New Outpatient Cardiac Rehabilitation Services Requirements for Medi-Cal
Date: 06/27/18
Per the Department of Health Care Services (DHCS), effective April 1, 2018, outpatient cardiovascular rehabilitation is a covered benefit for Medi-Cal members. California Health & Wellness Plan (CHWP) is notifying participating Medi-Cal providers about new prior authorization and claims coding requirements for outpatient cardiac rehabilitation services.
PRIOR AUTHORIZATION REQUIREMENT
Effective September 1, 2018, CHWP is requiring prior authorization for intensive outpatient cardiac rehabilitation (ICR) services for Medi-Cal members, including:
- Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise (G0422)
- Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise (G0423)
In accordance with DHCS treatment authorization request (TAR) requirements, ICR services must be provided within an ICR program approved by the Centers for Medicare & Medicaid Services (CMS). Providers must include the following when submitting a prior authorization request for ICR services:
When submitting a prior authorization request, please indicate:
- CMS-approved program the member is participating in
- Qualifying diagnosis
- Treatment plan
- Duration of services
Prior authorization requirements are available here.
Providers participating through the Community Care Independent Practice Association (CCIPA) must contact the CCIPA, follow the CCIPA's prior authorization process and use the CCIPA's forms.
CLAIMS CODING REQUIREMENT
Providers are required to submit appropriate CPT-4 or HCPCS codes and include one of the ICD-10-CM diagnosis codes listed in this update (billed in the primary diagnosis position) to receive reimbursement of cardiac rehabilitation claims for dates of service on or after April 1, 2018, for CHWP Medi-Cal members. Claims without the ICD-10 diagnosis code and/or not billed in the primary diagnosis position may be denied. Frequency restrictions also apply to outpatient cardiac rehabilitation services.
ADDITIONAL INFORMATION
Providers are encouraged to access CHWP's provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact your Provider Relations representative or call 1-877-658-0305.
CPT AND HCPCS CODES
Providers must use the appropriate CPT-4 or HCPCS codes from the table below when submitting claims to CHWP for cardiac rehabilitation services:
ADDITIONAL RESTRICTIONS
| CPT-4 code | Description | Frequency restrictions |
|---|---|---|
| 93797 | Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitor (per session) | When billing CPT-4 codes 93797 and 93798, there is a maximum of two one-hour sessions per day and up to a maximum of 24 one-hour sessions over a 24-week period. |
| 93798 | Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) | When billing CPT-4 codes 93797 and 93798, there is a maximum of two one-hour sessions per day and up to a maximum of 24 one-hour sessions over a 24-week period. |
| HCPCS code | Description | Frequency restrictions |
|---|---|---|
| G0422 | Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise (per session) | When billing HCPCS codes G0422 and G0423, there is a maximum of six one-hour sessions per day and up to a maximum of 72 one-hour sessions over an 18-week period. |
| G0423 | Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise (per session) | When billing HCPCS codes G0422 and G0423, there is a maximum of six one-hour sessions per day and up to a maximum of 72 one-hour sessions over an 18-week period. |
MODIFIERS
CPT-4 codes 93797 and 93798 are not reimbursed in the same calendar month as HCPCS codes G0422 and G0423, for any provider. Alternately, HCPCS codes G0422 and G0423 are not reimbursed in the same calendar month as CPT-4 codes 93797 and 93798, for any provider.
Providers may use modifiers SA, U7, 24, 25, and 99 with the CPT-4 and HCPCS codes noted in the table above.
ICD-10-CM DIAGNOSIS CODES
Providers must include one of the ICD-10-CM diagnosis codes (billed in the primary diagnosis position) in the table below when submitting cardiac rehabilitation claims to CHWP for reimbursement of CPT-4 codes 93797 and 93798 or HCPCS codes G0422 and G0423:
| Diagnosis Codes | ||
|---|---|---|
| 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 |