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CARDIAC REHAB AUDIT SHOWS PROVIDERS SKIPPING A BEAT

Published on Mon Dec 22, 2003

What all rehab provider types can learn from outpatient cardiac mistakes. 

Outpatient cardiac rehab providers have fallen under the HHS Office of Inspector General's microscope - and four billing hotspots have emerged that could easily burn all rehab providers.

Redding Medical Center in Redding, CA was at the center of a landmark $54 million settlement involving the alleged performance of medically unnecessary invasive heart procedures and soon will be sold to an unrelated third party under terms acceptable to the OIG. But the facility is also one of many hospitals scrutinized in a recent round of the watchdog agency's audit reports on rehab billing issues.

In one report, the OIG fingers Holy Cross Hospital in Silver Spring, MD for receiving $7,470 in reimbursement for services lacking adequate documentation or which were otherwise unallowable (A-03-03-00007). In another report, the OIG found that although Memorial Hospital Jacksonville designated a physician to directly supervise the services provided by its cardiac rehabilitation program, there was no supervision during exercise sessions.

These documentation, physician supervision and "incident to" problems come up again and again in the audit reports, notes Debbie Lund with the American Association of Cardiovascular and Pulmonary Rehabilitation. Here are some of the most common mistakes cardiac rehab providers make:

  • Documentation. In order to bill Medicare for cardiac rehab, providers must have documentation showing a Medicare-covered diagnosis, notes attorney Robert Ramsey with Buchanan Ingersoll in Pittsburgh. Also, they must document the physician's interaction with the patient, which many departments miss, urges cardiac rehab expert Gary Liguori, a professor in the department of health, nutrition, and exercise sciences at North Dakota State University in Fargo, ND.

    Also, if the rehab facility has a medical director agreement in place with a physician, it must document that the physician is doing what the rehab provider is paying him to do, counsels Ramsey. If it looks like they're paying a physician for nothing, the feds will assume that money is actually payment for referrals - a clear violation of the federal anti-kickback statute.

  • Physician supervision. Physician supervision is "critical" to kosher billing for cardiac rehab, insists attorney Donna Thiel with Morgan Lewis & Bockius in Washington. In order to bill incident to a physician's service, there has to be direct physician supervision, she reminds providers.

    The fact that departments are being dinged on supervision rules in these reports might indicate that the Centers for Medicare & Medicaid Services wants even closer supervision than providers traditionally have thought, since even the OIG concedes that physician supervision is assumed to be met in an outpatient hospital department, Ramsey says.

    Providers should check with their fiscal intermediary or carrier about what it considers to be "direct" supervision, advises Lund. Many FIs and carriers interpret the rules differently, she notes. "Some will say basically within the hospital, and others are saying 'very close proximity' to the exercise suite."

    A rehab facility can have the best supervision on earth, but if it doesn't document it, it might as well have none at all. "There needs to be a paper trail," Lund stresses. Providers should write on the patient's chart who served as supervising physician for the day, and always document when a patient visits his physician, she advises.

  • Incident to. In order to bill incident to a physician's services, the therapy provided must actually be incident to a course of treatment from the physician - a point many rehab providers are missing, Thiel points out. That means there must be a documented established relationship between the patient and a physician, she says.

  • Unallowable diagnoses. Many facilities are facing recoupments of reimbursement because they listed stable angina as the diagnosis for patients who have undergone angioplasty (PTCA), Lund reports. "The way the regs read, the only way angina can be the diagnosis is if [the patient] currently has angina," she explains. And if the patient had a PTCA, then the angina was fixed, "and you should no longer be using that angina diagnosis," Lund continues.

    These audit reports should serve as a major "wake-up call" to cardiac rehab providers, Liguori says.

    To see the reports, go to http://oig.hhs.gov/oas/oas/cms.html.

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