Centers for Medicare & Medicaid Services

Content Section

Publication Number

100-3

Manual Section Number

20.10

Version Number

Effective Date of this Version

3/22/2006

Implementation Date

6/21/2006

Benefit Category

Incident to a physician's professional Service

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

CIM 35-25

A. General

Phase II cardiac rehabilitation, as described by the U.S. Public Health Service, is a comprehensive, long-term program including medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. Phase II refers to outpatient, medically supervised programs that are typically initiated 1-3 weeks after hospital discharge and provide appropriate electrocardiographic monitoring.

Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for services performed on or after March 22, 2006, Medicare coverage of cardiac rehabilitation programs is considered reasonable and necessary only for patients who: (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; or (3) have stable angina pectoris; or (4) have had heart valve repair/replacement; or (5) have had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or (6) have had a heart or heart-lung transplant.

1. Program Requirements

a. Duration

Services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 36 sessions. Patients generally receive 2 to 3 sessions per week for 12 to 18 weeks. Coverage of additional sessions is discussed in section D below.

b. Components

Cardiac rehabilitation programs must be comprehensive and to be comprehensive they must include a medical evaluation, a program to modify cardiac risk factors (e.g., nutritional counseling), prescribed exercise, education, and counseling.

c. Facility

The facility must have available for immediate use the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator.

d. Staff

The program must be staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. The program must be under the direct supervision of a physician, as defined in 42 CFR §410.26(a)(2) (defined through cross reference to 42 CFR §410.32(b)(3)(ii), or 42 CFR §410.27(f)).

C. Nationally Non-Covered Indications

Except as provided in section D., all other indications are not covered.

D. Other

The contractor has the discretion to cover cardiac rehabilitation services beyond 18 weeks. Coverage must not exceed a total of 72 sessions for 36 weeks.

(This NCD last reviewed March 2006.)

Transmittal Number

Transmittal Link

http://www.cms.hhs.gov/transmittals/downloads/R52NCD.pdf

Revision History

10/1985 - Clarified reimbursement limitation applied to freestanding clinics and coverage policy for physicial and occupational therapy. Effective date NA. (TN 2)

08/1989 - Clarified term "direct supervision" to mean a physician must be immediately available and accessible but not required to be physicially present in excercise room itself. Effective date NA. (TN 41)

04/2006 - The NCD Manual now includes a comprehensive description of the services that must be provided as part of a comprehensive cardiac rehabilitation program, extends the window of time during which the services must be provided and restructures the language for clarity. Effective date: 03/22/2006. Implementation date: 06/21/2006. (TN 52) CR4149

Claims Processing Instructions

TN 909 (Medicare Claims Processing)

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.