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Celebrating Cardiac Rehab Week: A Review of Medicare Coverage Requirements

Published on 

Tuesday, February 12, 2013

This week we would like to acknowledge Cardiac Rehab Week. Cardiac Rehabilitation Week was initiated by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) to focus national attention on cardiac rehabilitation’s contribution to the improvement of the health and physical performance of individuals at risk for heart disease and/or those individuals diagnosed with heart disease or dysfunction. MMP, Inc. expresses our appreciation to the dedicated individuals who work with patients, physicians, and other health care providers to make us all “heart healthier”. And to assist cardiac rehab providers, we offer the following guidance on Medicare coverage of Cardiac Rehabilitation services.

Make sure the cardiac rehabilitation services you are providing meet all of Medicare’s requirements in order to ensure appropriate reimbursement. Palmetto GBA, the Part A MAC for Jurisdiction 11, has conducted service specific complex reviews of cardiac rehab services in South Carolina, North Carolina, Virginia, and West Virginia. In the last round of reviews, denial rates, although continuing to decrease, were still between 48 – 64%.

In addition to lack of timely submission of medical records and services not documented, the findings demonstrated the following denial reasons:

  1. Cardiac Rehab Not Warranted for Diagnosis - Medicare covers cardiac rehabilitation items and services for patients who have experienced one or more of the following:
  2. An acute myocardial infarction within the preceding 12 months; or
  3. A coronary artery bypass surgery; or
  4. Current stable angina pectoris; or
  5. Heart valve repair or replacement; or
  6. Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
  7. A heart or heart-lung transplant.
  8. Cardiac Rehab Session Did Not Include the Required Services - Cardiac rehabilitation programs must include the following components:
  9. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
  10. Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
  11. Psychosocial assessment;
  12. Outcomes assessment; and
  13. An individualized treatment plan detailing how components are utilized for each patient.
  14. Physician Must Be Readily Available - All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for the direct supervision for hospital outpatient therapeutic services.

Also, providers need to be aware of the frequency limitations for Cardiac Rehab services. Cardiac Rehab services are limited to a maximum of two 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.

More information concerning Cardiac Rehab and Medicare coverage and billing requirements can be found at:

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.