Description
Cardiac rehabilitation (CR) is a physician or nonphysician practitioner-supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meets Federal guidelines and Medicare coverage criteria.
Affected Code(s)
93797, 93798, G0422, G0423
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1848(b)(5)- Treatment of Intensive Cardiac Rehabilitation Program
9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(2)(CC), (DD)- Medical and Other Services- Cardiac Rehabilitation Program, Intensive Cardiac Rehabilitation Program
10. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(eee)(1), (4)(A)- Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation Program
11. 42 CFR §410.49 – Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage
12. Medicare National Coverage Determinations (NCD), Part 1 - Coverage Determinations, § 20.10.1 - Cardiac Rehabilitation Programs for Chronic Heart Failure; §20.31 - Intensive Cardiac Rehabilitation (ICR) Programs; §20.31.1 – The Pritikin Program; §20.31.2 - Ornish Program for Reversing Heart Disease; §20.31.3 – Benson-Henry Institute Cardiac Wellness Program
13. Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, §232 - Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished on or After January 1, 2010
14. Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services, §140- Cardiac Rehabilitation Programs, Intensive Cardiac Rehabilitation Programs, and Pulmonary Rehabilitation Programs; §140.2- Cardiac Rehabilitation Program Services Furnished on or after January 1, 2010; §140.3- Intensive Cardiac Rehabilitation Program Services Furnished on or after January 1, 2010
15. AMA CPT Codebook
16. HCPCS Level II Codebook