Local Coverage Article Billing and Coding

Billing and Coding: Outpatient Cardiac Rehabilitation

A54070

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Article Information

General Information

Article ID
A54070
Article Title
Billing and Coding: Outpatient 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

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Article Guidance

Article Text

Medicare covers cardiac rehabilitation (CR) services to beneficiaries as per Sections 1861(s)(2)(CC) and 1861(eee)(1) of the Social Security Act and 42CFR410.49 which defines key terms and the cardiac conditions that would enable a beneficiary to obtain CR services.

As specified in 42 CFR 410.49, Medicare Part B covers Cardiac Rehabilitation (CR) for beneficiaries who have experienced one or more of the following:

  • An acute myocardial infarction (MI) within the preceding 12 months,
  • A coronary artery bypass surgery,
  • Current stable angina pectoris,
  • Heart valve repair or replacement,
  • Percutaneous transluminal coronary angioplasty (PTCA) 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 (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks, on or after
    February 18, 2014, for CR, or
  • Other cardiac conditions as specified through a national coverage determination (NCD).

CR must include all of the following components:

  • Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise combined with other types of exercise (such as strengthening and stretching) as determined to be appropriate for individual patients by a physician each day CR items and services are furnished.
  • Cardiac risk factor modification. Cardiac risk factor modification, including education, counseling, and behavioral intervention, tailored to the individual’s needs.
  • Psychosocial assessment. Psychosocial assessment means an evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation which includes an assessment of those aspects of an individual’s family and home situation that affects the individual’s rehabilitation treatment, and psychosocial evaluation of the individual’s response to and rate of progress under the treatment plan.
  • Outcome’s Assessment. Outcome's assessment means an evaluation of progress as it relates to the individual’s rehabilitation which includes all of the following:
    • Evaluations, based on patient-centered outcomes, which must be measured by the physician or program staff at the beginning and end of the program. Evaluations measured by program staff must be considered by the physician in developing and/or reviewing individualized treatment plans.
    • Objective clinical measures of exercise performance and self-reported measures of exertion and behavior.
  • Individualized treatment plan. Individualized treatment plan means a written plan tailored to each individual patient that includes all of the following:
    • A description of the individual’s diagnosis.
    • The type, amount, frequency, and duration of the items and services furnished under the plan.
    • The goals set for the individual under the plan. The individualized treatment plan detailing how components are utilized for each patient, must be established, reviewed, and signed by a physician every 30 days.

As specified at 42 CFR 410.49(f)(1), the number of CR sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time.

For providers who perform an additional 36 sessions, the KX modifier must be appended to the appropriate CR CPT® code listed in the CPT HCPCS section below.

Every CR Program must have the following Physician Standards:

  1. Medical director who oversees the CR program at a particular site. The medical director is the physician responsible for a CR program and, in consultation with staff, is involved in directing the progress of individuals in the program and must possess all of the following:
    1. Expertise in the management of individuals with cardiac pathophysiology.
    2. Cardiopulmonary training in basic life support or advanced cardiac life support.
    3. Be licensed to practice medicine in the State in which the CR or  program is offered.
  2. A supervising physician who is immediately available and accessible for medical consultations and medical emergencies at all times items and services are being furnished to individuals under CR programs. Physicians acting as the supervising physician must possess all of the following:
    1. Expertise in the management of individuals with cardiac pathophysiology.
    2. Cardiopulmonary training in basic life support or advanced cardiac life support.
    3. Be licensed to practice medicine in the State in which the CR program is offered.

Medicare Part B pays for CR in a physician’s office or a hospital outpatient setting (Place of Service 11, 19 & 22) and are performed incident to a physician’s service.

Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1-hour sessions per day. 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 1-hour session increments.

Effective January 1, 2022, Cardiac Rehabilitation (CR) codes 93797 and 93798 have been assigned as category 3 codes on the Physician Fee Schedule List of Telehealth Services CY 2022 and will allow these services via telehealth until December 31, 2023.

Public Health Emergency Telehealth Services

Per MLN Matters® SE20011-Revised, when billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the PHE, bill with:

  • Place of Service (POS) equal to what it would have been had the service been provided in-person
  • Modifier 95, indicating that you provided the service via telehealth

There are no billing changes for institutional claims. Critical access hospital method II claims should continue to bill with modifier GT.


Sources:

 

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

The Current Procedural Terminology (CPT) Manual codes appropriate for cardiac rehabilitation include:

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)

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET

ICD-10-CM Codes that Support Medical Necessity

Group 1

(87 Codes)
Group 1 Paragraph

The following diagnoses support cardiac rehabilitation:
*Use Z48.812 only to describe cardiac valvular repair for dates of service October 1, 2015 and after.

Group 1 Codes
CodeDescription
I20.1 Angina pectoris with documented spasm
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
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
I25.111 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
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
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
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable 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
I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable 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
I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable 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
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
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
I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
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
I50.42 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
I5A Non-ischemic myocardial injury (non-traumatic)
Z48.21 Encounter for aftercare following heart transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z48.812 Encounter for surgical aftercare following surgery on the circulatory system
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
Z96.82 Presence of neurostimulator
Z96.89 Presence of other specified functional implants
Z98.61 Coronary angioplasty status
Z98.890 Other specified postprocedural states

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.

CodeDescription
013x Hospital Outpatient
085x Critical Access Hospital

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.

CodeDescription
0943 Other Therapeutic Services - Cardiac Rehabilitation

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2022 R11

Added revenue code 0943 back into the article as it was removed inadvertently.

10/01/2022 R10

The following ICD-10 updates were completed per the Annual ICD-10-CM Update effective 10/01/2022:

  • Added I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762 & I25.792.
01/01/2022 R9

Corrected the links to Transmittal 11175, CR 12549 dated January 14, 2022 and Transmittal 11272, CR 12613 dated February 14, 2022 in the Article Text.

01/01/2022 R8

Updated the Coverage criteria and the use of the KX modifier to indicate the additional 36 services are medically necessary for Outpatient Cardiac Rehabilitation Services in the Article Text.

Added the KX modifier to the CPT/HCPCS Modifiers section.

Removed I50.32 - Chronic diastolic (congestive) heart failure from the ICD-10 Codes that Support Medical Necessity.

01/01/2022 R7

Noted 93797 & 93798 were assigned as category 3 codes on the Physician Fee Schedule List of Telehealth Services CY 2022 until December 31, 2023 per CR12549 and added how to bill for telehealth services.

10/01/2021 R6

Converted this article to a Billing and Coding article effective 04/28/20 and added I5A to the Group 1 ICD-10 Codes effective 10/01/2021.

10/01/2019 R5

Added ICD-10 code Z96.82 effective 10/01/2019 per the 2019 Annual update.

02/09/2018 R4

Effective date corrected from 2/8/2018 to 2/9/2018 to allow dx I50.82, I50.83, I50.84, I50.89 I50.812 and I50.814.

Corrected hyperlink for Transmittal 1798, CR 9982.

02/08/2018 R3

Added ICD-10-CM codes I21.21, I22.2, I22.9, Z98.890 effective 5/26/2017 and I50.82, I50.83, I50.84, I50.89 I50.812 and I50.814 effective 02/08/2018.

07/01/2017 R2

Per CR 9982 Clarified when providers can perform both Intensive Cardiac Rehab & Cardiac Rehab and switching between the two types effective 0701/2017. Also deleted the Group 2 Section for Intensive Cardiac Rehabilitation HCPCS codes which is covered in the IOM “Medicare Processing Manual”, Publication 100-4, Chapter 32, Section 140.3.

12/22/2016 R1 Article revised to add ICD-10 codes I21.01, I21.02, I22.0, I22.1 and I22.8 to the Group 1 ICD-10 codes effective 09/13/2016. Effective 12/22/16, this Local Coverage Article combines JFA A54069 into the JFB article A54070 so that both JFA and JFB contract numbers will have the same final MCD article number as JFB A54070.

Associated Documents

Related Local Coverage Documents
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Updated On Effective Dates Status
10/14/2022 10/01/2022 - N/A Currently in Effect You are here
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06/09/2022 01/01/2022 - 09/30/2022 Superseded View
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01/20/2022 01/01/2022 - N/A Superseded View
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Keywords

  • Outpatient
  • Cardiac
  • Rehabilitation
  • 93797
  • 93798