• CMS Expands Coverage for Cardiac Rehabilitation Programs But Emphasizes the Direct Physician Supervision Requirement
  • April 28, 2006 | Authors: Kurt L. Hudson; Stephen T. Moore
  • Law Firms: Hinshaw & Culbertson LLP - Chicago Office; Hinshaw & Culbertson LLP - Rockford Office
  • On March 22, 2006, CMS issued a national coverage decision memorandum which expands coverage for cardiac rehabilitation programs to include patients with acute myocardial infarction (AMI), coronary artery bypass graft (CABG), stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and heart or heart lung transplant. However, CMS also determined that the evidence is not adequate to conclude that cardiac rehabilitation is reasonable and necessary for congestive heart failure and, therefore, it will not be covered.

    Additionally, CMS indicated that cardiac rehabilitation programs must be staffed by personnel necessary to conduct the program safely and the program must be under the direct supervision of a physician, as defined in 42 C.F.R. § 410.26(a)(2) (defined through cross reference to 42 C.F.R. § 410.32(b)(3)(ii), or 42 C.F.R. § 410.27(f).

    The analysis section of the national coverage decision memorandum states that cardiac rehabilitation services fall under the benefit category of "incident to" a physician's professional services which require that services be performed under "direct physician supervision" as defined in the Medicare regulations. Direct supervision for hospital outpatient services means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. See 42 C.F.R. §410.27 which cross references 42 C.F.R. §413.65 (the hospital based regulations); see also 42 C.F.R. §410.26(a)(2) and 42 C.F.R. §410.32(b)(3)(ii). Supervision can be the responsibility of multiple physicians but cannot be done by telephone (i.e. general supervision is not adequate for cardiac rehabilitation programs.)

    A Word of Caution to Hospitals
    Many hospitals operate cardiac rehabilitation programs in off campus locations several miles from the main hospital campus. These programs are operated as outpatient departments of the hospital and meet the Medicare requirements for hospital based departments contained in 42 C.F.R. § 413.65. However, the CMS decision memorandum on cardiac rehabilitation programs emphasizes that these programs must also meet the requirements of the hospital based department rules. These rules state that if the cardiac rehabilitation program is an offsite hospital outpatient department, direct physician supervision is required. Offsite hospital outpatient departments are those departments that are not located adjacent to or within 250 yards of the main hospital campus or building.

    If the cardiac rehabilitation program is located on the main campus (i.e. adjacent to or within 250 yards of the main hospital building), physician supervision can be assumed per Intermediary Manual Section 3112.4(A) and Medicare Benefits Manual Section, 6-20.4.1. See also 42 C.F.R. § 410.27 and 65 Federal Register 18525. When the cardiac rehabilitation program is located on the main campus, CMS assumes that there are physicians immediately available for such programs.

    Previously, many hospitals believed that because these cardiac rehabilitation programs were outpatient departments of the hospital, even if off campus, the physician supervision should be assumed. However, CMS has now made it clear that off site cardiac rehabilitation programs must meet the direct supervision requirement of the hospital based department regulations and supervision cannot be assumed for offsite cardiac rehabilitation programs.