Cardiac

Cardiac Rehabilitation and Intensive Cardiac Rehabilitation

Medicare Part B pays for CR and ICR programs and related items/services.

Specific criteria must be met by the Medicare beneficiary, the cardiac rehabilitation program itself, the setting in which it is administered and the physician administering the program.

Medicare Part B covers CR and ICR for beneficiaries who have experienced one or more of the following; for services furnished on or after 1/1/2010:

  • Acute myocardial infarction within the preceding 12 months;
  • Coronary artery bypass surgery;
  • Current stable angina pectoris;
  • Heart valve repair or replacement;
  • PTCA or coronary stenting;
  • Heart or heart-lung transplant;
  • Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and NYHA class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks, on or after 2/18/2014; or
  • Other cardiac conditions as specified through a NCD.

CR and ICR must include all of these elements:

  • Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
  • Cardiac risk factor modification, including education, counseling and behavioral intervention, tailored to the individual's needs.
  • Psychosocial assessment;
  • Outcomes assessment;
  • An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days.

A list of approved ICR programs, identified through the NCD process, will be listed in the Federal Register and is available on CMS’ Intensive Cardiac Rehabilitation (ICR) Programs web page.

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;
  • Reduced the need for percutaneous coronary interventions

An ICR program must also demonstrate through peer-reviewed published research that it accomplished a statistically significant reduction in five or more of the following measures for patients from their levels before CR services to after CR services:

  • Low density lipoprotein
  • Triglycerides
  • Body mass index
  • Systolic blood pressure
  • Diastolic blood pressure
  • The need for cholesterol, blood pressure and diabetes medications

CPT codes for CR services:

  • 93797 - Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring, per session
  • 93798 - Physician or other qualified care health professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring, per session

CR sessions are limited to a maximum of two one-hour sessions per day; 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.

Effective for claims with dates of service on or after 1/1/2010, 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.

Note: 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.

In order to report one session of CR in a day, the duration of treatment must be at least 31 minutes.

  • Two sessions of CR may only be reported in the same day if the duration of treatment is at least 91 minutes.

In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes if two sessions are reported.

  • If several shorter periods of CR are furnished on a given day, the minutes of service during those periods must be added together for reporting in one-hour session increments.

For more billing examples, please see CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.2.1

HCPCS codes for ICR services:

  • G0422 - Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
  • G0423 - Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session

ICR sessions are limited to 72 one-hour sessions up to six sessions per day, over a period of up to 18 weeks.

Effective for claims with dates of service on and after 1/1/2010, CWF shall reject ICR claims (G0422 and G0423) that exceed 72 sessions or any provided/billed sessions after 126 days from the date of the first session including those without the KX modifier on the claim line.

Allowed POS for CR/ICR:

  • POS 11 is used for CR and ICR services provided in a physician’s office.
  • POS 22 is used for CR and ICR services provided in a hospital outpatient setting.
  • All other POS codes shall be denied.

Note: All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program.

  • This provision is satisfied if the physician meets the requirements for direct supervision.

Beneficiaries switching from ICR to CR

A beneficiary may switch from an ICR program to a CR program. The beneficiary is limited to a one-time switch, multiple switches are not allowable. Once the beneficiary switches from ICR to CR he/she will be limited to the number of sessions remaining in the program.

Example: A beneficiary who switches from ICR to CR after 12 sessions will have 24 sessions of CR remaining, (i.e., 12 sessions of ICR + 24 sessions of CR = total of 36 sessions).

Upon completion of a CR or ICR program, beneficiaries must experience another indication in order to be eligible for coverage of more CR or ICR.

Note: The KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch.

Reviewed 10/11/2023