(Medicare Claims Processing Manual)

Group Code PR (Patient Responsibility)  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  140.2.2.3  Frequency Edits for CR and ICR Claims  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)   Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all CR claims (both professional and institutional claims) that exceed 2 units per date of service for CR and 6 units per date of service for ICR.   The following messages shall be used when contractors deny CR and ICR claims for exceeding units per date of service:   CARC 119 -  Benefit maximum for this time period or occurrence has been reached.   RARC N362 -  The number of days or units of service exceeds our acceptable maximum.  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Group Code PR  Where a claim is received with the GA modifier indicating that a signed ABN is on file.   Group Code CO  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.   Contractors shall not research and adjust CR claims (HCPCS 93797 and 93798) paid for more than 2 units on the same date of service processed prior to the implementation of edits. However, contractors may adjust claims brought to their attention.  Contractors shall not research and adjust ICR claims (HCPCS G0422 and G0423) paid for more than 6 units on the same date of service processed prior to the implementation of edits. However, contractors may adjust claims brought to their attention.  140.2.2.4  Edits for CR Services Exceeding 36 Sessions  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all claims with HCPCS 93797 and 93798 (both professional and institutional claims) that exceed 36 CR sessions when a - KX modifier is not included on the claim line.   The following messages shall be used when contractors deny CR claims that exceed 36 sessions, when a - KX modifier is not included on the claim line:  -CARC- ) 119  Benefit maximum for this period or occurrence has been reached.   RARC N435 -  Exceeds number/frequency approved/allowed within time period without support documentation. MSN 23.17-  Medicare wont cover these services because they are not considered medically necessary.   Spanish Version -  Medicare no cubrir estos servicios porque no son considerados necesarios por razones mdicas.   Group Code PR  Where a claim is received with the GA modifier indicating that a signed ABN is on file.   Group Code CO  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.   Contractors shall not research and adjust CR claims paid for more than 36 sessions processed prior to the implementation of Common Working File (CWF) edits. However, contractors may adjust claims brought to their attention.   140.2.2.5  Edits for ICR Services Exceeding 126 Days and 72 Sessions  (Rev. 1974, Issued: 05- 21-10, Effective: 01 -10-10, Implementation: 10- 04-10)  Effective for claims with dates of service on and after January 1, 2010, CWF shall reject ICR claims (G0422 and G0423)  that exceed 72 sessions or where any billed sessions were provided after126 days from the date of the first session and a KX modifier is  not included on the claim line.   The following messages shall be used when contractors deny ICR claims that exceed 72 sessions or where any billed sessions were received after the 126 days from the date of the first session:   Claim Adjustment Reason Code (CARC) 119 -  Benefit maximum for this time period or occurrence has been reached.   RARC N435 -  Exceeds number/frequency approved/allowed within time period without support documentation.  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Group Code PR (Patient Responsibility)  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  Contractors shall not research and adjust ICR claims paid for more than 72 sessions or where any billed sessions were received after 126 days from the date of the first session that were processed prior to the implementation of CWF edits.  However, contrac tors may adjust claims brought to their attention.   140.2.2.6  Supplier Specialty Code 31 Requirements for ICR Claims (Rev. 1974, Issued: 05- 21-10, Effective: 01 -10-10, Implementation: 10- 04-10)  Effective for claims with dates of service on and after January 1, 2010, contractors shall pay for ICR services when submitted by providers enrolled as the new supplier specialty code 31 for ICR. ICR services submitted by providers enrolled as other than t he new supplier specialty code 31 for ICR are to be denied using the following messages:   CARC 8: The procedure code is inconsistent with the provider type/specialty (taxonomy).  NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N95: This provider type may not bill this service.  MSN 21.18  This item or service is not covered when performed or ordered by this provider.  Spanish Version: Este servicio no est cubierto cuando es ordenado o rendido por este proveedor.   Group Code PR (Patient Responsibility)  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  140.3  ICR Program Services Effective for Dates of Service On or After January 1, 2024  (Rev. 12497; Issued: 02-08- 24; Effective: 01 -01-24; Implementation: 03-12-24)  As specified at 42 CFR 410.49, Medicare Part B covers ICR for beneficiaries who have experienced one or more of the following:   An acute MI within the preceding 12 months;  A coronary artery bypass surgery;  Current stable angina pectoris;  Heart valve repair or replacement;   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 NYHA class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks, on or after February 9, 2018; or,  Other cardiac conditions as specified through an NCD. The NCD process may also be used to specify non-coverage of a cardiac condition for ICR if coverage is not supported by clinical evidence.   ICR must include all of the following components:   Physician prescribed exercise each day CR items and services are furnished.   Cardiac risk factor modification, including education, counseling, and behavioral intervention, tailored to the individuals needs.  Psychosocial assessment.  Outcomes assessment.   An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days. A list of approved ICR programs, identified through the NCD process, will be listed in the Federal Register and is available on the CMS website at https://www.cms.gov/Medicare/Medicare- General -Information/MedicareApprovedFacilitie/ICR . In order to be approved, a program must demonstrate through peer-reviewed, published research that it has accomplished one or more of the following for its patients:   Positively affected the progression of coronary heart disease.   Reduced the need for coronary bypass surgery.  Reduced the need for percutaneous coronary interventions.  An ICR program must also demonstrate through peer -reviewed published research that it accomplished a statistically significant reduction in 5 or more of the following measures for patients from their levels before CR services to after CR services:    Low density lipoprotein.  Triglycerides.   Body mass index.  Systolic blood pressure.  Diastolic blood pressure.  The need for cholesterol, blood pressure, and diabetes medications.   Medicare Part B pays for ICR in a physicians office or a hospital outpatient setting. All settings must have a physician or nonphysician practitioner immediately available and accessible for medical consultations and emergencies at all times when items an d services are being furnished under the program. This provision is satisfied if the physician or nonphysician practitioner meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42 CFR 410.27. Note: Nonphysician practitioners are eligible to supervise ICR effective January 1, 2024.   As specified at 42 CFR 410.49(f)(2), ICR sessions are limited to 72 1- hour sessions (as defined in section 1848(b)(5) of the Act), up to 6 sessions per day, over a period of up to 18 weeks.   140.3.1  Coding Requirements for ICR Services Furnished On or After January 1, 2010  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)   The following are the applicable HCPCS codes for ICR:   G0422 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring, with exercise, per hour, per session)   G0423 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring, without exercise, per hour, per session)   Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 6 1 -hour sessions per day. In order to report one session of ICR in a day, the duration of treatment must be at least 31 minutes. Additional sessions of ICR beyond the first session may only be reported in the same day if the duration of treatment is 31 minutes or greater beyond the hour increment. In other words, in or der to report 6 sessions of ICR on a given date of service, the first five sessions would account for 60 minutes each and the sixth session would account for at least 31 minutes. If several shorter periods of ICR are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1- hour session increments.   Example : If the patient receives 20 minutes of ICR in the day, no ICR session may be reported because less than 31 minutes of services were furnished.   Example : If a patient receives 20 minutes of ICR in the morning and 35 minutes of ICR in the afternoon of a single day, the hospital or practitioner would report 1 session of ICR under 1 unit of the appropriate HCPCS code for the total duration of 55 minutes of I CR on that day.  Example : If the patient receives 70 minutes of ICR in the morning and 25 minutes of ICR in the afternoon of a single day, the hospital or practitioner would report two sessions of ICR under the appropriate HCPCS code(s) because the total duration of ICR on that day of 95 minutes exceeds 90 minutes.  Example : If the patient receives 70 minutes of ICR in the morning and 85 minutes of ICR in the afternoon of a single day, the hospital or practitioner would report three sessions of ICR under the appropriate HCPCS code(s) because the total duration of ICR on that  day is 155 minutes, which exceeds 150 minutes and is less than 211 minutes.   140.4  PR Program Services Effective for Dates of Service On or After January 1, 2024  (Rev.  12497; Issued: 02- 08-24; Effective: 01 -01-24; Implementation: 03 -12-24)  As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:    With moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease;   Who have had confirmed or suspected COVID -19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective January 1, 2022);   Additional medical indications for coverage for PR may be established through an NCD.   PR must include all of the following components: