MAC Update

“Medicare 101″ is an AACVPR online course designed to assist cardiac and pulmonary rehabilitation professionals to better understand Medicare reimbursement- the terminology of CMS and regulations surrounding their guidelines. The course is subtitled “Best Practice Essentials- Navigating Medicare” and imperative for any cardiac and pulmonary rehabilitation manager or anyone affiliated with billing and programmatic decisions at an institution. More information on this course can be found on the members’ only reimbursement section of the AACVPR website.

For those needing complete first hand documentation of Medicare Regulations for Cardiac Rehabilitation, the following articles should provide the most up to date and comprehensive discussion of all aspects of the cardiac rehab Medicare billing process:

Medicare Claims Processing Manual, Chapter 32, Section 140

Code of Federal Regulations (CFR), Cardiac Rehab: 42 CFR 140/49

CMS Change Request 6850, May 12, 2010

As a reminder, Cardiac and Pulmonary Rehabilitation are not under “Rehabilitation Services”. We have our own Medicare Benefit Category.

42 CFR 410.49 outlines the 6 eligible diagnosis for cardiac rehab- Acute MI, CABG, Stable Angina, Heart Valve Repair or Replacement, PTCA and/or Stent, Heart or heart-lung transplant. Heart Failure is not yet accepted by CMS as reimbursable diagnosis, but is covered by Michigan BC/BS and HAP, possibly Aetna. LVADs will be covered if a tricuspid valve annuloplasty is also done (v 43.3).

The recommendation from AACVPR is that a PTCA/Stent which is planned “sequential” interventions should be considered as ONE diagnosis, in other words ONE CR course. AACVPR feels that payers do not clearly see these as separate events, so could be confusing to attempt separate events/separate course of rehab.

Regarding coding and billing- The CMS Change Request 6850 provides clear instructions for billing cardiac rehab services. This document was sent to all providers in May 2010 and is posted on the AACVPR website if further review is needed by your billing department. This document goes into great detail regarding use of codes 93798 and 93797 as well as duration of program allowance. It does outline that patients are expected to attend minimum of one session per week, but does allow for rare various absences- illness, family urgency, vacation, but all absences should be documented on your records. Utilization of either 93798 or 93798 requires some exercise every day, but not every session. In order to bill for two sessions of cardiac rehab, the sessions must last more than 90 minutes, but CMS does not specify how many minutes must be exercise. Further examples for use of 93798 and 93797 can be found in CMS change request 6850. (Reminder: Always check with non-Medicare Payers if CPT code 93797 is covered for counseling or non-ECG monitored exercise “as Medicare regulations do.”)

Use of KX Modifier in Cardiac Rehab was specifically stated in the CMS change request 6850 document. CMS does not limit the total lifetime visits of cardiac rehab (as with Pulmonary), but a KX modifier is required for any CR sessions beyond the first 36 visits the patient had received as a Medicare beneficiary. It is very; very rare to receive extensions of one course of cardiac rehab beyond 36 visits, but a new course of CR for eligible diagnosis in later months/years is not uncommon. The CMS Common Working File (CWF) tracks # of sessions received to date up to 36- then the number remained “frozen”. Providers may access these “provider inquiry screens” to see the patient’s cardiac rehab session history. It is not necessary to use KX modifier before session 36, but is required to use KX modifier after session 36 or the charge will be denied. AACVPR suggested options for billing is to check Provider Inquiry Screen for all Medicare patients prior to enrollment and/or set up a new charge master code with XY attached to start when first set of 36 sessions has been reached.

Use of modifier 59 in Cardiac Rehab is not required per NCCI edits (National Correct Coding Initiative), version 18.1, effective 4-1-12 posted at http://www.cms/gov/nationalcorrectcodinited/ncciep/list.asp#topofpage

In hospital outpatient setting, reimbursement for 93798 and 93797 are the same amount. In a physician owned program, 93797 is roughly half of the reimbursement for 93798. For calendar year 2013 proposed payment rates for hospital outpatient program is expected to be $80 with co-pay of $16 (this can vary regionally so check with your own institution business office departments). Physician owned settings use a different calculation which is typically half the reimbursement of the rate for a hospital setting. This increase in reimbursement for hospital based programs is largely due to initiatives by AACVPR to encourage more accurate cost reporting by institutions on the yearly Medicare Hospital Cost Report, due to the utilization of the cardiac rehabilitation nonstandard cost center. Please ask your business office liaison if they can provide your programs data to CMS as a nonstandard cost center, so this data can be more accurately “pulled” for CMS to find it when forecasting future reimbursement amounts.

Other states in our nation have received denials for missing documentation. Reasons for 25% if these denials were that specified components were not included in the medical record- physician prescribed exercise, cardiac risk factor modification, psycho-social assessment, outcomes assessment and ITP. 15% of the denials were related to “condition required for coverage” of cardiac rehab was not submitted in the medical record and 3.5 % of denials were because medical records were not received in required time frame in response to an ADR (Additional Documentation Requested). Take home point here, it is important to have good relationships with your billing office to insure ADR are not left uncared for resulting in an unnecessary denial. 47% of denials were for direct physician supervision requirement was not being met, i.e. need to provide documentation that physician is present in the facility and immediately available to furnish assistance. AACVPR suggests keeping physician supervision records in the department and place such records in each patient chart in case of CMS audit.

Non-physician Practitioners (NP, PA, CNS) may NOT provide direct physician supervision for CR or PR services. They cannot serve as supervising physician or sign ITPs. CMS needs a technical correction from congress to allow this, AACVPR has initiated senate bill S2057 in order to change the Medicare language to allow NPP’s to provide these roles. AACVPR also recommends physician signature for all cardiac rehab referrals, as the NPP referral option varies based on individual MAC interpretation. If not yet done so, we strongly recommend every AACVPR member write their senator to support S2057. Directions and links are easy and found on the AACVPR website.

Further information on these topics can be found at,html?redirect=/center/coverage.asp or


  • 28th Annual MSCVPR Conference

    Spring 2017 | Bay City, Michigan

    We are already working on next years,
    check back often for updates

    DoubleTree by Hilton

    more information »