Brought to you by the Legislative and Reimbursement Committee of CV & P Section in collaboration with APTA Government Affairs Department

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On July 1, 2009, the Centers for Medicare & Medicaid Services (CMS) posted on its web site proposed changes to policies and payment rates for services to be furnished during calendar year (CY 2010) by physicians and non-physician practitioners (Medicare Physician Fee Schedule or MPFS) and for services provided by hospitals under the Outpatient Prospective Payment System (OPPS). Within both of these documents are new proposed rules for cardiac and pulmonary rehabilitation. The rules in the OPPS and in the MPFS are separate but related. Both are consistent with one another and are in response to the legislative mandate given to CMS by Congress via the Medicare Improvements for Patients and Providers Act (MIPPA), passed in July, 2008. CMS will accept comments on the proposed rules until August 31, and will respond to all comments in final rules to be issued by November 1, 2009. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after January 1, 2010.

APTA and representatives from the Cardiovascular and Pulmonary Section have reviewed and are continuing analysis of these proposed changes and are working on communications to CMS to articulate their effect on physical therapy. In addition, APTA and the Section are working on recommendations to these proposals that would allow physical therapists the ability to effectively and appropriately bill for their services under the Medicare physical therapy benefit separate and apart from the mandates of the cardiac and pulmonary rehabilitation benefits.

The following is a brief summary of key points that have been PROPOSED by CMS. 

Cardiac Rehabilitation (CR)

New program changes:

Traditional CR sessions need to be a minimum of 60 minutes with a minimum of 2 CR sessions per week and a maximum of 2 CR sessions per day. 

A new program entitled Intensive Cardiac Rehabilitation (ICR) and otherwise known as “lifestyle modification programs” will be permitted ONLY IF these programs have been approved by Medicare based upon scientific evidence demonstrating their outcomes.  ICR usually provides more than 2 sessions/day and consists of 72 one hour sessions over 18 weeks. 

Physician supervision was revised to state “Direct supervision of CR services by a doctor of medicine or osteopathy” and not “presumed” if in a hospital outpatient setting.

Pulmonary Rehabilitation (PR)

The only covered diagnosis for the NCD would be COPD with moderate to severe disease (GOLD classification II and III with FEV1/FVC < 70%).  CMS reports they would consider expanding the diagnosis list based on provision of evidence of patient benefit with other disease categories.

Each session must be a minimum of 60 minutes with a maximum number of sessions = 36.

The supervising physician is required to have initial direct contact with the patient prior to treatment by PR staff, and direct physician contact every 30 days.  The physician is responsible for reviewing, signing and modifying the individualized treatment plan as needed.

In the rule, CMS discusses whether CORFs could be considered a setting in which there could be a pulmonary rehabilitation program. CMS decided not to propose extending the PR program to CORFs. They state that individuals requiring PR program services have a chronic respiratory disease and are in need of supervised aerobic exercise, not physical therapy. In the CORF setting physical therapy is the cornerstone component and a mandatory service, while exercise is not. Thus the PR program is for an inherently different population and allows exercise for the first time. APTA has serious concerns with this distinction and will be communicating these concerns to CMS during the rulemaking process.

One HCPCS code would be created to describe and to bill for the services of a PR program: GXX30, Pulmonary rehabilitation, including aerobic exercise (includes monitoring), per session per day.  Work RVUs would be 0.18, practice expense RVUs would be 0.40 and malpractice RVUs would be 0.01. If the conversion factor for 2010 remained the same as 2009 (36.0660), these RVUs would result in a payment amount of $21.28.The settings that PR services are covered under this NCD include hospital outpatient and physicians offices and not CORF settings. 

APTA and the Section will be working with CMS to ensure that language is inserted into the final rule that recognizes the importance of physical therapy to patients with pulmonary dysfunction. We also will be seeking clarification that physical therapy services are medically necessary and are not duplicative to other services included in a pulmonary rehabilitation program.

Forward any questions or individual comments to the chair of the committee, Ellen Hillegass