New Cardiac and Pulmonary Rehabilitation Programs

Cardiac and Pulmonary Rehabilitation Programs

The Medicare Program has just issued final instructions on these two types of programs, although they technically have been in effect for some time.

While Medicare has long covered cardiac rehabilitation services, the MIPPA law established two types of cardiac rehabilitation services programs, a “regular” cardiac rehabilitation services program, and a brand new intensive cardiac rehabilitation services program. In addition, it called for an also brand new program of pulmonary rehabilitation services; all of these are effective with January 1, 2010. These are all outpatient services, and, as such, are covered under Part B. These programs have somewhat similar requirements, but are different enough so it helps to discuss them separately.

The cardiac rehabilitation programs must be:

1. physician supervised;

2. delivered only in hospitals and doctors’ offices and always with a physician immediately available;

3. given under a physician’s plan individualized for the beneficiary and specifying the “type, amount, frequency, and duration” of the services to be rendered to or performed by the beneficiary. This plan must be renewed every 30 days.

The programs’ specific services must consist of exercise(including aerobic exercise), both psychosocial and outcomes assessments, and a “cardiac risk factor modification” component, which includes education, counseling, and behavior intervention. Depending on the individual, these may include smoking cessation counseling, nutritional education, meal planning, stress management, drug education, and so forth.

To qualify for cardiac rehabilitation, the beneficiary must have or have had a specific coronary-related diagnosis or procedure. These are (1) an acute myocardial infarction (AMI) within the last 12 months, (2) coronary by-pass surgery, (3) stable angina pectoris, (4) a heart valve repair or replacement, (5) a percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, or (6) a heart or heart lung-transplant.

One way the two cardiac rehabilitation programs differ is that the “regular” program must conform to standards of frequency and duration of services that are prescribed in regulation, while this has been done in the statue for the “intensive“ program. Specifically, beneficiaries in the regular program are limited to a total of 36 sessions, each one hour in duration, over a period of 36 weeks. Because of the severity of the qualifying conditions, the sessions are limited to two per day. Under some conditions the program may be expanded up to an additional 36 sessions over an extended period of time.

The intensive program calls for up to 72 one-hour sessions, not exceeding six per day, and not exceeding 18 weeks in length. Finally, any intensive program has to be specifically qualified as such by the Centers for Medicare & Medicaid Services through its national coverage determination process. To date, both the Ornish and the Pritkin programs have been so approved.


The pulmonary rehabilitation program for beneficiaries must meet the same requirements (1) through (3) shown above.

Its specific services must comprise exercise (including aerobic exercise), both psychosocial and outcomes assessments, and an educational component. This latter must be designed to enable beneficiaries to adapt to their limitations and improve the quality of their life. It may include instruction in the use of home respiratory equipment, prevention and treatment of exacerbating conditions, respiratory techniques for physical energy conservation, work simplification, relaxation techniques, medication training, nutrition counseling, and smoking cessation.

To qualify, beneficiaries must have “moderate to very severe” chronic obstructive pulmonary disease or COPD. (These are technically defined in terms of a GOLD classification of II, III, and IV; GOLD, in turn, is a standardized measure of airflow limitation.) COPD is typically associated with chronic bronchitis, emphysema, persistent asthma, bronchiectasis, primary pulmonary hypertension, obesity-related respiratory disease and ventilator dependency.

As established in regulations, the program is limited to a total of 36 sessions, each one hour in duration. Because of the severity of the qualifying conditions, the sessions are limited to two per day. If medically necessary, the program may be extended up to an additional 36 sessions.

These are all Part B services; after you meet the Part B deductible, Medicare pays 80% of the cost, and the beneficiary is responsible for 20%. If you get them in a hospital, you will have a copayment.