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Reminder for Billing Cardiac Rehabilitation Session and Session Limitations

Effective 1/1/2010, Medicare B pays for CR and intensive cardiac rehabilitation (ICR) programs and related items/services if specific criteria is met by the Medicare beneficiary, the cardiac rehabilitation program itself, the setting in which it’s administered, and the physician administering the program. CR sessions are limited to a maximum of two (2) one-hour sessions per day for up to 36 sessions up to 36 weeks with the option of an additional 36 sessions over an extended period of time, if approved by the contractor under section 1862(a)(1)(A) of the Act. Sessions billed beyond the 36 sessions should be billed with the KX modifier if the services are medically necessary and meet all the Medicare Program requirements. CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.2.2.4, Edits for CR Services Exceeding 36 Sessions (720 KB) states, 

“Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all claims with HCPCS 93797 and 93798 (both professional and institutional claims) that exceed 36 CR sessions when a KX modifier is not included on the claim line.”

Medicare covers CR/ICR program services for beneficiaries who have experienced one or more of the following:

  • 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 or heart-lung transplant.
  • For CR only, other cardiac conditions as specified through an NCD.

CR session limitations are based on medically necessary events and not a lifetime limitation. Therefore, if a beneficiary has completed 72 sessions of cardiac rehabilitation and then has a new qualifying event they would be entitled to CR as long as all other program requirements are met.

 

Reminder for Billing Cardiac Rehabilitation Session and Session Limitations
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