93797
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.18
Facility
$7.68
Non-Facility
$17.70
Documentation Required
- ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim and supported by documentation in the patient's medical record.
- Inclusion of the KX modifier on the claim line(s) is accepted as the provider's attestation that documentation verifying further treatment beyond standard session limits is on file and meets coverage requirements; the medical record must reflect medical reasons and be available to Medicare upon request.
- If CR or ICR services involve electrocardiogram (ECG) monitoring, the medical record must document performance of such monitoring.
- Reported CPT/HCPCS codes must accurately capture the service performed (e.g., CPT 93798, 93797; HCPCS G0422, G0423).
Key Coverage Criteria
- Cardiac rehabilitation (CR) is covered for beneficiaries with qualifying cardiac indications (e.g., myocardial infarction within 12 months).
- CR is covered for beneficiaries with stable angina as an indication for CR.
- An additional 36 CR sessions (Phase IIB) may be allowed if a significant intercurrent illness or comorbidity occurs during the first 36 sessions and the program exit criteria have not been met.
- A new series of 36 CR sessions may be initiated and covered after an intervening event that qualifies as an indication for CR.
- Intensive Cardiac Rehabilitation (ICR) is covered for qualifying indications and may consist of up to 72 one-hour sessions over a period up to 18 weeks.
- Covered ICD-10 codes: Z51.89
3 Active Policies
AMBETTER-CP.MP.176 — Outpatient Cardiac Rehabilitation
A53775 — Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation
AETNA-CPB-0021 — Cardiac Rehabilitation: Outpatient
Related Codes
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