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.
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:
- an acute myocardial infarction within the preceding 12 months; or
- a coronary artery bypass surgery; or
- current stable angina pectoris; or
- heart valve repair/replacement; or
- percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or,
- heart or heart-lung transplant.
Cardiac rehabilitation programs must include the following components:
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Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
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Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
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Psychosocial assessment;
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Outcomes assessment; and,
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An individualized treatment plan detailing how components are utilized for each patient.
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:
- Positively affected the progression of coronary heart disease;
- Reduced the need for coronary bypass surgery; and,
- Reduced the need for percutaneous coronary interventions.
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:
- Low density lipoprotein;
- Triglycerides;
- Body mass index;
- Systolic blood pressure;
- Diastolic blood pressure; and,
- The need for cholesterol, blood pressure, and diabetes medications.
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:
- Once a member begins CR, he or she may not switch to ICR and once a member begins ICR, he or she may not switch to CR.
- Upon completion of a CR or ICR program, members must experience another indication in order to be eligible for coverage of more CR or ICR.
- If a member experiences more than one indication simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., a patient who had a myocardial infarction within 12 months and currently experiences stable angina is entitled to one series of CR sessions, up to 36 one-hour sessions with the option for an additional 36 sessions; or one series of ICR, up to 72 one-hour sessions over a period of up to 18 weeks.
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:
- Any additional sessions beyond 72 sessions within a 126 day period counting from the date of the first session meet the CMS medical necessity criteria; or,
- Sessions provided after 126 days from the date of the first session meet the CMS medical necessity criteria.
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.
06/2010, Cardiac rehabilitation services reporting guidelines outlined for Medicare Advantage
08/2010, Cardiac and intensive cardiac rehabilitation coverage guidelines explained
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