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National Coverage Determination (NCD)

Cardiac Rehabilitation Programs

20.10

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Tracking Information

Publication Number
100-3
Manual Section Number
20.10
Manual Section Title
Cardiac Rehabilitation Programs
Version Number
2
Effective Date of this Version
03/22/2006
Ending Effective Date of this Version
02/22/2010
Implementation Date
06/21/2006
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

CIM 35-25

A. General

Phase II cardiac rehabilitation, as described by the U.S. Public Health Service, is a comprehensive, long-term program including medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. Phase II refers to outpatient, medically supervised programs that are typically initiated 1-3 weeks after hospital discharge and provide appropriate electrocardiographic monitoring.
Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for services performed on or after March 22, 2006, Medicare coverage of cardiac rehabilitation programs is considered reasonable and necessary only for patients who: (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; or (3) have stable angina pectoris; or (4) have had heart valve repair/replacement; or (5) have had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or (6) have had a heart or heart-lung transplant.

1. Program Requirements

a. Duration

Services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 36 sessions. Patients generally receive 2 to 3 sessions per week for 12 to 18 weeks. Coverage of additional sessions is discussed in section D below.

b. Components

Cardiac rehabilitation programs must be comprehensive and to be comprehensive they must include a medical evaluation, a program to modify cardiac risk factors (e.g., nutritional counseling), prescribed exercise, education, and counseling.

c. Facility

The facility must have available for immediate use the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator.

d. Staff

The program must be 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 coronary disease. The program must be under the direct supervision of a physician, as defined in 42 CFR §410.26(a)(2) (defined through cross reference to 42 CFR §410.32(b)(3)(ii), or 42 CFR §410.27(f)).

C. Nationally Non-Covered Indications

Except as provided in section D., all other indications are not covered.

D. Other

The contractor has the discretion to cover cardiac rehabilitation services beyond 18 weeks. Coverage must not exceed a total of 72 sessions for 36 weeks.

(This NCD last reviewed March 2006.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
52
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R52NCD.pdf
Revision History

04/2006 - The NCD Manual now includes a comprehensive description of the services that must be provided as part of a comprehensive cardiac rehabilitation program, extends the window of time during which the services must be provided and restructures the language for clarity. Effective date: 03/22/2006. Implementation date: 06/21/2006. (TN 52) CR4149

08/1989 - Clarified term "direct supervision" to mean a physician must be immediately available and accessible but not required to be physicially present in excercise room itself. Effective date NA. (TN 41)

10/1985 - Clarified reimbursement limitation applied to freestanding clinics and coverage policy for physicial and occupational therapy. Effective date NA. (TN 2)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Cardiac Rehabilitation Programs - RETIRED 4 04/10/2023 - N/A View
Cardiac Rehabilitation Programs 3 02/22/2010 - 04/10/2023 View
Cardiac Rehabilitation Programs 2 03/22/2006 - 02/22/2010 You are here
Cardiac Rehabilitation Programs 1 08/01/1989 - 03/22/2006 View
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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