|
· Title XVIII of the Social Security Act, Section 1862
(a)(7)
This section excludes routine physical examinations.
· 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.
· 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.
· CMS Manual System, Pub 100-3, Cardiac
Rehabilitation Programs, Section 20-10 (Coverage Issues Manual, section
35-25)
This section covers Cardiac Rehabiltation
Programs.
· Change Request 4401, Pub. 100-03 Medicare National
Coverage Determinations, section 20.10
This transmittal provides expanded coverage for Cardiac Rehabilitation
programs.
· Change Request 5946, Pub. 100-04, Medicare Claims
Processing Manual, Chapter 4, Section 200.5 Billing and Payment for Cardiac
Rehabilitation
|
|
In accordance with IOM
100.3 (Coverage Issues Manual) Chpt. 1 Section
20.10, Cardiac rehabilitation is a comprehensive program of medical
evaluation, monitored exercise, cardiac risk factor modification, education
and counseling designed to medically benefit patients with coronary or valvular heart disease. 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. In accordance with the CIM, Medicare
covers Phase II Cardiac Rehabilitation for 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. ” The CIM
specifies coverage for 2 to 3 sessions per week for up to 36 sessions over
12 to 18 weeks, with contractor discretion for additional sessions up to 72
sessions or 36 weeks. This LCD implements the diagnostic criteria and
contractor discretion provisions of the NCD.
A. Riverbend will consider Cardiac Rehabilitation to be medically necessary
in accordance with the NCD when it is initiated within 12 months of a
qualifying event. Those events are:
· Myocardial infarction
· CABG
· Valve repair or replacement
· PTCA (with or without stent placement)
· Heart-lung transplant
When the time lag is greater than 1 year, Riverbend will consider the
documented event to be incidental rather than causal.
In addition, Cardiac Rehabilitation is medically necessary for patients
with active diagnoses of stable angina pectoris. For angina, all patients
must have a pre-entry stress test or nuclear perfusion study that
demonstrates exercise-induced ischemia within the 6 months prior to the
start of cardiac rehabilitation. A positive stress test in this context
implies a junctional depression of 2 mm or more
with associated slowly rising ST segment, or 1 mm horizontal or
down-sloping ST segment depressions.
B. Frequency and duration
Services at a frequency of less than 2 sessions per week or more than 3
sessions per week will be considered not medically necessary. Effective
January 1, 2008, hospitals may report more than one unit of HCPCS 93797 or
93798 for a date of service if more than one session lasting at least one
hour each is provided on the same day. In order to report more than one
session for a given date of service, each session must last a minimum of 60
minutes.
Sessions exceeding 36 in number will be considered not medically necessary
except in accordance with the extension criteria below.
C. Non-covered diagnoses and services
Use of any ICD-9-CM code not included in the "ICD-9-CM Codes That
Support Medical Necessity" section of this LCD will be cause for
denial of claims. Congestive heart failure in the absence of other covered
conditions is not included as a covered condition for cardiac
rehabilitation in accordance with the Coverage Issues Manual (100.3 Section
20-10.)
Cardiac rehabilitation exercise without continuous EKG monitoring is not
medically necessary, therefore CPT 93797 is rarely
covered. Clinical evaluations (other than the E&M evaluations of the refering and supervising physicians) are considered to
be part of the cardiac rehabilitation benefit and count toward the total
number of sessions. These evaluations may be performed at sessions that
include monitored physical activity but may also be performed without
monitored exercise. Sessions that consist of clinical evaluations, with or
without education and ancillary services, but without monitored activity
will only be considered to be medically necessary at the start and end of
the program and at no more than 12 session intervals within the program.
Note that this does not preclude evaluations as part of monitored sessions
at any time, nor does it preclude medically necessary E&M sessions by
physicians or non-physician practitioners. (See accompanying coding
article.)
D. Extension Criteria--Duration of Program
1. The CIM permits Contractors to allow CR for up to 36 weeks. Riverbend
will accept extensions of the time span for CR for up to a 36-week period
as long as the medical record documents a reasonable explanation.
2. The CIM states that coverage shall not exceed 36 weeks. It does not
mandate contiguous weeks, therefore Riverbend will allow interruptions in
the span with due cause.
a. In counting weeks, Riverbend would not consider interruptions for
reasons of health (e.g. rehospitalization,
episode of illness, etc) to be part of the 36 week span and will not count
those weeks as part of the 36 week limitation.
b. If the Cardiac Rehab program is interrupted for unforeseen reasons
(patient fatigue, necessary travel, etc.), Riverbend would not consider the
interruption to be part of the 36-week span and will not count those weeks
as part of the 36-week limitation.
c. Holidays, provider vacations, inclement weather and intentionally light
schedules (e.g. bi-weekly sessions) do not impact the 36 week limitation.
(In the event of a natural disaster, Riverbend will automatically allow
exception to the 36 week--but not the 36 session--limitation.)
3. Including interruptions, the program span may not continue beyond 88
weeks from the qualifying event, i.e. 52 weeks plus 36 weeks.
4. Note that there should still be a medical basis for breaks in the
program as the literature supports early, not delayed, intervention.
E. Extension Criteria--Number of Sessions
Coverage is limited, except as defined below, to thirty-six sessions
regardless of the number of weeks. Interruptions in a Cardiac Rehab program
do not reset the 36 session limitation although they may allow additional
sessions on a case by case basis.
1. If the beneficiary starts Cardiac Rehab, is interrupted for reasons of
health or any other reason and then restarts the program, the count of
sessions should continue where it left off regardless of the duration of
the break.
2. If the beneficiary starts Cardiac Rehab, stops the program for any
reason and then restarts the program with a different provider, the count
of sessions should continue where it left off regardless of the duration of
the break. It is therefore incumbent upon CR providers to obtain medical
records from past CR providers.
3. Exceptions to the 36-session limitation will be granted on the following
basis:
a. Riverbend will automatically approve an extension of 9 sessions in the
event of a significant intercurrent illness or comorbidity during CR AND exit criteria are not met.
Documentation must be available on request to show that exit criteria have
not been met. (Patient endurance and progress are likely to be impaired.)
Exit criteria are considered met when the patient has achieved a stable
level of exercise tolerance (7 METS). In the American Heart Association’s
functional classification, Class I, or normal function status, begins at 7
metabolic equivalent units (METS). Therefore, completion of 6 minutes of
exercise during a treadmill or stress imaging test, utilizing the Bruce
protocol, without significant ischemia or dysrhythmia
is a reasonable exit criterion. Although the exit criterion only applies
definitively to extensions beyond the initial 36 sessions, facilities are
encouraged to apply that criterion to the initial 36 sessions for patients
with ischemic heart disease as well.
F. Rentry Criteria
The NCD Decision Memorandum specifies that it is CMS' intention to consider
medical necessity on a per-episode basis.
If the beneficiary has a second qualifying event at any time, the 36
session counter is considered to be re-set at 0 regardless of the current
status within a program or the time lapse since the completed program.
1. The definition of a new event is self-explanatory in the case of MI,
PTCA or cardiac surgery.
2. Angina, being a condition rather than an event, will be considered to be
a new event if the patient has recurrent symptoms following a two year
period with no symptoms, no treatment and no positive diagnostic tests
since the last "qualifying" episode of angina OR if the patient
has a recurrent positive diagnostic test following a negative test of equal
or greater sensitivity and the patient was not being treated for angina. Typically
these situations would be expected to occur when a patient is treated with
an interventions such as PTCA, becomes symptom (and diagnosis) free, and
then suffers a recurrence several years later.
|