Overcoming Barriers to Cardiac Rehab Enrollment Part 3: How to Leverage Virtual Cardiac Rehab and Get Paid for It

Wednesday, January 20, 2021 | Terri McDonald

In part 1 of this blog series I explored the benefits of cardiac rehab (CR) and some of the enrollment barriers providers face today. In part 2 I shared strategies for overcoming financial barriers and addressed patient adherence and access. Part 3 delves into opportunities to develop virtual models of care and how to use Public Health Emergency (PHE) temporary waivers to deliver and bill virtual CR services in your hospital-based program.

Virtual Cardiac Rehabilitation: Benefits and Opportunities

In-center CR capacity in the U.S. has been stressed by the COVID-19 pandemic. Approximately 3.3 million sessions were interrupted in 2020. Although many centers reopened as quickly as practical, physical distancing requirements have forced many centers to reduce the number of patients in centers, creating wait lists. When compared with traditional in-center programs, virtual CR programs that deliver the same comprehensive components as in-center programs have been demonstrated to be equally effective for low-risk patient populations.

There are a growing number of software platforms available to support virtual CR. Allowing low-risk patients to complete CR in a home-based setting may be a future solution to many access-related barriers that were present before the pandemic. The challenge to fully developing a virtual CR model lies in the lack of coverage and reimbursement by Medicare and other major payers.

How to Use PHE Temporary Waivers to Deliver and Bill Virtual CR Services in Your Hospital-Based Program

As the pandemic rages on we now face shifting state and local pandemic policies directed at managing surges after the 2020 holiday season, with hospital-based centers managing wait lists and fluctuating volumes. On Jan. 2, 2021, the Department of Health and Human Services renewed the PHE, moving the expiration date to April 21, 2021. With this extension CR programs can leverage virtual CR to reach patients who cannot attend in-center sessions. Here’s how:

In March 2020 the Centers for Medicare and Medicaid Services (CMS) established the Hospital Without Walls initiative as a part of the COVID-19 Emergency Declaration Waivers, allowing hospitals to provide hospital services at expansion sites. Under the temporarily streamlined extraordinary circumstances relocation exception policy hospitals can relocate provider-based departments (PBD) such as CR to other locations, including the patient’s home, and continue to receive the full Outpatient Prospective Payment System (OPPS) payment amount. The purpose of relocated PBDs under the waiver is to compliment state and local pandemic measures aimed at decreasing the potential for the spread of COVID-19, while continuing to deliver essential care and service to Medicare and Medicaid beneficiaries.

Because there was uncertainty around the CMS requirement for direct physician supervision of CR services, the extent of this opportunity for center-based CR was not clearly understood until late in 2020 when CMS provided clarification about the provision of virtual direct supervision by a physician. That clarification is provided in CY 2021 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1736-FC) (pages 739-740). In summary, the salient points for virtual direct physician supervision in a relocated PDB are:

  • The requirement for direct physician supervision during the PHE may be met through virtual presence using audio/video real-time communications technology
  • The supervising practitioner must be immediately available to engage via both audio and video technology
  • Specifically speaking to CR services real-time presence or observation of the service via interactive audio and video technology throughout the performance of the procedure [by the supervising physician] is not required, however (identical to the center-based requirement for supervision), the physician must be immediately available to respond.
What Does This Mean for Your Hospital-Based CR Program?

This allows your CR program to relocate to more than one location, including patients’ homes, while still maintaining the original CR center-based location. Essentially, your CR team will overlay the Medicare statutory requirements for CR in the patient’s home through a virtual care delivery model. Exercise sessions will be consistent with the patient’s CR treatment plan. Patients must be supervised real-time just as you do in-center but using both audio and visual technology real-time to supervise the exercise session. Direct physician supervision of CR sessions may be provided through the immediate availability of the physician to respond to emergencies or questions from the CR team about the patient’s care through real-time audio-visual technology. Basic documentation requirements for consent, the ITP, exercise sessions, education, etc. are the same. Programs will need to leverage internal resources to make this work – here are some key considerations as a starting point:

Patient Selection

A common concern about virtual sessions among CR teams is the lack of immediate emergency care for patients in the event of an adverse event related to exercise. This is a real concern as 911 emergency service becomes the source of care if that does happen. But we know the incidence is low across the spectrum and we can establish sound processes for assessing clinical risk in our patient population. This should be led by the medical director with the input of the CR team. An assessment of the home environment can assist in determining if the patient has someone in the home who can assist if there is a medical emergency. Ideally the patient would be admitted through the traditional center-based intake model for this assessment, with subsequent exercise sessions planned for home or a hybrid of in-center exercise session and home-based exercise sessions. If current pandemic circumstances or individual patient needs prohibit in-center visits, consider a totally virtual intake design. These considerations and the virtual CR plan should be documented in the EMR as a part of the patient’s treatment plan.

Audio-Visual Platform

To supervise home exercise sessions the CR team may use platforms like Zoom, Microsoft Teams, Skype, etc. for the duration of the PHE waivers. A patient consent to the use of the audiovisual platform should be documented in the medical record. The physician supervision can be a separate platform, simply accomplished using smartphone apps like Facetime.

Exercise Equipment

Without access to the traditional in-center gym environment, the medical director and CR team will need to establish alternative strategies for exercise sessions. This might include step devices, bands, sit-to-stand, balancing/stretching exercises, or any equipment the patient has available in the home, such as a treadmill. Group exercise sessions with other patients using an audiovisual platform may be considered, with the same safeguards for patient privacy that you would apply in-center with multiple patients present in an exercise session.

Supervising and Recording Exercise Sessions

The same principles we apply in-center for supervising patient exercise sessions should be applied to virtual sessions. Patient wearables may be used as a source for assessing the patient’s heart rate during exercise.

Software Solutions – Now and Later

Identifying a software solution to help with planning, managing and delivering virtual CR can be a part of short-term or longer-term strategies to permanently incorporate virtual CR into your program. If contracting and interfacing software solutions is a complicated and lengthy process in your system get started without one – the current window to demonstrate the value and safety of virtual CR with home-based exercise in the low-risk Medicare population is now, using the PHE waivers. Starting here we can build on the PHE strategies to define and refine our strategies for virtual care in the future. If your program does choose to use a software solution to support virtual CR choose a solution designed for CR with Bluetooth-enabled peripheral devices as an option. For example, integration of data from patient wearables, blood pressure cuff, and scale.


It is important to include your coding, billing and compliance professionals in the billing processes for virtual CR under the PHE waivers. As an on-campus hospital-based PDB you may bill with modifier “PO” to be paid under the OPPS for the services at the same rate billed for in-center sessions. Hospitals have 120 days from the date on which they begin furnishing services at a relocated PBD (in this case the patient home) to submit a temporary extraordinary circumstances relocation exception request (85 FR 27561) to your regional Medicare office. An encrypted email notification should include 1) hospital CCN; 2) addresses of current and relocated PBD; 3) start date of services at relocated PBD; 4) brief justification for relocation and role of relocation in hospital’s response to COVID-19; 5) why the location is appropriate for outpatient services; and 6) attestation the relocation is not inconsistent with state emergency/pandemic plan. Hospitals are not required to submit a separate email for every relocation site. Your billing team can send a request that includes all the addresses to which the PBD relocated over a period of weeks or months, rather than a single request for each location.

Non-federal payer coverage will need to be determined on a case-by-case basis and may impact the patient’s treatment plan.

Act Now

The COVID-19 pandemic has created a time of rapid innovation in delivering care – we’ve seen firsthand how complex organizations can work strategically and quickly to deliver essential services. Now that we have clarity around how to deliver CR virtually for Medicare patients during the PHE we can and should move forward.

Learn more about the MedAxiom Consulting Team and how we can help you and your organization tackle issues such as patient access, effective leadership, staffing/operational efficiencies, adaptability and more.

Illustration: Lee Sauer

About the Author
Terri McDonald

Terri McDonald, RN, MBA, CPHQ is Vice President, MedAxiom Consulting. She brings extensive knowledge and experience in leading, managing and optimizing every level of the cardiovascular service line. Following a clinical career in cardiac and critical care nursing, Terri gained a diverse knowledge of administrative, operations and clinical nursing management in the acute care setting. As VP of Consulting Terri fulfills her lifelong passion for cardiology and cardiovascular care helping her clients succeed through understanding challenges and designing collaborative, practical solutions using evidence-based guidelines and emerging technologies.

To contact, email: tmcdonald@medaxiom.com


Posted by: Jodi Alderman BSN RN on February 25, 2021 @2:21:41 pm

Thank you this is very informative and useful information

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