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

**  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.