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    v1.0.30
    OpenPayerPolicy UpdatesPhysical Medicine, Rehab & TherapiesDHA Cardiac Rehabilitation Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentDHAPolicy 6010.63-M

    Cardiac Rehabilitation

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    Coverage criteria for inpatient and outpatient cardiac rehabilitation services, including qualifying cardiac events, treatment limits, and exclusions.

    Policy Summary
    PayerDHA
    PolicyCardiac Rehabilitation
    Policy CodePolicy 6010.63-M
    Change TypeNo material change
    Effective DateJul 18, 2016
    Next Review DateN/A
    Key ActionObtain a physician order and confirm a qualifying cardiac event occurred within the preceding 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7Qualifying cardiac event categories
    36Maximum sessions per event
    12 monthsEvent lookback
    93797-93798CPT codes
    Phase III home/unsupervisedExcluded setting

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3/week × 12 weeks
    Usual schedule

    Covered Cardiac Rehabilitation Services

    Covered cardiac rehabilitation services

    Covered when all of the following are met:

    Cardiac rehabilitation coverage

    • Program and ordering requirements

      • Services and supplies are provided on an inpatient or outpatient basis in connection with a cardiac rehabilitation program.
      • Services are ordered by a physician.

    • ONE qualifying cardiac event

      • Myocardial infarction (MI).
      • Coronary artery bypass graft (CABG).
      • Coronary angioplasty.
      • Percutaneous transluminal coronary angioplasty (PTCA).
      • Chronic stable angina.
      • Heart valve surgery.
      • Heart transplant, including heart-lung transplant.
      • Congestive heart failure (CHF) or stable chronic heart failure (SCHF).

    Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded from coverage.

    Codes and Treatment Limits

    Covered CPT CodesCPTCovered
    93797
    93798
    Qualifying cardiac event lookback
    Lookback periodWithin the preceding 12 months
    Qualifying event requirementThe patient must have experienced a qualifying cardiac event within the preceding 12 months
    Covered settingCardiac rehabilitation services may be provided on an inpatient or outpatient basis
    Outpatient treatment limit
    Maximum treatment36 outpatient sessions per cardiac event
    Initial evaluation and testingA separate allowance applies for the initial evaluation and testing
    Usual schedule

    Provider and Billing Requirements

    Documentation Required

    Physician Order and Qualifying Cardiac Event Required

    Cardiac rehabilitation services are cost-shared only when ordered by a physician and provided as treatment for a patient who experienced a qualifying cardiac event within the preceding 12 months.

    • Qualifying events include myocardial infarction (MI), coronary artery bypass graft (CABG), coronary angioplasty, percutaneous transluminal coronary angioplasty (PTCA), chronic stable angina, heart valve surgery, heart transplant (including heart-lung transplant), and congestive heart failure (CHF)/stable chronic heart failure (SCHF).
    Denial Risk

    No Qualifying Cardiac Event Within 12 Months

    Do not bill cardiac rehabilitation as a covered benefit when the patient has not experienced a qualifying cardiac event within the preceding 12 months.

    • The 12-month qualifying-event window applies to MI, CABG, coronary angioplasty, PTCA, chronic stable angina, heart valve surgery, heart transplant (including heart-lung transplant), and CHF/SCHF.

    Cardiac Rehabilitation Overview

    Cardiac rehabilitation is intended to restore or improve a patient's physical, medical, and psychological status after a cardiac event. It may include inpatient Phase I, medically supervised outpatient Phase II, and lifetime maintenance Phase III, with potential components such as exercise, patient education, and risk-factor modification. Program intensity and duration may vary.

    Cardiac Rehabilitation Phases

    Phase I
    SettingInpatient hospitalization
    TimingBegins during hospitalization
    ManagementManaged by the patient's personal physician
    Phase II
    SettingOutpatient program
    SupervisionMedically supervised
    TimingBegins following discharge
    Policy Summary
    PayerDHA
    PolicyCardiac Rehabilitation
    Policy CodePolicy 6010.63-M
    Change TypeNo material change
    Effective DateJul 18, 2016
    Next Review DateN/A
    Key ActionObtain a physician order and confirm a qualifying cardiac event occurred within the preceding 12 months.
    SourceLink
    On This Page
    Covered Cardiac Rehabilitation ServicesCodes and Treatment LimitsProvider and Billing RequirementsCardiac Rehabilitation OverviewCardiac Rehabilitation Phases
    Three sessions per week for 12 weeks
    Chronic stable angina and CHF/SCHF treatment limit
    Applicable conditionsChronic stable angina and congestive heart failure/stable chronic heart failure (CHF/SCHF)
    Treatment limitOne treatment episode of 36 sessions
    Time periodPer calendar year
    Billing Rule

    Session and Episode Limits

    After the initial intake evaluation and testing, outpatient cardiac rehabilitation is limited to a maximum of 36 sessions per cardiac event, usually three sessions per week for 12 weeks. Patients diagnosed with chronic stable angina or CHF/SCHF are limited to one treatment episode of 36 sessions per calendar year.

    • The initial evaluation and testing has a separate allowance.
    • Do not bill outpatient treatment beyond 36 sessions for a cardiac event.
    • For chronic stable angina and CHF/SCHF, do not bill more than one 36-session treatment episode in a calendar year.
    Denial Risk

    Unsupervised Lifetime Maintenance Rehabilitation Excluded

    Phase III cardiac rehabilitation for lifetime maintenance is excluded when performed at home or in medically unsupervised settings.

    • The exclusion applies to Phase III lifetime maintenance rehabilitation, which emphasizes continued physical fitness with periodic follow-up.
    Phase III
    Program typeLifetime maintenance program
    PurposeEmphasizes continuation of physical fitness with periodic follow-up
    Excluded settingsPerformed at home or in medically unsupervised settings