CMS Guidelines
On July 18, 2014, CMS (The Centers for Medicare &
Medicaid Services) published a National Coverage Determination (NCD) and
accompanying instructions regarding cardiac rehabilitation (CR) for heart
failure (HF) patients. As the final
Medicare policy states (NCD,2014), coverage of cardiac rehabilitation for beneficiaries
with stable, chronic heart failure was effective for dates of service on and
after February 18, 2014. The
implementation date is August 18, 2014. This means that all Medicare
contractors (known as MACs or Medicare Administrative Contractors) must have
completed changes to their claims processing software so that appropriate heart
failure diagnoses (ICD-9 codes) are not denied. For CR programs that received
denials for CR services provided to heart failure patients as of February 18th
or later, re-submission after August 18th may necessary for reimbursement. Some
MACs, J5 for instance, was ready for implementation on the February 18th
date. All MACs must be ready and able to
process these claims by August 18th.
The NCD guidelines for stable, chronic heart failure contain the following provisions:
• Left ventricular ejection fraction ≤ 35%
• NYHA class II-IV symptoms despite being on optimal medical therapy for at least 6 weeks
• Stable: have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalization or procedures
HF is an addition to the current diagnoses currently covered by Medicare for CR (NCD, 2014).
In general, stable means that the patient's symptoms from heart failure are not worsening relatively rapidly, requiring prompt evaluation for medication adjustment or procedures. Although patients with heart failure can have "good days and bad days", progressive declines in functional capacity due to fatigue or dyspnea or rapid increase in edema or weight may be symptoms of medical instability. Stability should be determined by the referring physician.
Optimal medical therapy varies, depending on a patient's tolerance for medications, but in general includes a beta blocker such as carvedolol or metoprolol and an ACEI or ARB. Referring physicians will understand the concepts of stable and optimal medical therapy, as they relate to patients with heart failure. The referring physician is going to guide the access to CR.
Patients cannot have been hospitalized for HF or major cardiac event for at least 6 weeks. What is “major”? Usually, PCI, pacemaker or ICD implantation are not considered major procedures in the medical realm. Hospitalization for an acute HF episode, LVAD insertion or CABG would be considered major hospitalizations or procedures.
LVEF ≤ 35% is a requirement, at this time. Patients with preserved LV function are not covered by CMS.
These guidelines appear to be broad. In all likelihood, CMS will not provide further explanation of eligibility criteria. Interpretation of these criteria is at the discretion of the MACs. For that reason, those interpretations may vary regionally. It is up to the medical community to collaborate with each MAC to achieve a clinical understanding of referral appropriateness for this CR patient population.
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) has a liaison person and committee for each MAC in the country. If you have questions regarding the policy, it would be wise to contact your local CR affiliate or AACVPR. The MACs prefer to have one central person contacting them instead of receiving calls from multiple CR programs or facilities.
A survey of 50 large commercial insurance companies, representing 80% of the health insurance market in the United States, found that two thirds of the companies reported providing coverage for CR for patients with HF. Most of these insurance carriers do not have the same stipulations that CMS has imposed (Keteyian, Squires, Ades, & Thomas, 2014, p. 229).
The interpretations on the new CMS criteria for HF admission into CR are strictly my own, based on my many years of experience in CR, and do not reflect the actual reimbursement by CMS or your own local MAC. As with all new coverage diagnosis for CR by CMS, we will have to see what actually transpires.
References:
Keteyian, S. J., Squires, R. W., Ades, P. A., & Thomas, R. J. (2014). Incorporating patients with chronic heart failure into outpatient cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation & Prevention, 34, 223-232. http://dx.doi.org/10.1097/HCR.0000000000000073
National Coverage Determination (NCD) for Cardiac Rehabilitation Programs for Chronic Heart Failure (20.10.1), 20.10.1 CMS § 20.10.1 (2014).
The NCD guidelines for stable, chronic heart failure contain the following provisions:
• Left ventricular ejection fraction ≤ 35%
• NYHA class II-IV symptoms despite being on optimal medical therapy for at least 6 weeks
• Stable: have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalization or procedures
HF is an addition to the current diagnoses currently covered by Medicare for CR (NCD, 2014).
In general, stable means that the patient's symptoms from heart failure are not worsening relatively rapidly, requiring prompt evaluation for medication adjustment or procedures. Although patients with heart failure can have "good days and bad days", progressive declines in functional capacity due to fatigue or dyspnea or rapid increase in edema or weight may be symptoms of medical instability. Stability should be determined by the referring physician.
Optimal medical therapy varies, depending on a patient's tolerance for medications, but in general includes a beta blocker such as carvedolol or metoprolol and an ACEI or ARB. Referring physicians will understand the concepts of stable and optimal medical therapy, as they relate to patients with heart failure. The referring physician is going to guide the access to CR.
Patients cannot have been hospitalized for HF or major cardiac event for at least 6 weeks. What is “major”? Usually, PCI, pacemaker or ICD implantation are not considered major procedures in the medical realm. Hospitalization for an acute HF episode, LVAD insertion or CABG would be considered major hospitalizations or procedures.
LVEF ≤ 35% is a requirement, at this time. Patients with preserved LV function are not covered by CMS.
These guidelines appear to be broad. In all likelihood, CMS will not provide further explanation of eligibility criteria. Interpretation of these criteria is at the discretion of the MACs. For that reason, those interpretations may vary regionally. It is up to the medical community to collaborate with each MAC to achieve a clinical understanding of referral appropriateness for this CR patient population.
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) has a liaison person and committee for each MAC in the country. If you have questions regarding the policy, it would be wise to contact your local CR affiliate or AACVPR. The MACs prefer to have one central person contacting them instead of receiving calls from multiple CR programs or facilities.
A survey of 50 large commercial insurance companies, representing 80% of the health insurance market in the United States, found that two thirds of the companies reported providing coverage for CR for patients with HF. Most of these insurance carriers do not have the same stipulations that CMS has imposed (Keteyian, Squires, Ades, & Thomas, 2014, p. 229).
The interpretations on the new CMS criteria for HF admission into CR are strictly my own, based on my many years of experience in CR, and do not reflect the actual reimbursement by CMS or your own local MAC. As with all new coverage diagnosis for CR by CMS, we will have to see what actually transpires.
References:
Keteyian, S. J., Squires, R. W., Ades, P. A., & Thomas, R. J. (2014). Incorporating patients with chronic heart failure into outpatient cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation & Prevention, 34, 223-232. http://dx.doi.org/10.1097/HCR.0000000000000073
National Coverage Determination (NCD) for Cardiac Rehabilitation Programs for Chronic Heart Failure (20.10.1), 20.10.1 CMS § 20.10.1 (2014).
