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Cardiac rehabilitation is the process by which people with cardiovascular disease are restored to their optimal functional status, including their physiological, psychological, social, vocational, and emotional status. Cardiac rehabilitation services include formal exercise sessions, risk factor education, and behavior modification counseling. Phase II cardiac rehabilitation is immediate outpatient therapy during the convalescent period following hospital discharge. Individualization of the program is achieved through a case management perspective with attention to patient and family needs.
POLICYNOTE: This policy applies only to those contracts which specifically include cardiac rehabilitation as a benefit. This policy does not apply if cardiac rehabilitation is specifically excluded by the individual contract. Also, most contracts limit cardiac rehabilitation to a maximum of 36 visits per calender year regardless of the number of qualifying episodes per calender year.
Prior approval is required for underwritten and most self-funded groups.
Phase II Cardiac Rehabilitation
Phase II cardiac rehabilitation (immediate outpatient therapy during the convalescent period following hospital discharge) may be offered to patients with the following cardiovascular disease diagnoses (qualifying episodes) including:
Contraindications for participation in Phase II cardiac rehabilitation include:
Minimal guidelines for risk stratification are as follows:
Three factors determine the appropriateness of discontinuing the cardiac rehabilitation program. These include:
- Evidence that the patient is clinically stable
- Achievement of the goals set at program entry
- Determination that the patient has received optimal or near-optimal benefits
The final decision as to risk determination shall be the joint responsibility of the referring physician and the director of the cardiac rehabilitation program.
Place of Service
Formal cardiac rehabilitation services must be conducted at a facility meeting the following criteria:
The cardiac rehabilitation program holds a current certification from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) and is listed in the AACVPR Program Directory online at https://www.aacvpr.org/Resources/Program-Directory. All AACVPR certified programs are listed in the online directory. The program does not have to be in the State of Mississippi, as long as it is certified by the AACVPR.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/1999: Approved by the Medical Policy Advisory Committee (MPAC)
9/19/2000: Revisions to "Place of Service; "may" changed to "must" and the programs certified by AACVPR for Cardiac and Pulmonary Rehabilitation added
7/10/2001: Certified hospitals as of 5-31-2001 table added to "Place of Service", word "Pulmonary" deleted. This policy is specific to Cardiac Rehabilitation only.
8/2001: Reviewed by MPAC
9/20/2001: Natchez Regional Medical Center added to the Mississippi AACVPR certified program list
12/11/2001: Covered ICD-9 Procedure codes, ICD-9 Diagnosis codes, and Non-Covered ICD-9 Diagnosis codes added to the "Code Reference" section.
1/9/2002: Clay County Medical Center, North Mississippi Health Services and Oktibbeha County Hospital added to AACVPR certified program list
4/18/2002: Type of Service and Place of Service deleted.
5/14/2002: AACVPR table hyperlink added
5/29/2002: Code Reference section updated, ICD-9 procedure codes 36.11-36.17, 36.01-36.09 and 37.5 deleted
7/17/2002: Appeals statement deleted. Case Management reference deleted (depends on individual contract). Policy Guidelines statement added.
10/11/2002: ICD-9 Procedure code 89.44 deleted, HCPCS S9445 deleted
2/14/2003: AACVPR table updated, AACVPR hyperlink and separate AACVPR file deleted
6/12/2003: FEP Policy Exception deleted for Case Management and prior authorization, Case Management approval requirement added for underwritten and most self funded groups
6/18/2003: Magnolia Regional Health Center Cardiac Rehabilitation Program added to AACVPR certified program list
8/26/2003: Delta Regional Medical Center Cardiac Rehabilitation Program added to AACVPR certified program list
9/8/2003: Jackson Rehab and Wellness Center and Baptist Memorial Hospital DeSoto Cardiac Rehabilitation Programs added to AACVPR certified program list
9/18/2003: Hancock Medical Center Cardiac Rehabilitation Program added to AACVPR certified program list
10/10/2003: University of Mississippi Medical Center Cardiac Rehabilitation Center added to AACVPR certified program list
3/26/2004: Central Mississippi Medical Center, Garden Park Medical Center and Baptist Memorial Hospital at Oxford Cardiac Rehabilitation programs added to AACVPR certified program list
9/9/2004: Code Reference section updated, CPT code 93015, 93016 deleted covered codes, ICD-9 procedure code 93.36 added covered codes, ICD-9 diagnosis code range 410.00-410.92, 414.00-414.9, 427.0-427.9, 443.0-443.9 listed separately, ICD-9 diagnosis codes 426.10, 426.11, 426.12, 426.13, 426.2, 426.3, 426.4, 426.50, 426.51, 426.52, 426.53, 426.54, 426.6, 426.7, 426.81, 426.89, 426.9, 440.1, 440.20, 440.21, 440.22, 440.23, 440.24, 440.29, 440.30, 440.31, 440.32, 440.9, 441.00, 441.01, 441.02, 441.03, 441.1, 441.2, 441.3, 441.4, 441.5, 441.6, 441.7, 441.9, 442.0, 442.1, 442.2, 442.3, 442.81, 442.82, 442.83, 442.84, 442.89, 442.9, 459.81, 671.30, 671.31, 671.32, 671.33, 671.34, 671.40, 671.41, 671.42, 671.43, 671.44, V45.81, V45.82 added covered codes, rev code 943 deleted, non-covered table and codes 250.00-250.93, 411.1, 420.90, 420.91, 420.99, 422.90, 422.91, 422.92, 422.99, 424.1, 426.0, 428.0, 433.00-433.91, 434.1, 451.0-451.9, 780.6 deleted
10/5/2004: Singing River Hospital System/Ocean Springs Hospital Cardiac Rehabilitation added AACVPR certified program list
7/18/2005: AACVPR table updated, Southwest Mississippi Regional Medical Center Cardiac Rehabilitation added to AACVPR certified program list
9/15/2005: AACVPR table updated, Greenwood Leflore Hospital Cardiac Rehabilitation Department added to AACVPR certified program list
6/14/2006: AACVPR table updated, River Region Health System Cardiac Rehabilitation added to AACVPR certified program list
09/13/2006: Coding updated. ICD9 2006 revisions added to policy.
9/20/2007: Code reference section updated. ICD-9 2007 revisions added policy
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
3/12/2010: Code reference section updated. New HCPCS codes G0422 and G0423 added to covered table.
06/04/2010: Memorial Hospital at Gulport Cardiac Rehabilitation Program added to AACVPR certified program list.
12/30/2010: Added "in the Outpatient Setting" to the policy title.
08/11/2011: Policy reviewed; no changes.
05/07/2013: Removed ICD-9 procedure code 93.36 from the Code Reference section.
08/26/2015: Medical policy revised to add ICD-10 codes. Removed deleted ICD-9 diagnosis codes 671.32, 671.34, 671.41, and 671.43 from the Code Reference section.
09/29/2015: Policy statement updated to replace the provider table with the link to the Online AACVPR Program Directory in the Place of Service section. All AACVPR certified programs are listed in the online directory.
05/27/2016: Policy number added.
A search of the literature was completed through the MEDLINE database for the period of January 1990 through October 1996. The search strategy focused on references containing the following Medical Subject Heading: Cardiac Rehabilitation.
Cardiac Rehabilitation, Clinical Practice Guideline, Number 17, U.S. Department of Health & Human Services, October 1995.
American Association of Cardiovascular and Pulmonary Rehabilitation
Hayes Medical Technology Directory
Blue Cross Blue Shield Association policy # 8.03.08 (added 7-16-2001)
HCFA, Coverage Issues Manual, section 35-25 (added 8-16-2001)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
Physician services for outpatient cardiac rehabilitation, with continuous ECG monitoring (per session)
Cardiac rehabilitation program, non-physician provider, per diem
Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92
Myocardial infarction code range
I21.01 - I21.4
ST elevation and non-ST elevation myocardial infarction (code range)
I22.0 - I22.9
Subsequent ST elevation and non-ST elevation myocardial infarction (code range)
414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.10, 414.11, 414.12, 414.19, 414.8, 414.9
Coronary artery disease code range
I25.10, I25.110 - I25.119, I25.89, I25.9,
Atherosclerotic heart disease of native coronary artery (code range and codes)
Aneurysm of heart
I25.41 - I25.42
Coronary artery aneurysm and dissection (code range)
Silent myocardial ischemia
I25.700 - I25.799
Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris (code range)
I25.810 - I25.812, I25.89
Other forms of chronic ischemic heart disease (code range and code)
Chronic ischemic heart disease, unspecified
Chronic total occlusion of coronary artery
Chronic total occlusion of coronary artery
Coronary atherosclerosis due to lipid rich plaque
Coronary atherosclerosis due to lipid rich plaque
426.10, 426.11, 426.12, 426.13, 426.2, 426.3, 426.4, 426.50, 426.51, 426.52, 426.53, 426.54, 426.6, 426.7, 426.81, 426.89, 426.9, 427.0, 427.1, 427.2, 427.31, 427.32, 427.41, 427.42, 427.5, 427.60, 427.61, 427.69, 427.81, 427.89, 427.9
Arrhythmia code range
I44.0, I44.1, I44.30, I44.39, I44.4, I44.5, I44.60, I44.69, I44.7
Atrioventricular and left bundle-branch block
I45.0, I45.10, I45.19, I45.2, I45.3, I45.4, I45.5, I45.6, I45.89, I45.9
Other conduction disorders
I46.2 - I46.9
Cardiac arrest (code range)
I47.0 - I47.9
Paroxysmal tachycardia (code range)
I48.0 - I48.92
Atrial fibrillation and flutter (code range)
I49.01, I49.02, I49.1, I49.2, I49.3, I49.40, I49.49, I49.5, I49.8
Other cardiac arrhythmias code range
Severely depressed left ventricular function (ventricular dysfunction)
Heart disease, unspecified
Other heart disorders in diseases classified elswhere
440.1, 440.20, 440.21, 440.22, 440.23, 440.24, 440.29, 440.30, 440.31, 440.32, 440.4, 440.9, 441.00, 441.01, 441.02, 441.03, 441.1, 441.2, 441.3, 441.4, 441.5, 441.6, 441.7, 441.9, 442.0, 442.1, 442.2, 442.3, 442.81, 442.82, 442.83, 442.84, 442.89, 442.9, 443.0, 443.1, 443.21, 443.22, 443.23, 443.24, 443.29, 443.81, 443.89, 443.9, 459.81, 671.30, 671.31, 671.33, 671.40, 671.42, 671.44
Peripheral vascular disease code range
I70.1 - I70.92
Atherosclerosis (code range)
I71.00 - I71.9
Aortic aneurysm and dissection (code range)
I72.0 - I72.9
Other aneurysm (code range)
Aneurysm of aorta in diseases classified elsewhere
Heart replaced by transplant
Encounter for aftercare following heart transplant
Heart transplant status
Postsurgical aortocoronary bypass status
Presence aortocoronary bypass graft
Postsurgical percutaneous transluminal coronary angioplasty status
Presence of coronary angioplasty implant and graft
Coronary angioplasty status