How To Pay For Cardiac Rehabilitation

Transcription

1 Image description. Draft Stamp End of image description. Draft LCD for Draft LCD for Cardiac and Intensive Cardiac Rehabilitation (DL31393) Please note: This is a Draft policy. Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor. Image description. Future Stamp End of image description. Please note: This is a Future Draft LCD. Contractor Information Image description. Future Stamp End of image description. Image description. Future Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Contractor Name National Government Services, Inc. Contractor Number Contractor Type FI LCD Information Image description. Future Stamp End of image description. Image description. Future Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. LCD ID Number DL31393 LCD Title Draft LCD for Cardiac and Intensive Cardiac Rehabilitation

2 Contractor's Determination Number DL31393 AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1861(eee) creates and defines the Cardiac Rehabilitation and Intensive Cardiac Rehabilitation benefits. Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1862 (a)(7) excludes routine physical examinations. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations: 42 CFR Section (a)(2) which includes the definition of a physician. 42 CFR Section includes all coverage provisions for Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) items and services, identifies definitions, covered indications, settings, physician supervision requirements and physician standards, required CR and ICR components, limitations to the number of sessions covered, and the period of time over which the sessions may be covered. Federal Register: Federal Register, Vol. 74, No. 226, November , pages , discusses the definitions of Cardiac and Intensive Cardiac Rehabilitation, and defines the practitioner requirements for the service. CMS Publications: CMS Publication , Medicare Benefit Policy Manual, Chapter 15:

3 232 Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010 CMS Publication , Medicare Claims Processing Manual, Chapter 26: Nonphysician Practitioner, Supplier, and Provider Specialty Codes CMS Publication , Medicare Claims Processing Manual, Chapter 32: 140 Cardiac Rehabilitation Programs, Intensive Cardiac Rehabilitation Programs and Pulmonary Rehabilitation Programs CMS Publication , Medicare Program Integrity Manual, Chapter 10: Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) CMS Transmittal No. 126, Publication , Medicare Benefit Policy Manual, Change Request #6850, May 21, 2010, implementation of MIPPA CR and ICR coverage provisions. CMS Transmittal No. 1974, Publication , Medicare Claims Processing Manual, Change Request #6850, May 21, 2010, billing and reimbursement of Cardiac Rehabilitation and Intensive Cardiac Rehabilitation services. CMS Transmittal No. 170, Publication , Medicare Financial Management Manual, Change Request #6850, May 21, 2010, establishes new supplier specialty code for intensive cardiac rehabilitation services. CMS Transmittal No. 339, Publication , Medicare Program Integrity Manual, Change Request #6850, May 21, 2010, establishes new supplier specialty code for intensive cardiac rehabilitation services. CMS Transmittal No. 116, Publication , Medicare National Coverage Determinations Manual, Change Request #6855, March 5, 2010 provides CMS notification that Section of the Medicare National Coverage Determination Manual (Publication ) is repealed effective February 22, CMS Decision Memo for Intensive Cardiac Rehabilitation (ICR) Program Pritikin Program (CAG-00418N). This decision memo approves the Pritikin Program as a covered Intensive Cardiac Rehabilitation program. CMS Decision Memo for Intensive Cardiac Rehabilitation (ICR) Program Dr. Ornish s Program for Reversing Heart Disease (CAG-00419N). This decision memo approves the Ornish Program as a covered Intensive Cardiac Rehabilitation program. Primary Geographic Jurisdiction Wisconsin Oversight Region Region V

4 Projected Determination Effective Date For services performed on or after 03/01/2011 Original Determination Ending Date Revision Effective Date Revision Ending Date Indications and Limitations of Coverage and/or Medical Necessity Abstract: 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 or following cardiac transplant, to active and productive lives. Forms of counseling, such as dietary counseling, psychosocial intervention, dietary and lipid management and stress management are components of the program, and are not separately reimbursed. As specified at 42 CFR (f)(1), CR 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 contractor under section 1862(a)(1)(A) of the Act. ICR sessions are limited to 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. (See CMS Publication , Medicare Benefit Policy Manual, Chapter 15, Section 232) Cardiac rehabilitation is divided into three phases: Phase I is the immediate in hospital post-cardiac event phase; Phase II is the outpatient immediate post- hospitalization recuperation phase; Phase III is the long term, maintenance phase. This LCD encompasses outpatient post-hospital cardiac rehabilitation, or Phase II. The program consists of a series of supervised physician-prescribed exercise sessions, cardiac risk factor modification, psychosocial assessment, outcomes assessment, an individualized treatment plan detailing how components are utilized for each patient. Clinically optimal results are more probable if these sessions are conducted two or three times per week over a week period for 36 sessions. Indications: Cardiac rehabilitation (CR) means a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Individualized treatment plan means a written plan tailored to each individual patient that includes all of the following: (i) A description of the individual s diagnosis. (ii) The type, amount, frequency, and duration of the items and services furnished under the plan. (iii) The goals set for the individual under the plan.

5 Intensive cardiac rehabilitation (ICR) program means a physician-supervised program that furnishes cardiac rehabilitation and has shown, in peer reviewed published research, that it improves patients cardiovascular disease through specific outcome measurements. Standards for an intensive cardiac rehabilitation program: (1) To be approved as an intensive cardiac rehabilitation program, a program must demonstrate through peerreviewed, published research that it has accomplished one or more of the following for its patients: (i) Positively affected the progression of coronary heart disease. (ii) Reduced the need for coronary bypass surgery. (iii) Reduced the need for percutaneous coronary interventions; (2) 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 toafter cardiac rehabilitation services: (i) Low density lipoprotein. (ii) Triglycerides. (iii) Body mass index. (iv) Systolic blood pressure. (v) Diastolic blood pressure. (vi) The need for cholesterol, blood pressure, and diabetes medications. (See 42 CFR Section ) 1. Cardiac Rehabilitation and Intensive Cardiac Rehabilitation are covered for the following patients:

6 Patients who begin the program within 12 months of an acute myocardial infarction Patients who have undergone coronary artery bypass (CABG) surgery. The initiation of the program should be early enough to have a restorative effect on the recuperative process. Therefore the date of entry must be within six months of the CABG procedure. Patients with current stable angina pectoris. Patients must have a pre-entry stress test which is positive for exercise-induced ischemia within six months of starting cardiac rehabilitation. A positive stress test in this context implies a junctional depression of 2 mm or more with associated slowly rising ST segment, or 1 mm horizontal or down-sloping ST segment depressions. A "positive" stress test also includes imaging studies (nuclear scintigraphic perfusion and wall motion, PET scans, echocardiographic wall motion) which demonstrate ischemia. Patients who have had heart valve repair/replacement. The program should be early enough to provide a restorative benefit. Therefore, the date of entry must be within six months of surgery. Patients who have had percutaneous coronary angioplasty (PTCA) or coronary stenting. The program should be early enough to provide a restorative benefit. Therefore, the date of entry must be within six months of the procedure. Patients who have had a heart or heart-lung transplant. Patients who have had heart or heart-lung transplant may present special and complex post transplant management problems. The date of entry must be within one year of the surgery. 2. Sites of Service Cardiac rehabilitation and intensive Cardiac Rehabilitation programs may be provided only in the outpatient department of a hospital, a physician-directed clinic or in a physician's office. Cardiac Rehabilitation and Intensive Cardiac Rehabilitation are not covered by Medicare when provided in a CORF. 3. Supervision Appropriate direct physician supervision is a requirement for Medicare coverage. Direct supervision means that a physician must be in the exercise program area and immediately available and accessible for all emergencies. It does not require that a physician be physically present in the exercise room itself.

7 In a physician office setting, direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. [42 CFR (a)(2) and (b)(3)(ii)] In a hospital outpatient, direct supervision means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. [42 CFR (f)] [emphasis added]. Cardiac rehabilitation rendered within a hospital outpatient department is considered incident to a physician s services and requires physician supervision. The physician supervision requirement is presumed to be met when services are performed on the hospital premises (i.e., certified as part of the hospital and part of the hospital campus). In order to satisfy the immediately available criteria in an oncampus provider-based department or in an off-campus hospital site, the physician (or qualified NPP) must be present in the same building. CMS physician qualifications requirements are: Standards for the physician responsible for cardiac rehabilitation program. A physician responsible for a cardiac rehabilitation program or intensive cardiac rehabilitation programs is identified as the medical directors. The medical director, in consultation with staff, are involved in directing the progress of individuals in the program, must possess all of the following: (1) Expertise in the management of individuals with cardiac pathophysiology. (2) Cardiopulmonary training in basic life support or advanced cardiac life support. (3) Be licensed to practice medicine in the State in which the cardiac rehabilitation program is offered. Standards for supervising physicians. Physicians acting as the supervising-physician must possess all of the following: (1) Expertise in the management of individuals with cardiac pathophysiology. (2) Cardiopulmonary training in basic life support or advanced cardiac life support. (3) Be licensed to practice medicine in the State in which the cardiac rehabilitation program is offered. (See 42 CFR Section ) Based upon these CMS requirements for physicians to have expertise in cardiac pathophysiology, as well as life support training, Cardiac Rehabilitation and Intensive Cardiac Rehabilitation will be covered and reimbursed only when the medical director and supervising physicians are cardiologists with training in exercise physiology or cardiac rehabilitation. 4. Facilities The facility or office 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 staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for heart disease. Services of nonphysician personnel must be furnished under the direct supervision of a physician. The nonphysician personnel are employees of either the physician, hospital or clinic conducting the program and their services are "incident-to" a physician's professional services (under Part A incident to provision). 5. Description of Services

8 A Cardiac rehabilitation program consists of a series of supervised physician-prescribed exercise sessions, cardiac risk factor modification, psychosocial assessment, outcomes assessment, and an individualized treatment plan detailing how components are utilized for each patient. Cardiac Rehabilitation must include physician-prescribed exercise on each day services are provided. Exercise capacity will vary among patients and the volume, intensity and duration of exercise must be individualized and appropriately prescribed. The exercise component may vary depending upon the patient s ability to exercise, although it is expected that it will increase as the patient progresses. Failure to progress may suggest that the patient is failing to benefit from the program and result in subsequent sessions being considered not medically necessary. Individualized treatment planning and outcomes assessment are included as part of the Cardiac Rehabilitation sessions, and are counted towards the total 36 sessions. These services may not be billed separately as E&M or other services. Sessions including monitored physician-prescribed exercise should be billed with CPT code and those without exercise or with unmonitored exercise are billed using the The individualized treatment plan must be established, reviewed and signed by a physician every 30 days. (See CMS Publication , Medicare Benefit Policy Manual, Chapter 15, Section 232) ICR programs must be approved by CMS through the NCD process and must meet certain criteria for approval. Individual sites wishing to provide ICR services via an approved ICR program must enroll with their local Medicare contractor or MAC as an ICR program supplier using CMS 855B. Contractors and MACs must ensure that claims submitted from individual ICR sites are submitted by enrolled ICR program sites. (See CMS Publication , Medicare Program Integrity Manual, Chapter 10, Section 2.2.8) ICR programs that are approved through the NCD process will be identified in the NCD manual (Pub ), on the CMS Web site and in the Federal Register. Once ICR programs are approved through the NCD process, sites wishing to furnish ICR services via an approved ICR program may begin to enroll as ICR program suppliers using CMS 855B. Limitations: 1. Frequency and Duration The frequency and duration of the program are generally a total of 36 sessions, occurring 2-3 times per week for weeks. Sessions extending beyond the 18 weeks will be denied as not medically necessary, unless additional documentation of necessity is demonstrated. Services at a frequency of less than 2 sessions per week suggest a maintenance program, and may be considered not medically necessary. 2. Phases of Cardiac Rehabilitation Phase I: Acute in-hospital phase of Cardiac Rehabilitation. This is included in the hospital care for the acute illness and is not included under the Cardiac Rehabilitation benefit. Phase II: For the purposes of this LCD, Phase II is divided into Phase IIA and Phase IIB. Phase IIA is the initial outpatient cardiac rehabilitation, consisting of 36 or fewer sessions, occurring up to 2 sessions per day. Phase IIB consists of up to an additional 36 sessions and will only be allowed if determined to be medically necessary. Phase IIB benefits must meet additional medical necessity criteria. Specifically, there must be clear demonstration that the patient is benefiting from cardiac rehabilitation and that the exit criteria below from phase IIA have not been met. The maximum number of allowable sessions under Phase IIA and IIB is 72.

9 Phase III: Cardiac Rehabilitation programs, that are self-directed or self-controlled/monitored exercise programs. Phase IV: Cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision. Only Phase II Cardiac Rehabilitation programs meet the supervisory requirements of the benefit and are covered under Medicare. 3. Exit Criteria Once a patient has reached the exit criteria, further cardiac rehabilitation will not be considered reasonable and necessary. Ischemic heart disease: Patients s/p myocardial infarction, CABG, PTCA or stent, and patients with angina undergoing stress testing without demonstrating significant ischemia or dysrhythmia after completion of six minutes of a Bruce protocol, or equivalent, achieving a stable level of exercise tolerance (7 METS). [In the American Heart Association s functional classification, Class I, or normal function status, begins at 7 metabolic equivalent units (METS)]. Following valve repair/replacement: Patients achieving a stable level of exercise tolerance (7 METS). Heart and heart-lung transplant patient: Issues such as deconditioning and cachexic deterioration may complicate the definition of reasonable exit criteria. Based on the study of long term cardiopulmonary exercise performed after heart transplant (Osada et al), a peak oxygen consumption (VO 2) of greater than 90% of predicted will be used as the exit criterion for phase IIA. Patients whose peak VO 2 is less than 90% of predicted may qualify for phase IIB. The patient following heart and heart-lung transplant patient poses a special challenge for the cardiac rehabilitation team. Issues such as deconditioning and cachexic deterioration may complicate the definition of reasonable exit criteria. Based on the study of long term cardiopulmonary exercise performed after heart transplant by Osada et al, this contractor will use a peak oxygen consumption (VO 2) of greater than 90% of predicted as the exit criterion for phase IIA. Patients whose peak VO 2 is less than 90% of predicted may qualify for phase IIB. 4. Non-covered Diagnoses Claims will be denied if the reason for the referral is not listed as an indication in the narrative of this LCD and identified by one of the ICD-9-CM diagnosis codes listed as supporting medical necessity. Congestive heart failure in the absence of other covered conditions is not included as a covered condition for cardiac rehabilitation in CMS Manual System, Pub 100-3, Cardiac Rehabilitation Programs, Section (CIM 35-25). 5. Other Services Evaluation and management services (E & M), electrocardiograms, (ECG) 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 reasonable and necessary, but would not be covered if provided routinely as part of the Cardiac Rehabilitation program. 6. Patients returning to Cardiac Rehabilitation after an extended period of time will require a new physician prescription. The remaining sessions must be within the covered 36 week (CR) or 18 week (ICR) time period, otherwise the beneficiary would have to experience another occurrence of a qualifying event included among the indications in order to begin the rehabilitation again.

10 7. Cardiac rehabilitation requires an order/referral from the physician or qualified non-physician provider treating the patient for his/her cardiac condition. A qualified non-physician practitioner may order the Cardiac Rehabilitation if it is within his/her scope of practice under state license. 8. Contractors will only pay for ICR services when submitted by providers enrolled as suppliers of Intensive Cardiac Rehabilitation, specialty code 31. ICR services submitted by providers enrolled as other than specialty 31 will be denied. 9. Rehabilitation services provided under circumstances not meeting the supervision and facility requirements noted in the indications section will be denied as not medically necessary. 10. Physicians may not bill for supervision of Cardiac Rehabilitation or Intensive Cardiac Rehabilitation services provided in an outpatient hospital setting. Other Comments: For claims submitted to the fiscal intermediary or Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims. Bill type codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. Coding Information Image description. Future Stamp End of image description. Image description. Future Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 013x Hospital Outpatient

11 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes Other Therapeutic Services - Cardiac Rehabilitation 0960 Professional Fees - General Classification 0969 Professional Fees - Other Professional Fee 0982 Professional Fees - Outpatient Services 0983 Professional Fees - Clinic CPT/HCPCS Codes PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; WITHOUT CONTINUOUS ECG MONITORING (PER SESSION) PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; WITH CONTINUOUS ECG MONITORING (PER SESSION) G0422 G0423 INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING WITH EXERCISE, PER SESSION INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING; WITHOUT EXERCISE, PER SESSION ICD-9 Codes that Support Medical Necessity

12 It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE

13 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED TRUE POSTERIOR WALL INFARCTION INITIAL EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED SUBENDOCARDIAL INFARCTION INITIAL EPISODE OF CARE SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE 412* OLD MYOCARDIAL INFARCTION OTHER AND UNSPECIFIED ANGINA PECTORIS 414.8* OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE V15.1* PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH V42.1 HEART REPLACED BY TRANSPLANT V42.2 HEART VALVE REPLACED BY TRANSPLANT

14 V43.3 HEART VALVE REPLACED BY OTHER MEANS V45.81 POSTSURGICAL AORTOCORONARY BYPASS STATUS V45.82 PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS *ICD-9-CM code 412 (old myocardial infarction) should be reported for patients currently not experiencing symptoms, with a history of myocardial infarction diagnosed on the basis of electrocardiographic or other special tests, having occurred 8 weeks to 12 months prior to entry into the Cardiac or Intensive Cardiac Rehabilitation program. *ICD-9-CM code should be reported for patients currently experiencing related symptoms, with a history of a myocardial infarction having occurred 8 weeks to 12 months prior to the entry into the Cardiac or Intensive Cardiac Rehabilitation program. *ICD-9-CM code V15.1 should be reported for patients who have undergone heart valve repair (rather than replacement). Diagnoses that Support Medical Necessity Not applicable ICD-9 Codes that DO NOT Support Medical Necessity Not applicable ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity Not applicable General Information Image description. Future Stamp End of image description. Image description. Future Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Documentation Requirements

15 The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The qualifying event must be recorded in the patient's medical record maintained by the cardiac rehabilitation provider. This information may include copies of the referring physician's or qualified non-physician provider s records or reports. A prescription for cardiac rehabilitation from the referring physician or qualified non-physician provider must be maintained in the patient's medical record by provider of cardiac rehabilitation. The physician prescribed exercise and treatment plan must be included in the medical record and available for review. The treatment plan must be individualized for each patient. A template plan used for multiple patients will be deemed to not meet this requirement, and resultant cardiac rehabilitation services may be denied as not medically necessary. Physician evaluation must be performed and documented at a minimum of monthly intervals. Documentation of patient activity and services provided must be documented in the medical record for each session billed. Sessions billed as with monitoring should also be documented by a sample electrocardiographic rhythm strip with identified rhythm and note of any abnormality. 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. Appendices Not applicable Utilization Guidelines Cardiac Rehabilitation (CR) Providers may bill up to two sessions 1-hour sessions of Cardiac Rehabilitation per day. Up to 36 sessions are covered if medically necessary, and an additional 36 sessions may be covered if, when supported by additional submitted documentation, they are deemed medically necessary by the local contractor. A single session must last at least 31 minutes in order to be billable. If two sessions are billed for a single day, then the total combined time must last at least 91 minutes (60 minutes for the first session and at least 31 minutes for the second session). No more than two sessions (utilizing any combination of the CPT codes and 93798) are billable per day, regardless of the total duration of the sessions. For the purposes of this LCD, Phase II is divided into Phase IIA and Phase IIB. Phase IIA is the initial outpatient cardiac rehabilitation, not to exceed a total of 36 sessions occurring as a maximum of two 1-hour sessions per day furnished over a period up to 36 weeks. Phase IIB consists of an additional series of 36 sessions and will only be allowed if determined to be medically necessary. The total number of allowable sessions in Phase II is 72. Phase IIB benefits must meet additional medical necessity criteria, specifically, there must be clear demonstration that the patient is benefiting from cardiac rehabilitation and that the exit criteria above have not been met.

16 Intensive Cardiac Rehabilitation (ICR) A single session must last at least 31 minutes in order to be billable. If more than one session is billed on a single day, then the total combined time must be equal to the sum of 60 minutes for each session except the last, which must be at least 31 minutes in duration. No more than six 1-hour sessions (utilizing any combination of the HCPCS codes G0422 and G0423) are billable per day, regardless of whether the sessions exceed six hours in a day. Providers may bill up to six 1-hour sessions per day over a period of 18 weeks. No more than 72 sessions will be covered in an 18 week period. No sessions will be covered after the initial 126 days. Patients may be eligible for additional cardiac rehabilitation if there has been the occurrence of a new qualifying event (e.g., patient previous in CR following an acute MI, undergoes CABG and would now be eligible for an additional course of cardiac rehabilitation). Once a beneficiary begins CR, he or she may not switch to ICR and once a beneficiary begins ICR, he or she may not switch to CR. 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. Should a beneficiary experience more than one 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 one series of CR sessions, up to 36 1-hour sessions with contractor discretion for an additional 36 sessions; or one series of ICR sessions, up to 72 1-hour sessions over a period up to 18 weeks). Sources of Information and Basis for Decision This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th edition; edited by Libby, Peter; Chapter 46 Exercise-Based, Comprehensive Cardiac Rehabilitation, Thompson, Paul D. Copyright Fletcher BJ, Thiel J, Fletcher GF. Phase II intensive monitored cardiac rehabilitation for coronary artery disease and coronary risk factors - a six session protocol. Am.J Cardiol Apr 1;57(10): Fletcher BJ, Lloyd A, Fletcher GF. Outpatient rehabilitative training in patients with cardiovascular disease: emphasis on training method. Heart Lung Mar;17(2): Osada N. Long-term cardiopulmonary exercise performance after heart transplantation. Am J Cardiol Feb 15;79(4): Personal Communication. Connecticut Society for Cardiac Rehabilitation Meeting January 28, Discussion Society members and National Government Services Medical Director and Provider Education and Outreach staff. Rodriguez O, et al. Components of cardiac rehabilitation and exercise prescription. UpToDate. October 19, Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol. 2007;50:

17 Wenger NK. Current status of cardiac rehabilitation. J Am Coll Cardiol. 2008;51: Advisory Committee Meeting Notes Carrier Advisory Committee Meeting Date(s): Connecticut: 09/28/2010 Indiana: 09/27/2010 Kentucky: 09/30/2010 New York: 09/29/2010 This coverage determination does not reflect the sole opinion of the contractor or contractor Medical Director. Although the final decision rests with the contractor, this determination is developed in consultation with representatives from Advisory Committee members and/or from various state and local provider organizations. Start Date of Comment Period 09/09/2010 End Date of Comment Period 10/23/2010 Start Date of Notice Period Revision History Number Not applicable Revision History Explanation Not applicable Reason for Change Last Reviewed On Date 09/09/2010 Related Documents Article(s) A Cardiac and Intensive Cardiac Rehabilitation Draft Supplemental Instructions Article LCD Attachments There are no attachments for this LCD.

18 Draft Contact National Government Services Medical Policy Unit - PartBLCDComments@anthem.com P.O. Box 7073 Indianapolis, IN All Versions Image description. Future Stamp End of image description. Image description. Future Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Image description. Draft Stamp End of image description. Updated on 09/03/2010 with effective dates 03/01/ N/A