Corporate Compliance

Tip: Take these 10 steps to check outpatient cardiac rehab billing compliance

Compliance Monitor, January 5, 2005

Make sure that all outpatient cardiac rehabilitation (OCR) services that your hospital provides meet Medicare's standards. Follow the steps that the Office of Inspector General (OIG) uses when it audits outpatient cardiac rehabilitation:

1. Compare the hospital's policies and procedures for OCR to national Medicare coverage requirements and fiscal intermediary (FI) local medical review policies. Identify any differences.

2. Document how the hospital staff provides direct physician supervision for OCR services.

  • Tip: Nonphysician personnel must provide cardiac rehabilitation under the direct supervision of a physician. This means that the physician must be in the exercise area and immediately available and accessible for an emergency while the nonphysician conducts the exercise program.

    3. Verify that the hospital's cardiac rehabilitation program personnel are qualified in accordance with Medicare requirements. Ensure that nonphysician personnel have received training in both basic and advanced life support techniques, as well as in exercise therapy for coronary disease.

    4. Verify the availability of advanced cardiac life support equipment in the cardiac rehabilitation exercise area.

    5. Obtain the medical record for each patient in your sample. These records should include the following:

    • Rehabilitation services documentation
    • Inpatient medical records
    • Physician referrals
    • Supporting medical records

    6. For each Medicare beneficiary in your sample, obtain the most recent calendar year's Medicare OCR paid claims and compare this data to the hospital's OCR service documentation.

    7. Review the medical records to determine whether personnel provided services incident to a physician's professional service.

  • Tip: In order to be covered under the incident-to benefit in an outpatient hospital department, personnel must furnish services as an integral, though incidental part of the physician's professional service in the course of diagnosis or treatment of an illness or injury.

    8. Verify the accuracy of the diagnoses identified on the Medicare claims against each beneficiary's inpatient medical record, the prescribing physician's referral form, and the hospital's OCR medical record.

    9. Obtain and review the referring physician's medical records for a beneficiary with a Medicare-covered diagnosis of stable angina. The goal is to verify the accuracy of the diagnosis.

    10. Verify whether Medicare reimbursed the hospital beyond the maximum number of services allowed. Cardiac rehabilitation services may be considered reasonable and necessary for up to 36 sessions, usually three sessions per week, in a single 12-week period, according to the OIG.

    Editor's note: Do you want to know more about cardiac rehabilitation compliance? Do you have specific questions you need answered on the subject? Join us at 1 p.m. EST Tuesday, January 18, for Outpatient Cardiac Rehab: Review and Recommendations to Comply in Trying Times to ensure that your facility is doing everything in its power to stay within the rules. Visit HCPro's Healthcare Marketplace or call our Customer Service Department at 877/727-1728 to register or find out more about this program.

  • Most Popular