Chapter 32 of the Medicare Claims Processing Manual has been revised effective January 4, 2010 to reflect the final OPPS rules for Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services and Pulmonary Rehabilitation Services.

Section 140.2 reviews the Cardiac Rehabilitation Services. It states:

“As specified at 42 CFR 410.49, Medicare covers cardiac rehabilitation items and services for patients who have experienced one or more of the following:

  • An acute myocardial infarction within the preceding 12 months; or
  • A coronary artery bypass surgery; or
  • Current stable angina pectoris; or
  • Heart valve repair or replacement; or
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
  • A heart or heart-lung transplant.

Cardiac rehabilitation programs must include the following components:

  • Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished; Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
  • Psychosocial assessment;
  • Outcomes assessment; and
  • An individualized treatment plan detailing how components are utilized for each patient.

Cardiac rehabilitation items and services must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for the direct supervision of physician’s office services as specified at 42 CFR 410.26 and for hospital outpatient therapeutic services as specified at 42 CFR 410.27.

As specified at 42 CFR 410.49(f)(1), cardiac rehabilitation program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.

The following are the applicable CPT codes for cardiac rehabilitation services:

93797 - Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) and

93798 - Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)

Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session of cardiac rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Two sessions of cardiac rehabilitation services may only be reported in the same day if the duration of treatment is at least 91 minutes. In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes if two sessions are reported. If several shorter periods of cardiac rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.”

Section 140.3 reviews the Intensive Cardiac Rehabilitation Program Services. It states:

“As specified at 42 CFR 410.49, Medicare covers intensive cardiac rehabilitation items and services for patients who have experienced one or more of the following:

An acute myocardial infarction within the preceding 12 months; or

A coronary artery bypass surgery; or

Current stable angina pectoris; or

Heart valve repair or replacement; or

Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or

A heart or heart-lung transplant.

Intensive cardiac rehabilitation programs must include the following components:

Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished; Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;

Psychosocial assessment;

Outcomes assessment; and

An individualized treatment plan detailing how components are utilized for each patient.

Intensive cardiac rehabilitation programs must be approved by Medicare. 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; and

Reduced the need for percutaneous coronary interventions.

An intensive cardiac rehabilitation 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 cardiac rehabilitation services to after cardiac rehabilitation services:

Low density lipoprotein;

Triglycerides;

Body mass index;

Systolic blood pressure;

Diastolic blood pressure; and

The need for cholesterol, blood pressure, and diabetes medications.

Intensive cardiac rehabilitation items and services must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for direct supervision of physician office services as specified at 42 CFR 410.26 and for hospital outpatient therapeutic services as specified at 42 CFR 410.27.

As specified at 42 CFR 410.49(f)(2), intensive cardiac rehabilitation program sessions are limited to 72 1-hour sessions, up to 6 sessions per day, over a period of up to 18 weeks.

The following are the applicable HCPCS codes for intensive cardiac rehabilitation services:

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 cardiac rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Additional sessions of intensive cardiac rehabilitation services 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 order to report 6 sessions of intensive cardiac rehabilitation services 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 intensive cardiac rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.”

Section 140.4 reviews the Pulmonary Rehabilitation Services. It states:

“As specified in 42 CFR 410.47, Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease.

Pulmonary rehabilitation programs must include the following components:

Physician-prescribed exercise. Some aerobic exercise must be included in each pulmonary rehabilitation session;

Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling;

Psychosocial assessment;

Outcomes assessment; and

An individualized treatment plan detailing how components are utilized for each patient.

Pulmonary rehabilitation items and services must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for direct supervision of physician office services as specified at 42 CFR 410.26 and for hospital outpatient therapeutic services as specified at 42 CFR 410.27.

As specified at 42 CFR 410.47(f), pulmonary rehabilitation program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.

The following is the applicable HCPCS code for pulmonary rehabilitation services:

G0424 (Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session

Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session of pulmonary rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Two sessions of pulmonary rehabilitation services may only be reported in the same day if the duration of treatment is at least 91 minutes. In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes, if two sessions are reported. If several shorter periods of pulmonary rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.”

Issues for consideration at your facility prior to January 1, 2010:

Do the patients in your facility’s rehabilitation programs meet medical necessity requirements according to the diagnoses listed in the Medicare Claims Processing Manual?

Are the requirements met for direct physician supervision of these services?

Is your facility’s CDM current and accurate?

Is the patient care staff involved in these services knowledgeable of the medical record documentation (including time) requirements for billing? Is your facility compliant?