Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
Policy #:MA10.002b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM REQUIREMENTS

CR/ICR programs are considered medically necessary and, therefore, covered, when the following CR/ICR requirements are met:
  • The individual meets one of the following indications:
    • Acute myocardial infarction documented within the preceding 12 months
    • Post-Coronary artery bypass surgery
    • Current stable angina pectoris
    • Post-heart valve repair or replacement
    • Post-percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
    • Post-heart or heart-lung transplant
    • Chronic heart failure defined as left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms, despite being on optimal heart failure therapy for at least six weeks
  • The CR or ICR program includes ALL of the following components:
    • Physician-prescribed exercise. This physical activity includes aerobic exercise combined with other types of exercise (i.e., strengthening, stretching) as determined to be appropriate for individuals by a physician each day CR/ICR items/services are furnished.
    • Cardiac risk-factor modification. This includes education, counseling, and behavioral intervention, tailored to individuals' needs.
    • Psychosocial assessment. This assessment means an evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation. It should include both:
      • An assessment of aspects of the individuals family and home situation that affect the individual’s rehabilitation treatment; and
      • A psychosocial evaluation of the individual’s response to, and rate of progress under, the treatment plan.
    • Outcomes assessment, which includes all of the following:
      • Assessments from the start and conclusion of CR/ICR, based on individual-centered outcomes, which must be measured by the physician; objective clinical measures of the effectiveness of the CR/ICR program for the individual, including exercise performance; and self-reported measures of exertion and behavior.
    • Individualized treatment plan. This plan should be written and tailored to each individual and include all of the following:
      • A description of the individual’s diagnosis.
      • The type, amount, frequency, and duration of the CR/ICR items/services furnished.
      • The goals set for the individual under the plan. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.

The following programs have received approval from Original Medicare as a component of ICR:
  • The Ornish Program for Reversing Heart Disease
  • The Pritikin Program
  • The Benson-Henry Institute Cardiac Wellness Program

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) SESSION LIMITS

CR sessions are limited to a maximum of two one-hour sessions per day up to 36 sessions furnished over a period of up to 36 weeks, with the option for an additional 36 sessions, over an extended period of time.

ICR sessions are limited to 72 one-hour sessions, up to six sessions per day, over a period of up to 18 weeks.

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM GUIDELINES
  • Once a individual begins CR, he or she may not switch to ICR, and once an individual begins ICR, he or she may not switch to CR.
  • Upon completion of a CR or ICR program, individuals must experience another indication in order to be eligible for coverage of more CR or ICR.
  • If an individual experiences more than one indication simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., an individual who had a myocardial infarction within 12 months and currently experiences stable angina is entitled to one series of CR sessions, up to 36 one-hour sessions with the option for an additional 36 sessions; or one series of ICR, up to 72 one-hour sessions over a period of up to 18 weeks).

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, cardiac rehabilitation and intensive cardiac rehabilitation programs are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

CARDIAC REHABILITATION AND INTENSIVE CARDIAC REHABILITATION

Cardiac rehabilitation and intensive cardiac rehabilitation programs are services that are separate from physical and occupational therapy.

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM SETTING REQUIREMENTS
CR/ICR services should be furnished in a physician’s office or a hospital outpatient setting (for ICR, the hospital outpatient setting should provide ICR using an approved ICR program). All settings should have a physician immediately available and accessible for medical consultations and emergencies at all times when items/services are being furnished under the program. This provision is satisfied if the physician meets the requirements for direct supervision of physician office services, and for hospital outpatient services. “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.

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM PHYSICIAN REQUIREMENTS
Physicians responsible for CR/ICR programs should oversee and/or supervise the CR/ICR program at a particular site. The physician, in consultation with the staff, is involved in directing the progress of individuals in the program and must possess all of the following:
  • Expertise in the management of individuals with cardiac pathophysiology
  • Cardiopulmonary training in basic life support or advanced cardiac life support,
  • Licensed to practice medicine in the state in which the CR/ICR program is offered


Description

CARDIAC REHABILITATION

Cardiac rehabilitation (CR) services mean a professional provider--supervised program that furnishes professional provider--prescribed exercise; cardiac risk-factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; outcomes assessment; and other items/services. Cardiac rehabilitation programs aim to reduce risk factors for reinfarction, sudden death, or other possible complications, and are usually performed over 36 one-hour sessions.

INTENSIVE CARDIAC REHABILITATION

The intensive cardiac rehabilitation (ICR) program is a physician-supervised program that furnishes cardiac rehabilitation services more frequently and in a more rigorous manner. The program is usually performed over 72 one-hour sessions (up to six sessions per day) over an 18-week period.

An ICR program must demonstrate its safety and efficacy through the following measures and outcomes:
  • It must accomplish one or more of the following for those participating in the program:
    • Positively affect the progression of heart disease
    • Reduce the need for coronary bypass surgery
    • Reduce the need for percutaneous coronary interventions
  • It must accomplish a statistically significant reduction in five or more of the following measures, as supported through published peer-reviewed research, from start to completion of the program:
    • Low-density lipoprotein blood levels
    • Triglycerides blood levels
    • Body mass index
    • Systolic blood pressure
    • Diastolic blood pressure
    • Need for cholesterol, blood pressure, and diabetes medications

MEDICARE-APPROVED PROGRAMS

A list of approved ICR programs and their approval dates are listed and maintained on the CMS Approved Facilities website at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/.

The following intensive cardiac rehabilitation (ICR) programs have been approved by CMS through the national coverage determination (NCD) process:

The Ornish Program for Reversing Heart Disease (also known as the Multisite Cardiac Lifestyle Intervention Program, the Multicenter Cardiac Lifestyle Intervention Program, and the Lifestyle Heart Trial Program) was initially described in the 1970s and incorporates comprehensive lifestyle modifications including exercise, a low-fat diet, smoking cessation, stress management training, and group support sessions. Over the years, the Ornish program has been refined but continues to focus on these specific risk factors.

The Pritikin Program was designed and adopted by Nathan Pritikin in 1955. The diet was modeled after the diet of the Tarahumara Indians in Mexico, which consisted of 10% fat, 13% protein, 75-80% carbohydrates, and provided 15-20 grams per day of crude fiber with only 75 mg/day of cholesterol. Over the years, the Pritikin Program (also known as the Pritikin Longevity Program) evolved into a comprehensive program that is provided in a professional provider’s office and incorporates a specific diet (10%-15% of calories from fat, 15%-20% from protein, 65%-75% from complex carbohydrates), exercise, and counseling lasting 21-26 days. An optional residential component is also available for participants.

The Benson-Henry Institute Cardiac Wellness Program was developed by Herbert Benson, MD, over 40 years ago. The Cardiac Wellness Program is a multicomponent intervention program that includes supervised exercise, behavioral interventions and counseling and is designed to reduce cardiovascular risk and improve health outcomes.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services. [CMS Web site]. 11/17/2017. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c32.pdf. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.1.1: Cardiac rehabilitation programs for chronic heart failure. [CMS website]. 02/18/2014. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=359&ncdVer=1. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31: Intensive cardiac rehabilitation (ICR) programs. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=339&ncdver=1&DocID=20.31&bc=gAAAAAgAAAAAAA%3D%3D&. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.1: The Pritikin Program. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=340&ncdver=1&bc=AAAAQAAAAAAAAA%3d%3d&. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.2: Ornish Program for Reversing Heart Disease. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=341&ncdver=1&bc=AAAAQAAAAAAAAA%3d%3d&. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.3: Intensive cardiac rehabilitation program - Benson-Henry Institute Cardiac Wellness Program. [CMS website]. 05/06/2014. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=362&ncdver=1&bc=AAAAQAAAAAAAAA%3d%3d&. Accessed January 12, 2018.

Medicare Learning Network (MLN). MLN Matters. MM4401 Cardiac rehabilitation programs. [Centers for Medicare & Medicaid Services (CMS) Web site]. 11/01/2012. Available at:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM4401.pdf. Accessed 01/25/2018.

Novitas Solutions, Inc. Local Coverage Article. A55758: Cardiac rehabilitation (CR) and intensive cardiac rehabilitation (ICR) physician requirements. [CMS Web stie]. 10/12/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55758. Accessed January 12, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

93797, 93798


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)



G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session

G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session

S9472 Cardiac rehabilitation program, nonphysician provider, per diem



Revenue Code Number(s)

0943 Other Therapeutic Services--Cardiac Rehabilitation

Coding and Billing Requirements


Cross References

Attachment A: Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
Description: Medically Necessary ICD-10 Codes







Policy History

MA10.002b
09/25/2019This policy has been reissued in accordance with the Company's annual review process.
02/15/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs.
10/01/2017This version of the policy will become effective 10/01/2017.

The following ICD-10 CM codes have been added to this policy: (Medically Necessary)

I21.9 Acute myocardial infarction, unspecified
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure

The following ICD-10 CM narrative has been revised in this policy:

FROM: I50.1 Left ventricular failure
TO: I50.1 Left ventricular failure, unspecified

MA10.002a
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
10/12/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs.
10/01/2016The following ICD-10 CM code has been deleted from this policy:
Z98.89

ICD-10 CM code has been added to this policy:

Z98.890: Other specified postprocedural states
Attachment with ICD 9 codes deleted.

MA10.002
04/29/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs.
01/01/2015This is a new policy.






Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 09/26/2019