Cardiac and Pulmonary Rehabilitation Programs

Medicare established coverage provisions for Cardiac Rehabilitation (CR) and Pulmonary Rehabilitation (PR) programs. The regulation at 42 CFR 410.49 includes coverage provisions for CR and PR items and services, physician standards and limitations to the sessions that may be covered.

Cardiac Rehabilitation Program

Coverage
Criteria

Patients must meet one or more of the following:

  • Have a documented diagnosis of acute myocardial infarction within preceding 12 months; or
  • Have had coronary bypass surgery; or
  • Have current stable angina pectoris; or
  • Have had heart valve repair/replacement; or
  • Have had percutaneous transluminal coronary angioplasty or coronary stenting; or
  • Have had a heart or heart-lung transplant
  • Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and NY Heart Association class II to IV symptoms despite being on optimal heart failure therapy for at least six (6) weeks
  • Other cardiac conditions as specified through an NCD. The NCD process may also be used to specify non-coverage of a cardiac condition for ICR if coverage is not supported by clinical evidence
Components

Must include the following:

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

 

Pulmonary Rehabilitation Program

Coverage
Criteria

Pulmonary rehab services are for patients with moderate to very severe COPD (defined as GOLD classification II, III, IV), when referred by the physician treating chronic respiratory disease; Who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least 4 weeks (effective January 1, 2022). Additional medical indications for coverage may be established through an NCD.

  • Must include the following:
    • Physician-prescribed exercise. Some aerobic exercise must be included in each session;
    • Education or training closely and clearly related to individuals care and treatment which is tailored to their needs
    • Psychosocial assessment;
    • Outcomes assessment; and
    • An individual treatment plan detailing how components are utilized for each patient
Sessions
  • Rehabilitation services should not exceed 36 sessions
  • Limited to a maximum of 2 1-hour sessions per day
  • If Completing 2 one-hour sessions per (equates up to 18 weeks)
  • Two sessions only reported same day if treatment duration is at least 91 minutes
  • Each unit reported must be at least 31 minutes in length
Duration
  • Acceptable termination
  • Achieved a stable level of exercise tolerance
  • Symptoms of angina are stable at maximum exercise level
  • Resting blood pressure and heart rate are normal
  • Stress test is not positive during exercise
Stress
Testing
  • Reasonable for one or more of the following:
    • Evaluation of chest pain
    • Development of exercise prescriptions
    • Pre and Postoperative evaluation of patients undergoing coronary artery by-pass procedures
Frequency
Edits
  • Claims exceed two units on same date of service
  • KX modifier is not present over 36 sessions for CPT 94625 and 94626
  • Patient may require additional 36 sessions for COVID-19 if he/she previously received PR services for COPD initially or vice versa
  • Additional sessions for second approved condition, must append KX modifier to subsequent 36 sessions.

 

CR, ICR, and PR Orders

To comply with federal statute, Medicare covered CR, ICR and/or PR services must be ordered by a Medical Doctor or Doctor of Osteopathy licensed in the state where the services are rendered. For either CR, ICR or PR, the medical director or supervising MD/DO must be present and immediately available during rehab activities.

The sole exception, per § 512.630, is for a provider or supplier of CR and ICR services to an Episode Payment Model beneficiary during an AMI and CABG episode, as defined in § 512.2, wherein CMS waives the physician definition to allow the functions of supervising physician, prescribing exercise, and establishing, reviewing, and signing an individualized treatment plan for CR and ICR services to be furnished under the direction of:

  1. A physician, as defined in section 1861(r)(1) of the Act; or
  2. A qualified nonphysician practitioner, as defined by CMS.

Questions regarding Advancing Care Coordination through Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model can be directed to epmrule@cms.hhs.gov.

Resources

 

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