weight in (iv) above, one would expect to see a note made of the fact that if weight loss did not occur and some discussion of how the treatment plan was being modified to improve the results. Some examples of inadequate documentation include medical records with no notes from the ordering physician and no orders written by a physician, files with logs of activities with no indication they are part of a treatment plan, and notes solely by non-physician staff. The documentation must affirmatively show the stated requirements are met.

The rule:

  1. Settings:
    1. Medicare pays for cardiac rehabilitation and intensive cardiac rehabilitation in one of the following settings:
      1. A physician's office
      2. A hospital outpatient setting
    2. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for supervision for physician office services, at section 410.26 of this subpart; and for hospital outpatient services at section 410.27 of this subpart.

Explanation: The requirements for physician supervision differ for hospital-based versus non-hospital-based settings. Section 1861(eee)(2)(B) of the Social Security Act specifies that, for hospital-based settings, the immediate availability and accessibility of a physician for medical consultation and medical emergencies is presumed.

Non-hospital-based settings: The claim must show the place of service and the facility must provide documentation to verify a physician is immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. The Code of Federal Regulations (42 CFR § 410.27) provides a further discussion of the meaning of such supervision.

  1. "direct supervision" means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or non-physician practitioner must be present in the room when the procedure is performed. For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or osteopathy, as specified in §§410.47 and 410.49, respectively.

Procedures and protocols: Programs providing cardiac rehabilitation services typically follow a set of procedures, policies and protocols. CGS anticipates that these protocols would include information about how the direct supervision requirement is met. For example, some facilities have a hospitalist who is on duty in their facility. Providers must maintain documentation which demonstrates there is a procedure in place which meets this requirement and that the procedure was followed in the specific case being reviewed (on the day of service in question.) For example: a copy of the section of the procedure, policy, and/or protocol that explains it, and a log section verifying a particular physician, signed and dated by him/her showing that the physician was indeed on duty to do this service, would suffice. Regardless of the manner in which direct supervision is documented, it is important to show all of the elements required by the rule are met. For a non-hospital based facility, a log identifying the direct supervising physician that is signed and dated by that physician is expected. In addition, when requested, it is expected that a non-hospital based facility provide its policies, procedures, and protocols that ensure adherence to the rules set forth above. The requested records must include the policies, protocols and procedures, plus the signed and dated log book that clearly shows that an MD was readily available on that particular day.

Physician supervision: Physician supervision of cardiac rehabilitation is specifically addressed by statute. Because the Congress explicitly stated services must be "physician-supervised," non-physician practitioners may not serve the supervising role for cardiac rehabilitation services even if those practitioners may sometimes supervise other services in other settings under separate legal authority, such as state law.

Non-hospital-based services:

  • The policy and procedure, calendar, schedule, or call log are required to substantiate physician supervision and must be provided.
  • "direct supervision" means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or non-physician practitioner must be present in the room when the procedure is performed. For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or osteopathy, as specified in §§410.47 and 410.49, respectively.

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