Knowledge Base Article

Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health!  According to the American Heart Association website, cardiac rehab  is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.

However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services.  One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.

Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier.  Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.”  Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.

Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials).  Diagnoses supporting coverage of cardiac rehabilitation services are:

• An acute myocardial infarction within the preceding 12 months; or
• A coronary artery bypass surgery; or
• Current stable angina pectoris; or
• Heart valve repair or replacement; or
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
• A heart or heart-lung transplant; or
• Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.

Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy.  These include:

• Physician-prescribed exercise each day cardiac rehabilitation 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.

For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.

Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.