A Medicare cardiac or pulmonary rehabilitation program is a supervised program of physician-prescribed exercise and related services that has to meet the coverage conditions in 42 CFR 410.49 (cardiac) and 42 CFR 410.47 (pulmonary). It is for a hospital or practice that is starting an outpatient rehabilitation program, or adding one to the other, and needs the program elements and documentation in place. Integral Healthcare Solutions (IHS) drafts the design, templates and checklists for your medical director and clinicians to approve.
Last updated: November 2026
What does Medicare require of a cardiac or pulmonary rehabilitation program?
Medicare requires a supervised program with defined elements, a written plan for each patient and a physician who oversees it. Section 410.49(a) says: "Cardiac rehabilitation (CR) means a physician or nonphysician practitioner supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment." Section 410.47(a) says pulmonary rehabilitation "means a physician or nonphysician practitioner supervised program for COPD and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy."
The governing texts are 42 CFR 410.49, the cardiac rehabilitation and intensive cardiac rehabilitation conditions of coverage, and 42 CFR 410.47, the pulmonary rehabilitation conditions for coverage, as they stand in the current eCFR Title 42 (last amended October 8, 2026). We read both sections on November 5, 2026 from the Government Publishing Office eCFR data file built November 4, 2026. The approval criteria for an intensive cardiac rehabilitation program are outside this page.
| Current eCFR provision | Requirement | IHS draft |
|---|---|---|
| 410.49(b)(2); 410.47(b)(2) | Both programs include physician-prescribed exercise, psychosocial and outcomes assessments, and an individualized treatment plan. Cardiac exercise occurs each day services are furnished; pulmonary exercise occurs each session. Cardiac risk factor modification includes education, counseling and behavioral intervention tailored to individual needs. Pulmonary education or training must closely relate to care and treatment, address individual needs and support independence in daily activities, adaptation to limitations and improved quality of life. It includes respiratory problem management and, if appropriate, brief smoking cessation counseling. | Program design and component records |
| Both sections (a), (b)(2)(v) | A written, patient-specific plan describes diagnosis; service type, amount, frequency and duration; goals; and how components are used. A physician establishes, reviews and signs it every 30 days. | Treatment plan and review tracker |
| Both sections (a) | Outcomes assessments include patient-centered evaluations at program start and end, measured by the physician or staff. The physician considers staff evaluations when developing or reviewing plans. Assessments include objective exercise-performance measures and self-reported behavior plus exertion for cardiac rehabilitation or shortness of breath for pulmonary rehabilitation. | Outcomes forms |
| Both sections (b)(3) | Part B pays in physician offices and hospital outpatient settings. A physician or nonphysician practitioner must be immediately available and accessible for consultations and emergencies throughout services. This condition is satisfied by meeting direct-supervision requirements under 410.26 for offices or 410.27 for hospital outpatient services. Pulmonary settings also need medically necessary cardio-pulmonary, emergency, diagnostic and therapeutic life-saving equipment accepted by the medical community to treat chronic respiratory disease. | Setting, coverage and equipment records |
| 410.49(d); 410.47(c) | The physician medical director oversees the site and, with staff, directs patients' progress. Required qualifications are expertise in managing individuals with cardiac or respiratory pathophysiology respectively, cardiopulmonary training in basic life support or advanced cardiac life support, and a medical license in the program's State. | Director role and credentials |
| Both sections (a); 410.49(e); 410.47(d) | Supervisors may be physicians, physician assistants, nurse practitioners or clinical nurse specialists. They need expertise in managing individuals with the relevant cardiac or respiratory pathophysiology and cardiopulmonary training in basic life support or advanced cardiac life support. | Supervisor roles and credentials |
Both programs require physician review and signature of each treatment plan every 30 days. The draft documents in the table are IHS’s proposed evidence tools, not CMS-prescribed forms.
Who needs it and what triggers it?
This service is for hospitals and practices starting or adding a rehabilitation program. Patient eligibility differs by track under 42 CFR 410.49(b)(1) and 42 CFR 410.47(b)(1), current eCFR; page opened November 5, 2026.
Cardiac coverage includes acute myocardial infarction within the preceding 12 months; coronary bypass surgery; current stable angina; heart valve repair or replacement; percutaneous transluminal coronary angioplasty or coronary stenting; and heart or heart-lung transplant. Stable chronic heart failure qualifies with left ventricular ejection fraction of 35 percent or less and NYHA class II–IV symptoms despite optimal heart failure therapy for at least six weeks, effective February 18, 2014 for cardiac rehabilitation and February 9, 2018 for intensive cardiac rehabilitation. Other cardiac conditions may be specified through a national coverage determination; that process may also specify noncoverage for intensive cardiac rehabilitation when clinical evidence does not support coverage.
Pulmonary coverage includes moderate to very severe COPD (GOLD II, III or IV) with referral by the physician treating the chronic respiratory disease, or confirmed or suspected COVID-19 with persistent symptoms including respiratory dysfunction for at least four weeks. Additional pulmonary indications may be established through a national coverage determination.
How IHS helps
IHS assesses gaps against both sections, maps evidence and drafts missing documents. We then conduct a mock document review and help your team resolve readiness gaps. The drafts are a program design document, protocols and documentation templates, an individualized treatment plan template with a 30-day review tracker, outcomes assessment forms, an eligibility and referral checklist, a compliance checklist and role descriptions for the medical director and supervising practitioner. Integral Healthcare Solutions (IHS) was founded in 2002 by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC, and works across three practice lines: accreditation consulting, compliance services and program development. This build sits in our Program Development practice line.
Your organization supplies the medical director and supervising practitioners and their credentials, the clinical protocols your clinicians approve, equipment and emergency procedures, referral and eligibility documents for each patient, and the physician signatures on treatment plans.
The limit: IHS does not set exercise prescriptions or clinical protocols, because the medical director and clinicians approve them. IHS does not enroll the program or bill Medicare; your organization does.
What to have ready
These items let a gap assessment start quickly, and each ties to the two sections as read on November 5, 2026.
- Medical director designation, qualifications and role (42 CFR 410.49(a), (d); 410.47(c)).
- Supervising practitioners, credentials and coverage schedule (42 CFR 410.47(a), (b)(3), (d); 410.49(e)).
- Program components, including cardiac risk factor modification or pulmonary education (42 CFR 410.47(b)(2); 410.49(b)(2)).
- Patient-specific treatment plan and physician 30-day review tracker (42 CFR 410.49(a), (b)(2)(v); 410.47(b)(2)(v)).
- Physician-prescribed exercise records (42 CFR 410.49(b)(2)(i); 410.47(b)(2)(i)).
- Separate eligibility checklists, including the treating-physician referral for COPD (42 CFR 410.47(b)(1); 410.49(b)(1)).
- Setting and pulmonary emergency equipment records (42 CFR 410.47(b)(3); 410.49(b)(3)).
- Psychosocial and outcomes assessment forms (42 CFR 410.49(a), (b)(2); 410.47(a), (b)(2)).
If several are missing, book the free introductory call and bring what you have.
How does outside drafting support compare with other routes?
An internal build puts drafting and review with your medical director and staff. IHS drafting support adds a gap assessment, document preparation and a mock review; your clinicians still approve clinical content. Compare the drafting capacity you need and the clinician time available for review.
What does it cost?
Neither reviewed CFR section publishes a program-start fee schedule; these coverage rules do not establish all costs of starting a program. IHS scopes each engagement after a free introductory call. Scope depends on the programs, sites and documents involved.
Budget staff time to supply records and review drafts, and physician time to establish, review and sign treatment plans.
What this is not
This is not legal advice. IHS is a consulting firm, not a law firm, and your counsel and billing staff confirm coverage and billing questions. It is not a guarantee that Medicare covers a service or that a contractor accepts a claim. IHS does not enroll the program or bill Medicare; your organization does.
Frequently asked questions
What does Medicare require of a cardiac rehabilitation program?
Section 410.49 defines cardiac rehabilitation as a physician or nonphysician practitioner supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment and outcomes assessment. Each patient needs an individualized treatment plan, and a physician oversees the program as medical director. IHS drafts the design document and templates.
What must an individualized treatment plan contain, and how often must a physician sign it?
Both sections define a written, patient-specific plan describing diagnosis, service type, amount, frequency and duration, and goals. Under 410.49(b)(2)(v) and 410.47(b)(2)(v), it details how components are used and must be established, reviewed and signed by a physician every 30 days. IHS drafts the template and review tracker.
What does Medicare require of a pulmonary rehabilitation program?
Under 410.47, pulmonary rehabilitation combines physician-prescribed exercise each session, patient-specific education or training, psychosocial and outcomes assessments, and an individualized treatment plan. The table above details the education, supervision and plan-review requirements. IHS drafts documentation for clinical approval.
Which COPD patients qualify for pulmonary rehabilitation?
Section 410.47(b)(1)(i) covers a patient with moderate to very severe COPD, defined as GOLD classification II, III and IV, when referred by the physician treating the chronic respiratory disease. The section also covers a patient with confirmed or suspected COVID-19 and persistent symptoms that include respiratory dysfunction for at least four weeks. IHS's eligibility and referral checklist carries each criterion for your clinicians to confirm.
Who may supervise cardiac and pulmonary rehabilitation sessions?
Both programs permit supervision by a physician, physician assistant, nurse practitioner or clinical nurse specialist who is immediately available and accessible for medical consultations and emergencies throughout services. Sections 410.49(e) and 410.47(d) require expertise in managing individuals with cardiac or respiratory pathophysiology respectively and cardiopulmonary training in basic life support or advanced cardiac life support. The settings provisions recognize satisfaction through the applicable direct-supervision requirements in 410.26 or 410.27.
What does the medical director do?
The physician medical director oversees the program at its site and, in consultation with staff, directs patients’ progress. Sections 410.49(d) and 410.47(c) require expertise in managing individuals with the relevant cardiac or respiratory pathophysiology, cardiopulmonary training in basic life support or advanced cardiac life support, and a medical license in the program’s State. IHS drafts the role description for physician approval.
Where does Medicare Part B pay for cardiac rehabilitation?
Medicare Part B pays for cardiac rehabilitation in physician offices and hospital outpatient settings under 410.49(b)(3). Both settings require a physician or nonphysician practitioner immediately available and accessible for consultations and emergencies throughout services; this condition is satisfied by meeting 410.26 or 410.27 direct-supervision requirements for the respective setting.
Should a program combine cardiac and pulmonary rehabilitation documentation?
IHS can draft a shared document structure for clinical review while retaining separate eligibility criteria and program components for each track. Both rules use the same supervising-practitioner definition, but require expertise in managing individuals with cardiac or respiratory pathophysiology respectively.
What does a rehabilitation program readiness build cost?
Neither reviewed CFR section publishes a program-start fee schedule; that does not establish all startup costs. IHS scopes each engagement after a free introductory call, based on programs, sites and existing documents. Include staff review and physician time in your budget.