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Last Modified: 11/17/2024 Location: FL, PR, USVI Business: Part B

Cardiac and pulmonary rehabilitation programs

Medicare pays for cardiac rehabilitation (CR), intensive cardiac rehabilitation (ICR), and pulmonary rehabilitation (PR) programs if specific criteria are met. This criterion includes coverage provisions for CR, ICR, and PR items and services, physician standards, required components, and limitations to the sessions that may be covered.

CR programs

These are defined as physician-supervised programs that furnish physician prescribed exercise, cardiac risk factor modification, including:
Education
Counseling
Behavioral intervention
Psychosocial assessment
Outcomes assessment
Other items/services as determined by the Secretary under certain conditions

ICR programs

These are defined as physician-supervised programs that furnish the same items/services under the same conditions as a CR program.
An ICR program must demonstrate through peer-reviewed, published research that it 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, or
Reduced the need for percutaneous coronary interventions.
ICR program must 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 cardiac rehabilitation services to after cardiac rehabilitation services:
Low density lipoprotein
Triglycerides
Body mass index
Systolic blood pressure
Diastolic blood pressure
Need for medications
Cholesterol
Blood pressure
Diabetes

PR programs

These are defined as a multi-disciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy and an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities.

Cardiac rehabilitation and intensive cardiac rehabilitation programs

Coverage requirements

Beneficiaries must meet one or more of the following:
An acute myocardial infarction within the preceding 12 months.
A coronary artery bypass surgery.
Current stable angina pectoris.
Heart valve repair or replacement.
Percutaneous transluminal coronary angioplasty chronic obstructive pulmonary disease (COPD) or coronary stenting.
A heart or heart-lung transplant.
Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks.

Component requirements

CR and ICR programs must include:
Physician-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.
Psychosocial assessment.
Outcomes assessment.
An individualized treatment plan detailing how components are utilized for each patient.

Frequency limitations and duration

CR sessions:
Limited to a maximum of two one-hour sessions per day, up to 36 sessions over a period of up to 36 weeks.
Option for an additional 36 session over an extended period of time if the KX modifier is reported and services are medically necessary.
Duration of treatment must be at least 31 minutes for one session or at least 91 minutes for two sessions on the same day.
ICR sessions:
Limited to 72 one-hour sessions, up to six sessions per day over a period of up to 18 weeks.
Additional sessions require the KX modifier if medically necessary.
Duration of the treatment must be at least 31 minutes.
Additional sessions beyond the first session may only be reported in the same day if the duration of treatment is 31 minutes or greater beyond the hour increment.

Coding requirements

The following are the applicable HCPCS codes for CR and ICR:
93797 - Physician services for outpatient cardiac rehabilitation; without continuous electrocardiographic (ECG) monitoring (per session).
93798 - Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session).
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.

Pulmonary rehabilitation programs

Coverage requirements

PR services are covered for beneficiaries with moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease.

Component requirements

PR programs must include the following components:
Physician-prescribed exercise.
Note: Some aerobic exercise must be included in each pulmonary rehabilitation session.
Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling.
Psychosocial assessment.
Outcomes assessment.
An individualized treatment plan detailing how components are utilized for each patient.

Frequency limitations and duration

Limited to 2 one-hour sessions per day, for up to 36 lifetime sessions (in some instances, up to 72 lifetime sessions).
Note: Report modifier KX for medically necessary sessions 37-72.

Coding requirements

The following are the applicable HCPCS codes for PR services.
94625 (Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)
94626 (Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session)

References

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