Local Coverage Article Billing and Coding

Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation

A53775

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Article Information

General Information

Article ID
A53775
Article Title
Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §232 Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §140 Cardiac Rehabilitation (CR) Programs, Intensive Cardiac Rehabilitation (ICR) Programs, and Pulmonary Rehabilitation (PR) Programs

42 CFR §410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage

Article Guidance

Article Text

 Cardiac Rehabilitation Program

  • The frequency and duration of the program is generally a total of 36 sessions over a maximum of 36 weeks.
  • A single session must last at least 31 minutes in order to be billable. If 2 sessions are billed for a single day, then the total combined time must be at least 91 minutes (60 minutes for the first session and at least 31 minutes for the second session) in duration.
  • No more than 2 1-hour sessions, utilizing any combination of the CPT® or HCPCS codes (93798, 93797 or G0422, G0423) will be allowed per day for up to 36 sessions over a maximum of 36 weeks (Phase IIA).
  • An additional 36 sessions may be allowed if a significant intercurrent illness or comorbidity occurred during the first 36 sessions and the exit criteria have not been met (Phase IIB). Inclusion of the KX modifier on the claim line(s) will be accepted as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the CR coverage requirements. The medical record must reflect the medical reasons for further treatment and be available to Medicare upon request.
  • An additional series of 36 sessions may be allowed as a new series of CR initiated after an intervening event described as an indication for CR in this article. Inclusion of the KX modifier on the claim line(s) will be accepted as an attestation by the provider of the service that documentation is on file verifying that an additional series of CR meets the CR coverage requirements.

Intensive Cardiac Rehabilitation Program (ICR)

A beneficiary may switch from an ICR program to a CR program. The beneficiary is limited to a 1-time switch, multiple switches are not allowable. Once the beneficiary switches from ICR to CR, he or she will be limited to the number of sessions remaining in the program. For 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).  Should a beneficiary experience more than 1 indication simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., a patient who had a myocardial infarction within 12 months and currently experiences stable angina is entitled to 1 series of CR sessions, up to 36 1-hour sessions with contractor discretion for an additional 36 sessions; or 1 series of ICR sessions, up to 72 1-hour sessions over a period up to 18 weeks). Beneficiaries may not switch from CR to ICR. 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.

Contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy or, for ICR, that any further sessions beyond 72 sessions within a 126 day period counting from the date of the first session or for any sessions provided after 126 days from the date of the first session meet the requirements of the medical policy.  Beneficiaries who switch from ICR to CR may also be eligible for up to 72 combined sessions with contractor discretion for CR sessions after 36 (to include completed ICR sessions prior to switch). In these cases and consistent with the information above, the KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch.

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

Any diagnosis submitted must have documentation in the patient’s record to support coverage and medical necessity.

IF rendering CR or ICR services that involve ECG monitoring, the medical record must document performance of such monitoring. This should not be construed as a requirement for ECG monitoring for all CR or ICR services. Reported CPT® codes should accurately capture the service that was performed.

Coding Information

CPT/HCPCS Codes

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
93797 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; WITHOUT CONTINUOUS ECG MONITORING (PER SESSION)
93798 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 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

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

KX

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(83 Codes)
Group 1 Paragraph

The CPT® codes included in this article will be subject to “procedure to diagnosis” editing. The following list includes only those diagnoses for which the identified CPT® procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT® codes 93797, 93798, G0422, and G0423:

Group 1 Codes
CodeDescription
I20.1 Angina pectoris with documented spasm
I20.2 Refractory angina pectoris
I20.8 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I21.9 Acute myocardial infarction, unspecified
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.112 Atherosclerosic heart disease of native coronary artery with refractory angina pectoris
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.2* Old myocardial infarction
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.702 Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.712 Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.722 Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.732 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with refractory angina pectoris
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.752 Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
I25.762 Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.792 Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris
I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
I50.22 Chronic systolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.812 Chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
Z48.21 Encounter for aftercare following heart transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z94.1 Heart transplant status
Z94.3 Heart and lungs transplant status
Z95.1 Presence of aortocoronary bypass graft
Z95.2 Presence of prosthetic heart valve
Z95.3 Presence of xenogenic heart valve
Z95.4 Presence of other heart-valve replacement
Z95.5 Presence of coronary angioplasty implant and graft
Z98.61 Coronary angioplasty status
Z98.890 Other specified postprocedural states
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

ICD-10 code I25.2* (old myocardial infarction) refers to a MI that has occurred more than 4 weeks (28 days) prior to cardiac rehabilitation services.

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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.

N/A

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.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2022 R14

Under Article Text removed the verbiage “When billing HCPCS/CPT® codes 93798, G0422 or G0423, the documentation must clearly indicate the patient is receiving continuous ECG monitoring” and replaced it with the verbiage “IF rendering CR or ICR services that involve ECG monitoring, the medical record must document performance of such monitoring. This should not be construed as a requirement for ECG monitoring for all CR or ICR services. Reported CPT® codes should accurately capture the service that was performed.” This revision is effective on 9/1/22.

10/01/2022 R13

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added I20.2, I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762 and I25.792. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/22.

Under CMS National Coverage Policy updated section headings for regulations. Formatting, punctuation and typographical errors were corrected throughout the article. This revision will become effective 10/1/22.

04/07/2022 R12

Under CMS National Coverage Policy removed CMS Internet-Only Pub. Med 100-4, Medicare Claims Processing Manual, Chapter 15, Section 232, Cardiac Rehabilitation and Intensive Cardiac Rehabilitation and added regulations CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §232 Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010, CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §140 Cardiac Rehabilitation Programs, Intensive Cardiac Rehabilitation Programs, and Pulmonary Rehabilitation Programs, 42 CFR §410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage and Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph moved verbiage “ICD-10-CM code I25.2* (old myocardial infarction) refers to a MI that has occurred more than 4 weeks (28 days) prior to cardiac rehabilitation services” under Group 1: Medical Necessity ICD-10-CM Codes Asterisk Explanation. Formatting was corrected throughout the LCD.

08/27/2020 R11

Under ICD-10 Codes that Support Medical Necessity Group 1 Paragraph changed verbiage to read four weeks (28 days).

10/17/2019 R10

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual. Under CMS National Coverage Policy removed sentence “CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.” And added CMS Internet-Only Medicare Claims Processing Manual, Chapter 15 Section 232 Cardiac Rehabilitation and Intensive Cardiac Rehabilitation. Under Article Text removed italics and replaced “LCD” with article. Added CPT® where appropriate throughout the article. Under CPT/HCPCS Modifiers added modifier KX. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph removed word “note” and under Group 1: Codes added asterisk to ICD-10 code I25.2.

04/05/2019 R9

Under Article Title added Billing and Coding and removed supplemental instructions. Under Article Text added Documentation Requirements. Under Covered ICD-10 Codes added verbiage to Group 1: Paragraph and corresponding diagnosis codes to Group 1: Codes.

02/26/2018 R8 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
01/29/2018 R7 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
09/26/2017 R6

Under Article Text - Intensive Cardiac Rehabilitation Program (ICR) revised the verbiage to read “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 or she will be limited to the number of sessions remaining in the program. For 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).  Should a beneficiary experience more than one indication simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., a patient who had a myocardial infarction within 12 months and currently experiences stable angina is entitled to one series of CR sessions, up to 36 1-hour sessions with contractor discretion for an additional 36 sessions; or one series of ICR sessions, up to 72 1-hour sessions over a period up to 18 weeks). Beneficiaries may not switch from CR to ICR. 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.

Contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy or, for ICR, that any further sessions beyond 72 sessions within a 126 day period counting from the date of the first session or for any sessions provided after 126 days from the date of the first session meet the requirements of the medical policy.  Beneficiaries who switch from ICR to CR may also be eligible for up to 72 combined sessions with contractor discretion for CR sessions after 36 (to include completed ICR sessions prior to switch). In these cases and consistent with the information above, the KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch”.

 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

01/19/2017 R5 Annual validation performed-no changes made.
01/22/2016 R4 Under Article Text added the first sentence related to italicized text. Under Article Text-Cardiac Rehabilitation Program in the last sentence of the fourth bullet added”…the medical reasons for further treatment…” Under Article Text-Intensive Cardiac Rehabilitation Program deleted the existing verbiage for the second bullet and added the language as found in the CMS Internet-Only Manual. This revision becomes effective 01/22/2016.
06/25/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed from the LCDs. For consistency, they are also being removed from the articles.
10/01/2015 R2 Under Associated Contract Numbers added 11202, 11302, 11402 and 11502.
10/01/2015 R1 Added Annual Validation date.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/25/2022 10/01/2022 - N/A Currently in Effect You are here
08/16/2022 10/01/2022 - N/A Superseded View
03/28/2022 04/07/2022 - 09/30/2022 Superseded View
08/16/2020 08/27/2020 - 04/06/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Cardiac Rehabilitation
  • Intensive Cardiac Rehabilitation