Skip over navigation

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
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

  • 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
  • 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

 

Audit Findings - OIG

Cardiac Medical Devices and Manufacturer Credit Billing Instruction

The Office of Inspector General (OIG) has published several reports finding that Noridian providers for Jurisdiction E have incorrectly billed Medicare for replacement medical devices. It has been reported that many providers bill Medicare for replacement devices without accounting for the related credit which is refunded by the manufacturer. 

Education has been provided regarding hospital charges with respect to medical devices for inpatient and outpatient services. If a hospital receives a replacement medical device for free, the hospital should not be charging the patient or Medicare for that device. The hospital should not be including costs on the cost report or charges on the Medicare claim.

Common cardiac devices used to treat beneficiaries occasionally require replacement due to defects, recalls, batter depletions or mechanical complications. These items may be covered under manufacturer warranty; defibrillators, pacemakers and their associated electrical leads.

A recent audit for years 2012 -2014 found 191 claims incorrectly paid.  There were 52 inpatient and 139 outpatient claims that did not comply with Medicare requirements for reporting manufacturer credits. This resulted in an overpayment of $2,132,458 that hospitals did not identify, refund or adjust the claims reviewed.

Medicare payment is reduced if the hospital receives a full or partial credit from the manufacturer. The following billing guidelines should be followed: 

  • Full credit for device - append modifier FB to procedure code (not the device code) that reports the service provided to replace the device
    • Equal or lesser priced replacement device bill token charge
    • Net cost incurred bill difference between usual charge of device and credit
  • Partial credit for device – append modifier FC to procedure code (not the device code) that reports the service provided to replace the device
    • 50 percent or more credit received for the replacement device bill either a token charge ($0.01) or the difference between usual charge of device and credit
  • Value code FD and amount used when device is provided as a clinical trial, free sample or furnished without cost
    • 49 Product replacement within Product Lifecycle – Replacement of product earlier than the anticipated lifecycle.
    • 50 Product replacement for known Recall of a Product – Manufacturer or FDA has identified the product for recall and replacement.
    • 53 Initial placement of medical device provided as part of a clinical trial or free sample – Outpatient claims

CMS recognizes that showing a charge for a device that has been furnished without cost is not optimal, but showing a token charge in this circumstance will allow claims for reasonable and necessary services to be adjudicated.

Hospitals should take advantage of warranty replacement devices and take corrective action to ensure correct billing practices by:

  • Establishing internal controls to coordinate functions among various department to identify when the credit was received 
  • Review the manufacturer warranty and create an internal process to obtain a replacement, full or partial credit
  • Follow the Medicare billing requirements for reporting manufacture credits for replaced medical devices
    • Submit the claim without the modifiers and the later correct the claim with the proper coding or
    • Hold claim until a determination is made on the level of credit.

Resources

Last Updated May 26, 2017