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MP 8.03.08 Cardiac Rehabilitation in the Outpatient Setting

Medical Policy    
Section
Therapy
 
Original Policy Date
5/30/97
Last Review Status/Date
Reviewed with literature search/6:2013
Issue
6:2013
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


Description

Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. National organizations have recently specified core components to be included in cardiac rehabilitation programs.

Background

In 1995, the U.S. Public Health Service (USPHS) defined cardiac rehabilitation services as, in part, “comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients.” This USPHS guideline recommends cardiac rehabilitation services for patients with coronary heart disease (CHD) and with heart failure, including those awaiting or following cardiac transplantation. (1) This definition remains current as of 2011.

A 2010 definition of cardiac rehabilitation by the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation is as follows: “Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients.” (2)

Note: This policy does not address programs considered to be “Intensive Cardiac Rehabilitation Programs,” such as the Dean Ornish Program for Reversing Heart Disease and the Pritikin Program.

Regulatory Status

Not applicable. 


Policy

Outpatient cardiac rehabilitation programs are considered medically necessary for patients with a history of the following conditions and procedures:

  • acute myocardial infarction (MI) (heart attack) within the preceding 12 months;
  • coronary artery bypass graft (CABG) surgery;
  • percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
  • heart valve surgery;
  • heart or heart-lung transplantation;
  • current stable angina pectoris; and
  • compensated heart failure.

Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered investigational.


Policy Guidelines

The following components must be included in cardiac rehabilitation programs:

  • Physician-prescribed exercise each day cardiac rehabilitation services are provided;
  • Cardiac risk factor modification;
  • Psychosocial assessment;
  • Outcomes assessment; and
  • Individualized treatment plan detailing how each of the above components are utilized.

A cardiac rehabilitation exercise program is eligible for coverage for 3 sessions per week up to a 12-week period (36 sessions). Programs should start within 90 days of the cardiac event and be completed within 6 months of the cardiac event.

A comprehensive evaluation may be performed prior to initiation of cardiac rehabilitation to evaluate the patient and determine an appropriate exercise program. In addition to a medical examination, an electrocardiogram (EKG) stress test may be performed. An additional stress test may be performed at the completion of the program.

Physical and /or occupational therapy are not medically necessary in conjunction with cardiac rehabilitation unless performed for an unrelated diagnosis. 


Benefit Application
BlueCard/National Account Issues

 

Cardiac rehabilitation must be performed in a facility approved by the Plan. A single initial visit with the physician for referral to a program may be allowed under CPT code 99215.

Services that are educational in nature, e.g., lectures or counseling, which are performed as part of the cardiac rehabilitation program, are not eligible for coverage, even when occurring on a different date of service, unless specifically specified in the contract or certificate of coverage.

Psychological testing and psychotherapy are not a usual component of cardiac rehabilitation. Such services for patients who have a psychiatric diagnosis must be considered under the Mental Health benefits of the contract.

The ongoing maintenance program that follows the 12-week rehabilitation program is not eligible for coverage.

Some contracts have an exclusion for cardiac rehabilitation, as this is considered “self-care” or “self-help” training. In these cases, any related diagnostic testing must also be excluded


Rationale

The policy was created in 1997 with a literature review using MEDLINE and incorporated a clinical practice guideline on cardiac rehabilitation issued by the U.S. Department of Health and Human Services (HHS), issued in 1995. (1) The policy was on “no further review” status from 2003 to 2010, at which time it returned to active review. The most recent literature search was from April 2012 through May 13, 2013. The following is a description of the key literature.

Many randomized controlled trials (RCTs) have been published comparing cardiac rehabilitation to usual care for patients with established heart disease, and a number of meta-analyses of RCTs have been performed. In 2012, Oldridge identified 6 independent meta-analyses published since 2000 that reported outcomes from RCTs after cardiac rehabilitation interventions. (3) The RCTs included in the meta-analyses enrolled patients with myocardial infarction (MI), coronary heart disease (CHD), angina, percutaneous coronary intervention (PCI) and/or coronary artery bypass graft (CABG). RCTs compared cardiac rehabilitation programs (exercise only and/or comprehensive rehabilitation) to usual care. Cardiac rehabilitation was associated with a statistically significant (p<0.05) reduction in all-cause mortality in 4 of the 5 meta-analyses that reported this outcome. In addition, cardiac rehabilitation was associated with a statistically significant reduction in cardiac mortality in 3 of the 4 meta-analyses that reported disease-specific mortality as an outcome.

Two of the meta-analyses on cardiac rehabilitation were conducted by the Cochrane collaboration. One of these included patients with CHD and the other focused on patients with systolic heart failure.(4, 5) Both reviews addressed exercise-based cardiac rehabilitation programs (exercise-alone or as part of comprehensive program). In 2011, Heran and colleagues identified 47 RCTs with a total of 10,794 patients comparing cardiac rehabilitation to usual care in patients with CHD. (4) Seventeen of the studies used exercise-only interventions, and 29 used comprehensive rehabilitation (i.e., exercise plus psychosocial and/or educational interventions). The majority of studies (32 of 47, 68%) were conducted in Europe. Trial sample size ranged from 28 to 2,304. The median duration of rehabilitation interventions was 3 months, and there was a median follow-up duration of 24 months. The investigators reported that most studies had limited information available on methodologic quality. Due to the nature of the intervention, patients were not blinded to treatment group in any of the studies. Only 4 studies reported that there was blinded assessment of study outcomes. In a pooled analysis of data from 17 trials reporting all-cause mortality after at least 12 months of follow-up, cardiac rehabilitation resulted in a significantly lower mortality rate compared to usual care (relative risk [RR]: 0.87, 95% confidence interval [CI]: 0.75-0.99). Similarly, a pooled analysis of findings from 12 trials with at least 12 months’ follow-up found a significantly lower rate of cardiovascular mortality in the cardiac rehabilitation compared to the usual care group (RR: 0.74, 95% CI: 0.63-0.87). In sensitivity analyses of a priori defined variables, the investigators did not find a significant association between health outcomes and the type of cardiac rehabilitation (i.e., exercise-only versus comprehensive cardiac rehabilitation), length of the intervention or study publication date (i.e., published before 1995 or 1995 and later).

The 2010 Cochrane review by Davies and colleagues identified a total of 19 trials with 3,647 heart failure patients; one large trial, HF-ACTION, contributed 2,331 (60%) patients. (5) The overall quality of the studies was judged to be poor; for example, only 3 studies adequately described their randomization process, and only 3 studies had blinded outcome assessment. A pooled analysis of the 13 studies reporting all-cause mortality with up to 12 months’ follow-up, did not find a statistically significant difference in mortality between groups (RR: 1.02, 95% CI: 0.70 to 1.51). Similarly, there was not a significant difference between groups in all-cause mortality in a pooled analysis of the 4 studies reporting more than 12 months’ follow-up (RR: 0.88, 95% CI: 0.73 to 1.07). No significant between-group differences were found for the other primary outcome variable, hospital admissions. For example, when findings from 5 studies reporting hospital admissions up to 12 months were pooled, the relative risk was 0.79 (95% CI: 0.58 to 1.07). The vast majority of the studies included in the Cochrane review, including the HF-ACTION trial, were exercise-only interventions; thus, conclusions cannot be drawn from this review regarding the impact of comprehensive cardiac rehabilitation programs on mortality or hospital admissions in patients with heart failure. The Cochrane review did not require that studies only included patients with compensated heart failure.

A 2011 meta-analysis by Lawler and colleagues addressed exercise-based cardiac rehabilitation programs for patients who had a recent myocardial infarction (MI). (6) To be included in the review, trials needed to include a minimum intervention duration of 2 weeks and a minimum of 12 weeks of follow-up. Interventions could involve any form of exercise program, with or without other interventions. A total of 34 RCTs with 6,111 patients met the review’s inclusion criteria. In a pooled analysis of data from 18 trials, patients randomized to cardiac rehabilitation had a significantly lower risk of reinfarction than patients randomized to a control condition (odds ratio [OR]: 0.53, 95% CI: 0.38-0.76). There was also a lower risk of all-cause mortality (OR: 0.74, 95% CI: 0.58-0.95) and cardiovascular mortality (OR: 0.60, 95% CI: 0.40-0.76) in the group randomized to cardiac rehabilitation compared to a control intervention.

Findings of a large, multicenter RCT from the United Kingdom (U.K.) that evaluated the effectiveness of cardiac rehabilitation in a ‘real-life’ setting were published by West and colleagues in 2012. (7) Called the Rehabilitation After Myocardial Infarction Trial (RAMIT), the study included patients from centers with established cardiac rehabilitation programs that were multifactorial (including exercise, education and counseling), involved more than one discipline, and provided an intervention lasting a minimum of 10 hours. A total of 1,813 patients from 14 centers were randomized, 903 to cardiac rehabilitation and 910 to a control condition. Vital status was obtained at 2 years for 99.9% of participants (all but one patient) and at 7-9 years for 99.4% of participants. By 2 years, 166 patients had died, 82 (9.1%) in the cardiac rehabilitation group and 84 (9.2%) in the control group. The between-group difference in mortality at 2 years (the primary study outcome) was not statistically significant (RR: 0.98, 95% CI: 0.74 to 1.30). After 7-9 years, 488 patients had died, 245 (27%) in the cardiac rehabilitation group and 243 (26.7%) in the control group (RR: 0.99, 95% CI: 0.85-1.15). In addition, at 2 years, cardiovascular morbidity did not differ significantly between groups. For a combined endpoint including death, non-fatal MI, stroke or revascularization, the RR was 0.96 (95% CI: 0.88-1.07). In discussing the study’s negative findings, the trial authors noted that medical management of heart disease has improved over time, and patients in the control group may have had better outcomes than in earlier RCTs on this topic. Moreover, an editorial accompanying publication of study findings emphasized that RAMIT was not an efficacy trial but instead a trial evaluating the effectiveness of actual cardiac rehabilitation programs in the U.K. (8) Finally, these results may in part reflect the degree to which clinically based cardiac rehabilitation programs in the U.K. differ from the treatment protocols used in RCTs that were based in research settings.

Repeat cardiac rehabilitation

No studies were identified that evaluated the effectiveness of repeat participation in a cardiac rehabilitation program.

Summary

Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. A joint national U.S. guideline has specified core components of cardiac rehabilitation programs. Numerous randomized controlled trials (RCTs) have been performed, and meta-analyses of randomized controlled trials have found that cardiac rehabilitation improves health outcomes for selected patients. The evidence is insufficient to support repeat participation in cardiac rehabilitation programs.

Practice Guidelines and Position Statements

In 2012, the American College of Physicians, American College of Cardiology Foundation, American Heart Association/American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association and Society of Thoracic Surgeons published a joint guideline on management of stable ischemic heart disease. (9) The guideline included the following statement on cardiac rehabilitation: Medically supervised exercise programs, i.e., cardiac rehabilitation and physician-directed home-based programs, are recommended for at-risk patients at first diagnosis of stable ischemic heart disease.

In 2007, the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation issued an updated consensus statement on the core components of cardiac rehabilitation programs. (10) The 10 core components are: patient assessment prior to beginning the program, nutritional counseling, weight management, blood pressure management, lipid management, diabetes management, tobacco cessation, psychosocial management, physical activity counseling, and exercise training. Programs that only offer supervised exercise training are not considered to be cardiac rehabilitation. The updated guidelines specify the assessment, interventions, and expected outcomes for each of the core components. For example, symptom-limited exercise testing prior to exercise training is strongly recommended. The national guideline does not specify the optimal overall length of programs or number or duration of sessions.

In 2010, Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation published a position paper on cardiac rehabilitation. (2) Recommendations were based on a review of national guidelines from the U.S. and Europe. They stated that core components of cardiac rehabilitation are patient assessment, physical activity counseling, exercise training, diet/nutritional counseling, weight-control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. The recommended criteria for adequate exercise training are:

  • Mode: Continuous endurance e.g., walking, jogging, cycling, swimming, etc.
  • Duration: At least 20-30 minutes (preferably 45-60 minutes)
  • Frequency: Most days (at least 3 days per week and preferably 6-7 days per week)
  • Intensity: 50-80% of peak oxygen consumption or of peak heart rate or 40-60% of heart rate reserve.

The position paper did not address repeat participation in cardiac rehabilitation programs.

Medicare National Coverage

There was a change in Medicare coverage for cardiac rehabilitation as of January 1, 2010. (11) Indications for coverage remain the same; namely, patients who have experienced at least one of the following:

  • Acute myocardial infarction within the preceding 12 months
  • Coronary artery bypass surgery
  • Current stable angina pectoris
  • Heart valve repair or replacement
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
  • Heart or heart-lung transplant

The new criteria specify the required components of cardiac rehabilitation programs. Programs must include all of the following:

  • 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
  • Individualized treatment plan detailing how components are utilized for each patient.

In addition, criteria on the frequency and duration of cardiac rehabilitation services were updated. On or before December 31, 2009, Medicare covered 18 weeks of cardiac rehabilitation services, with contractor discretion to cover services beyond 18 weeks. Coverage could not exceed a total of 72 sessions for 36 weeks.

Beginning January 1, 2010, the criteria are: “Cardiac rehabilitation items and services must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program….cardiac rehabilitation program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option of an additional 36 sessions over an extended period of time if approved by the Medicare contractor.”

Also, beginning on January 1, 2010, Medicare added intensive cardiac rehabilitation as a benefit. Intensive cardiac rehabilitation programs must be approved by Medicare on an individual basis. (12)

References:

  1. Wegner NK, Froelicher ES, Smith LK. Cardiac Rehabilitation, Clinical Practice Guideline No. 17. US Dept of Health and Human Services AHCPR Publication No 96-0672 1995.
  2. Corra U, Piepoli MF, Carre F et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2010; 31(16):1967-74.
  3. Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited. Future Cardiol 2012; 8(5):729-51.
  4. Heran BS, Chen JM, Ebrahim S et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; (7):CD001800.
  5. Davies EJ, Moxham T, Rees K et al. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2010; (4):CD003331.
  6. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J 2011; 162(4):571-84 e2.
  7. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart 2012; 98(8):637-44.
  8. Doherty P, Lewin R. The RAMIT trial, a pragmatic RCT of cardiac rehabilitation versus usual care: what does it tell us? Heart 2012; 98(8):605-6.
  9. Qaseem A, Fihn SD, Dallas P et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012; 157(10):735-43.
  10. Balady GJ, Williams MA, Ades PA et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115(20):2675-82.
  11. Medicare Claims Processing Manual Publication 100-04 Chapter 32. Available online at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//clm104c32.pdf. Last accessed May, 2013.
  12. Medicare National Coverage Determination (NCD) for Intensive Cardiac Rehabilitation Programs (20.31). Available online at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=339&ncdver=1&CoverageSelection=National&KeyWord=intensive+cardiac&KeyWordLookUp=Title&KeyWordSearchType=And&clickon=search&bc=gAAAABAAAAAA&. Last accessed May, 2013.

 

Codes

Number

Description

CPT  93015  Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report 
  93016  Same as 93015, but with physician supervision only, and without interpretation and report 
  93797  Physician services for outpatient cardiac rehab; without continuous ECG monitoring (per session) 
  93798  Physician services for outpatient cardiac rehab; with continuous ECG monitoring (per session)  
  99215  Physician office visit for comprehensive examination, established patient 
ICD-9 Procedure  89.44  Other cardiovascular stress test (includes EKG stress test) 
  89.7  General physical examination 
  93.36  Cardiac retraining (cardiac rehabilitation regimen following myocardial infarction or coronary bypass graft procedure) 
ICD-9 Diagnosis  410.00-410.92 Acute myocardial infarction code range
  412  History of, or “old,” myocardial infarction (MI is healed, presenting no symptoms, and greater than 8 weeks since MI) 
  413.9  Angina pectoris (includes stable) 
  428.0 Congestive heart failure, unspecified (indcludes compensated)
  V42.1 Organ or tissue replaced by transplant; heart
  V45.81  Other postprocedural status: aortocoronary bypass status
  V45.82 Other postprocedural status; percutaneous transluminal coronary angioplasty status
HCPCS  S9472  Cardiac rehabilitation program, non-physician provider, per diem 
ICD-10-CM (effective 10/1/14) I20.8-I20.9 Angina pectoris, other/unspecified code range
  I21.01-I21.4 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction code range
    I50.1-I50.9 Heart failure code range
    Z94.1 Heart transplant status
    Z94.3 Heart and lungs transplant status
    Z95.1 Presence of aortocoronary bypass graft
    Z95.2-Z95.4 Presence of heart valve code range
    Z95.5 Presence of coronary angioplasty implant and graft
   Z98.61 Coronary angioplasty status
ICD-10-PCS (effective 10/1/14)   Not applicable. Policy is only for outpatient services.
Type of Service  Medical 
Place of Service   


Index

Cardiac rehabilitation
Rehabilitation, cardiac  
 


Policy History
Date Action Reason
5/30/97 Add to Rehabilitation Therapy section New policy
7/12/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled
6/9/11 Replace policy Policy updated with literature review through April 2011. References 2, 5 and 8 added; no change to policy statements.
06/14/12 Replace policy Policy updated with literature review through April 2012. References 3, 5, 6 and 7 added; other references renumbered or removed. No change to policy statements.
07/12/12 Replace policy – correction only Bulleted list in first policy statement changed to say “or” rather than “and” – and Policy Guidelines changed to indicate that it is “preferable” that the program start within 90 days of the cardiac event to eliminate any conflict with the timeframe in the policy statement.
6/13/13 Replace policy Policy updated with literature review through May 13, 2013. References 3 and 9 added; other references renumbered or removed. No change to policy statements.