Description
Cardiac rehabilitation (CR) is a physician or nonphysician practitioner-supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meets Federal guidelines and Medicare coverage criteria.
Affected Code(s)
Claims with payment indicator A2; G2; J8; P2; P3; R2
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §424.5(a)(6)- Sufficient information
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package
10. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; §40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; §40.5- Payment for Multiple Procedures
11. Ambulatory Surgical Center Payment System; Addendum AA; Payment indicators A2 (Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight), G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate. ASC Payment rates, P2 (Office-based surgical procedure on ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight), P3 (Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on MPFS non-facility PE RVUs), and R2 (Office-based surgical procedure on ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight) available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
12. National Correct Coding Initiative (NCCI) Policy Manual
13. AMA CPT Codebook
14. HCPCS Level II Codebook
15. AMA CPT Assistant
16. AHA Coding Clinic for HCPCS