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Cardiac Rehabilitation is a New Medi-Cal Benefit

April 20, 2018

Effective for dates of service on or after April 1, 2018, the following CPT-4 and HCPCS codes are Medi-Cal benefits for cardiac rehabilitation:

CPT-4 Code Description
93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitor (per session)
93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
   
HCPCS Code Description
G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise, per session

Treatment Authorization Request (TAR) Requirements
A TAR is required for HCPCS codes G0422 and G0423. A TAR approval requires documentation that a patient meets diagnostic criteria for cardiovascular rehabilitation, and that the program be a CMS-approved intensive cardiovascular rehabilitation program. CPT-4 codes 93797 and 93798 may not be reimbursed in the same calendar month as HCPCS codes G0422 and G0423, for any provider. Similarly, HCPCS codes G0422 and G0423 may not be reimbursed in the same calendar month as CPT-4 codes 93797 and 93798, for any provider.

Modifiers SA, U7, 24, 25 and 99 are all allowable for CPT-4 codes 93797 and 93798, as well as HCPCS codes G0422 and G0423.

Qualified Practitioners
Licensed practitioners who are eligible for reimbursement of CPT-4 codes 93797 and 93798 include physicians, physician assistants, nurse practitioners and physical therapists.

Licensed practitioners who are eligible for reimbursement of HCPCS codes G0422 and G0423 include physicians, physician assistants, nurse practitioners, psychologists, licensed clinical social workers, marriage and family therapists and physical therapists.

ICD-10-CM Diagnosis Codes
When billing for CPT-4 codes 93797 and 93798 or HCPCS codes G0422 and G0423, the claim must include one of the following:

I20.1 – I22.9 I25.761 – I25.769 I70.411 – I70.413
I25.111 – I25.119 I25.791 – I25.799 I70.511 – I70.513
I25.701 – I25.709 I50.22 I70.611 – I70.613
I25.711 – I25.719 I50.32 I70.711 – I70.713
I25.721 – I25.729 I50.42 Z95.1
I25.731 – I25.739 I70.211 – I70.213 Z95.5
I25.751 – I25.759 I70.311 – I70.313 Z98.61

Frequency Restrictions
Providers may bill CPT-4 codes 93797 and 93798 for a maximum of two one-hour sessions of cardiovascular rehabilitation per day and up to 24 one-hour sessions over a 24-week period. The combined total number of sessions billed with CPT-4 codes 93797 and 93798 must not exceed 24 in a 24-week period. A TAR may be used to override the frequency limit.

Providers may bill HCPCS codes G0422 and G0423 for a maximum of six one-hour sessions of intensive cardiovascular rehabilitation per day and up to 72 one-hour sessions over an 18-week period. The combined total number of sessions billed with HCPCS codes G0422 and G0423 must not exceed 72 in an 18-week period. A TAR may not be used to override the frequency limit.

For more information, providers may refer to the Rehabilitative Services section of the Rehabilitation Clinics manual.