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OIG Work Plan Update

OIG Work Plan Update May 16, 2018

The OIG updated their Work Plan yesterday to include Medicare claims for Part B outpatient cardiac and pulmonary rehabilitation services. The OIG will conduct audits to determine whether Medicare payments for these services were allowable in accordance with Medicare requirements. In order for cardiac and pulmonary rehabilitation services to be covered, they must meet medical necessity and very specific documentation requirements. Historically, the OIG has found that claims did not comply with these requirements.

Additional information regarding the work plan is available at: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000292.asp

We have provided several links to various CMS publications regarding these services. Please note that many Medicare Administrative Contractors have published Local Coverage Articles and Local Coverage Determinations as well. These should also be reviewed.

• Medicare Benefit Policy Manual Chapter 15, Sections 231 and 232: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
• Medicare Claims Processing Manual Chapter 32, Section 140: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf
• MLN Matters MM6850 Cardiac Rehabilitation and Intensive Cardiac Rehabilitation: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6850.pdf
• National Coverage Determination for Cardiac Rehabilitation Programs for Chronic Heart Failure (20.10.1): https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=359&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=cardiac+rehab&KeyWordLookUp=Title&KeyWordSearchType=And&FriendlyError=MissingNCDID&bc=gAAAACAAAAAA&
• National Coverage Determination for Intensive Cardiac Rehabilitation Programs (20.31): https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=339&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=cardiac+rehab&KeyWordLookUp=Title&KeyWordSearchType=And&FriendlyError=MissingNCDID&bc=gAAAACAAAAAA&
• Decision Memo for Cardiac Rehabilitation Programs – Chronic Heart Failure: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=270

We recommend providers review the Work Plan updates monthly and conduct proactive audits of the applicable areas identified in the Work Plan.

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