Road Map to Reform (R2R)

On December 20, 2016 CMS decided to go forward with a bundled payment incentive model for AMI and CABG procedures at 98 metropolitan statistical areas (MSAs). They also released a 90-day cardiac rehab incentive model for 90 MSAs. The CR incentive payment model is being implemented with the hopes that it will increase the number of patients who go to cardiac rehab. Participating hospitals with get incentive payments based on the how many of their patients utilize cardiac rehab.

For more information visit this link of the Road Map to Reform: R2R


Reimbursement Report MNACVPR 8/28/15


Proposed 2016 Payment for Pulmonary Rehab, Respiratory Care Services, Cardiac Rehab, & Intensive Cardiac Rehab Services


Based on the CMS methodologies described above, APC categories have changed for all cardiac rehab (CR), intensive cardiac rehab (ICR) services and for pulmonary/respiratory services. The status indicator has changed for pulmonary rehab and respiratory care/therapy services. These changes explain the following payment rates for CY 2016.


 CY 2016 Proposed Payment Rates


HCPCS Code Service Status Indicator APC Payment Rate Co-Payment


93797 Cardiac Rehab S 5771 $104.33 $20.87
93798 Cardiac Rehab/Monitor S 5771 $104.33 $20.87


G0422 Intens. cardiac rehab with exer. S 5772 $291.66 $58.34
G0423 Intens. cardiac rehab no exer. S 5772 $291.66 $58.34
G0424 Pulmonary rehab w exer. Q1 5733 $56.70 $11.34


G0237 Therapeutic procd. strg. endur. Q1 7733 $93.27 $18.66
G0238 Oth. resp. proc., indiv. Q1 5733 $56.70 $11.34
G0239 Oth. resp. proc., group. Q1 5732 $31.03 $6.21


As this information indicates, there is virtually no change in payment for cardiac rehabilitation services billed with codes 93797 and 93798. Intensive cardiac rehab receives a huge bump due to data received from hospital based programs’ claims data.   


In the pulmonary rehabilitation arena, G0424 and G0238 receive a modest bump upwards, and G0237 receives a large increase. Please note that G0424 and G0238 now reside in the same APC (APC 5733) while G0237 finds a new home in APC 5734.


These are proposed payment rates and can be adjusted in the final rule in November as CMS will have more comprehensive data available at that time.

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