CMS has clarified a coding requirement for cardiac rehabilitation services that was not included in the Cardiac Rehabilitation Change Request 6850, published May 21, 2010. Change requests are specific billing instructions sent to providers. Your billing department would have received these change requests for both cardiac and pulmonary rehabilitation. The change request for pulmonary rehabilitation is # 6823, published May 7, 2010.

When billing for more than one session of cardiac rehabilitation per day, modifier “-59” must be used. This is because two CR sessions in a day are considered different patient encounters. The policy for Modifier -59 is found in the CMS publication, MLN Matters SE0715 (CLICK HERE to access). This means whenever any combination of CPT/HCPCS 93798 and 93797 are provided for two CR sessions in one day, proper billing requires use of the modifier. Failure to use the modifier -59 when submitting two charges for one day has resulted in denial of payment for some CR programs.

Pulmonary rehabilitation (PR) does NOT need to use modifier -59 because of coding edits that CMS put in place with the new procedure code, G0424 in January, 2010. However, the procedure codes, G0237-39, used previously for pulmonary rehabilitation and now used for respiratory therapy services (i.e., non-COPD diagnoses) continue to require use of the modifier -59. (This requirement was discussed in AACVPR News & Views, May/June, 2009.)

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