The following are the applicable HCPCS codes:
93797 – Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session); and
93798 – Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session).
Effective for dates of service on or after January 1, 2008 and before January 1, 2010, providers and practitioners may report more than one unit of Procedure code 93797 or 97398 for a date of service if more than one cardiac rehabilitation session lasting at least 1 hour each is provided on the same day. In order to report more than one session for a given date of service, each session must last a minimum of 60 minutes. For example, if the cardiac rehabilitation services provided on a given day total 1 hour and 50 minutes, then only one session should be billed to report the cardiac rehabilitation services provided on that day.
Cardiac Rehabilitation Program Services Furnished On or After January 1, 2010
As specified at 42 CFR 410.49, Medicare covers cardiac rehabilitation items and services 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 or replacement; or
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
• A heart or heart-lung transplant; or
• Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks (effective February 18, 2014).
Cardiac rehabilitation programs must include the following components:
• Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
• Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
• Psychosocial assessment;
• Outcomes assessment; and
• An individualized treatment plan detailing how components are utilized for each patient.
Cardiac rehabilitation items and services 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 times items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for the direct supervision of physician’s office services as specified at 42 CFR 410.26 and for hospital outpatient therapeutic services
Cardiac rehabilitation by national LCD is covered for only six groups of patients:
- Patients who begin the program within 12 months of an acute Myocardial Infarction (MI).
- Patients who have had Coronary Artery Bypass Graft (CABG) surgery.
- Patients with stable angina pectoris.
- Patients who have had heart valve repair/replacement.
- Patients who have had Percutaneous Transluminal Coronary Angioplasty (PTCA) or coronary stenting.
- Patients who have had a heart or heart-lung transplant.
- The facility meets the definition of a hospital outpatient department or a physician-directed clinic, i.e., a physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician.
- The facility has available for immediate use all the necessary cardiopulmonary emergency diagnostic and therapeutic life-saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment or defibrillator.
- The program is conducted in an area set aside for the exclusive use of the program while it is in session.
- The program is staffed by personnel necessary to conduct the program safely and effectively and who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. When conducted in a hospital, an identified physician must be immediately available. This does not require that a physician be physically present in the exercise room itself but must be immediately available and accessible at all times in case of an emergency.
- When conducted in the hospital, the non-physician personnel are employees of the hospital conducting the program.
- When conducted in a clinic or physician’s office, the non-physician personnel are employees of the physician or clinic conducting the program and their services are “incident to” a physician’s professional services.
- For MI, the date of entry into the program must be within 12 months of the date of infarction.
- For CABG, the initiation of the program should be early enough to have a restorative effect on the recuperative process. Therefore, the date of entry should be within six months of the CABG procedure.
- For angina, all patients must have a pre-entry stress test that is positive for exercise-induced ischemia within six months of starting cardiac rehabilitation (see “Group II Services” below). A positive stress test in this context implies a junctional depression of 2 mm or more with associated slowly rising ST segment, or 1 mm horizontal or downsloping ST segment depressions. Over the years, nuclear perfusion studies have supplanted standard Electrocardiogram (ECG) treadmill tests as a means of evaluating ischemic heart disease, especially for patients who have abnormal rest ECGs. Therefore, the positive stress test also includes perfusion studies that demonstrate ischemia.
- For patients with heart valve repair or replacement, the program should be early enough to provide a restorative benefit. Therefore, the date of entry must be within six months of surgery.
- For patients who have had a PTCA or stent replacement, the program should be early enough to provide a restorative benefit. Therefore, the date of entry must be within six months of surgery.
- Patients who have had a heart or heart-lung transplant may present special and complex posttransplant management problems. The date of entry is extended to within one year of the surgery.
C. Frequency and Duration
- The frequency and duration of the program are generally a total of 36 sessions, two to three times per week over 12–18 weeks. Sessions extending beyond the 18 weeks may be reviewed to confirm medical necessity.
- Services at a frequency of fewer than two sessions per week will be considered not medically necessary unless additional documentation is demonstrated verifying the patient was unable to attend due to illness or hospitalization.
- For the purposes of this LCD, Phase II is divided into Phase IIA and Phase IIB:
- Phase IIA is the initial outpatient cardiac rehabilitation, not to exceed a total of 36 sessions, two to three sessions per week for 12–18 weeks.
- Phase IIB consists of an additional series of 36 sessions, two to three times per week for 12–18 weeks and will only be allowed if determined to be medically necessary. The total number of allowable sessions (Phase IIA and IIB combined) is 72 within a 36-week period. Phase IIB benefits must meet additional medical necessity criteria; specifically, there must be clear demonstration the patient is benefiting from cardiac rehabilitation and that the exit criterion below has not been met.
D. Exit Criterion
- The patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia.
- Symptoms of angina or dyspnea are stable at the patient’s maximum exercise level.
- The patient’s resting blood pressure and heart rate are within normal limits.
- The stress test is not positive during exercise. A positive stress test in this context implies an ECG with a junctional depression of 2 mm or more associated with slowly rising, horizontal or down-sloping ST segment.
- For patients with valvuloplasty or valve replacement, benefits are available for Phase IIA only. Data showing that extension of the program beyond the 36 sessions is reasonable and necessary is not available.
- The posttransplant patient poses a special challenge for the cardiac rehabilitation team. Issues such as deconditioning and cachexic deterioration may complicate the definition of a reasonable exit criterion. Based on the study of long-term cardiopulmonary exercise performed after heart transplant by Osade et al, this contractor will use a peak oxygen consumption (VO2) of greater than 90 percent predicted as the exit criterion for Phase IIA. Patients whose VO2 is less than 90 percent predicted may qualify for the additional Phase IIB.
E. Non-Covered Diagnoses
- Use of any ICD-9-CM diagnosis code not in the “ICD-9-CM Diagnosis Codes That Support Medical Necessity” section of this LCD will be cause for denial of claims.
- A patient with unstable angina will not qualify for cardiac rehabilitation services.
- Congestive heart failure in the absence of other covered conditions is not included as a covered condition of cardiac rehabilitation in the CMS National Coverage Determination Manual, Publication 100-03, Section 20.10.
F. Other Services
- Evaluation and Management (E/M) services, ECGs and other diagnostic services may be covered on the day of cardiac rehabilitation if these services are separate and distinct from the cardiac rehabilitation program and are medically necessary.
- Forms of counseling, such as dietary counseling, psychosocial intervention, lipid management and stress management, are components of the cardiac rehabilitation program and are not separately reimbursed.
G. Definition of Group Services
- Group I services include:
- Continuous ECG telemetric monitoring during exercise.
- ECG rhythm strip with interpretation and physician’s revision of exercise prescription.
- Limited examination for physician follow-ups to adjust medication or for other treatment changes.
- Group II services include:
- New patient comprehensive evaluation, including history, physical and preparation of initial exercise prescription. One will be allowed at the beginning of the program if not already performed by the patient’s attending physician or if that performed by the patient’s physician is not acceptable to the program’s director.
- ECG stress test (treadmill or bicycle ergometer) with physician monitoring and report. One will be allowed at the beginning of the program and one after three months (usually the completion of the program).
- Other physician services, as needed.
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Providers are reminded to refer to the long descriptors of the
Medicaid guidelines CARDIAC REHABILITATION:
Effective January 1, 2010, New York Medicaid will cover medically necessary cardiac rehabilitation for fee-forservice enrollees when ordered by a physician. Cardiac rehabilitation programs must be comprehensive and include a medical evaluation, a program to modify cardiac risk factors (e.g., nutritional counseling), prescribed exercise, education, and counseling.
The American Heart Association/American Association of Cardiovascular and Pulmonary Rehabilitation (AHA/AACVPR) defines cardiac rehabilitation (CR) as coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality
To be reimbursed by Medicaid, cardiac rehabilitation therapy must be provided:
** in an Article 28 hospital outpatient department; or
** in a physician’s office; or
** Upon APG implementation in Freestanding Diagnostic and Treatment Centers (D&TCs) or Federally Qualified Health Centers (FQHCs) that bill using APGs.
The following practitioners may administer cardiac rehabilitation in a clinic setting: Physicians, Physician Assistants, Nurse Practitioners, Physical Therapists, Physical Therapy Assistants, and Registered Nurses. Medicaid coverage of cardiac rehabilitation is consistent with Medicare’s coverage guidelines. Coverage is subject to the following conditions:
** The facility meets the definition of a hospital outpatient department or a freestanding D&TC, i.e., a physician is on the premises and available to perform medical duties at all times while the facility is open, and each patient is under the care of a hospital or clinic physician;
** The facility has immediately available all cardiopulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
** While in session, the program is conducted in an area set aside for its exclusive use; and, ** The facility is staffed by necessary personnel to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. Services of non-physician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area and immediately available and accessible for an emergency at all times while the exercise program is being conducted. It does not require that a physician be physically present in the exercise room. However, the physician must be in close proximity considered immediately available and accessible.
To be eligible for covered cardiac rehabilitation services, Medicaid beneficiaries must have a qualifying cardiac event with an ICD-9 diagnosis supporting medical necessity as follows:
** acute myocardial infarction within the preceding 12 months (all ICD-9 codes beginning with 410 or 412 or V58.73); or
** stable angina pectoris (all ICD-9 codes beginning with 413 or V58.73); or
** heart or heart-lung transplant (ICD-9 V42.1); or
** heart valve repair/replacement (ICD-9 V42.2, V43.3); or
** previous coronary artery bypass (CABG) surgery (ICD-9 V45.81); or
** percutaneous transluminal coronary angioplasty – PTCA – or coronary stenting (ICD-9 V45.82).
Note: Congestive heart failure in the absence of other covered conditions is NOT included as a covered condition for cardiac rehabilitation.
The frequency and duration of the program generally consists of 36 sessions, occurring 2-3 times per week for 12-18 weeks. No prior authorization is necessary for this phase. Prior authorization will be required for cardiac rehabilitation beyond the initial 36 sessions for patients who do not meet the exit criteria. Prior authorization must be obtained by a physician or nurse practitioner. The additional 36 sessions (2-3 times per week for 12-18 weeks) may be granted when:
** the patient’s qualifying diagnosis was not V42.2 or V43.3 (valvuloplasty or valve replacement); and;
** the patient is benefiting from cardiac rehabilitation; and
** the patient has failed to meet the exit criteria after completion of the first 36 visits.
A visit including one or more of the following services is considered one routine cardiac rehabilitation visit. The same rate of reimbursement will be allowed for each visit. A visit does not require that all of the services be performed. In order for the visit to be reimbursable, at least one of these services must be performed:
** continuous ECG telemetric monitoring during exercise;
** ECG rhythm strip with interpretation and physician’s revision of exercise prescription; and
** limited examination for physician follow-up to adjust medication or other treatment changes.
Each session must last a minimum of 60 minutes. One session per day is reimbursable. Two or three sessions are allowed per week. Sessions at a frequency of less than two per week will be considered not medically necessary. Other Covered Services Include:
** New patient comprehensive evaluation, including history, physical, and preparation of initial exercise prescription. One is allowed at the beginning of the program if not already performed by the patient’s attending physician.
** ECG stress test (treadmill or bicycle ergometer) with physician monitoring and report. Allow one at the beginning of the program and one after 3 months (usually upon completion of the program).
** Other physician services, as needed.
In a clinic setting, cardiac rehabilitation is billed under Ambulatory Patient Groups (APGs) with one of the following rate codes as appropriate: 1400, 1407, 1413, 1422, 1425, 1432, 1435 or 1441.
The CPT Codes for Cardiac Rehabilitation Include:
** 93797, Physician services for outpatient cardiac rehabilitation, without continuous ECG monitoring (per session); and
** 93798, Physician services for outpatient cardiac rehabilitation, with continuous ECG monitoring (per session).
Either of these codes will group to APG 94, Cardiac Rehabilitation (a significant procedure APG). These APG rate codes are applicable for cardiac rehabilitation payment. When cardiac rehabilitation is provided in a physician’s office, the physician can bill using these CPT codes. Payment for these procedure codes can be found in the Physician Medicine Fee Schedule at www.emedNY.org.
Patients who participate in cardiac rehabilitation programs may require medically necessary services beyond the normal service limits. These service limits are established and based on each beneficiary’s clinical information, including diagnoses, procedures, prescription drugs, age and gender. As a result, most Medicaid beneficiaries will have service limits increased to clinically appropriate levels and will not need additional services authorized. However, when indicated, the physician may request approval of higher limits by submitting a Threshold Override Application (TOA).
Acute myocardial infarction of anterolateral wall
Acute myocardial infarction of other anterior wall
Acute myocardial infarction of inferolateral wall
Acute myocardial infarction of inferoposterior wall
Acute myocardial infarction of other inferior wall
Acute myocardial infarction of other lateral wall
True posterior wall infarction
Acute myocardial infarction of other specified sites
Acute myocardial infarction of unspecified site
Old myocardial infarction
Note: ICD-9-CM code 412 (old myocardial infarction) refers to an MI that has occurred more than eight weeks prior to cardiac rehabilitation services.
Other and unspecified angina pectoris
Heart replaced by transplant
Heart valve replaced by transplant
Organ or tissue replaced by transplant, other
Note: Use V42.89 for heart-lung transplant
Heart valve replaced by other means
Post-surgical aortocoronary bypass status
Percutaneous transluminal coronary angioplasty status
Aftercare following surgery of the circulatory system not elsewhere classified