By Anna Horner | News & Views

The Centers for Medicare & Medicaid Services (CMS) revises Medicare rules and regulations each year. To appropriately bill for services and avoid audits and payment denials, it is crucial that cardiopulmonary (CR/PR) providers are aware of and understand the changes that will be implemented in 2025.

Lorri Lee, MHA, BS, CCRP, CEP, FAACVPR, cardiopulmonary rehabilitation supervisor at CHRISTUS Santa Rosa – New Braunfels, and Susan Flack, RN, MS, FAACVPR, manager of cardiac and pulmonary rehabilitation at UnityPoint Health-Des Moines, emphasize the importance of CR and PR practitioners familiarizing themselves with the latest reimbursement rates and rulings. Changes on the horizon pertain to CR, Intensive CR (ICR), Supervised Exercise Therapy for Peripheral Artery Disease (SET PAD), PR, and Outpatient Respiratory Services (ORS) programs. “In particular, providers need to be aware that virtual supervision, which includes MDs, DOs, non-physician providers (NPPs) (i.e., nurse practitioners, physician assistants, and clinical nurse specialists), is extended through Dec. 31, 2025. For Medicare telehealth services, CR/ICR and PR will remain on the provisional status list. This applies to physician clinics only,” Lee notes. “The extension of virtual supervision will play an important role in continuation of services in many CR and PR programs.”

It also is important to recognize how Medicare rules and regulations affect NPPs. Lee explains, “NPPs can supervise CR, ICR, PR, and SET PAD programs, but they cannot order services, sign individualized treatment plans, or serve as medical directors.” Distinguishing between PR and ORS is important as well. According to Flack, “Medicare and most other insurers provide specific, black-and-white qualifying criteria for PR. Only patients who meet that criteria may be registered and billed under PR. Medicare does not have clearly written criteria for patients to receive ORS.”

Flack offers tips to help CR and PR practitioners determine the appropriate program for patient referrals. “First, look at the diagnosis,” she advises. “Second, look at the specific insurance, then see if the referred patient meets the criteria to participate in the program. Next, check to see if a more appropriate referral diagnosis is available. Only register patients who truly meet the criteria to participate.”

The constant evolution of rules and regulations for CR, ICR, and PR services can lead to confusion, Lee and Flack acknowledge. “Practitioners may not know that different Medicare Administrative Contractors may have different interpretations and additional regulatory clarifications that only apply to their specific region,” says Lee.

Flack adds, “It’s important to check and review each individual patient’s insurance. Some allow more diagnoses or different qualifying criteria than Medicare. Additionally, some may not realize that the Code of Federal Regulations is regularly updated to reflect real changes by CMS, as well as ‘notices of intent’ to change regulations. If practitioners don’t stay updated on current regulations, they have no way to know what has changed.”