MAC J-15 Cardiac & Pulmonary Probe Audit / Ohio & Kentucky (March 2012) J. Rosneck MAC 15 Chairperson

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1 Greetings All, MAC J-15 Cardiac & Pulmonary Probe Audit / Ohio & Kentucky (March 2012) I discovered late last week from the AACVPR, prior to presenting at the Kentucky state meeting, that the RAC probe auditors who are conducting CR & PR probe audits in Ohio & Kentucky are the same group of auditors who recently performed a similar audit of CR programs in North & South Carolina (J-11). Below are findings from those recent audits (highlights are mine) [Pgs 2-5]. The error rates were extremely high and have prompted a focused record review of CR billing in these states. The AACVPR national leadership is working with the medical director in J-11 to rectify the situation. The main contention of the RAC reviewers was inadequate documentation of daily medical supervision. Reviewers wanted to see daily documentation in the individual patient record of this coverage a calendar schedule of physician coverage did not suffice. A number of CR & PR programs in Kentucky have recently been audited, typically with a request for 5-10 patient records. Many of the Kentucky programs document physician coverage via a monthly calendar schedule (AACVPR believed this would be adequate). My suggestion to them was to ask the physician covering to initial/sign on the calendar dates covered. Also, to add on the calendar a signature key to establish for the reviewers what scratch belongs to each physician providing documentation of coverage. I haven t been able to get a response from our compliance people but, I believe this can be done by a physician retrospectively to attest that they were present and available on the dates and times scheduled if audited. Perhaps the best solution would be to add a place on ones daily reports for a supervising physician signature. The doc would then be able to sign after the fact as an attestation to their being the supervising physician on the date and time the service took place. We have already made this change to our own database but plan to only generate these daily documents upon audit for physician documentation. Another concern is the auditors request in the CGS PR documentation request guidelines [pg. 6 below]. In addition to supervising physician documentation auditors are looking for documentation of individual session times. Again, what they are requiring are individual recordings of the patient s daily time-in / time-out of program NOT scheduled session time. We have known that CMS would require this documentation given the statutory rules for both PR & CR requiring at least 31 documented minutes for the billing of one session and 91 minutes for two sessions. Hopefully, all are observing and documenting individually. (Although there was not a specific reference to time documentation in the CGS CR documentation request guidelines [pg. 7 below], I would strongly suggest being prepared for that eventuality.) I and my colleagues on the MAC J-15 committee will continue to keep the OACVPR apprised of any updates regarding this and other H&PP issues as they occur. Jim Rosneck RN, MS, FAACVPR AACVPR MAC J-15 Chairperson 1

2 J11 AB MAC Medical Review Audit Cardiac Rehabilitation Program Services Findings, Documentation Requirements, and Medicare Requirements Coverage for Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) programs was provided under the 2008 Medicare Improvements for Patients and Providers Act (MIPPA). Conditions for coverage for CR and ICR was added, with Section in the Code of Federal Regulations (42 CFR), through rule making in calendar year (CY) Certain requirements need to be met In order for CR and ICR to be covered and reimbursed under Medicare. Section provides the type of items and services, definitions and indications for coverage, settings, standards and physician supervision requirements needed in order for a CR or ICR program to received reimbursement under Medicare. J11 AB MAC Pre-payment Audit Results for CR Palmetto GBA, J11 AB MAC has recently completed pre-payment probe review and audit of CR services of Medicare claims submitted by providers in the states of North Carolina and South Carolina. The audits discovered an 85% error rate in SC and 98% in NC. As a result of these findings Palmetto GBA is expanding pre-payment review of CR services throughout the J11 territories. This article addresses only CR program requirements because CR program services were the specific focus of the J11 AB MAC pre-payment audits. Documentation Deficiencies Documentation deficiencies resulting in denials of submitted claims include but are not limited to the following: Validation there is Direct Physician Supervision Confirmation that the physician is immediately availability Compliance with CR Program Physician Requirements Compliance with Signature Requirements Documentation Requirements 2

3 There must be documentation in the clinical record that validates there is Direct Physician Supervision by a medical director actually involved with the patient s CR program management, interacting with the staff and providing consultative services. The documentation must also allow the Medical Review auditor to confirm that a physician is immediately available for emergency services. The supervising physician or medical director does not necessarily have to serve as the physician readily available to respond to emergencies. This needs to be clearly stated and documented in the clinical record. The scheduled On Call or Code Blue physician lists attested to and presented by the hospital does not by itself meet the requirements of Direct Supervision or supervision by a CR program medical director. If the On Call or Code Blue physician actually serves as the CR program medical director then the documentation needs to state and confirm that the physician is actually serving in a dual capacity as the CR program medical director and On Call or Code Blue physician, meeting all of the Medicare requirements for CR program services as stated below. It is anticipated that a Medicare participating hospital, meeting Federal and State certification requirements, provides physician level credentialing that meets Medicare requirements for the CR program. The requirements for supervising physician as well as physician availability to respond to emergencies are listed below. It is anticipated that the hospital Medical Staff office keeps the credentialing file on site and available upon request. Signature authentication and validation for services actually ordered by the prescribing physician is mandated by Federal Law through the Social Security Act. The clinical record must clearly identified and provide legible documentation that the prescribing physician actually ordered, signed and dated an order for the CR program services billed to Medicare. Medicare Beneficiary Coverage for CR Program Services Medicare beneficiary coverage requirements for CR (effective January 1, 2010) services include one or more of the following: An acute myocardial infarction within the preceding 12 months; A coronary artery bypass surgery; Current stable angina pectoris; Heart valve repair or replacement; Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; A heart or heart-lung transplant; or, Other cardiac conditions as specified through a national coverage determination (NCD) (CR only) In order for a CR program to receive reimbursement the following components must be provided: 3

4 Physician-prescribed exercise Cardiac risk factor modification Psychosocial assessment Outcomes assessment An individualized treatment plan Frequency and Duration of CR Program Sessions 42 CFR (f)(1) limits CR sessions to a maximum of 2 1-hour sessions daily for up to 36 sessions over 36 weeks. Exception can be made with an option for an additional 36 sessions over an extended period of time provided the Medicare Contractor approves these as reasonable and necessary under section 1862(a)(1)(a) of the Act. CR Program Setting Requirements CR services must be furnished in a physician s office or a hospital outpatient setting. When sessions are being furnished under the CR program a physician must be immediately available and accessible to provide medical consultations and respond to emergencies at all times. This provision is considered satisfied if the physician services meet requirements stated in 42 CFR for direct supervision in the physician office setting or those stated in 42 CFR for hospital outpatient services. CR Program Physician Requirements Physicians who are responsible for overseeing or supervising the CR program, at a particular site, are identified as medical directors. A medical director, in consultation with staff, is involved in actually directing the patient s progress during the CR program. The designated medical director, as well as supervising physician(s), must have all of the following clinical expertise: (1) Expertise in the management of individuals with cardiac pathophysiology, (2) Cardiopulmonary training in basic life support or advanced cardiac life support, and (3) Licensed to practice medicine in the state in which the CR program is offered. A supervising physician or the designated medical director must meet the definition of physician supervision in order to satisfy Medicare requirements for CR under 42 CFR Medicare References 4

5 Pub , Medicare Claims Processing Manual, chapter 32, section This provides specific claims processing, coding, and billing requirements for CR program services. Additional Medicare CR program References, Medlearn (MLN) Matters Articles, Transmittals or Change Request

6 CGC Pulmonary Rehab Documentation Request Guidelines 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) 6

7 CGC Cardiac Rehab Documentation Request Guidelines 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) 7