Cardiac Rehabilitation for Ambulatory Care Providers


What is cardiac rehabilitation (CR)?

-          CR is a comprehensive intervention that includes medical evaluation, exercise, cardiac risk factor modification, and education.  The goals is to reduce the risk of death, control cardiac symptoms, and improve the psychosocial and vocational status1

-          CR typically includes exercise sessions 2-3 times per week for 12-18 weeks

o        Most also include counseling on diet, smoking cessation, medication adherence, and psychosocial support

-          CR is endorsed by the American Heart Association (AHA), American College of Cardiology2, CMS/HHS3 & AHRQ4

-          Despite strong evidence, it is an underused resource:

o        Less than 30% of eligible patients participate in CR after a CV event nationwide5-7   

o        Only about 12% of eligible New York State Medicare patients had CR after a CV event in 19978

o        Women, the elderly, and non-whites are less likely than whites to be referred and enroll in CR5, 9


What is the evidence for CR?

-          The benefit of CR in secondary cardiovascular disease prevention is well established with a mortality benefit of 20-25%2

o        A meta-analysis of 48 randomized control trials (RCT) with a median follow-up of 15 months showed in patients with coronary heart disease, compared to usual care participation in CR was associated with10:

§         20% reduction in all-cause mortality (OR 0.80; 95% CI: 0.68-0.93)

§         26% reduction in cardiac mortality (OR 0.74; 95% CI: 0.61-0.96)

§         Greater reductions in total cholesterol level, triglyceride level, systolic blood pressure, and lower rates of self-reported smoking

o        A meta-analysis of 63 RCTs showed a 17% reduction in recurrent MI over a median 12-month follow-up11 

Text Box: ICD-9-CM Codes for CR:

410.00-410.92 Acute MI
412        Old MI (>8 weeks)
413.9     Other and unspecified angina pectoris 
414.8     Other specified forms of chronic                     
                ischemic heart disease 
V15.1    Personal history of surgery to heart 
                and great vessels  
V42.1    Heart replaced by transplant 
V42.2    Heart valve replaced by transplant 
V43.3    Heart valve replaced by other means 
V45.81  Postsurgical aortocoronary bypass 
V45.82  Postprocedural PTCA status

Who should be referred?

-           According to the AHA,  all patients evaluated in the outpatient setting who in the last 12 months have experienced2 :

o        MI/acute coronary syndrome

o        CABG

o        PCI/PTCA

o        Chronic stable angina

o        Heart valve surgical repair or replacement

o        Heart or heart/lung transplantation

-          There is growing evidence for the benefit of CR in chronic heart failure and peripheral arterial disease

-          Those with contraindications to exercise or existing high-risk condition should not be referred


How do I refer a patient?

-         Encourage your patient to follow-up: A main predictor of patient participation in CR is strong physician endorsement 12

-          Identify and contact a cardiac rehab facility

o        Choose a facility close to the patient’s home to promote patient follow-up12

o        Facilities vary on their referral processes; many require a standard form that must be faxed

-          How do I know if my patient’s insurance covers cardiac rehab? 

o        Most CR facilities have billing departments that will contact the insurance provider to determine eligibility and obtain prior authorization.  They CR facility may contact you if your patient is ineligible or if more information is needed for authorization. 

o        Insurance carriers vary by qualifying conditions, number of sessions allowed, and the time frame for referral after an event; some only accept referral from a cardiologist

o        Medicare covers referral for all AHA recommended conditions.  Patients with MI must referred within one year of the event, but there is no time limit on other diagnoses

o        A list of ICD-9 codes covered by most Medicare programs are found above

-          Include necessary documents in the referral to facilitate insurance approval

        Recent clinical note or hospital discharge summary documenting medical necessity

        Cardiac catheterization report, stress test, relevant laboratory studies (lipid panel, HbA1c)

        Recent stress test is often needed to qualify for coverage for stable angina



1.        Wenger NK, Foelicher ES, Smith LK, Ades PA, et al.  Cardiac Rehabilitation: Practice Guideline 17: U.S. Department of Health and Human Services; 1995.  

2.        Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J; American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee.  AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.  Circulation. 2007 Oct 2;116(14):1611-42.

3.        Centers for Medicare and Medicaid Services Decision Memo for Cardiac Rehabilitation Programs (CAG-00089R)U.S. Department of Health & Human Services; 2006.

4.        Agency for Health Care Research Technology Assessment Program.  Randomized trials of secondary prevention programs in coronary artery disease: a systematic review.  Agency for Health Care Research and Quality.  2005. 

5.        Thomas RJ, Miller NH, Lamendola C, et al. National survey on gender differences in cardiac rehabilitation programs: patient characteristics and enrollment patterns. J Cardiopulm Rehabil 1996;16:402–12.

6.        Receipt of cardiac rehabilitation services among heart attack survivors—19 states and the District of Columbia, 2001

MMWR Morb Mortal Wkly Rep 2003;52:1072-1075.

7.        Cortes O, Arthur HM. Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review Am Heart J 2006;151:249-256.

8.        Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB.  Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery.  Circulation. 2007 Oct 9;116(15):1653-62.

9.        Witt BJ. Jacobsen SJ. Weston SA. Killian JM. Meverden RA. Allison TG. Reeder GS. Roger VL. Cardiac rehabilitation after myocardial infarction in the community. Journal of the American College of Cardiology. 44(5):988-96, 2004 Sep 1.

10.     Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials Am J Med 2004;116:682-692.

11.     Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease Ann Intern Med 2005;143:659-672.

12.     Jackson et al.  Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors.  Heart 2005;91:10-14.