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Cardiac Rehabilitation Programs – Medical Policy Article (A45888) Contractor Information Contractor Name National Government Services, Inc. Contractor Number Number 00130 00131 00160 00180 00181 00270 00308 00332 00450 00452 00453 00454 00630 00660 00805 13101 13102 13201 13202 13282 13292 Type FI FI FI FI FI FI FI FI FI FI FI FI Carrier Carrier Carrier MAC MAC MAC MAC MAC MAC State(s) IN IL KY ME MA NH, VT CT, DE, NY OH WI MI VA, WV AS, CA, CNMI, GU, HI, NV IN KY NJ CT – Part A CT – Part B NY – Part A NY – Part B NY- Part B NY – Part B Contractor Type Carrier Fiscal Intermediary MAC – Part A MAC – Part B Article Information Article ID Number A45888 Article Type Article Key Article Yes Article Title Cardiac Rehabilitation Programs – Medical Policy Article AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Primary Geographic Jurisdiction Number 00130 00131 00160 00180 00181 00270 00308 00332 00450 00452 00453 00454 00630 Type FI FI FI FI FI FI FI FI FI FI FI FI Carrier State(s) IN IL KY ME MA NH, VT CT, DE, NY OH WI MI VA, WV AS, CA, CNMI, GU, HI, NV IN 00660 00805 13101 13102 13201 13202 13282 13292 Carrier Carrier MAC MAC MAC MAC MAC MAC KY NJ CT – Part A CT – Part B NY – Part A NY – Part B NY- Part B NY – Part B Original Article Effective Date 10/01/2007 Article Revision Effective Date 07/18/2008 Article Text Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the article. The article clarifies CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10. Cardiac rehabilitation programs must be comprehensive and to be comprehensive they must include a medical evaluation, a program to modify cardiac risk factors (e.g., nutritional counseling), prescribed exercise, education, and counseling. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) Cardiac rehabilitation programs are designed to restore certain patients with coronary or valvular heart disease to active and productive lives. Forms of counseling, such as dietary counseling, psychosocial intervention, lipid management and stress management are components of the program, and are not separately reimbursed. Cardiac rehabilitation, as described in the medical literature, is divided into three phases: Phase I is the immediate in - hospital post cardiac event phase; Phase II is the outpatient immediate post hospitalization recuperation phase. Phase II cardiac rehabilitation, as described by the U.S. Public Health Service, is a comprehensive, long-term program including medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. Phase II refers to outpatient, medically supervised programs that are typically initiated 1-3 weeks after hospital discharge and provide appropriate electrocardiographic monitoring; (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) Phase III is the long term, maintenance phase. The program consists of a series of supervised exercise sessions. Services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 36 sessions. Patients generally receive 2 to 3 sessions per week for 12 to 18 weeks. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) Phase I cardiac rehabilitation programs are covered, but not separately payable, as they are included in the inpatient payment. Phase II begins with an overall treatment plan including a physician’s prescription for progressive exercise based on the individual’s clinical status and physical capacity. Programs incorporate close monitoring, individualized progressive increase in the intensity of physical activity and patient education and counseling to modify cardiac risk factors (e.g., encouraging lifestyle changes, dietary modifications, and smoking cessation). Phase II exercise programs for cardiac patients may be conducted in specialized, freestanding, cardiac rehabilitation clinics as well as in outpatient hospital departments. Phase III refers to maintenance programs (e.g., continued lifestyle changes and aerobic exercise) without physician supervision and monitoring. Medicare does not provide coverage for Phase III programs. Indications: Effective for services performed on or after March 22, 2006, Medicare coverage of cardiac rehabilitation programs is considered reasonable and necessary only for patients who: (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; or (3) have stable angina pectoris; or (4) have had heart valve repair/replacement; or (5) have had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or (6) have had a heart or heart-lung transplant. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) 1. The following information is intended as a further clarification of the nationally covered indications listed above: o o o o o o Patients who begin the program within 12 months of an acute myocardial infarction (ICD-9-CM codes 410.00 - 410.02, 410.10 - 410.12, 410.20 - 410.22, 410.30 - 410.32, 410.40 - 410.42, 410.50 – 410.52, 410.60 - 410.62, 410.70 - 410.72, 410.80 - 410.82, 410.90 - 410.92,412, and 414.8) Patients who are status post coronary artery bypass (CABG) surgery (ICD-9-CM code V45.81) Patients with stable angina pectoris (ICD-9-CM code 413.9) Patients who have had heart valve repair/replacement (ICD-9-CM code V15.1, V42.2 and V43.3) Patients who have had percutaneous coronary angioplasty (PTCA) or coronary stenting (ICD-9-CM code V45.82) Patients who have had a heart or heart-lung transplant (ICD-9-CM code V42.1) 2. Cardiac rehabilitation is covered when the patient’s condition meets the following requirement(s): o o o For myocardial infarction, the date of entry in the program must be within 12 months of the date of the infarction. For CABG, in order to support the medical necessity for cardiac rehabilitation services, the initiation of the program should be early enough to have a restorative effect on the recuperative process. For angina, all patients should have a pre-entry stress test which is positive for exercise-induced ischemia within 6 months of starting cardiac rehabilitation. A positive stress test in this context implies a junctional o o 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 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 which demonstrate ischemia. For patients with heart valve repair or replacement, the program should be early enough to provide a restorative benefit. For patients who have had a percutaneous transluminal angioplasty (PTCA) or stent placement, the program should be early enough to provide a restorative benefit. 3. Facilities: Cardiac rehabilitation programs may be provided at the outpatient department of a hospital, a physician-directed clinic or in a physician's office. Coverage is subject to the following conditions: o For the facility meeting the definition of a hospital outpatient department or a physician-directed clinic, a physician must be on the premises available to perform medical duties at all times that the facility is open, and each patient must be under the care of a hospital or clinic physician; o For a physician's office, the physician must be on the premises and available for all medically appropriate duties. o The facility must have available for immediate use the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator; (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) o The program must be staffed by personnel necessary o 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. The program must be under the direct supervision of a physician, as defined in 42 CFR §410.26(a)(2) (defined through cross reference to 42 CFR §410.32(b)(3)(ii), or 42 CFR §410.27(f)). (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) Direct supervision means that a physician must be in the exercise program area and immediately available and accessible for all emergencies. It does not require that a physician be physically present in the exercise room itself. The nonphysician personnel are employees of either the physician, hospital or clinic conducting the program and their services are "incident-to" a physician's professional services or under Part A incident to provision. Limitations: 1. Frequency and duration: o o o o The frequency and duration of the program are generally a total of 36 sessions, occurring 2-3 times per week for 12-18 weeks. Sessions extending beyond the 18 weeks will be denied as not medically necessary, unless additional documentation of necessity is demonstrated. Services at a frequency of less than 2 sessions per week will be considered not medically necessary. 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 occurring 2-3 times per week for 12-18 weeks. Phase IIB consists of an additional 36 sessions, occurring 2-3 times per week, over 12-18 weeks, and will only be allowed if determined to be medically necessary. Phase IIB benefits must meet additional medical necessity criteria. Specifically, there must be clear demonstration that the patient is benefiting from cardiac rehabilitation and that the exit criterion o o (criteria) below from phase IIA has (have) not been met. The maximum number of allowable sessions under Phase IIA and IIB is 72. Coverage must not exceed a total of 72 sessions for 36 weeks. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10) Exit Criterion In the American Heart Association’s functional classification, Class I, or normal function status, begins at 7 metabolic equivalent units (METS). Therefore, for the patients who are status post MI, status post CABG, status post PTCA or stent, or patients with angina, completion of 6 minutes of exercise during a treadmill or stress imaging test, utilizing the Bruce protocol, without significant ischemia or dysrhythmia is a reasonable exit criterion. The post heart and heart-lung transplant patient poses a special challenge for the cardiac rehabilitation team. Issues such as deconditioning and cachexic deterioration may complicate the definition of reasonable exit criteria. Based on the study of long term cardiopulmonary exercise performed after heart transplant by Osade et al, a peak oxygen consumption (VO 2) of greater than 90% of predicted would be the exit criterion for phase IIA. Patients whose peak VO 2 is less than 90% of predicted may be appropriate for phase IIB. For patients with valvuloplasty or valve replacement benefits are available for phase IIA only. Extension of the program beyond 36 sessions (for patients postvalve surgery) is not reasonable and necessary because supporting data is not available. 2. Other services Evaluation and management services (E & M), electrocardiograms, (ECG) 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 reasonable and necessary. Coding Guidelines: General Guidelines for claims submitted to Carriers or Intermediaries: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and UPIN or NPI of the referring/ordering physician must be reported on the claim. The diagnosis code(s) must best describe the patient's condition for which the service was performed. A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. ICD-9-CM code 412 (old myocardial infarction-MI) refers to an MI that has occurred more than 8 weeks and less than 52 weeks prior to cardiac rehabilitation services. Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services): An ABN may be used for services which are likely to be noncovered, whether for medical necessity or for other reasons. Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ. The –GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Fiscal Intermediary, occurrence code 32 and the date of the ABN is required. The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. For claims submitted to the carrier: Claims for cardiac rehabilitation services are payable under Medicare Part B in the following places of service: office (11), outpatient hospital (22), independent clinic (49), comprehensive outpatient rehabilitation facility (62), and state or local public health clinic (71). For claims submitted to the fiscal intermediary: Hospital Outpatient Claims: The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82). The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. Bill Type Guidelines CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100(B) states that no type of technical services, such as…a technical component of a diagnostic or screening service, is ever billed on TOBs 71x or 73x...Technical services/components associated with professional services/components performed by independent RHCs or FQHCs are billed to Medicare carriers…Technical services/components associated with professional services/components performed by provider-based RHCs or FQHCs are billed by the base-provider on the TOB for the base-provider and submitted to the FI. Per CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100(B), only four types of services are billed on TOBs 71X and 73X: Professional or primary services not subject to the Medicare outpatient mental health treatment limitation are bundled into line item(s) using revenue code 052X; services subject to the Medicare outpatient mental health treatment limitation are billed under revenue code 0900 (previously 0910); …telehealth originating site facility fees under revenue code 0780 [and] FQHC supplemental payments are billed under revenue code 0519, effective for dates of service on or after 01/01/2006. For dates of service on or after July 1, 2006, the following revenue codes should be used when billing for RHC or FQHC services, other than those services subject to the Medicare outpatient mental health treatment limitation or for the FQHC supplement payment…: 0521, 0522, 0524, 0525, 0527 and 0528 (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100[B].) Beginning January 1, 2008, hospitals may report more than one unit of HCPCS codes 93797 or 93798 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 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. (See Change Request (CR) 5912, Transmittal 1417, January 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS)) Coverage Topic Cardiac Rehabilitation Program Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. 13x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) 85x Special facility or ASC surgery-rural primary care hospital (eff 10/94) Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X. 0482 Cardiology-stress test 0943 Other therapeutic services-cardiac rehabilitation 0960 Professional fees-general classification 0969 Professional fees-other 0982 Professional fees-outpatient services 0983 Professional fees-clinic CPT/HCPCS Codes 93797 Cardiac rehab 93798 Cardiac rehab/monitor ICD-9 Codes that are Covered ICD-9-CM code 414.8 should be reported for patients with a history of a myocardial infarction from eight weeks to twelve months from the date of the myocardial infarction. ICD-9-CM code V15.1 should be reported for patients who have undergone heart valve repair. 410.00 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED 410.01 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL EPISODE OF CARE 410.02 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE 410.10 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED 410.11 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL INITIAL EPISODE OF CARE 410.12 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE 410.20 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED 410.21 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL INITIAL EPISODE OF CARE 410.22 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE 410.30 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED 410.31 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL INITIAL EPISODE OF CARE 410.32 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE 410.40 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED 410.41 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL INITIAL EPISODE OF CARE 410.42 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE 410.50 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED 410.51 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL INITIAL EPISODE OF CARE 410.52 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE 410.60 TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED 410.61 TRUE POSTERIOR WALL INFARCTION INITIAL EPISODE OF CARE 410.62 TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE 410.70 SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED 410.71 SUBENDOCARDIAL INFARCTION INITIAL EPISODE OF CARE 410.72 SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE 410.80 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED 410.81 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES INITIAL EPISODE OF CARE 410.82 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE 410.90 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED 410.91 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE INITIAL EPISODE OF CARE 410.92 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE 412 OLD MYOCARDIAL INFARCTION 413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS 414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE V15.1 PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH V42.1 HEART REPLACED BY TRANSPLANT V42.2 HEART VALVE REPLACED BY TRANSPLANT V43.3 HEART VALVE REPLACED BY OTHER MEANS V45.81 POSTSURGICAL AORTOCORONARY BYPASS STATUS V45.82 PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS ICD-9 Codes that are Not Covered Not applicable. Other Information Other Comments These instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims. Revision History Explanation Article published July 2008. This article was revised to add the Jurisdiction 13 (J-13) MAC contractor numbers. This revised article is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut – Part B the article is effective on August 1, 2008; for Upstate New York – Part B, the article is effective on September 1, 2008; and for New York and Connecticut – Part A, the article is effective on November 14, 2008. For New York – Part A (contract 00308), the content of this article is currently in effect but the article will be transferred to the J-13 contract number 13201 on November 14, 2008. Article published Febuary 2008: Source of revision internal/external: Added exit criterion to Limitations, #1. Added intermediary guidelines based on CR 5912. This article was revised on November 1, 2007 to include the language from CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10. Article published October 2007.