Medicare coverage of cardiac rehabilitation programs are considered reasonable and necessary only for patients with a clear medical need, who are referred by their attending physician and (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; and/or (3) have stable angina pectoris.
Cardiac rehabilitation programs may be provided either by the outpatient department of a hospital or in a physician-directed clinic. Coverage for either program is subject to the following conditions:
- The facility meets the definition of a hospital outpatient department or a physician-directed clinic, i.e., a physician is on the premises available to perform medical duties at all times the facility is open, and each patient is under the care of a hospital or clinic physician;
- The facility has available for immediate use all 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;
- The program is conducted in an area set aside for the exclusive use of the program while it is in session;
- The program is staffed by personnel necessary 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. Services of nonphysician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area and immediately available and accessible for an emergency at all times the exercise program is conducted. It does not require that a physician be physically present in the exercise room itself, provided the contractor does not determine that the physician is too remote from the patients' exercise area to be considered immediately available and accessible. The examples below are for illustration purposes only. They are not meant to limit the discretion of the contractor to make determinations in this regard.
- The case in which a contractor determines that the presence of a physician in an office across the hall from the exercise room who is available at all times for an emergency meets the requirement that the physician is immediately available and accessible; or
- The case in which a contractor determines that the presence of a physician in a building other than that containing the exercise room does not meet the requirement that the physician is immediately available and accessible; and
- 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."
Contractors need not undertake elaborate or costly monitoring activities to determine whether these requirements are met, but need only satisfy themselves to the extent that they ordinarily do in connection with, for example, the requirements for coverage of services in physician-directed clinics.
In addition to the conditions listed above, coverage for cardiac rehabilitation programs furnished by hospitals to outpatients are also subject to the rules described in the Medicare Benefit Policy Manual, Chapter 6, "Hospital Services Covered Under Part B §20.4.1.
B - Diagnostic Testing - Stress Testing
A prospective candidate for a cardiac rehabilitation program must be evaluated for his suitability to participate. A valuable diagnostic test for this purpose is the stress test. The program need not necessarily include a stress test, but may accept one performed by the patient's attending physician. Stress testing performed in the outpatient department of a hospital or in a physician-directed clinic may be covered when reasonable and necessary for one or more of the following:
- Evaluation of chest pain, especially atypical chest pain;
- Development of exercise prescriptions for patients with known cardiac disease; and/or
- Pre and postoperative evaluation of patients undergoing coronary artery by-pass procedures.
Refer to subsection E, Utilization Screens, for the acceptable frequency of stress testing performed during an individual's exercise program.
ECG Rhythm Strips. ECG rhythm strips (and other ECG monitoring) constitute an important and necessary procedure which should be done periodically while a cardiac patient is engaged in a physician-controlled exercise program. See subsection E, "Utilization Screens," for allowable screens.
C - Other Diagnostic and Therapeutic Services
A freestanding or hospital based cardiac rehabilitation clinic may also provide diagnostic and therapeutic services other than stress testing and ECG monitoring. Any such other services must meet the usual coverage requirements for the specific service, e.g., the incident-to, and reasonable and necessary requirements.
1 - Psychotherapy and Psychological Testing
It would not normally be considered reasonable and necessary to provide psychotherapy to all cardiac rehabilitation patients, or even to test all such patients to determine whether they may have a mental, psychoneurotic, or personality disorder. However, where a patient has a diagnosed mental, psychoneurotic, or personality disorder, psychotherapy furnished by a psychiatrist - or by a psychologist rendering such services incident to a physician's professional service - may be covered. Similarly, diagnostic testing of a cardiac rehabilitation patient for a mental problem may be covered where the patient shows appropriate symptoms, e.g., excessive anxiety or fear associated with the cardiac disease.
2 - Physical and Occupational Therapy
Physical therapy and occupational therapy would not be covered when furnished in connection with cardiac rehabilitation exercise program services covered under this section unless there also is a diagnosed noncardiac condition requiring such therapy, e.g., where a patient who is just recuperating from an acute phase of heart disease may have had a stroke which would require physical and/or occupational therapy. (While the cardiac rehabilitation exercise program may by some be considered a form of physical therapy, it is a specialized program conducted and/or supervised by specially trained personnel whose services are performed under the direct supervision of a physician.) Restrictions on coverage of physical therapy and occupational therapy under this section do not affect rules regarding coverage or noncoverage of such services when furnished in a hospital inpatient or outpatient setting.
(See the Medicare Benefit Policy Manual, Chapter 1 "Inpatient Hospital Services," §90.)
3 - Patient Education Services.
Many cardiac rehabilitation programs provide health education in the form of lectures or counseling in which patients and/or family members are given information, e.g., on diet, nutrition, and sexual activity to assist them in adjusting their living habits because of the cardiac condition. However, the same kind of information would have been furnished to a patient and/or family members by the attending physician following the patient's acute cardiac episode. Therefore, formal lectures and counseling on these subjects are not considered reasonable and necessary as a separately identifiable service when provided as a part of a cardiac rehabilitation exercise program. In addition, where a free-standing cardiac rehabilitation clinic provides board and room for the patient (and in some cases family members), these services are not covered under Medicare.
D - Duration of the Program
Services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 36 sessions, usually 3 sessions a week in a single 12 week period. Coverage for continued participation in cardiac exercise programs beyond 12 weeks would be allowed only on a case-by-case basis with exit criteria taken into consideration.
Although firm exit criteria for terminating the therapeutic outpatient exercise treatment and rehabilitation program have not been established, the following guidelines have been identified as acceptable:
- The patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia;
- Symptoms of angina or dyspnea are stable at the patient's maximum exercise level;
- Patient's resting blood pressure and heart rate are within normal limits; or
- The stress test is not positive during exercise. (A positive test in this context implies an ECG with a junctional depression of 2mm or more associated with slowly rising, horizontal, or down sloping ST segment.)
Accordingly, claims for coverage of cardiac rehabilitation exercise programs beyond 12 weeks are reviewed by the contractors' medical consultants. When claims are accompanied by acceptable documentation that the patient has not reached an exit level, coverage may be extended, but should not exceed a maximum of 24 weeks.
E - Utilization Screens
Patients who participate in cardiac rehabilitation programs will require certain services more frequently than other patients being treated on an outpatient basis. Therefore, in order to provide coverage in a uniform manner, the following utilization screens should be implemented in addition to existing screens for any cardiac rehabilitation services not listed:
1 - Group 1 Services
Continuous ECG telemetric monitoring during exercise;
ECG rhythm strip with interpretation and physician's revision of exercise prescription; and
Limited examination for physician followup to adjust medication or other treatment changes.
A visit including one or more of this range of routine services is considered as one routine cardiac rehabilitation visit. In order for the visit to be reimbursable, at least one of the Group 1 services must be performed. The same rate of reimbursement would be allowed for each visit, but not all the services need be performed at each visit.
Allow a maximum of three visits per week.
2 - Group 2 Services
New patient comprehensive evaluation, including history, physical, and preparation of initial exercise prescription.
Allow one at the beginning of the program if not already performed by the patient's attending physician, or if that performed by the patient's attending physician is not acceptable to the program's director.
- ECG stress test (treadmill or bicycle ergometer) with physician monitoring and report.
Allow one at the beginning of the program and one after 3 months (usually the completion of the program).
- Other physician services, as needed.