Does S9472 require prior authorization?

No, S9472 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S9472?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S9472`, Cardiac rehabilitation program, non-physician provider, per diem

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

If billing CPT 93798 or other codes that indicate continuous ECG monitoring, documentation that continuous ECG monitoring was provided during the session
Entry into such programs is based on the demonstrated limitation of functional capacity on exercise stress testing (i.e., exercise stress test results before entering the program).

Medical evaluation documentation: 'Cardiac rehabilitation (CR) programs must include a medical evaluation ... prescribed exercise, education and counseling.'

Progress reports: 'there should be regular communication, in the form of progress reports, between the program staff and the patient’s attending physician.'

For CMS chronic HF coverage, documentation required: left ventricular ejection fraction (LVEF) value (≤35%), NYHA functional class (II to IV), and evidence patient has been 'on optimal heart failure therapy for at least 6 weeks.'

Documentation that patient is 'stable' for HF coverage: records that show no recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures.

Key Coverage Criteria

Covered ICD-10 codes: Z51.89
Covered ICD-10 codes: Z94.1
Covered ICD-10 codes: Z94.2
Covered ICD-10 codes: Z95.1
Covered ICD-10 codes: Z95.2
Covered ICD-10 codes: Z95.3

6 Active Policies

AETNA-CPB-0021, Cardiac Rehabilitation: Outpatient

AMBETTER-CP.MP.176, Outpatient Cardiac Rehabilitation

BCBSIL-THE803.023, Cardiac Rehabilitation in the Outpatient Setting

BCBSMT-THE803.023, Cardiac Rehabilitation in the Outpatient Setting

BCBSNM-THE803.023, Cardiac Rehabilitation in the Outpatient Setting

BCBSOK-THE803.023, Cardiac Rehabilitation in the Outpatient Setting

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S9472, Cardiac rehabilitation program, non-physician provider, per diem