Cardiology Coding Alert

Showing doctor involvement clinches $15 per session

To report clean claims for your cardiac rehabilitation services, you'll need the right documents, including the attending physician's script, the supervising physician's signature on exercise sessions, and plenty of support for separate services during rehab sessions.

By now, you're aware that the HHS Office of Inspector General (OIG) is targeting cardiac rehab programs in this year's Work Plan. (See "Get Your Dx Right for CPT 93798 and Cash in on Cardiac Rehab" in the April 2004 Cardiology Coding Alert for more on how to report cardiac rehab services.)

So far this year, the OIG has audited 34 cardiac rehab programs to make sure they are meeting current Medicare coverage requirements.

Missing Notes Attract Scrutiny

To keep your practice in the clear, review the following four most common problem areas identified by the OIG: 

Problem 1: The physician's professional services were not apparent.   

Lesson learned: Make sure your cardiologist performs both initial and subsequent services to reflect active participation in the course of treatment. "It's very important that the treating physician provide a written prescription for cardiac rehab services," says Sheldrian Leflore, CPC, a cardiology-coding consultant with Gates, Moore & Company in Atlanta.

Real-life advice: Before billing 93798 (Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring [per session]), document everything, says Happiness Miller, RN, an auditor with the cardiac catheterization lab in Central Baptist Hospital in Lexington, Ky. "Our outpatient cardiac rehab department has the patient's physician sign the prescription, the initial plan of care, the six-week update, and the follow-up documentation," she says. Getting your documentation right will eliminate reimbursement woes. Indeed, Medicare pays about $15 per facility session for 93798, according to national averages in the 2004 Physician Fee Schedule --and for a patient on a six-week protocol, this can really add up.

Also, remember that cardiac rehab services (93797 and 93798) have a zero-day global package. To bill for any additional physician services on the same day as cardiac rehab, append modifier -25 (Separately identifiable evaluation and management service ...) to the appropriate E/M code to prevent bundled-service denials. For instance, the physician might perform an interim physical exam to assess the therapy's impact and to make sure no adverse events are imminent. In this situation, you would report an established patient office visit (for example, 99213-25) and the cardiac rehab service. 

Problem 2: The reports didn't identify the supervising physician. 

Lesson learned: Be very clear about documenting who the supervising physician is for each cardiac rehab service.

A CMS official provided Cardiology Coding Alert with the following definition of direct supervision for cardiac rehab services: "It does not require that a physician be physically present in the exercise room itself, provided the contractor does not determine that the physician is too remote from the patients' exercise area to be considered immediately available and accessible."

In other words, the supervising physician must be in the exercise program area and available for emergencies but does not have to be in the exercise room, Leflore says.

Best strategy: Have staff sign off on exercise summaries as "Provided under the direct supervision of Dr. X." In physician practices, any on-site physician can take on supervisory responsibility for incident-to services. But make sure you bill the cardiac rehab sessions under the on-site, supervising physician. Keep in mind that this physician may not be the patient's regular physician, who ordered the cardiac rehab or provided the first service.

Problem 3: The reports did not provide sufficient documentation to support each of the exercise sessions.

Lesson learned: Each service you report to Medicare must be specifically documented in the patient's record. At any point following billing, you might be required to submit proof of services that you billed; this is a long-standing condition of participation, coding experts say. Although CPT provides no definitive standard for cardiac rehab documentation (as for E/M services), a nurse summary of the exercise session should suffice. The nurse's notes may indicate exercise type, duration, electrocardiographic responses, and a comparison to previous rehab sessions.

Problem 4: The session notes lacked covered diagnosis documentation.

Lesson learned: Cardiac rehab services have three main covered indications: documented diagnosis of acute myocardial infarction within the preceding 12 months, coronary bypass surgery, and/or stable angina pectoris, according to Medicare's National Coverage Determination, Leflore says.

"The frequency and duration of the program are three sessions per week for 12 weeks," Leflore says. "Medical necessity must be provided to support additional sessions."

Indeed, if the physician does not document one or more of the above indications, Medicare will not cover the rehab.

ABNs Cover Your Losses

Be sure you check your local medical review policy for covered diagnoses, Miller says.

Good idea: Ask Medicare patients who do not meet coverage criteria but who require cardiac rehab to sign an advance beneficiary notice before you provide the rehab services. If you must file a claim to Medicare for these noncovered services, such as when you need Medicare denial before billing the secondary payer, append modifier -GA (Waiver of liability statement on file) to 93797 or 93798.

Note: To read the OIG reports of recent cardiac rehab audits, go to http://www.oig.hhs.gov/oas/oas/cms.html. For more on cardiac rehab, see the American Association of Cardiovascular and Pulmonary Rehabilitation's site http://www.aacvpr.org.