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Last Modified: 7/26/2024 Location: FL, PR, USVI Business: Part A, Part B

Checklist: Cardiac rehabilitation services

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for cardiac rehabilitation services.
It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation.

Check
Documentation description
 
Documentation is for the correct beneficiary.
 
Documentation contains a valid and legible signature.
 
Documentation is for the correct date of service.
 
Documentation includes evidence that the beneficiary experienced one or more of the following criteria:
An acute myocardial infarction within the preceding 12 months; or
A coronary bypass surgery; or
Current stable angina pectoris; or
Heart valve repair/replacement; or
Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
A heart or heart-lung transplant; or
Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks.
 
Documentation indicating the cardiac rehabilitation program includes the following components:
Physician-supervisor and prescribed exercise each day cardiac rehabilitation items and services are furnished;
Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
Nutritional services;
Psychosocial assessment;
Outcomes assessment; and
An individualized treatment plan detailing how components are utilized for each patient. Evidence that treatment plan was reviewed every 30 days, is applicable.
 
Documentation includes evidence of total time spent in sessions on the selected date of service for review.
 
If applicable and required, submitted documentation should include a beneficiary waiver of liability.
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.