Northeast Region

October 15, 2013

1.  AACVPR is urging all PR programs strongly to please review the Pulmonary Rehab toolkit and present to your financial department to adjust charges for G0424.  PR programs cannot continue to offer services when they are only being reimbursed for $39.  This is our own fault and we have the power to fix it.  If you have any questions or you need help convincing your CFO, please contact Jane Knipper.

2.  The AACVPR will be offering a Certified Cardiac Rehab Professional Certification exam next year at the National conference.  See the AACVPR website for more information.

3.  The AACVPR conference is in Denver Sept. 4-6, 2014.

4.  Day on the Hill is March 13 & 14, 2014.  We will continue to lobby about S.382, the technical correction to allow NPP’s to supervise rehab.

5.  The 5^th Edition of the the Guidelines for Cardiac Rehab are out.  Everyone should have this in their department says Karen Lui.

6.  We will have an opening for President Elect this year.  Please consider the position and let Claire know if you have any questions.

7.  AACVPR urged all rehab programs to join the CR and PR national AACVPR registry.  Many sessions at the conference urged tracking outcomes.  Our programs will become value based with the coming healthcare changes and we need to prove our worth!  At the Northwest meeting, some departments mentioned having issues with the registry.  Please let AACVPR know.  Give them an opportunity to improve what is a work in progress. 

8.  AACVPR has a new initiative to support the state affiliates and their leadership. They have formed regional groups and Iowa is with Wisconsin, Minnesota and Missouri and the other one I think is Kansas.  An AACVPR volunteer will coordinate a conference call 4/yr for us to network.  This is a great opportunity as Wisconsin was the affiliate of the year and they have a strong organization so we can learn great things from them.  Additionally, AACVPR will sponsor a leadership conference yearly in Chicago and will foot the bill for a hotel room for each affiliate (Pres and Pres elect can go).  This year it will be in June, but they do not have a set date as yet.

9.  Regarding several presentations on the potential healthcare changes in our future.  Here is what they said we should be doing to prepare:

     a.  Outcomes have to be presented?

     b.  Know your cost per case in rehab.  You made to know that to negotiate with insurance companies.

     c.  We need the ability for predictive modeling of outcomes with fixed costs.  We need a moneyball guy.  For example, does a late referral increase our cost and more.  An empty hospital will be better than a hospital with full beds because we will get cost per member per month from payers. 

     d.  When patients come into the hospital we will need to:  Assess risk, implement longitudinal care, and develop network of care providers.  This is where they predict homehealth will increase and our programs can make a difference. 

10.  G0424 will likely change to a new APC.  Jane Knipper is following this and will let us know when there are changes.

11.  We are hoping S382 can get pushed through the senate.  Many senators have not signed on.  Both Iowa senators are signed on.  The other states were urged to launch serious campaigns to get it done!

12.  Big news!  In June of this year CMS accepted a formal request for CHF to be a covered diagnosis.  In December, CMS is expected to post a proposed National coverage determination with a public comment period.  Karen Lui seemed very positive about the possibility that this could become affective in Spring 2014. 

13.  Lisa (Moeller), ARNP DNP with Dr. Sundaram’s office has started a local chapter of the PCNA (Preventative Cardiovascular Nurses Association) and is encouraging healthcare professionals (nurses, exercise physiologists, dieticians, etc) to join and support a local chapter.  Meetings will be held twice a year.  Benefits include:  webinars, CEU opportunities, local networking, and patient educational tools.  For more information, contact Erika Leonard at Allen Cardiac Rehab at 235-3911 or go to www.pcna.net and sign up under the Cedar Valley chapter.

Northwest Region

Thursday Oct. 17^th

Held at the Pocahontas Community Hospital, with 26 people attending!!

It was a great day of networking and great to have so many people come. A big thank you to Clarie Shannon for presenting us with information from the annual meeting and a copy of her balance assessment and exercises. Thank you too Jean Cipperly for informing us on some new statistics on diets and the use of fats making diets more successful.

Discussion about the amount everyone charges for each session of CR and PR. With higher prices it is difficult as we can miss some people that can not afford the co-pay but we also have to look at do we want to loose our whole program.

There is a new professional certification coming next September with the first exam being in Denver. Certified Cardiac Rehabilitation Professions (CCRP)

This year the Day on the Hill will be March 13 &14^th with the big issue being Dr. supervision. Please send any issues you have to Claire. Claire touched on the Physician in proximate distance of CR and told us there really was no change.

The 5^th addition of CR guidelines is out and can be ordered through AACVPR.

IACPR is in need of a president elect. Clarie talked about the responsibilities and how rewarding it has been for her. There are only 4 meetings with 3 being held by teleconference and the other meeting at the Heartland Conference.

We talked about the Registry and many voiced the problems they have had. Claire stressed that we need programs to join as we need outcomes. With Obama Care we will need to prove that we are cost effective. We talked about the nutrition survey programs use. Many use the Rate your Plate as it is easy and free. You can google it. We also talked about certification. Claire did mention that now once you complete your application they will no longer be sending things back for you to fix. If things are not done completely as they instruct you, you will not get certified.

Jean than shared some information that she had gotten at an AADE webinar; Healthy fats, Heart Disease and Type 2 Diabetes. She reviewed how the world’s top 12 health problems have changed from 1990 to 2010. Heart disease and stroke were 4^th and 5^th and now have moved up to 1^st and 3^rd. We all chuckled at the top risk factor in 1990 being low body weight and were reminded that this is world wide (in 2010 it was 8^th). In 2010 High blood pressure, smoking and alcohol are the top three with inactivity now on the charts at #10. Modified fat diets (decreasing saturated fats with unsaturated fats) have a better effect on major CV risk factors than reduced fat diets. Other points made were that no diet is better than the other and we need to individualize our plans and help our patients find what diet works for them and encourage them. Most people plateau in weight loss at 6 months and after that they don’t loose much, try help them learn to maintain. Pre-diabetics are more successful at loosing weight and we need to try help them than. More saturated fats will also increase insulin resistance. Monounsaturated fats will help boost the HDL some. It is more important to be fit than thin we were reminded.

Discussion about changes in health care coming with Obama Care, and that CR might be used on CHF pts. to help keep them out of the hospital, and/or there might be CR Home Health programs. There are some new plans for pts being discharged from the hospital called “See you in 7”. It has been shown that for every day a pt. is home and there is no contact with healthcare their attendance to CR decreases by 1% and their ER visits increase.  There is hope that CHF will be a covered diagnosis for CR. WATCH EMAILS, is could happen as early as spring 2014.

There was discussion about what programs were doing for competencies and how that sometimes is difficult for the one person department. We talked about referrals and how to keep clinic, ER’s, Home Care personnel informed so if a person gets missed they might catch it and make the referral.

Claire than presented us with her balance assessment and said we really should use this on any high risk pts. Those that have fallen in the last 6 months, feel unsteady, use a walker or cane etc. We than all did some of the balance exercises, some of us did not do as well as others J

Thanks to all for a great meeting

Mary Brandt RN, Coordinator of Pocahontas Community Hospital Cardiac rehab.

IACPR Spring 2013 Regional Meeting Summaries

Northeast Region

Tuesday, April 16^th in Independence at the Okoboji grill.  Deb Recker from Independence coordinated this one.  We had 13 in attendance.  Many had attended the Heartland conference so we rehashed for the other members the high points.  All Heartland attendees were complimentary of the pertinent information shared at the conference. 

1.        I shared handouts on the staff competencies that we use.  A discussion took place on how departments complete their competencies.  Some do a skills day and other do them monthly with their staff meetings.

2.      All departments have had a Takosubo patients and we shared our experiences.

3.      We discussed how each department is seeing CHF patients.  Some filter them into Phase II with a stable angina dx (mindful that it is truly angina), others incorporate them into their Phase III with a free consult to start. 

4.      We discussed billing two sessions in one day and what scenarios this will work in such as the long intake process on the first day.

5.      We shared how we manage tobacco cessation.  Some departments have RT to help and others do it on their own.  We all agreed that we do not have the expertise that the presenter at the conference has. 

6.      Attendees were encouraged to contact Senator Harkin and lobby for S.382.

7.      Claire let the group know that there is a BOD position open on IACPR.

8.      Participants that are not IACPR members were strongly encouraged to join the organization.

9.      Claire shared information on the new AACVPR membership option.

Our next meeting will be in mid- October and will be organized by Erika Leonard from Allen Memorial.

Claire

Fall 2012 IACPR Regional Meetings

Southeast Region

Sept 18, 2012

Newton, Iowa

Attendees: Lisa Reece, Susan Flack, Gwen Weghorst, Claire Shannon, Denise Sheston, Kari Hatfield, Jennifer Hoopes, Kim Boyd, Renee Edgar, Rick Terpstra, Stephanie Cooper, Nancy Steingreaber, Rose Groteluschen, Linda Groenendyk

Thank you to Nancy Steingreaber and Skiff Medical Center in Newton for hosting, and to Claire Shannon (IACPR President) for driving all the way from West Union to attend our meeting.                         

Claire Shannon introduced herself to the attendees and shared basic AACVPR information as well as information from the recent AACVPR National Conference in Orlando. Some of the highlights:

·        Rocky Mountain affiliate is disbanding due to lack of interest from its members. This highlights the importance of IACPR members becoming involved in the state association – we would hate for this to happen to us!

·        Claire reminded us that we are still looking for a President-elect for IACPR. Contact Claire C.Shannon@palmerlutheran.org or Susan flacksk@ihs.org for information about IACPR positions.

·        2013 Heartland Conference is scheduled for Apr 12/13 in West Des Moines

·        2013 AACVPR Annual Conference is scheduled for Oct 3-5 in Nashville

·        All Pulmonary Rehab programs should have worked with their revenue/billing departments by now to determine an appropriate amount to charge for PR services. If you are not familiar with the Pulmonary Rehab Toolkit, please check it out on the AACVPR website www.aacvpr.org. You may also contact Janie Knipper with questions at jane-knipper@uiowa.edu.

·        Discussed the Cardiac Rehab Registry. Several programs are currently enrolled and/or using the Registry, which is an excellent tool to assist with outcomes. It also helps you “compare” your outcomes with others to help determine where to focus your improvement initiatives.

·        Claire summarized a few of her favorite breakouts from the national conference.

·        Nationally, <20% of eligible patients participate in Cardiac Rehab. Nebraska has the highest participation at 53%; Iowa is 2^nd at 46%.

One topic that was discussed in the group involved monitoring/non-monitoring patients and “mixing” various diagnoses for rehab. Several programs were hi-lighted at the AACVPR conference who telemetry monitor their patients infrequently or not at all; we’re encouraged to use risk stratification to determine our patient care. Reminder: “monitoring” to CMS doesn’t necessarily mean “telemetry” – it refers to all monitoring techniques (pulse ox, HR, BP, etc). Both codes (93797 – non-monitored CR session and 93798 – monitored CR session) are reimbursed the same amount. Claire is currently non-monitoring patients in her program, so feel free to contact her if you want more information.

Claire presented information about Motivational Interviewing with the group, and we all had time to practice. *Claire shared a handout that she has found useful – see attachment.

Steph Cooper told the group about an American Medical Association video that also gives good information. The link is http://www.youtube.com/watch?v+cGtTZ_vxjyA You may need to copy and paste this in your browser. If your hospital blocks your access to You Tube, you may need to watch at home…

Question came up about valvuloplasty and whether this was a reimbursable procedure. Susan checked with Candy Steele and Claire reviewed a PowerPoint from Karen Lui. Valsuloplasties (Valve Repair) and Transcatheter Valve Replacements (Valve Replacement) would both be covered. Remember that CMS reimburses for “heart valve repair or replacement” without specifying method. For specific questions about Cardiac Rehab reimbursement, contact Candy Steele at candace.steele@wfhc.org

 The next meeting of the IACPR SE Quadrant is scheduled for Tues, Apr 23 at 10am, hosted by Renee Edgar in Oskaloosa.

Respectfully submitted by Susan Flack

Northeast Region

Leadership:  Looking for a President elect.  Job Description handout.  North Carolina exceptional affiliate increased Physician involvement, improved finances of their org.  legislation to bill for Ex Phys. license.  Rocky Mountain (3states) folded due to lack of leadership.

Heartland Conference Dates:  April 12,13 at Marriott in Des Moine.  Next National AACVPR conference in Nashville Oct 3,4,5

PR Tool kit:  Contact Janie Knipper if you have taken the tool kit to your financial department to realign you charges for G0424.  Contact Janie if you need help.

Cardiac Rehab Registry:

• 383 applied
  
• 160 currently active programs
  
• 69% male, 31 % female
  
• 30% MI, 29% PCI, 21%, CABG
  
• 30% diabetic
  
• 43% high risk, 34%, Intermediate, 15% low
  
• Mean program length 13 weeks.
  

Do not foresee that Registry will be a requirement for certification.

The registry is how we measure our work: Motivation, strategy, culture.  Can compare to all programs in state, hospital size and all programs in registry.  Participation agreement, pay subscription fee, view registry webinar (1 hour), complete data entry training (20 min)

Pulmonary Registry coming:  Next June.  Possible to be early adopter and pay only $50. 

Nutrition:  What is the right diet?  DASH, Very Low fat vegan, Mediterranean, The New American Plate,  “Expect different strokes for different folks.”  “The plan that works is the plan that is followed.”  “Nutrition counseling to get the right fit and get support.

Key Messages on Physical Activity:  1.  Its not just for wt. control. 2. Can be 10-15 min blocks. 3.  Limit TV/Screen time.  4.  Find ways to add small bits of movement throughout the day.

Extreme Endurance Exercise:  There are 6 heart attacks each year during marations and 4 are fatal.  Is more better?  14 deaths last year during triathlons – mean age 43.  11male – 3female.  13 of deaths were in swimming part of race.  Location of death is usually during last quarter of event so after 20 miles in marathon.  50% happen at last mile.  .54 deaths per 100,000 participants.  Possible presentation for Heartland conference.

Cardiac Rehab referrals:  19% eligible medicare patients currently participate in rehab.  53% in Nebraska (#1), 46% Iowa (#3). Too many not attending, dropping out, and don’t continue compliance.   Research tells us that the maximum outcome is achieved at 38 weeks.  To modify: enhance self-efficacy, increase long term adherence, (maintenance programs) increase accessibility (modify hours for those that work, increase program capacity with open gym model, maximize outcomes, reduce costs.

Innovation in Rehab model:  Goal to get patient into rehab within 5-7 days.

Mark Lui:  Think out of the box. Our core business is changing behavior.  Participants knowledge that they can change behavior.  His rec:  1.  Take off monitors. 2.  Individual does active warm-up and cool-down on own. 3.  Open gym model.  4.  Could use heart rate monitors.  5.  Patients self record data.  6.  Perceived exertion and enjoyment.  7.  Self prescribed exercise by session 10-18.  8.  Motivational interviewing.

Zack Clint;  Rehab Ed;  Group vs. Individual

Lecture Pros: efficient, shared experience, easy to document

Cons:  hard to meet individuals needs, confrontational        

Atmosphere (forced to attend class), retention

Coach approach: Train our staff, collaborate with pts in a change process, listening, asking, reflecting, evocative (pt doing the participating)

5 to thrive:  Emotional Well Being, Smoking cessation, Healthy nutrition, medication adherence, exercise and physical activity. 

Evaluate 1^st visit, pt drive ship, help set goals.  Coach every session, revisit goals, exploring successes, and failures.

We reviewed Legislative and Regulatory Issues presented by Karen Lui at the National conference.

Erika Leonard from Allen Hospital in Waterloo brought flyer encouraging nurses to join newly formed local PCNA chapter coordinated by Lisa Moellers NP from Cedar Valley Medical clinic in Waterloo. 

IACPR membership:  Many of you have forgotten to renew your membership or are not a current member of IACPR.  I urge you to remedy this soon.  We need paid members in order to continue to be a strong, viable, financially sound affiliate. 

The next meeting is tentatively set for Tuesday, April 23^rd in Waterloo.  The Allen Hospital program will pick a meeting place. 

 Spring 2012 IACPR Regional Meetings

Northwest Region 

The Northwest Iowa Regional Cardiac and Pulmonary Rehab Spring  Meeting was held Thursday March 8^th at

PocahontasCommunityHospital. We started about 9:30 am with 16 people in attendance.

Susan Flack gave us interesting information about the AACVPR day at the hill. She enlightened us on the upcoming bills and the interpretation of them. She gave us nice background information and the need for a call to action. Our rehabs undercharge and are under utilized, but it is very cost effective and there is lots of evidenced based information.

We had nice discussion about phase III in our departments and communities and phase IV in some areas. Some were seeing Humana pts. under their supervised fitness programs

We discussed briefly about the AACVPR registry and Susan made a good point. We can think our programs are the best, but if we don’t compare it to anything how do we know they are good and could it be better. 

A nice discussion was targeted to teaching and health coaching, with several ideas going around. A few people had been to the health coaching classes and thought it was very helpful. We need to focus on the pts. goals not ours. Sometimes they are so overwhelmed they can’t think of anything. We need to be understanding and compassionate with our pts. and help them see what they can do. PR and CR need to document progression.

A light lunch was served and than a tour of the PCH cardiac rehab department was given for those who could stay. Of course our discussion continued through lunch and after.

Mary Brandt RN

Cardiac Rehab Coordinator

Pocahontas CommunityHospital

Southeast Region

Pella, IA

May 8, 2012

Attendees: Ruth Gassman (Des Moines); Sherrilyn Nikkel (Pella); Kim Boyd (Anamosa); Jennifer Hoopes (Muscatine); Rose Groteluschen (Marshalltown); Renee Edgar (Oskaloosa); Nancy Steingreaber (Newton); Susan Huff (Keosauqua); Sigrid Vogelpohl (Keosauqua); Wanda Coleman (Pella); Linda Groenendyk (Pella); Susan Flack (Des Moines

Thank you to Sherrilyn Nikkel and Pella Regional Hospital for hosting the SE Quadrant IACPR meeting on Tuesday, May 8, 2012.

The meeting started with sign-in and introductions. Meeting participants varied greatly in Cardiac and Pulmonary Rehab experience. Discussion topics included:

ü      AACVPR

§         Number of members, programs, certifications

§         Importance of AACVPR membership dues – support legislation, assist with program certification and outcomes, education, etc (21% of AACVPR dues support legislative activites which directly help our programs)

§         “Possible” that CHF will be added to a list of reimbursable diagnoses for CR (should hear by 2013)

ü      Heartland Cardiopulmonary Rehabilitation Network Conference

§         2012 conference recently held in Omaha – presenters included Steven Lichtman (current AACVPR president) and Jody Hereford (Past AACVPR President, and current consultant for ICCC, who spoke on Health Coaching)

§         2013 Conference is scheduled for April 12 and 13 – West Des Moines Marriott, West Des Moines, Iowa

ü      AACVPR Annual Meeting is scheduled for Sept 6-8, 2012 in Orlando, Florida

ü      Certification / Recertification – discussion held and questions answered

ü      Core Competencies for Cardiac Rehabilitation / Secondary Prevention (2010 Update) – can find on www.aacvpr.org  

ü      Pulmonary Rehabilitation Toolkit: Guidance to Calculating Appropriate Charges for G0424 – can find on www.aacvpr.org

ü      Outcomes – discussed a variety of assessment tools

ü      AACVPR Outcomes Registry – Cardiac launch June 2012; Pulmonary launch in 2013

ü      Outpatient monitoring technology (interfacing with EMR)

ü      Shared and discussed ITPs

The next meeting of the IACPR SE Quadrant is scheduled for Tues, Sept 18, 2012 with site and time TBD. Watch your email and check the IACPR website for details.

Northeast Region

 It was held March 27^th in New Hampton.  I reviewed the PR toolkit with the attendees.  I reviewed some of the highlights of the Heartland conference.  Attendees brought ideas for some of the extracurricular activities their departments are involved in in the community including:  

Allen Hospital, Waterloo:  Annual Heart Walk.  They are involved in Heart Aware.  They participate in health fairs, and do cholesterol checks.

Central Community Hospital, Elkader:  During heart month, they go into schools to present on heart health.

Other ideas from other northeast Iowa CR’s: Go Red Friday contests and raise money for donations to AHA, wearing red hair extensions on Go Red day, articles on patients published in papers, Cardiac Rehab Christmas party inviting all participants from previous year, Heart Risk Appraisal that includes Framingham questionnaire, Cholesterol, Glucose, Sleep apnea questionnaire, blood pressure, BMI, activity level and then results reviewed with participant by RN rehab staff.  

Fall 2011 Regional Meetings 

Southwest Region

The Southwest Regional IACPR meeting was held on September 29, 2011, at 10:00 AM at MontgomeryCountyMemorialHospital in Red Oak.  Special guest was IACPR President, Susan Flack, who had recently attended the AACVPR Annual Meeting.  She reported on several topics of interest from the meeting including the upcoming AACVPR Outcomes Registry project, Supervising Physicians, and the possibility of cardiac and pulmonary rehab services being a part of a bundled payment for a hospitalization instead of getting paid per session as it is now. 

Benefits of membership to IACPR and AACVPR were reviewed. 

Discussion was held about how and when to hold southwest regional meetings.  It was recommended to try to meet at least twice a year and that the best attendance would require hospitals in the center of the region to host most often.  It was agreed that it would be beneficial to have the president or a board member who had attended the national meeting come and give a report at the fall meeting. 

The attendees took a tour of the Cardiopulmonary Rehab Department, which was followed with lunch. 

Peggy Dunbar is planning to host the next meeting in Atlantic, possibly in February.   

Diane McGrew

Northeast Region

 

16 people attended including:

Deb Reiker – Buchanan CountyHealth, Independence

Karen Wahls – Central Community Hosp., Elkader

Pat Swenka – MercyHospital, Oelwein

Michelle Litterer – WaverlyhealthCenter, Waverly

Maggie Pearson – Franklin General Hosp, Hampton

Stacy Gooder – Franklin General Hosp, Hampton

Betty Meighan – CommunityMemorialHospital, Sumner

Kim Wilmes – WinneshiekHospital, Decorah

Claire Shannon-PalmerLutheranHealthCenter, West Union (big group came from my hosp)

I sent the info below to 3 rehabs that were hoping to attend, but could not make it that day.

In addition to networking and getting to know each other, I reviewed some of the information acquired from the National conference.  Susan Flack unable to attend.

1.        Coaching tips:

a.        Listen until you don’t exist.

b.      Affirm strengths

c.       Balance open ended questions with reflections

d.      Use few words, ask one question at a time

e.      Have client speak more than you do

f.        Get permission before you give advice

g.       Show empathy, non-judgmental acceptance

2.        Impact of CR on ability of elderly DHF patient to perform common household tasks:

a.       ‘Bottom line, findings strongly support a role for muscle strength in determining the physiological capacity to perform activities of daily living.  From a clinical perspective, our results suggest that interventions designed to lessen physical disability in CHF patients should consider improving muscle strength as one of their goals.”  Resistance/strength training should be part of CR/PR programs.

3.        Sleep Apnea:  CPAP can help CHF patients diagnosed with OSA.  Must have titration study for CPAP pressure. 

4.       National Registry Update for CR and PR discussed.

AACVPR site recommended for further details.

5.        It sounds like NE rehabs are running into the insurances that have high co-pays.

6.       Most NE rehabs have had LVAD patients in the past year.  Policy and Procedures discussed.

7.        Most NE rehabs doing some type of Phase III and charging $5 per session.

The rest of the time we ate and visited informally.  The consensus was that we would like to continue to do this every six months, Spring and Fall. 

Southeast Region

Ottumwa, IA

October 13, 2011

Attendees: Kim Boyd, Jones Regional Medical Center, Anamosa; Steph Cooper, Mercy, Cedar Rapids; Wanda Coleman, Pella Regional Hospital; Renee Edgar, Mahaska Health, Oskaloosa; Susan Flack, Iowa Health-Des Moines; Ruth Gassman, Mercy Medical Center, Des Moines; Kari Hatfield, Keokuk County Health Center, Sigourney; Diane Hunt, Marshalltown Medical Surgical Center; Leslie Heemsbergen, Ottumwa Regional Health Center; Sherrilyn Nikkel, Pella Regional Health Center; Cathy Packard, Fort Madison Community Hospital; Pam Poulos, Trinity Medical Center, Moline, IL; Sigrid Vogelpohl, Van Buren County Hospital, Keosauqua

Thank you to Leslie Heemsbergen and OttumwaRegionalHealthCenter for hosting the SE Quadrant IACPR meeting on Thursday, Oct 13, 2011. Attendees introduced themselves and gave a bit of background on their rehab and association experience.

Current IACPR President Susan Flack presented highlights from the recent AACVPR Annual Meeting in Anaheim.

ü      National Cardiac Rehabilitation Registry is targeted for release in June, 2012. A few programs in Iowa have already registered to be a part of this project, and it sounds very exciting. The United States’ first nationwide registry of its kind, it will give programs an efficient means to track, document and communicate patient outcomes and program performance. Subscribers will be allowed access to high-quality data in real time via the Internet. In addition, programs will be able to see how their clinical, behavioral, health and service outcomes compare to aggregate data from other programs (in their state or nationally).  The Registry will most certainly prove to be an important and effective tool in program promotion. More information can be found on the AACVPR website at www.aacvpr.org

ü      In a breakout given by Karen Lui, EOCs (Episodes of Care) were discussed. The Affordable Care Act includes provisions for bundled payments, clearing the way for more “global fees”. This could significantly impact reimbursement for our services, as cardiac rehab could be “bundled” with the cardiac event (MI, CABG, etc). Instead of billing for each session of care, CMS would make a global payment to the medical institution, intended to cover virtually all services received. There is certain to be more communication on this topic from the AACVPR, but in the meantime, Karen encouraged us to streamline our care and make our programs as efficient as possible, as the current billing practices may disappear.

ü      CMS has proposed to cut reimbursement for hospital-based pulmonary rehabilitation from $63 per session (national average) to $38 (national average). Actual Iowa reimbursement would be lower. Unfortunately, this decision was reached due to hospital “charges” being too low. CMS uses a formula to determine payments, and the data reported to them by hospitals regarding charges for pulmonary rehab resulted in this decline in payment. Pulmonary Rehab programs are encouraged to discuss session charge rates with their Business or Reimbursement Office to make sure they are submitting appropriate charge amounts.

In addition, there was discussion about the importance of “patient progression” while participating in Cardiac Rehab. Although CMS allows up to 36 sessions over 36 weeks, the average patient does not require this many sessions. There has been at least one instance where CMS visited a Cardiac Rehab program (in our area) and reviewed medical records to check on patient progression. The hospital was forced to reimburse CMS a substantial amount of money because patients had continued to participate in Cardiac Rehab after plateauing with their exercise. Cardiac Rehab needs to be individualized for each patient: this includes education as well as MET level (functional) goals. Patients are to be discharged when they are no longer showing progression.

The next meeting of the IACPR SE Quadrant is scheduled for Tues, May 8, 2012 in Pella. Details will be posted at a later date.

Northwest Region

Representatives from 12 hospitals attended the district meeting at St. Anthony Regional Hospital on Thursday, September 15, 2011.  Susan Flack, IACPR President was unable to attend.  The meeting dealt with networking and sharing of information.  Some topics of discussion included:

1. CEUs through AACPR/Academy Medical—AACVPR webinars are more expensive than Academy Medical.  Academy Medical educational programs are $49 through IACPR membership.
2. State surveys of hospitals—Surveyors were looking for locked up patient records, outdated medications or syringes, MSDS sheets on hand sanitizer gel.
3. Resistance training—One program starts resistance training 4 to 5 weeks into Cardiac Rehab with 1,3,5, and 10 pound weights for 5 minutes using 10 reps.
4. Patient education—Some programs are using Krames “Living with Heart Disease”.  Others are using Active Partnership which includes a CD (cost of $20).  
5. Program administration issues—Pulmonary Rehab participants need documentation of “face to face” contact with their physician.  One program pages their medical director for documentation of response time.
6. Patient outcomes—Some programs are using Duke Activity Status Index (DASI), Depression forms PH Q2 and Q9, Montana Outcomes.
7. Patient knowledge assessment—American Heart Association diet quiz (dated 1996).
8. Staff competencies—Programs shared examples of their staff competencies which included ACLS protocols, ACLS meds, rhythm strips, department-specific emergency protocols. 

Pocohontas

CommunityHospital will host the next NW district meeting sometime in early spring 2012. 

(Submitted by Darlene Rueter, RN from St. Anthony Regional Hospital in Carroll.)

Heartland Cardiopulmonary Rehab Conference

The Annual Heartland Cardiopulmonary Rehab Conference will be held April 12-13, 2013 at the West Des Moines Marriott in West Des Moines, Iowa.

We will update the information as it becomes available. 

COPD Patients:

Pulmonary Rehab Reimbursement Alert

The Medicare reimbursement for pulmonary rehabilitation for patients with COPD was reduced on January 1, 2012 from approximately $68.00 per session to $37.00 per session. Therefore, it is imperative that ALL pulmonary rehab programs work with their billing departments to determine if you are charging an appropriate amount for G0424 (Pulmonary Rehab for patients with COPD). The toolkit provides a step-by-step approach to do this. I am happy to help anyone with this if you need clarification or assistance. It is important that your hospital adjust your charge for G0424 as soon as possible so your charge is consistent with what is outlined in the toolkit. If we don’t do this, programs are at risk of closing because of the low reimbursement rate for G0424 of $37.00 per session. If we act now, the earliest we may see an improvement in the reimbursement rate is 2014. So, please don’t delay in evaluating your current charge for G0424.

That being said, the codes that are listed in the toolkit are examples of codes that could POTENTIALLY be bundled into the G0424 code. In other words, if we didn’t have G0424 to bill COPD patients for pulmonary rehab services, we would be charging for each individual service we provide, and the codes listed in the toolkit are examples of what services we might be charging. Therefore, every possible service we provide to COPD patients should be considered when determining the amount you charge for G0424.

Patients with a non-COPD diagnosis:

Your natural reaction as you read the toolkit might be: Should we be charging non-COPD patients for all of the services listed in the toolkit? Not necessarily. Charges reflecting the services we are providing to our non-COPD patients may vary depending on the MAC jurisdiction in which we work. Your MAC may not allow use of some of the codes. For example, oximetry is typically bundled into G0237, G0238, and/or G0239; therefore you would not bill separately for that service. The same is true for the six minute walk test.

Reminder: the PFT criteria for non-COPD patients participating in Pulmonary Rehab is as follows: FVC, FEV1, OR DLCO < 60% predicted. This may be different than what you used in the past if you are not working in Iowa. However, the J5 MAC Medical Director has specifically instructed us to follow this PFT criteria for non-COPD patients.

If you have any questions about whether or not you should use a particular code, you should check with your Compliance Office, contact your MAC liaison for your jurisdiction (that is me for MAC J5), or do both.

Janie Knipper, RN, MA, FAACVPR, AE-C J5 MAC Liaison
Phone: 319-356-8396
E-mail: jane-knipper@uiowa.edu

Additional Information:

Clarification from William Ruiz at CMS on use of Modifier 59 for pulmonary rehab:

Pulmonary Rehab no longer has to use Modifier 59 when billing for more than one of the non- COPD “G” codes on the same day. So, for example, if G0238 and G0239 were charged on the same visit, you don’t have to use Modifier 59. 

For more information and to download a brochure, see the Continuing Education page.

CMS has clarified a coding requirement for cardiac rehabilitation services that was not included in the Cardiac Rehabilitation Change Request 6850, published May 21, 2010. Change requests are specific billing instructions sent to providers. Your billing department would have received these change requests for both cardiac and pulmonary rehabilitation. The change request for pulmonary rehabilitation is # 6823, published May 7, 2010.

When billing for more than one session of cardiac rehabilitation per day, modifier “-59” must be used. This is because two CR sessions in a day are considered different patient encounters. The policy for Modifier -59 is found in the CMS publication, MLN Matters SE0715 (CLICK HERE to access). This means whenever any combination of CPT/HCPCS 93798 and 93797 are provided for two CR sessions in one day, proper billing requires use of the modifier. Failure to use the modifier -59 when submitting two charges for one day has resulted in denial of payment for some CR programs.

Pulmonary rehabilitation (PR) does NOT need to use modifier -59 because of coding edits that CMS put in place with the new procedure code, G0424 in January, 2010. However, the procedure codes, G0237-39, used previously for pulmonary rehabilitation and now used for respiratory therapy services (i.e., non-COPD diagnoses) continue to require use of the modifier -59. (This requirement was discussed in AACVPR News & Views, May/June, 2009.)

If you are a member of AACVPR, you will receive the most up-to-date reimbursement information. Please consider joining now!

Photos from the first annual Heartland Conference in Des Moines, 2011. If you have photos you'd like to share, email them to Candy Steele or Leah Lenz. Be sure to identify the people in your photos!

Above: Nancy Steingraeber (left), Skiff Medical Center, Laura Mackaman (center), Iowa Health - Des Moines, recipient the IACPR Distinguished Member of the Year Award, and Susan Flack, IACPR President (right)

Claire Shannon-Klann, IACPR President-elect, greets visitors at the IACPR informational booth.

Clarification on coverage from questions asked of John Wrynn, Outreach Analyst for WPS Medicare on teleconference held 02/23/11. Mary Sue Gardner, RN, BSN, Medicare Outreach Nurse Analyst (Omaha office) was also on the call and this includes her feedback. 

1. Cardiac Rehab is covered for 36 sessions or 36 weeks, which ever comes first.

2. If you are billing beyond 36 sessions, be sure to bill using the KX modifier. An ABN is not necessary, but in the absence of an ABN the provider is liable for the bill if the modifier is not used. Services beyond 36 sessions are subject to medical review, and no pre-authorization is required.
3. Although cardiac rehab is covered up to 36 sessions, it still must be medically necessary for the patient to continue. Patients are not entitled to 36 sessions; that what is allowed based on medical necessity. It is the physician’s responsibility to document medical necessity. He/she must be fully involved and aware of patient status and condition. Please note that CMS makes specific reference to outcomes. If a patient has not progressed in a reasonable amount of time, they should be discharged from the program.
4. Physician supervision: CMS changed physician supervision rules for 2011 by removing any reference to any particular physical boundary and removing the reference to ‘on the same campus’ or ‘in the off-campus provider-based department’ (italics are CMS’ exact words on pg 72008, Fed Reg, 11-24-10).
5. Per CMS, MI is the only diagnosis with the 12 month time limit from event. For the other diagnoses, WPS will not enforce a time limit. However, physician documentation must still support medical necessity in order to participate.
6. If a patient has another event during cardiac rehab participation, you have two choices for continued participation:
   1. Discharge the patient from the current service and readmit with new diagnosis. Even if this is the same diagnosis (i.e., PCI), the onset date will be different.
   2. Continue with current service, and if medically necessary, continue treating patient up to 72 sessions using the KX modifier as described above. Duration of participation is always based on medical necessity.
7. If services beyond 72 sessions are ordered, medical necessity and appropriate diagnosis must exist. It is essential to get an ABN in these rare instances or the provider will be liable for the bill. The patient should also be aware that coverage beyond 72 sessions will undergo medical review and they will be liable for the bill if CMS determines services do not meet criteria for medical necessity.
8. Patients cannot switch back and forth between CR and ICR.

Submitted by Candy Steele

CALL FOR ACTION -- SUPPORT FOR HR 6376 (10/21/2010)

A bill has been introduced in the House of Representatives that will correct a misguided interpretation of the cardiac and pulmonary rehabilitation Medicare provisions enacted by Congress in July, 2008 and effective January 1, 2010.

As the Centers for Medicare and Medicaid Services moved forward with implementation of Section 144 of PL 110-275 (new statutory coverage of cardiac and pulmonary rehabilitation programs), it made a very narrow, strict interpretation of the statute, declaring that:

1. Only physicians could actually supervise a cardiac or pulmonary rehabilitation program, precluding the role of non physician practitioners (NPPs) such as physician assistants and nurse practitioners filling that role, despite a broad change in the 2010 rules for hospital outpatient services that now permit  NPPs to provide direct supervision of certain hospital outpatient therapeutic services because those services are analogous to physicians’ services; 
2. In critical access hospitals (CAHs), where NPPs can fill in for physicians in the Emergency Department, CAHs that provide either cardiac or pulmonary rehabilitation services must have physician supervision; 

The practical effect of these interpretations means that other hospital outpatient services that permit NPPs to meet the physician supervision requirement of Medicare do not apply to either cardiac or pulmonary rehabilitation.  Likewise, even though CAHs may have an Emergency Department staffed by NPPs, such hospitals must have a physician supervise a cardiac or pulmonary rehabilitation outpatient program.

The plan is for HR 6376 to be included as part of a larger “physician fee fix” bill that Congress will need to adopt to forgo major cuts to physician payments slated for later this year.  Hence, the “legislative vehicle” for HR 6376 will be the legislation addressing a physician fee fix. This will only happen if we get strong support from our US House congressional members for HR 6376.

ACTION TO BE TAKEN:  Write to your Congressman/Congresswoman today and urge him to sign on as a co-sponsor to HR 6376.  A letter has been provided at the link below for you to send to the US Representative in your District. THIS IS A VERY EASY LETTER SUBMISSION PROCESS AND WILL TAKE ONLY MINUTES OF YOUR TIME. The successful passage of HR 6376 will provide flexibility for cardiac and pulmonary rehabilitation programs in meeting physician supervision requirements.

You should include the NPs/PAs in your institution in this effort-it very directly affects their role in the hospital setting.

Physician supervision is an issue of concern for providers of the services, not for patients. Please do not include a patient letter campaign.

CLICK HERE TO TAKE ACTION!

Thursday, October 7th, 2010 11:30 – 12:30 CT

Room 202 DE at the Frontier Airlines Center, Milwaukee, WI

Iowa Chronic Care Consortium (ICCC) at the AACVPR Annual Meeting

Join a gathering of committed thought leaders and innovators in discussing how together we can create a positive future for cardiac and pulmonary rehabilitation.

Health care reform has created a fertile field for innovation that targets the optimal management of chronic diseases, the adoption of population health models, and improvement in health outcomes.  This interactive discussion, hosted by the Iowa Chronic Care Consortium, is built from the belief that cardiac and pulmonary rehabilitation professionals are perfectly poised to be active players in this changing world of health care delivery.  Join a gathering of your colleagues in discussing how to create an expanding role for cardiac and pulmonary rehabilitation.  

Box lunch is provided to the first 100 to register: click here to register.

The discussion will be facilitated by William Appelgate, PhD, Kathy Kunath, RN, Jody Hereford, BSN, MS and Karen Lui, BSN, MS.

The Iowa Chronic Care Consortium has at the heart of its mission a commitment to reduce the burden of chronic disease and build capacity in partner organizations to effectively manage the most prevalent chronic diseases.  For questions, please contact Jody Hereford.