Indications and Limitations of Coverage and/or Medical Necessity
Cardiac rehabilitation is a comprehensive program of medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling designed to restore certain patients with coronary or valvular heart disease to active and productive lives. Cardiac rehabilitation as described in the medical literature is divided into three phases: Phase I is the immediate in-hospital post-cardiac event phase; Phase II is the outpatient immediate posthospitalization recuperation phase; Phase III is the long-term maintenance phase and is not payable under Medicare. This LCD encompasses Phase II or outpatient post-hospital cardiac rehabilitation. Phase II programs are typically initiated one to three weeks after hospital discharge and consist of a series of medically supervised exercise sessions with Continuous Electrocardiograph Monitoring (CEM). Clinically optimal results are obtained if these sessions are conducted two to three times per week over a 12–18-week period, generally for a total of 36 sessions.

Cardiac rehabilitation by national LCD is covered for only six groups of patients: • • • • • • Patients who begin the program within 12 months of an acute Myocardial Infarction (MI). Patients who have had Coronary Artery Bypass Graft (CABG) surgery. Patients with stable angina pectoris. Patients who have had heart valve repair/replacement. Patients who have had Percutaneous Transluminal Coronary Angioplasty (PTCA) or coronary stenting. Patients who have had a heart or heart-lung transplant.

Limitations A. Facilities
Cardiac rehabilitation programs may be provided either by the outpatient department of a hospital or a physician-directed clinic. Coverage for either program is subject to the following conditions: • • • • The facility meets the definition of a hospital outpatient department or a physician-directed clinic, i.e., a physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician. The facility has available for immediate use all the necessary cardiopulmonary emergency diagnostic and therapeutic life-saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment or defibrillator. The program is conducted in an area set aside for the exclusive use of the program while it is in session. The program is staffed by personnel necessary to conduct the program safely and effectively and who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. When conducted in a hospital, an identified physician must be immediately available. This does not require that a physician be physically present in the

Over the years. For the purposes of this LCD. B. nuclear perfusion studies have supplanted standard Electrocardiogram (ECG) treadmill tests as a means of evaluating ischemic heart disease. For patients who have had a PTCA or stent replacement. Frequency and Duration • • • • • • The frequency and duration of the program are generally a total of 36 sessions. A positive stress test in this context implies a junctional depression of 2 mm or more with associated slowly rising ST segment. Phase II is divided into Phase IIA and Phase IIB: Phase IIA is the initial outpatient cardiac rehabilitation. When conducted in a clinic or physician’s office. not to exceed a total of 36 sessions. the date of entry should be within six months of the CABG procedure. Therefore. For angina. or 1 mm horizontal or downsloping ST segment depressions. Phase IIB consists of an additional series of 36 sessions. For patients with heart valve repair or replacement. the non-physician personnel are employees of the physician or clinic conducting the program and their services are “incident to” a physician’s professional services. Sessions extending beyond the 18 weeks may be reviewed to confirm medical necessity. but are not restricted to. Services at a frequency of fewer than two sessions per week will be considered not medically necessary unless additional documentation is demonstrated verifying the patient was unable to attend due to illness or hospitalization. Therefore. the program should be early enough to provide a restorative benefit. Patients who have had a heart or heart-lung transplant may present special and complex posttransplant management problems. there must be clear demonstration the patient is benefiting from cardiac rehabilitation and that the exit criterion below has not been met. the program should be early enough to provide a restorative benefit. the positive stress test also includes perfusion studies that demonstrate ischemia. Therefore. specifically. Exit Criterion Exit criteria include. When conducted in the hospital. especially for patients who have abnormal rest ECGs. Phase IIB benefits must meet additional medical necessity criteria. two to three times per week for 12– 18 weeks and will only be allowed if determined to be medically necessary. the date of entry must be within six months of surgery.• • exercise room itself but must be immediately available and accessible at all times in case of an emergency. The date of entry is extended to within one year of the surgery. two to three sessions per week for 12–18 weeks. The total number of allowable sessions (Phase IIA and IIB combined) is 72 within a 36-week period. the following clinical parameters: . Diagnoses • • • For MI. the date of entry must be within six months of surgery. Therefore. the non-physician personnel are employees of the hospital conducting the program. two to three times per week over 12–18 weeks. D. the initiation of the program should be early enough to have a restorative effect on the recuperative process. the date of entry into the program must be within 12 months of the date of infarction. all patients must have a pre-entry stress test that is positive for exercise-induced ischemia within six months of starting cardiac rehabilitation (see “Group II Services” below). • • • C. For CABG.

Based on the study of long-term cardiopulmonary exercise performed after heart transplant by Osade et al. o The same rate of reimbursement would be allowed for each visit. lipid management and stress management. are components of the cardiac rehabilitation program and are not separately reimbursed. o Limited examination for physician follow-ups to adjust medication or for other treatment changes. • Congestive heart failure in the absence of other covered conditions is not included as a covered condition of cardiac rehabilitation in the CMS National Coverage Determination Manual. benefits are available for Phase IIA only. G. Symptoms of angina or dyspnea are stable at the patient’s maximum exercise level.10. The posttransplant patient poses a special challenge for the cardiac rehabilitation team. E. Patients whose VO2 is less than 90 percent predicted may qualify for the additional Phase IIB. such as dietary counseling. Definition of Group Services • Group I services include: o Continuous ECG telemetric monitoring during exercise. o ECG rhythm strip with interpretation and physician’s revision of exercise prescription. horizontal or down-sloping ST segment. psychosocial intervention. ECGs and other diagnostic services may be covered on the day of cardiac rehabilitation if these services are separate and distinct from the cardiac rehabilitation program and are medically necessary.• • • • • • The patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia. Publication 100-03. Group II services include: . o A visit including one or more of the Group I services is considered as one routine cardiac rehabilitation visit. this contractor will use a peak oxygen consumption (VO2) of greater than 90 percent predicted as the exit criterion for Phase IIA. For patients with valvuloplasty or valve replacement. Forms of counseling. Other Services • • Evaluation and Management (E/M) services. but not all services need to be performed at each visit. at least one of the Group I services must be performed. The stress test is not positive during exercise. F. Section 20. Non-Covered Diagnoses Use of any ICD-9-CM diagnosis code not in the “ICD-9-CM Diagnosis Codes That Support Medical Necessity” section of this LCD will be cause for denial of claims. Issues such as deconditioning and cachexic deterioration may complicate the definition of a reasonable exit criterion. Data showing that extension of the program beyond the 36 sessions is reasonable and necessary is not available. A positive stress test in this context implies an ECG with a junctional depression of 2 mm or more associated with slowly rising. The patient’s resting blood pressure and heart rate are within normal limits. For the visit to be reimbursable. • A patient with unstable angina will not qualify for cardiac rehabilitation services.

ECG monitoring. maintained in the patient’s medical record and made available to Medicare upon request. 93797© Cardiac rehab 93798©Cardiac rehab/monitor Documentation Requirements Documentation supporting medical necessity should be legible. including history.• • • • New patient comprehensive evaluation. Other physician services. including ECG strips. ICD-9-CM diagnosis codes supporting medical necessity must be submitted with each claim. smoking cessation. where appropriate. Any diagnosis submitted must have documentation in the patient’s record to support coverage and medical necessity. When billing CPT code 93798. “Physical Medicine and Rehabilitation. must be maintained. All cardiac rehabilitation providers must have documentation of the qualifying event in the patient’s medical record. It is not expected that every component is provided at each session but the total Phase II (A and B) record must reflect those benefits. This information may include copies of the referring physician’s records or reports. One will be allowed at the beginning of the program if not already performed by the patient’s attending physician or if that performed by the patient’s physician is not acceptable to the program’s director. One will be allowed at the beginning of the program and one after three months (usually the completion of the program). All components. A cardiac rehabilitation record must be maintained. . All components of the service (medical assessment. Claims submitted without such evidence will be denied as not medically necessary.” Article in AccuLibrary CPT/HCPCS Codes Note: . as needed. Outpatient. the documentation must clearly indicate the patient is receiving continuous ECG monitoring. ECG stress test (treadmill or bicycle ergometer) with physician monitoring and report. For requirements on physical medicine and rehabilitation modalities and procedures. A prescription for cardiac rehabilitation from the referring physician must be maintained in the patient’s medical record by the provider of the cardiac rehabilitation service. physical and preparation of initial exercise prescription. dietary counseling and psychological counseling) must be assessed and provided.

Delayed time to defibrillation after in-hospital cardiac arrest.” Section C. NM. Krumholz HM. Full disclosure of sources of information is found with original contractor LCD. TX) MAC Integration TrailBlazer adopted the TrailBlazer LCD. Chan PS. et al. Sources of Information and Basis for Decision J4 (CO. Utilization Guidelines Refer to “Indications and Limitations of Coverage and/or Medical Necessity.” . “Frequency and Duration” above. OK.A record must be kept indicating the identity of the supervising physician and the identity of the physician who will respond immediately should an adverse consequence develop. “Cardiac Rehabilitation.” for the Jurisdiction 4 (J4) MAC transition. This record must be made available to Medicare upon request. 2008 (1):9-17. Other Contractor Local Coverage Determinations “Cardiac Rehabilitation. NEJM. Nichol G.