Medicare Advantage Medical Policy Bulletin

Section: CMS National Guidelines
Number: N-1
Version: 005
Topic: Cardiac Rehabilitation Programs
Effective Date: January 31, 2011
Issued Date: January 31, 2011

General Policy

For services on or after 3/22/11 see policy V-1.

Cardiac Rehabilitation: Cardiac rehabilitation (CR) is a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment.

Intensive Cardiac Rehabilitation: Intensive cardiac rehabilitation (ICR) program means a physician-supervised program that furnishes cardiac rehabilitation and has shown, in peer-reviewed published research, that it improves patients' cardiovascular disease through specific outcome measurements.

Indications and Limitations of Coverage

Cardiac Rehabilitation Programs (93797, 93798)

Coverage of cardiac rehabilitation programs is considered reasonable and necessary only for patients who have experienced one or more of the following:

Cardiac rehabilitation programs must include the following components:

Cardiac rehabilitation must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and service are being furnished under the program. This provision is met if the physician meets the requirements for the direct supervision of physician’s office services and hospital outpatient therapeutic services. This requirement also applies to Intensive Cardiac Rehabilitation Programs. “Direct supervision'' means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

Cardiac rehabilitation program sessions are limited to a maximum of 2 one-hour sessions per day for up to 36 sessions for up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved. 

Providers may report a maximum of 2 one-hour sessions per day. In order to report one session of cardiac rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Two sessions of cardiac rehabilitation services may only be reported in the same day if the duration of treatment is at least 91 minutes. If several shorter periods of cardiac rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in one-hour session increments.

Intensive Cardiac Rehabilitation Program Services (G0422, G0423)
Intensive cardiac rehabilitation program services are eligible for the same conditions and must include the same components as those documented for Cardiac Rehabilitation Programs.  

In addition, intensive cardiac rehabilitation programs must be approved by Medicare. In order to be approved, a program must demonstrate through peer-reviewed published research that it has accomplished one or more of the following for its patients:

An intensive cardiac rehabilitation program must also demonstrate through peer-reviewed published research that it accomplished a statistically significant reduction in 5 or more of the following measures for patients from their levels before cardiac rehabilitation services to after cardiac rehabilitation services:

Intensive cardiac rehabilitation program sessions are limited to 72 one-hour sessions, up to 6 sessions per day, over a period of up to 18 weeks.

In order to report one session of cardiac rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Additional sessions of intensive cardiac rehabilitation services beyond the first session may only be reported in the same day if the duration of treatment is 31 minutes or greater beyond the hour increment. For example, in order to report 6 sessions of intensive cardiac rehabilitation services on the same date of service, the first five sessions would account for 60 minutes each and the sixth session would account for at least 31 minutes. If several shorter periods of intensive cardiac rehabilitation services are furnished on the same date of service, the minutes of service during those periods must be added together for reporting in one-hour increments.

Effective August 12, 2010, the Dean Ornish Program for Reversing Heart Disease (also known as the Multisite Cardiac Lifestyle Intervention Program, the Multicenter Cardiac Lifestyle Intervention Program, and the Lifestyle Heart Trial Program) and the Pritikin Program meet the intensive cardiac rehabilitation (ICR) program requirements and are eligible for reimbursement. If a specific ICR program is not included on the list as a Medicare-approved ICR program, it is not covered. A participating, preferred, or network provider can bill the member for the denied service.

The following guidelines apply to both cardiac rehabilitation and intensive cardiac rehabilitation:

Reasons for Noncoverage

Services provided for any other conditions not listed above or that exceed the frequency guideline will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

The individualized treatment plan should be maintained in the medical record and available upon request. Patient’s individualized treatment plan should include: 1) description of the individual’s diagnosis; 2) the type, amount, frequency, and duration of the CR or ICR furnished; and 3) the goals set for the individual under the plan. The individualized treatment must be established, reviewed, and signed by a physician every 30 days.

GA, GZ, and KX Modifiers

Providers should report the KX modifier with cardiac rehabilitation (93797, 93798) indicating that documentation is on file verifying that further treatment beyond 36 sessions of CR, up to a total of 72 sessions, meets CMS’ medical necessity criteria.

Providers should report the KX modifier with intensive cardiac rehabilitation (G0422, G0423) to indicate one of the following:

When codes 93797, 93798, G0422, or G0423 are reported with a GA modifier, indicating that the Pre-Service Denial Notice is on file, they will be denied as not medically necessary and are billable to the member.

When codes 93797, 93798, G0422, or G0423 are reported with a GZ modifier, indicating that a Pre-Service Denial Notice is not on file, they will be denied as not medically necessary and are not billable to the member.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

9379793798G0422G0423  

Coding Guidelines

Publications

PRN

06/2010, Cardiac rehabilitation services reporting guidelines outlined for Medicare Advantage
08/2010, Cardiac and intensive cardiac rehabilitation coverage guidelines explained

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Manual, 100-3, Chapter 1, Part 1, Section 20.10, 20.31.1, 20.31.2

CMS On-Line Manual, 100-4, Chapter 32, Sections 140.2-140.3

CAG - 00089R

CAG - 00418N

CAG - 00419N

Transmittal 52 NCD, CR 4401

Transmittal 116 NCD, CR 6855

Transmittal 1871 CP, CR 6751

Transmittal 125 NCD, CR 7113

Transmittal 126 NCD, CR 6850

Federal Register. Vol. 74(226); November 25, 2009: 62004 - 62005

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

410.00-410.92412413.9414.00-414.07
V42.1V42.2V42.3V45.00
V45.81V45.82  

ICD-10 Diagnosis Codes

INFORMATIONAL ONLY

I20.8I20.9I21.01I21.02
I21.09I21.11I21.19I21.21
I21.29I21.3I21.4I22.0
I22.1I22.2I22.8I22.9
I25.10I25.110I25.111I25.118
I25.119I25.2I25.700I25.701
I25.708I25.709I25.710I25.711
I25.718I25.719I25.720I25.721
I25.728I25.729I25.730I25.731
I25.738I25.739I25.750I25.751
I25.758I25.759I25.760I25.761
I25.768I25.769I25.790I25.791
I25.798I25.799I25.810I25.811
I25.812Z48.21Z48.280Z94.1
Z94.3Z94.5Z95.1Z95.3
Z95.4Z95.5Z95.9Z98.61

Glossary

TermDescription

Outcome Assessment

An evaluation of progress as it relates to the individual’s rehabilitation which includes all of the following:

  1. Minimally, assessments from the commencement and conclusion of cardiac rehabilitation and intensive cardiac rehabilitation, based on patient-centered outcomes which must be measured by the physician immediately at the beginning of the program and at the end of the program.
  2. Objective clinical measures of exercise performance and self-reported measures of exertion and behavior.

Physician

Doctor of Medicine or Osteopathy

Physician-prescribed exercise

Aerobic exercise combined with other types of exercise (that is, strengthening, stretching) as determined to be appropriate for individual patients by a physician.

Psychosocial assessment

An evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation which includes an assessment of those aspects of an individual’s family and home situation that affects the individual’s rehabilitation treatment, and psychosocial evaluation of the individual’s response to and rate of progress under the treatment plan.

Supervising physician

A physician who is immediately available and accessible for medical consultations and medical emergencies at all times services are being furnished to individuals under cardiac rehabilitation and intensive cardiac rehabilitation programs.






Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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