EMPIRE MEDICARE SERVICES LOCAL COVERAGE DETERMINATION ARTICLE (CODING GUIDELINE)

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Contractor Name
Empire Medicare Services

Contractor Number
00308

Contractor Type
Intermediary

Article Database ID Number
A22410

Article Type
General

Is the AMA/CPT and ADA/CDT Copyright Statement Required?
Yes
CPT codes, descriptions and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction
New York – Entire State
Connecticut
Delaware

Secondary Geographic Jurisdiction
Massachusetts

Article Publication Date
09/01/2004

Article Beginning Effective Date
02/01/1995

LCD Description:

Cardiac rehabilitation is a comprehensive program of medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling designed to restore certain patients with coronary heart disease to active and productive lives. Cardiac rehabilitation, as described in the medical literature, is divided into three phases: Phase I is the immediate in hospital post cardiac event phase; Phase II is the outpatient immediate post hospitalization recuperation phase; Phase III is the long term, maintenance phase. This policy encompasses outpatient post hospital cardiac rehabilitation, or Phase II. The program consists of a series of supervised exercise sessions with continuous electrocardiograph monitoring (CEM). Clinically optimal results are obtained if these sessions are conducted three times per week over a 12-week period. Cardiac rehabilitation without continuous EKG monitoring is not covered.

1. Structured cardiac rehabilitation programs must be billed under the revenue code 943.
2. The occurrence code 11 (date of onset of symptoms or illness) and the date must be present on each claim for cardiac rehabilitation. The date must indicate the most recent onset or exacerbation of the date of CABG. This date will not change during the course of treatment.
3. The occurrence code 46 (date treatment began) and the date must be present on each claim for cardiac rehabilitation services. This must be the date of the patient’s first treatment in his current cardiac rehabilitation program. The date treatment began does not change during the course of treatment and should be later than the date of the occurrence code 11.
4. The value code 53 (cardiac rehabilitation visits) should be present and represent the total number of cardiac rehabilitation visits.
5. ICD-9-CM diagnosis codes must be coded to the highest level of specificity.
6. The following CPT codes are no longer billable to Medicare Part A: 93000, 93014, 93015, 93016, 93040, 93042, 93268, 93272, G0005 - G0007 and G0015 - G0016. CPT code 93012 is a bundled service and is not reimbursed separately.
7. CPT code 93797 should be used for Group 1, type 2 or Group I, type 3 services.
8. CPT code 93798 should be used for Group 1, type 1 services.
9. Group 2 services would require the appropriate CPT codes.
10. A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under 1833 (e) of the Social Security Act.

Reasons for Denial:

1. A claim submitted without one of the ICD-9-CM diagnoses codes listed in the "ICD-9-CM Diagnosis Codes That Support Medical Necessity" section of this policy will be denied under 1862(a)(1)(A) of the Social Security Act.

2. The following conditions are not covered for cardiac rehabilitation:

1. Status post heart or heart/lung transplant
2. Status post coronary angioplasty
3. Status post non-(CABG) cardiac surgery
4. Congestive heart failure

3. Any diagnosis submitted must have documentation in the patient’s record to support coverage and medical necessity.

4. A claim for cardiac rehabilitation submitted without an occurrence code 11, date of onset of event (for diagnosis CABG or MI), or without the date of the most recent stress test (for chronic angina), will be returned to the provider.

5. Services exceeding the initial 36 sessions, without further documentation of medical necessity, will be denied as not medically necessary.

6. Services in excess of 72 sessions, without a new qualifying event, will be denied as non-covered.

7. Cardiac rehabilitation is available only with a written prescription from the patient’s treating physician.

8. Cardiac rehabilitation without EKG monitoring is not covered, and will be denied.

9. Failure to meet entry criteria under the "Indications and Limitations" section will result in denial.

Other Comments:

For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier must provide the patient with an acceptable advance notice of Medicare’s possible denial of payment. An Advanced Beneficiary Notice (ABN) should thus be signed when a provider/supplier does not want to accept the financial responsibility for the service.

This policy was revised to coordinate with Part B and a new comment period was initiated. Changes to the policy include the description, indications and limitations of coverage, ICD-9-CM diagnosis codes that support medical necessity, reasons for denial, coding guidelines and documentation requirements.

1. Title XVIII of the Social Security Act, Section 1862 (a)(7)
   This section excludes routine physical examinations

2. Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)
   This section allows coverage and payment for only those services considered medically reasonable and necessary.

3. Title XVIII of the Social Security Act, Section 1833 (e)
   This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Coverage Topic
Cardiac Rehab Program

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Ted J. Triana, D.O.
Fiscal Intermediary Medical Director

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