Treatment plans that are cookie cutter, unsigned and otherwise noncompliant put claims for cardiac rehabilitation and pulmonary rehabilitation at risk of denial, experts say. With cardiac and pulmonary rehab on the recovery audit contractor (RAC) hit list and CMS adding COVID-19 as another covered diagnosis for pulmonary rehab, they might be ripe for an internal review. But improving compliance may be complicated by the fact that Medicare requirements aren’t always detailed enough, according to the HHS Office of Inspector General (OIG).[1]
On the one hand, the 2021 audit of 100 claims for cardiac and pulmonary rehab submitted by one provider found errors on all of them. On the other hand, OIG “was pointing the finger at CMS for these errors, saying it has not been clear enough about some of the regulations and guidance,” said Georgia Rackley, a senior clinical specialist at SunStone Consulting.
Some Medicare requirements for cardiac and pulmonary rehab, however, are black and white, such as physicians signing individualized treatment plans every 30 days. Wanda Cidor, a manager in the Deloitte & Touche advisory practice, said physicians failing to review and sign them timely is one of the top mistakes in this area. That’s presumably something RACs look at in their reviews, which focus on whether cardiac and pulmonary rehab is medically necessary and meets Medicare coverage criteria.[2]
Cardiac rehab, intensive cardiac rehab and pulmonary rehab are outpatient physician-supervised programs that include exercise, education, counseling, behavioral intervention, psychosocial intervention and an outcomes assessment. Medicare covers cardiac rehab for patients who had an acute myocardial infarction within the preceding 12 months, coronary artery bypass surgery, have current stable angina pectoris, had heart valve repair or replacement, percutaneous transluminal coronary angioplasty, coronary stenting, a heart or heart-lung transplant, stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks. Medicare covers pulmonary rehab for patients with moderate to very severe chronic obstructive pulmonary disease (defined as GOLD classification II, III and IV) when they’re referred by the physician treating the chronic respiratory disease. CMS extended coverage for patients “who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective January 1, 2022),” according to Medicare Transmittal 11,426.[3]
