Cardiovascular diseases are one of the leading causes of death in the United States. According to a report by the American Heart Association, every 34 seconds, a person dies of a cardiac disease in the country. Often, the cardiac patients require rehabilitation services and continuous monitoring to recover. However, these services can be tricky to bill.
Since the demand for cardiology services is immense, healthcare providers can’t afford claim denials. Otherwise, they will lose a significant portion of the revenue. That’s why we have created this detailed guide on CPT code 93798, which is among the most used billing codes for cardiac rehabilitation.
So, let’s start.
CPT Code 93798 – Description
CPT code 93798 is defined as:
“Physician or other qualified healthcare professional services for outpatient cardiac rehabilitation, with continuous ECG monitoring (per session).”
Let’s break this down in more detail.
93798 is a cardiology billing code. This code is designated for outpatient sessions in which the patient exercises under the direct supervision of a physician or a qualified healthcare professional. During the exercise, the patient’s heart rhythm is monitored in real-time via electrocardiography.
The defining feature of CPT code 93798 is the “continuous ECG monitoring.” This part differs from CPT code 93797, which covers cardiac rehabilitation without continuous ECG.
An important point to note is that code 93798 is a per-session code, not a time-based code in the traditional sense of billing by 15-minute increments. However, there are specific timing criteria for these sessions, which we will discuss in the later sections.
Appropriate Use Cases for CPT Code 93798
To better understand how to use CPT code 93798 effectively, let’s look at a couple of real-world scenarios in which it can be used:
Angina Pectoris
Suppose that a male patient with refractory angina pectoris attends a cardiac rehabilitation session. Despite optimal medical management, his chest pain persists with minimal exertion. He participates in a supervised treadmill exercise program with continuous ECG monitoring.
An exercise physiologist guides the session under the direct supervision of the cardiac rehabilitation physician. The supervising physician monitors the ECG for ischemic changes and carefully adjusts exercise intensity to manage his angina symptoms. He also counsels the patient on stress management techniques and medication adherence.
Here, CPT code 93798 applies.
Myocardial Infarction
Let’s consider another scenario.
A patient recovering from a recent myocardial infarction participates in a cardiac rehabilitation program. The goal is to improve cardiovascular function and prevent future cardiac events.
During the session, she engages in numerous exercises.
A trained exercise specialist monitors her ECG continuously under the direct supervision of the program’s physician. The supervising physician observes her cardiac response to exercise, reviews real-time ECG data for arrhythmias or ischemia, and modifies her exercise prescription accordingly.
Therefore, the billing department can bill a claim with CPT code 93798.
Modifiers to Append with CPT Code 93798
The following are some of the most used modifiers with CPT code 93798:
| Modifier Name | Short Description | Usage |
|---|---|---|
| Modifier 59 | Distinct separate procedure | Cardiac rehabilitation is distinct and separately payable from other same-day services. It prevents bundling. |
| Modifier KX | Requirements met | Service exceeds Medicare’s therapy thresholds but is medically necessary. |
| Modifier GA | ABN on file | Advance Beneficiary Notice (ABN) on file. The patient acknowledges that the payer may not cover the service. |
| Modifier GZ | Expected denial notice | The physician expects denial due to a lack of medical necessity. An ABN is not on the file. |
Reimbursement Guidelines for CPT Code 93798
For proper reimbursement, you must be aware of certain billing requirements and limitations. Here are some points to consider while filing claims for CPT code 93798:
Documentation Requirements for Payment
To withstand an audit and avoid claim denials, the medical record for every session of CPT 93798 must be complete. For CPT code 93798, you must provide the following details:
- A clear order from the treating physician establishing the need for cardiac rehabilitation.
- A valid diagnosis with an ICD-10 code that supports the medical necessity.
- Documented proof that the procedure was performed under the supervision of a physician or a qualified professional.
- Start and stop times to prove the 31-minute minimum requirement.
- Since this code requires continuous ECG monitoring, there must be a record of the rhythm strip review or a summary of the ECG.
Billing and Session Limitations
CMS guidelines state that a single session must be at least 31 minutes in duration to be billable. If a provider wishes to bill for two sessions in a single day (which is the maximum allowed daily), the total duration of treatment must be at least 91 minutes. That is 60 minutes for the first session and 31 minutes for the second session.
Also, you cannot bill more than 36 sessions in a span of 36 weeks. Additional sessions will only be allowed if a significant illness or comorbidity occurs.
Medicare Reimbursement Rate
According to the latest Medicare Physician Fee Schedule, the national average reimbursement for CPT code 93798 is $24.58 in non-facility settings and $12.94 in facility settings.
However, this rate varies significantly for each Medicare Administrative Contractor (MAC) locality. You can check the exact amount for your MAC via the PFS Lookup Tool.
Final Thoughts on CPT Code 93798
In this guide, we simplified the CPT code 93798 for you. It is one of the most used codes in cardiology and requires attention to detail and proper documentation for reimbursement.
If you are facing frequent denials, we recommend getting professional cardiology billing services. Many billing companies, like NeuraBill, offer premium services at affordable prices.
