Medicare Compliance & Reimbursement

Show off your outcomes data to keep docs hyped about your program.

The word from CMS is that many outpatient cardiac rehab facilities don't ensure proper physician supervision, and now the OIG wants to see who's minding the shop. If you're using an ER doc to cover your rehab therapy, you could be next in line for an audit, experts warn.
 
Specifically, the HHS Office of Inspector General's 2005 Work Plan targets incident-to compliance in hospital outpatient departments that provide cardiac rehab. The Centers for Medicare & Medicaid Services specifies that non-physician personnel providing cardiac rehab services in these settings should be under direct physician supervision for reimbursement.
 
Basic flaw: But CMS is fuzzy on what "direct" supervision actually means in these settings - which makes complying with this rule difficult, says Gary Liguori, a cardiac rehab specialist and assistant professor at North Dakota State University in Fargo.
 
In addition, FIs vary in their physician supervision descriptions, says Debbie Lund, a clinical therapist with the cardiac rehab unit of North Arundel Hospital in Glen Burnie, MD, and a member of the reimbursement committee of the American Association of Cardiovascular and Pulmonary Rehabilitation.
 
Ideally, Medicare wants a physician to be in the cardiac rehab area and an integral part of the care, Lund explains. The doctor can be the medical director or he can designate a colleague of his choosing as the supervising physician.
 
How one cardiac program makes the grade: "Our medical director, who is an internist, is onsite every day, and we have a backup physician," offers Ann Pondrom, clinic manager for St. John's Therapy Services in St. Robert, MO. "We do not operate unless we have a physician in the building. We do not start therapy until [the physicians] start their day."
 
Warning: You won't find favor with auditors if you're using your ER physician as your supervising doctor. Lots of rural hospitals with only a couple of doctors on staff take this approach, Lund and Liguori note. ER physicians are dealing with emergencies and won't be available to help you.
 
To make sure you're doing all you should to show physician supervision in your program, follow this advice:
 
1. Have your supervising physicians sign contracts, Lund recommends. If you're designating a hospital staff physician as your supervisor, you need a contract with him to indicate that he's supervising the cardiac rehab area. 
 
2. Keep physicians jazzed about your program by showing that your patients make progress. You have to show that your program works by giving outcome data to show efficacy, Liguori says. "Programs that have good outcomes also have good physician involvement. Doctors won't see the point of documenting if the outcomes aren't clear."

3. Ask physicians to sign daily logs to show when they were onsite, Lund says.

4. Establish weekly reviews with your medical director. Once a week, St. John's medical director reviews pre- and post-exercise records for each of their cardiac phase II patients, Pondrom explains. "He signs the records and documents anything that he thinks is questionable." 
 
5. Send "FYI faxes" to the referring physician if something unusual happens during the exercise session, Pondrom recommends.
 
6. Provide progress summaries for follow-up visits. When patients go to referring physicians for follow-up, send a summary showing how they're doing and include space on the form for the physician's signature, Pondrom advises.
 
Patients should bring this form back when they return to the program. If they don't, document that you sent the form.
 
7. Learn all you can about cardiac rehab from the CMS site and your FI, says Nancy Kranzley, an administrator with Cincinnati Therapy Centers in Cincinnati.