Article - Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation (A53775)

CMS National Coverage PolicyTitle 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, 2010CMS 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) Programs42 CFR 410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverageArticle TextCardiac Rehabilitation ProgramThe 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 CPTor 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 sessionsandthe 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)Abeneficiarymayswitchfrom anICRprogram to a CRprogram.The beneficiaryislimitedto a1-time switch,multiple switchesare notallowable. Oncethebeneficiaryswitches fromICRto CR, he or she will belimitedto thenumberofsessionsremaining in theprogram.Forexample,abeneficiarywhoswitchesfromICRto CRafter12sessionswillhave24sessionsof CRremaining,(i.e.,12sessionsofICR+ 24sessionsof CR = total of 36sessions).Should abeneficiary experiencemorethan 1indicationsimultaneously,he or shemay participatein a singleseriesof CR orICR sessions(i.e.,apatientwho had amyocardialinfarctionwithin12monthsandcurrently experiencesstable angina isentitledto 1seriesof CRsessions,up to 361-hoursessionswithcontractordiscretionfor anadditional36sessions;or1 seriesofICR sessions,up to 721-hoursessionsovera period up to 18weeks).Beneficiariesmaynotswitchfrom CR toICR.Uponcompletionof a CR orICR program,beneficiariesmustexperience anotherindication inorderto beeligibleforcoverageofmoreCR or ICR.Contractorsshallaccepttheinclusionof the KXmodifieron theclaim line(s)as anattestationby theproviderof theservicethatdocumentationis onfile verifyingthatfurthertreatmentbeyond36 sessions of CR up to a total of 72sessionsmeetstherequirementsof themedicalpolicyor, forICR,that anyfurthersessionsbeyond72 sessions within a 126 dayperiodcountingfrom the date of the firstsessionorforanysessionsprovidedafter126daysfrom the date of the firstsessionmeettherequirementsof the medicalpolicy.BeneficiarieswhoswitchfromICRto CRmayalso beeligiblefor up to 72combinedsessions withcontractordiscretionfor CRsessionsafter36(toinclude completedICRsessions prior toswitch).Inthesecases,andconsistentwith theinformationabove,the KXmodifiermustbeincludedon theclaimshould thebeneficiary participateinmorethan 36 CRsessionsfollowing theswitch.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 patients 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 CPTcodes should accurately capture the service that was performed.