By Kent Eichenauer, PsyD, FAACVPR | January 29, 2018

We are called to create even greater improvements in our successful cardiac and pulmonary rehab programs with the CMS pilot project and R2R. Many programs are evaluating the important psychosocial component for improved adherence and outcomes. The enhanced study is the latest trial to support the long-term efficacy of integrated and substantial stress management training in cardiac rehab. 

The addition of a substantial stress management component to cardiac rehab resulted in far fewer clinical events in the three-year follow-up as follows:

• Control Group — 47 percent
• Comprehensive Cardiac Rehab — 33 percent
• Comprehensive Cardiac Rehab plus Stress Management — 18 percent

The addition of stress management improves outcomes by 45 percent compared to traditional comprehensive cardiac rehab. We all know these are the kind of numbers that make our payers happy, but, most importantly, allow us to feel confident we are providing the most effective care for our patients that we can.

So, where are these psychosocial providers that provide this care? How do I find them, and how can I afford this service?

First, the psychosocial providers are often closer than you think. Though, this might require a bit of silo-hopping for both the rehab administrator and the psychosocial provider. If your program is within a university, there is likely a department of psychiatry or psychology that may house psychosocial providers of different disciplines, which might include psychologists, clinical counselors and social workers.

If you are in a hospital setting, depending on the hospital size, you may find a psychologist employed by the hospital, or there may be mental health facility affiliated with your hospital.

There are likely psychosocial providers in private practice in your area. Some tools to prioritize your list of community providers include:

• Ask your patients who they currently see (or have seen) and how beneficial their provider was for them.
• Our primary care physicians are the typical gatekeeper for referrals to psychosocial providers. Ask your own physician and other community physicians to whom they usually refer patients.
• Search online for your state’s associations for psychologists, counselor and social workers. There is usually a “Find a Provider” tool located on association websites.

Invite the provider to your program to provide information regarding cardiac and pulmonary rehab and discuss what level of involvement is agreeable to each. You may want to start small to test the waters.

Regarding a contractual arrangement, there may be a cost center sharing arrangement if the provider is a member of your hospital or university staff. If you choose a community provider, you will need to develop a mutually agreeable financial contract.

Of course, programs need to question the affordability of a contracted psychosocial provider. It is affordable, particularly when using the CPT code 93797. It is now possible and encouraged by Medicare and AACVPR to address our patients’ broader concerns within the rehab program.  We now know this care can significantly impact outcomes.

The aforementioned code is to be used for programming other than ECG-monitored exercise.  This includes its use for billing individual psychosocial consultation and group stress management programming. The 93797 CPT code generally reimburses at the same rate as traditional 93798 CPT code. Therefore, it is not difficult to develop a model that adequately covers a provider’s contracted rate and allows the program to make money.

Yes, the use of this code does count toward the total allowed billing units for each patient. And yes, this frequently does require a shift in our thinking of the definition of traditional “comprehensive” cardiac rehab. Of course, exercise is the mainstay of cardiac rehab.  Indeed, exercise is an incredible benefit for the long term health of our patients — as long as they exercise. A strong psychosocial component can contribute to improved long-term outcomes. This is what we want, and it is what CMS wants.

^1. Blumenthal JA, Sherwood A, Smith PJ, et al. Enhancing cardiac rehabilitation with stress management training: a randomized clinical efficacy trial. Circulation. Published online March 21, 2016.

Dr. Eichenauer is chair of the Psychosocial and Nutrition Experts Group, and is a member of the Quality of Care Committee and the Professional Certification Commission. He is also co-author of the Psychosocial Risk Factor Survey.

This article was originally published in the March/April 2017 issue of News & Views.