Checklist: Cardiac rehabilitation services

This checklist is intended to provide Healthcare providers with a reference for use when responding to medical documentation requests for cardiac rehabilitation services (CR). It is not intended to replace the published guidelines. Healthcare providers retain responsibility to submit complete and accurate documentation.

Check	Documentation description
	Documentation is for the correct beneficiary.
	Documentation contains a valid and legible signature.
	Documentation is for the correct date of service.
	Documentation includes evidence that the beneficiary experienced one or more of the following criteria: An acute myocardial infarction within the preceding 12 months; or A coronary bypass surgery; or Current stable angina pectoris; or Heart valve repair/replacement; or Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or A heart or heart-lung transplant; or Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
	Documentation indicating the cardiac rehabilitation program includes the following components: Physician-supervisor and prescribed exercise each day cardiac rehabilitation items and services are furnished; Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs; Nutritional services; Psychosocial assessment; Outcomes assessment; and An individualized treatment plan detailing how components are utilized for each patient. Evidence that treatment plan was reviewed every thirty days, is applicable.
	Documentation includes evidence of total time spent in sessions on the selected date of service for review.
	If applicable and required, submitted documentation should include a beneficiary waiver of liability.

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.

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Last modified: 11/16/2022

Person(s) with Medicare