CMS Rehabilitates CR, ICR, and PR Guidelines

By G. John Verhovshek, MA, CPC

To comply with Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requirements, the Centers for Medicare & Medicaid Services (CMS) updated chapter 32 of the Medicare Claims Processing Manual to define coverage and appropriate coding for cardiac rehabilitation (CR) programs, intensive cardiac rehabilitation (ICR) programs, and pulmonary rehabilitation (PR) programs for Medicare beneficiaries. These updates are outlined extensively in the 2010 Medicare Physician Fee Schedule (MPFS) final rule, published in the Nov. 25, 2009 Federal Register (http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf).

Follow CR Rules

CR is a “lifestyle modification” program that aims to stabilize or reverse the progression of cardiovascular disease, and to reduce a patient’s heart disease or chance of a cardiac event or death. As defined in Publication 100-04, Medicare Claims Processing Manual, chapter 32, section 140 (revised Dec. 11, 2009), Medicare covers CR in a physician’s office or a hospital outpatient setting for patients who have experienced at least one of the following:

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  • Acute myocardial infarction within the preceding 12 months
  • Coronary artery bypass surgery
  • Current stable angina pectoris
  • Heart valve repair or replacement
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
  • Heart or heart-lung transplant

To qualify for Medicare coverage, a CR program must include all of the following:

  • Physician-prescribed exercise each day CR items and services are furnished;
  • Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
  • Psychosocial assessment;
  • Outcomes assessment; and
  • An individualized treatment plan detailing how components are utilized for each patient.

The 2010 MPFS final rule further specifies, “The items and services furnished by a CR program are individualized and set forth in written treatment plans that describe the patient’s individual diagnosis; the type, amount, frequency, and duration of items and services furnished under the plan; and the goals set for the individual under the plan. These written plans must be established, reviewed, and signed by a physician every 30 days.” [emphasis added]

Regulations limit CR programs to a maximum of two, one-hour sessions per day, to a maximum total of 36 sessions within 36 weeks. An additional 36 sessions over an extended time also may be covered, if approved specifically by the local Medicare contractor.

To report CR services, call on CPT® 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) or 93798 Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session), depending on whether electrocardiogram (ECG) monitoring occurs.

Providers should document the length of each CR session (ideally, this would include both start and stop times). The minimum time requirement to report an initial session is 31 minutes. To report two CR sessions on the same day, however, the minimum combined CR time must equal 91 (not 62) minutes. The Medicare Claims Processing Manual further specifies, “If several shorter periods of cardiac rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.”

For example, if the patient receives 20 minutes of cardiac rehabilitation services in the day, CR may not be reported because the minimum time requirement was not met. If, however, the patient receives 20 minutes of cardiac rehabilitation services in the morning and 30 additional minutes later the same day, one session of CR may be reported.

In all cases, CR services must be provided under a physician’s direct supervision. That is, a physician must be immediately available and accessible for medical consultations and emergencies during all timed items. Documentation should reflect that this requirement has been met.

ICR Abides Slightly Different Guidelines

ICR includes the same items and services under many of the same conditions (listed above), including the physician supervision requirements, as a CR program. ICR sessions are, however, “furnished in highly structured environments in which sessions of the various components may be combined for longer periods of CR and may be more rigorous,” according to CMS in the 2010 MPFS final rule.

To gain necessary Medicare approval, an ICR program must demonstrate through peer-reviewed published research that it accomplished at least one of following for its patients:

  • Positively affected the progression of coronary heart disease
  • Reduced the need for coronary bypass surgery
  • Reduced the need for percutaneous coronary interventions

According to the Medicare Claims Processing Manual, an ICR program also must “demonstrate through peer-reviewed published research that it accomplished a statistically significant reduction in five or more of the following measures …”

  • Low-density lipoprotein
  • Triglycerides
  • Body mass index (BMI)
  • Systolic blood pressure
  • Diastolic blood pressure
  • The need for cholesterol, blood pressure, and diabetes medication

HCPCS Level II gained two new codes in 2010 for reporting ICR services: G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring, with exercise, per hour, per session and G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring, without exercise, per hour, per session.

Frequency rules differ for CR, ICR: Unlike a CR program, an ICR program may include up to 72, one-hour sessions, with up to six sessions per day, over a period of up to 18 weeks.

These are time-based codes and, as such, a minimum service time of 31 minutes is required to report the first unit of either G0422 or G0423, as follows:

Once again, CMS says that if several shorter periods of ICR services are furnished on a given day, “the minutes of service during those periods must be added together for reporting in one-hour session increments.”

For example, if a patient receives 70 minutes of ICR services without exercise in the morning, and 95 additional minutes of ICR later that same day, correct coding would be G0423 x 3.

PR Coverage for COPD Patients

In addition to CR and ICR programs, Medicare offers coverage for PR items and services for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (those defined as GOLD classification II, III, and IV).

PR programs must be requested by the physician treating the COPD, and must include the following:

  • Physician-prescribed exercise. Some aerobic exercise must be included in each pulmonary rehabilitation session;
  • Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling;
  • Psychosocial assessment;
  • Outcomes assessment; and
  • An individualized treatment plan detailing how components are utilized for each patient.

As with CR and ICR programs, PR items and services must be furnished in a physician’s office or in a hospital outpatient setting, and require a physician’s direct supervision.

A single HCPCS Level II code, G0424 Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session, reports PR services. A maximum of two, one-hour sessions may be reported per day. The minimum service time to report one hour of service is 31 minutes. The minimum service time to report two hours of service is 91 minutes.

For example, according to the Medicare Claims Processing Manual, “If the patient receives 70 minutes of pulmonary rehabilitation services in the morning and 85 minutes of pulmonary rehabilitation services in the afternoon … report two sessions of pulmonary rehabilitation services under the HCPCS G code for the total duration of pulmonary rehabilitation services of 155 minutes. A maximum of two sessions per day may be reported, regardless of the total duration of pulmonary rehabilitation services.”

G. John Verhovshek, MA, CPC, is AAPC’s
director of clinical coding communications.

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