CMS Publishes Cardiac Rehabilitation Regulations

on Thursday, 24 June 2010. All News Items

On May 21, 2010, CMS released two transmittals that manualize the requirements for Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) services.  Following is a summary of some of the key points of those transmittals.  However, MMP, Inc. strongly encourages providers to carefully review the manual content contained in these transmittals for a complete understanding of coverage and billing requirements.  Transmittal 126 updates the Medicare Benefits Policy Manual and Transmittal 1974  updates the Medicare Claims Processing Manual.  Both transmittals are effective January 1, 2010 for claims processed on or after October 4, 2010.

“Effective January 1, 2010, Medicare Part B pays for CR/ICR programs and related items/services if specific criteria is met by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is administered, and the physician administering the program, as outlined below:”

Beneficiary Requirements:
Medicare covers CR/ICR items and services for patients with:

  • Acute myocardial infarction within the preceding 12 months
  • Coronary artery bypass surgery
  • Current stable angina pectoris
  • Heart valve repair or replacement
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
  • Heart of heart-lung transplant

Program Components:

  • Physician-prescribed exercise.  Aerobic exercise combined with other types of exercise as determined appropriate by a physician.
  • Cardiac risk factor modification including education, counseling, and behavioral intervention.
  • Psychosocial assessment.  A written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation.
  • Outcomes assessment conducted by the physician minimally at the start and end of the program, including objective clinical measures of exercise performance and self-reported measures of exertion and behavior.
  • An individualized treatment plan that includes a description of the individual’s diagnosis; the type, amount, frequency, and duration of CR/ICR items and services; and the patient’s goals.
  • The plan must be established, reviewed, and signed by a physician every 30 days. 

Setting Requirements:

CR/ICR must be furnished in a physician’s office or a hospital outpatient setting.

A physician must be immediately available and accessible for consultation and emergencies; for hospital outpatient services, this means the physician must be present on the campus for on-campus services and in the provider-based department for off-campus services.

Physician Requirements:

The medical director and the supervising physician must meet the following requirements:

  • Expertise in the management of individuals with cardiac pathophysiology
  • Licensed to practice medicine in the state in which the CR/ICR program is offered
  • Cardiopulmonary training in basic life support or advanced cardiac life support

The medical director, in consultation with staff, is involved in directing the progress of individuals in the program.

ICR Programs

  • Must be approved through the NCD process
  • A list of approved ICR programs will be posted to the CMS Web site and listed in the Federal Register.
  • Hospital outpatient settings must provide ICR using an approved ICR program

Billing Requirements:

Services should be billed with the following HCPCS codes:

  • 93797 for CR services without continuous monitoring
  • 93978 for CR services with continuous monitoring
  • G0422 for ICR services with exercise
  • G0423 for ICR services without exercise

Only 13X and 85X types of bill (TOB) are acceptable.  All other TOBs shall be denied.

Use revenue code 0943 for CR/ICR services.

Frequency:

Sessions are limited to a maximum of 2 1-hour sessions per day for CR and a maximum of 6 1-hour sessions per day for ICR.  Claims will be denied if units exceed the maximum units on the same date of service.

Treatment must last at least 31 minutes to report a unit of 1 session.  Additional sessions of CR/ICR 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.  The minutes of service of several shorter periods of CR/ICR must be added together for reporting in 1-hour session increments.

Duration:

Medicare covers up to 36 CR sessions over a period of up to 36 weeks, with the option for an additional 36 sessions if medically necessary.  Providers must append modifier –KX to medically necessary CR sessions beyond 36.

Medicare covers up to 72 ICR sessions over a period of up to 18 weeks.  Medicare will pay ICR claims which exceed 72 sessions within 126 days (18 weeks) from the date of the first session when the KX modifier is included on the claims. 

The CWF will display the remaining CR and ICR sessions on all CWF provider query screens.

Also see MLN Matters Article MM6850 for a summary of information on Cardiac and Intensive Cardiac Rehabilitation services.

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