MIAMI — Private insurers are likely to follow the Centers for Medicare and Medicaid Services in a move to expand coverage for cardiac rehabilitation services, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.
“In March 2006, Medicare made a big shift for cardiac rehab,” the first major coverage change in decades, Steven Keteyian, Ph.D., said. Since the 1980s, Medicare has covered cardiac rehabilitation for patients following a heart attack, coronary artery bypass surgery, or angina.
The expanded coverage includes heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and heart or combined heart-lung transplantation. These CMS changes are important because private insurers usually follow suit.
“Missing for me is the heart failure patient,” said Dr. Keteyian, program director of Preventive Cardiology at Henry Ford Hospital in Detroit. Data are insufficient regarding benefits of rehabilitation in patients with heart failure, although current studies might provide some answers.
Previously, CMS reimbursed only the exercise component of cardiac rehabilitation. Now coverage includes medical evaluation, risk factor modification, exercise, and education.
Historically, rehabilitation was limited to 36 visits in 12 weeks. Now physicians have up to 18 weeks to complete the same number of visits, Dr. Keteyian said. “This will give us a lot of flexibility in how we manage these patients.” In addition, following a review and approval, rehabilitation can be extended to 72 visits over 36 weeks.
ECG rhythm strips were mandatory for reimbursement prior to the policy change. Now the need for such monitoring is at the discretion of the physician.
Previously, requirements for physician supervision were unclear, Dr. Keteyian said. CMS only stipulated that physicians were proximal to the exercise area. More specific requirements now state that physicians should be on the premise or within 250 yards if the area is in a separate building on the hospital campus. They must be immediately available if the rehabilitation unit is freestanding, Dr. Keteyian said.
CMS had proposed identifying the “incident to” physician as the ordering physician only. However, the agency decided it would not be appropriate to have “incident to” rules specific for cardiac rehabilitation. The “incident to” physician can therefore be the ordering physician, a primary care physician, or a program medical director.
Not all patients will take advantage of the added coverage, Dr. Keteyian said. “We are doing an okay job with discharge recommendations—54% to 74% recommend cardiac rehab.” However, actual utilization is in the “25% to 40% range,” possibly because of insurance, social issues, or because of transportation concerns.