CMS Pub. 100-02, ch. 15, § 232

(ICR) Services Effective For Dates of Service On Or After January 1,

2024

(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)

Cardiac rehabilitation (CR) means a physician or nonphysician practitioner supervised

program that furnishes physician prescribed exercise; cardiac risk factor modification,

including education, counseling, and behavioral intervention; psychosocial assessment;

and outcomes assessment. Intensive cardiac rehabilitation (ICR) program means a

physician or nonphysician practitioner supervised program that furnishes CR and has

shown, in peer-reviewed published research, that it improves patients’ cardiovascular

disease through specific outcome measurements described in 42 CFR 410.49(c).

Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical

nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social

Security Act (the Act).

Effective January 1, 2010, Medicare Part B pays for CR/ICR if specific criteria are met

by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is

administered, and the physician administering the program, as outlined below.

Covered Conditions:

As specified in 42 CFR 410.49, Medicare Part B covers CR and ICR for beneficiaries

who have experienced one or more of the following:

• An acute myocardial infarction (MI) within the preceding 12 months;

• A coronary artery bypass surgery;

• Current stable angina pectoris;

• Heart valve repair or replacement;

• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;

• A heart or heart-lung transplant.

• 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, on

or after February 18, 2014, for CR and on or after February 9, 2018, for ICR; or

• Other cardiac conditions as specified through a national coverage determination

(NCD). The NCD process may also be used to specify non-coverage of a cardiac

condition for ICR if coverage is not supported by clinical evidence.

CR and ICR must include all of the following components:

Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise

combined with other types of exercise (such as strengthening and stretching) as

determined to be appropriate for individual patients by a physician each day CR/ICR

items and services are furnished.

Cardiac risk factor modification. Cardiac risk factor modification, including education,

counseling, and behavioral intervention, tailored to the individual’s needs.

Psychosocial assessment. Psychosocial assessment means an evaluation of an

individual’s mental and emotional functioning as it relates to the individual’s

rehabilitation which includes an assessment of those aspects of an individual’s family and

home situation that affects the individual’s rehabilitation treatment, and psychosocial

evaluation of the individual’s response to and rate of progress under the treatment plan.

Outcomes assessment. Outcomes assessment means an evaluation of progress as it relates

to the individual’s rehabilitation which includes all of the following: (i) Evaluations,

based on patient-centered outcomes, which must be measured by the physician or

program staff at the beginning and end of the program. Evaluations measured by program

staff must be considered by the physician in developing and/or reviewing individualized

treatment plans. (ii) Objective clinical measures of exercise performance and self-reported measures of exertion and behavior.

Individualized treatment plan. Individualized treatment plan means a written plan tailored

to each individual patient that includes all of the following: (i) A description of the

individual’s diagnosis. (ii) The type, amount, frequency, and duration of the items and

services furnished under the plan. (iii) The goals set for the individual under the plan. The

individualized treatment plan detailing how components are utilized for each patient,

must be established, reviewed, and signed by a physician every 30 days.

As specified at 42 CFR 410.49(f)(1), the number of CR 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 for an additional 36 sessions over an extended period of time if approved by the

Medicare Administrative Contractor (MAC).

As specified at 42 CFR 410.49(f)(2), ICR sessions are limited to 72 1-hour sessions (as

defined in section 1848(b)(5) of the Act), up to 6 sessions per day, over a period of up to

18 weeks.

CR and ICR Settings:

Medicare Part B pays for CR and ICR in a physician’s office or a hospital outpatient

setting. All settings must have a physician or nonphysician practitioner immediately

available and accessible for medical consultations and emergencies at all times when

items and services are being furnished under the program. This provision is satisfied if

the physician or nonphysician practitioner meets the requirements for direct supervision

for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42

CFR 410.27.

Standards for an ICR Program:

To be approved as an ICR program, a program must demonstrate through peer-reviewed,

published research that it has accomplished one or more of the following for its patients:

(i) Positively affected the progression of coronary heart disease. (ii) Reduced the need for

coronary bypass surgery. (iii) Reduced the need for percutaneous coronary interventions.

An ICR program must also demonstrate through peer-reviewed published research that it

accomplished a statistically significant reduction in 5 or more of the following measures

for patients from their levels before CR services to after CR services: (i) Low density

lipoprotein. (ii) Triglycerides. (iii) Body mass index. (iv) Systolic blood pressure. (v)

Diastolic blood pressure. (vi) The need for cholesterol, blood pressure, and diabetes

medications.

A list of approved ICR programs, identified through the NCD process, will be listed in

the Federal Register and is available on the CMS website at

https://www.cms.gov/Medicare/Medicare-

GeneralInformation/MedicareApprovedFacilitie/ICR. All prospective ICR sites must

apply to enroll as an ICR program site using the designated forms as specified at 42 CFR

424.510, and report specialty code 31 to be identified as an enrolled ICR supplier. For

purposes of appealing an adverse determination concerning site approval, an ICR site is

considered a supplier (or prospective supplier) as defined in 42 CFR 498.2.

CR and ICR Medical Director Standards:

Medical director means the physician who oversees the CR or ICR program at a

particular site. The medical director is the physician responsible for a CR or ICR program

and, in consultation with staff, is involved in directing the progress of individuals in the

program and must possess all of the following: (1) Expertise in the management of

individuals with cardiac pathophysiology. (2) Cardiopulmonary training in basic life

support or advanced cardiac life support. (3) Be licensed to practice medicine in the State

in which the CR or ICR program is offered.

Supervising Practitioner Standards:

Supervising practitioner means a physician or nonphysician practitioner that is

immediately available and accessible for medical consultations and medical emergencies

at all times items and services are being furnished to individuals under CR and ICR

programs. Physicians or nonphysician practitioners acting as the supervising practitioner

must possess all of the following: (1) Expertise in the management of individuals with

cardiac pathophysiology. (2) Cardiopulmonary training in basic life support or advanced

cardiac life support.

(See Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part

1, section 20.10.1, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, section

140, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, section 10.2.2.5, for

CR and ICR claims processing, coding, and billing requirements.)