Metric number and name
NQF #
Data collection method
Group overseeing the metric
ACO-8; risk-standardized all condition readmission
1789 (adapted)
Claims data
CMS
ACO-10; ambulatory sensitive conditions admission: heart failure
0277
Claims data
AHRQ
ACO-37; all-cause unplanned admissions for patients with heart failure
N/A
Claims data
CMS
ACO-38; all-cause unplanned admissions for patients with multiple chronic conditions
N/A
Claims data
CMS
ACO-31 (HF-6); heart failure: beta-blocker therapy for left ventricular systolic dysfunction
0083
GPRO WI
AMA/PCPI/ACC/AHA
ACO-33 (CAD-7); coronary artery disease: angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy – diabetes or left ventricular systolic dysfunction (left ventricular ejection fraction < 40 %)
0066
GPRO WI
AMA/PCPI/ACC/AHA
General Medicare Coverage of Heart Failure-Related Services
In September 2010, Medicare published the revised national coverage determinations, and in December 2010, and thereafter new programs and program revisions became effective (Table 3.2) [28–30]. Of note, although implantable cardiac hemodynamic monitoring for heart failure has not become an approved service as of yet, cardiac rehabilitation, transitional care visit (1 claim in 30 days), and other heart failure services that apply post hospitalization were approved (with conditions) in the last few years. Since cardiac rehabilitation programs provide medical evaluation, prescribed exercise, cardiac risk factor modification, diet education, and counseling in psychosocial, lipid, and stress management to restore active and productive lives, every patient who meets medical history qualifications should have post-discharge orders and be strongly encouraged to attend. In a Cochrane review of exercise program uptake and patient adherence, three programs developed to increase uptake of cardiac rehabilitation were effective, and two of seven programs to increase patient adherence to cardiac rehabilitation were effective [31].
Table 3.2
Centers for Medicare and Medicaid national coverage determinations
Category and factor | Details of coverage | Date implemented |
|---|---|---|
Medication: nesiritide | Must be inpatient and have a claim for acutely decompensated HF, not chronic HF and another cause of hospitalization Short-term intravenous treatment in patients with dyspnea at rest or with minimal activity | 03/22/2006 |
Cardiac rehabilitation | Stable, chronic HF (LVEF of ≤ 35 % and NYHF FC II–IV symptoms despite being on optimal HF therapy for at least 6 weeks) Stable also refers to no recent (≤6 weeks) or planned (≤6 months) major CV hospitalizations or procedures | 02/18/214 |
Cardiac devices: implantable cardioverter-defibrillator placement | Patient populations: (a) documented episode of cardiac arrest due to VF, not due to a transient or reversible cause; (b) documented sustained VT, either spontaneous or induced by an EP study, not associated with an acute MI and not due to a transient or reversible cause; (c) documented familial/inherited conditions with a high risk of life-threatening VT, such as hypertrophic cardiomyopathy; (d) prior MI with left ventricular ejection fraction ≤ 35 % and inducible, sustained VT or VF at EP study within 40 days of MI and did not have NYHA FC IV HF, cardiogenic shock, or symptomatic hypotension while in a stable rhythm; had CAB surgery or PCI within past 3 months; had an enzyme-positive MI within the past 40 days; had clinical symptoms or findings that would prompt candidacy for coronary revascularization or any noncardiac disease associated with <1-year survival; (e) ischemic dilated cardiomyopathy and documented prior MI, NYHA FC II and III HF, and LVEF ≤ 35 %; (f) nonischemic dilated cardiomyopathy >9 months, NYHA FC II and III HF and LVEF ≤ 35 %; (g) meet coverage requirements for CRT device and have NYHA FC IV HF Be enrolled in either a Food and Drug Administration approved Category B investigational device exemption clinical trial, a trial under the CMS Clinical Trial Policy, or a qualifying data collection system including approved clinical trials and registries Must be able to give informed consent | Version 3: 01/27/2005 |
Wearable Automatic external Defibrillator use | Must meet the following conditions: Have a documented episode of VF or a sustained (lasting ≥ 30 s) ventricular tachyarrhythmia Dysrhythmias (listed above) may be either spontaneous or induced during an EP study but may not be due to a transient or reversible cause and not occur during the first 48 h of an acute MI May be from a familial or inherited condition with a high risk of life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy Either documented prior MI or dilated cardiomyopathy and a measured LVEF ≤ 35% | January 2011 |
Implantable cardioverter-defibrillator interrogation (in-person and remote) | Electronic analysis (interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest/during activity, interpretation of ECG recordings at rest/exercise, and derived data elements, analysis of event markers, and device response) Reprogramming Monitoring period: in-person, 30 days; remote, 90 days Professional and technical component codes | |
Wearable cardioverter-defibrillator interrogation | Electronic analysis (interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity, interpretation of ECG recordings, analysis of event markers and device response) Same as above with reprogramming Monitoring period: in-person, 30 days or 90 days Professional and technical component codes | |
Cardiac output monitoring by electrical impedance | Patient populations: (a) differentiation of cardiogenic from pulmonary causes of acute dyspnea when medical history, physical examination, and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient; (b) optimization of A/V interval for patients with A/V sequential cardiac pacemakers when medical history, physical examination, and standard assessment tools provide insufficient information; (c) monitoring of continuous inotropic therapy for patients with terminal congestive HF at home or for patients waiting at home for a heart transplant; (d) evaluation for acute or chronic cardiac rejection post-heart transplant as an alternative to myocardial biopsy; and (e) optimization of fluid management in patients with congestive HF when medical history, physical examination, and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management Frequency: daily | Version 3: 01/06/2007 |
Implantable Cardiovascular monitor – in-person or remote interrogation | Interrogation device evaluation for analysis of one or more recorder physiologic CV data element from external and internal sensors Monitoring period: 30 days Professional and technical component codes | |
Transtelephonic ECG transmission | Indications: (a) detect, characterize, and document symptomatic transient dysrhythmias; (b) initiate, revise, or discontinue dysrhythmic drug therapy; or (c) early (24-h coverage must be provided) monitoring of patients discharged after MI Requirements: (a) capable of transmitting ECG Leads I, II, or III; and (b) tracing must be sufficiently comparable to a conventional ECG | 03/01/1980 |
External counterpulsation | Not covered for AHF or post-discharge after AHF episode; only disabling angina | Version 2: 04/03/2006 |
Telehealth monitoring | Limited set of telehealth-delivered services are covered if delivered by live video office visits and consultations that are provided using an interactive two-way telecommunications system (with real-time audio and video) by a doctor or certain other healthcare provider who is not at your location but is in specific, approved locations Store-and-forward-delivered services are not covered except in demonstration projects Home telemonitoring services are not covered | December 2015 |
Transitional care management services | The services are required during the beneficiary’s transition to the community setting following particular kinds of discharges, and the healthcare professional (a) accepts care of the beneficiary post-discharge from the facility setting without a gap and (b) takes responsibility for the beneficiary’s care The patient receiving services has medical and/or psychosocial problems that require moderate or high complexity medical decision-making The transitional care period is 30 days beginning on the date the patient is discharged from the inpatient hospital setting and continues for the next 29 days Must complete a face-to-face visit for coverage; only one eligible visit claim is covered during the 30-day period If patient is readmitted to the hospital within 30 days, may still bill for previous service | January 1, 2013 |
Thoracic electrical impedance monitoring | Cardiac output monitoring by thoracic electrical bioimpedance is covered for six indications: noninvasive diagnosis or monitoring of hemodynamics if suspected or known CV disease, differentiation of cardiogenic from pulmonary causes of dyspnea, optimization of cardiac pacemaker refractory periods (i.e., A/V interval), assess the need for inotropic therapy, early identification of rejection post cardiac transplantation, need for fluid management (excluding patients on dialysis or with liver cirrhosis and management of drug-resistant hypertension) | January 2003 |
Implantable cardiac hemodynamic monitoring for heart failure | Outpatient care: has not been proven to be medically effective and is therefore considered investigational Currently, there are no specific billing codes for use | August 20, 2015 |
Observation Unit Regulations in Acute Heart Failure
Observation care includes ongoing short-term assessment, treatment, and reassessment in order to make a decision about whether a patient will require a hospital admission or if discharge and outpatient care are feasible [32]. Regulations for observation services changed drastically after the “two-midnight” rule became effective, since the rule changed the definition of an appropriate inpatient admission under Medicare Part A [33]. Payment rates for inpatient and outpatient stays differ; inpatient stays are based on the discharge diagnosis, procedures completed, and severity of illness and require a minimum stay of two midnights. In contrast, outpatient services under Medicare Part B are a hybrid of prospective payment and a fee schedule. Observation status is often used for patients with acute heart failure who present for emergency care and who then require a significant period of monitoring or treatment before a decision concerning admission or resolution of dyspnea and other acute symptoms can be made. Generally, observation services should not exceed two calendar dates (48 h), and the majority of patients should have a decision as to whether hospital admission is needed in less than 24 h, based on the clock time documented in the medical record that coincides with the time the physician creates a written order for observation services. To receive reimbursement for observation services by Medicare, a minimum of 8 h of service is required and if over 24 h are used, Medicare will not pay separately for the excess hours used, with all costs included in a composite payment as discussed below.
Regulations specific to observation services of patients with acute heart failure include physician billing and hospital billing. Physician billing is linked to service type for initial services rendered when placing a patient in observation status and observation care following initiation of observation services. Medicare has specific documentation requirements for billing observation care services and admission to hospital service (inpatient status) following observation care. Table 3.3 provides the CPT codes used specifically for physician payment of observation services, based on the January 2010, Centers for Medicare & Medicaid Services revised consultation services payment policy for observation care, and documentation requirements [34].
Table 3.3
Medicare national coverage for medical management of heart failure in observation status
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