Cardiac and Pulmonary Rehabilitation Services: Office of Inspector General Audit Report

News | Published: Friday, May 28, 2021


Recently the Office of Inspector General (OIG) released the report of an audit focused on cardiac rehabilitation (CR) and pulmonary rehabilitation (PR). The audit was performed on claims from the third highest paid provider in the country in combined Medicare claims for both outpatient CR and PR.

The audit 100 sampled beneficiary medical records. The report states that documentation did not contain sufficient evidence to support whether Medicare coverage requirements for reimbursement of CR and PR services were met. This lack of evidence was an issue at varying levels in 100% of the records reviewed.

Issues of note:

  • Individualized treatment plans lacked evidence of physician supervision and were not tailored to meet beneficiaries’ individual medical needs
  • Individualized treatment plans did not include [detailed] description of beneficiaries’ diagnoses
  • Individualized treatment plans signed after the date of service or not signed
  • Inadequate psychosocial assessments – specifically noted as “crucial to planning, patient participation and monitoring”

The report concludes that Centers for Medicare and Medicaid Services (CMS) requirements regarding conditions of coverage are not sufficient to ensure providers maintained adequate evidence (documentation) in beneficiaries’ medical record and recommends a revision to the regulations. While revisions to the regulations will take longer, the CMS response indicates the sub regulatory guidance for coverage requirements was updated within the Medicare Benefit Policy Manual and Medicare Claims Processing Manual in March 2021. The OIG report is very informative, reasonably easy to read, and can provide valuable insight for your CR/PR managers.

Download the report.