Medicare Reimbursement “New Rules…New Game” Relating Public Policy Changes to Program Evolution

1. Medicare Reimbursement“New Rules…New Game”Relating Public Policy Changes to Program Evolution KCRA Annual Meeting March 15, 2012 Jim Rosneck RN, MS FAACVPR

2. Presentation Objectives • Describe Medicare Account Contractors (MACs) • Describe AACVPR Health & Public Policy Committee Functions • Report on current AACVPR national & local public policy initiatives • Discuss programming opportunities given the new rules • Describe national lobbying strategies and 2012 DOTH activities

3. Next Week’s Objectives • Ohio High School State Championship Tournament

4. CMS MAC-15 Update “What is a MAC”? • CMS Medicare Account Contractor (MAC)  ‘Integrate & centralize information and create efficient processes for delivery of comprehensive care to Medicare beneficiaries’. • Goals: • Full and open competitions to replace existing system of Fiscal Intermediary (FI) contractors • Increased efficiencies • Consistent approach to medical coverage across the service area • Competition among current MACs to encourage quality cost efficient service to health providers. • Focus on financial management to achieve more accurate claims payments and greater consistency in payment decisions.

5. Section 911, Medicare Prescription Drug, Improvement and Modernization Act of 2003 • 15 MAC Geographic Regions J-15 CIGNA “CGS”

6. CIGNA Government Services (CGS) Functions • CMS will ensure its MAC contracts focus on three critical areas: • Customer service • Operational excellence • Financial management. • Medicare coverage and billing requirements, and the receipt, processing, and payment of Medicare fee-for service core claims processing operations for both Part A and Part B. . • Interpret CMS statutory rules & national coverage determination “NCD” language and intent in the development of MAC-LCD’s • Maintain a staff of experts knowledgeable of all aspects of the fee-for-service program

7. AACVPR MAC J-15 Committee • Dalynn Badenhop, OH • Mike Bichsel, OH • Elaine Bohman, OH • Sherri Bradley, KY • Peggy Cox, KY • Tammy Garwick, OH • Jim Rosneck, OH • Rich Sukeena, OH • Stephanie Tucker, KY • (Physician Liaison: Rich Josephson, OH)

8. AACVPR J-15 Committee Functions • Maintain Communication • Insure that CGS  Cardiac & Pulmonary Rehab local coverage determination (LCD) represents the letter and intent of the recent national coverage determination. • Coordinate activities with AACVPR national H&PP committee members & leadership. • Communicate issues effectively with OACVPR & KCRA leadership to insure that member and non-member programs are aware of H&PP issues.

9. MAC J-15 Current History • CGS “Cutover” from NGS (Fiscal Intermediary) management October 17, 2011 • LCD Postings at least by September 1st 2011 • October 2012 CGS decision to adhere to the National Coverage Determination NCD and/or statutory rules interpretation

10. MAC J-15 “CGS Strategy” • “Watchful Waiting” • Announcement of CGS - LCD writing group • J-15… action committee will directly contact CGS medical director Gary Oakes MD. • Educate • Petition for adherence to Medicare NCD statute • Involve AACVPR national officers PRN

11. CMS: Components of Pulmonary Rehab Physician prescribed exercise: Patient centered Some aerobic training included in each session Education Tailored to individual needs Tailored to behavioral change Brief smoking cessation Nutrition Proper medication use & adherence Psychosocial Assessment Include assessment of home support Objective measure of progress (Pre & Post Testing) 11

12. CMS: Components of Pulmonary Rehab Outcomes assessment: Baseline assessment & patient centered goals Individual progress via objective measurements. Pretesting - Goal Setting – Post testing Individualized Treatment Plan Diagnosis Type, amount, frequency and duration of the items and services Patient centered goals Established reviewed and signed by a physician Reviewed & signed by the medical director Physician Supervision 12

13. CMS: Components of Pulmonary Rehab - Diagnosis COPD Moderate, severe and very severe COPD (GOLD guidelines) Billing code = G0424 Non-COPD All other previously recognized diagnoses Billing code = G0239 “Group Exercise” Billing code = G0238 “Individual Exercise q15min” Billing code = G0237 “Individual Education q15min” LCD will eventually determine the status of Non-COPD diagnosis Require the “59” modifier 13

14. Pulmonary Program Evolution Necessity of ECG monitoring? Aerobic exercise requirement (PR/session - CR/day) Two daily sessions 36 sessions / 36 weeks (PR limited 72 lifetime) Sessions in excess of 36 No restrictions re: program crossover Educational & Psychosocial requirements GOLD standard = increased PR patient eligibility Program individualization per patient focused needs Knowledge translated to behavioral change Require the “KX” modifier 14

15. How About Cardiac Rehab! 15

16. NGS & CGS Cardiac Rehab Coverage: “Similarities” • Physician directed & *supervised • Components include: • exercise prescription • risk factor modification • psychosocial assessment • outcome assessment • Individual treatment plan • diagnosis • individual goals • type, amount, frequency and duration of items and services provided. • Reviewed and signed by “a physician” every 30 days • Non-physician practitioner (NPP) may order the Cardiac Rehabilitation if it is within his/her scope of state practice under licensure *DOTH 2012 issue

17. Cardiac Rehab Performance Measures

18. NGS vs. CGS Cardiac Rehab Coverage • NGS: heart valve surgery, PTCA or stenting and stable angina must begin a program within “6mths” • CGS: accepted diagnosis can begin a program within 12mths of procedure or diagnosis • NGS: clause re: angina assessment via angiographic changes during GXT. • CGS: angina diagnosis is determined by the referring physician

19. NGS vs. CGSMedical justification for extended participation • “Once a patient has reached the exit criteria (i.e. 36 sessions), further CR will not be considered reasonable and necessary”…. unless • Proof of ischemia or dysrhythmia per GXT • Achievement of 7< METs “a stable level of exercise tolerance” (AHA Class I or normal FWC) • 6< minutes on a Bruce Protocol (or equivalent) • Significant ischemia or dysrhythmia > 6 minutes GXT • Heart Transplant < 90% predicted VO2 peak • CGS: Medical necessity proactively documented by the referring / supervising physician

20. CGS - Recent Developments

21. CGS Bulletin (Februar:y 10, 2012) • Probe Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (includes monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424) • Probe Medical Review of Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (93798) • CGSJ15 Part A Medical ReviewMail Code: AG-2562300 Springdale Drive, Building OneCamden, SC 29020 Recovery Account Contractor “RAC”

22. Pulmonary “Probe” Medical Review • Physician's orders for all services billed • UB-04 • Any documentation that supports medical necessity for pulmonary rehabilitation • Documentation that the physician was immediately available for each monitored session billed • Documentation of the actual in/out times for each session billed • Nurse's notes • Progress notes • Lab reports • X-ray reports (if applicable) • Radiology test results • Therapy notes (if applicable) • Any other diagnostic reports • Itemized supply or medication lists for all items billed for these dates of service • Please submit all documentation as required in the LCD or NCD (if applicable) Schedule of physician coverage or class times not sufficient!

23. Cardiac “Probe” Medical Review • Physician's orders for all services billed • UB-04 • Any documentation that supports medical necessity for continuous ECG monitoring • Documentation that the physician was immediately available for each ECG monitored session billed • Nurse's notes • Progress notes • Lab reports • X-ray reports (if applicable) • Radiology test results • Therapy notes (if applicable) • Any other diagnostic reports • Itemized supply or medication lists for all items billed for these dates of service • Please submit all documentation as required in the Local Coverage Determination (LCD) or National Coverage Determination (NCD) (if applicable) Schedule of physician coverage not sufficient!

24. Documentation Example

25. Pulmonary Rehab Cost Accounting Tool Kit: • Problem: CMS accounting methodology has reduced G024 reimbursement to $37.43/session • Solution: To use “non-standard” methodology to appropriately calculate G024 charges. • The “Tool Kit” = primer for pulmonary rehab clinicians to approach their finance depts with a step-by-step process for cost calculations. • Will be released March 29th with instructions via AACVPR state affiliate conference call.

26. AACVPR “Day On The Hill” DOTH 26

27. Day On The Hill: DOTH 27

28. DOTH AACVPR “Gang of Four” J- 15 Representatives 28

29. Talking Points…The “Pitch” 29

30. 1st Talking Point: NPP Supervision of CAH - C&P Programs • Issue: Critical Access Hospitals (CAH) programs in jeopardy due to physician supervision language in current statute. (Imposes strict requirements, describing the direct physician supervision standard for PR, CR services) • “Technical Correction” to existing 2008 legislation codifying Cardiac & Pulmonary rehab. • Bi-partisan co-sponsors • No additional $ involved. • Prevents use of Medicare services by constituents served by CAHs.

31. 2nd Talking Point: Cost Reporting • 2009 CMS commissioned Research Triangle Institute (RTI) to investigate HOPPS rate setting processes. • RTI data indicated a reimbursement of > $100/session (Current CR = $69.50…PR = $37.43) • RTI found the CMS processes mapping cost-to-charge relationships in C&P programs was flawed and easily corrected. CMS chose to not heed this advise. • HOPPS final rule page 101:CMS-1504-FC 101 (2011 rule changes this process & allows for the use of the “non-standard” methodology) • CRUCIAL all programs should contact their reimbursement depts. to insure they use this method of reporting costs to CMS.

32. 3rd Talking Point: Excessive Medicare “Advantage” Co-pays • Medicare “Advantage” = Pulmonary & Cardiac Rehab “Disadvantage” !!! • Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. • Mandated to follow rules set by Medicare. • Each Medicare Advantage Plan however has the freedom to require per-session co-pays greatly in excess of the typical 20% ($7.49) per session fee. • High co-payments = denial of services

33. Thank you…questions