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Gov’t audit insider: Outpatient cardiac rehabilitation services

Healthcare Auditing Weekly, November 11, 2003

The OIG performed this review to determine whether Medicare properly reimbursed St. Charles Hospital for outpatient cardiac rehabilitation services. The review is part of a nationwide analysis of provider compliance with Medicare coverage requirements for outpatient cardiac rehabilitation services.

The OIG used the following steps:

1. Compared the hospital's current policies and procedures for outpatient cardiac rehabilitation to national Medicare coverage requirements and the fiscal intermediary's local medical review policy and identified any differences.

2. Documented how the hospital's staff provided direct physician supervision for cardiac rehabilitation services and verified that the hospital's cardiac rehabilitation program personnel were qualified in accordance with Medicare requirements.

3. Verified the availability of advanced cardiac life support equipment in the cardiac rehabilitation exercise area.

4. For each sampled beneficiary, the OIG obtained the calendar year 2001 Medicare outpatient cardiac rehabilitation paid claims and lines of services and compared this data to the hospital's outpatient cardiac rehabilitation service documentation.

5. Reviewed the medical records maintained by the cardiac rehabilitation program to determine whether services were provided "incident to" a physician's professional service.

6. Verified the accuracy of the diagnoses identified on the Medicare claims to each beneficiary's inpatient medical record, the referring physician's medical record and referral, and the hospital's outpatient cardiac rehabilitation medical record.

7. Verified that Medicare did not reimburse the hospital beyond the maximum number of services allowed by obtaining Medicare payment history data for the statistical sample of beneficiaries. The OIG then identified any claims related to the outpatient cardiac rehabilitation services provided by the hospital, and ensured that services were not billed separately to Medicare.

Click here to read the audit report "Review of Outpatient Cardiac Rehabilitation Services-St. Charles Mercy Hospital, Oregon, Ohio."

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