PAD Rehab is Now Paid by Medicare

Posted by Kathy Dean on 10/24/2017

CPT 93668 Peripheral arterial disease (PAD) rehabilitation, per session

Billing for Peripheral Artery Disease (PAD) Rehabilitation
October 2017 OPPS Update Transmittal R3864CP

Effective May 25, 2017, the Centers for Medicare & Medicaid Services (CMS) will pay for supervised exercised therapy (SET) for beneficiaries with intermittent claudication for the treatment of symptomatic peripheral artery disease. To implement this National Coverage Determination (NCD), CMS will pay separately for CPT code 93668 under the hospital OPPS.

Prior to May 25, 2017 the PAD Rehab code 93668 was statutorily excluded from the Medicare program and no payment was made.

For purposes of Medicare coverage, services must meet all of the following eligibility criteria:

  • Consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication
  • Be conducted in a hospital outpatient setting, or a physician’s office
  • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
  • Be under the direct supervision of a physician (as defined in 1861(r)(1)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) who must be trained in both basic and advanced life support techniques.

Beneficiaries must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.

  1. MACs have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time. A second referral is required for these additional sessions.
  2. SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary physician.

Table 2 lists the long descriptor, status indicator, and APC assignment for CPT code 93668. The payment amount for CPT code 93668 is available in the October 2017 OPPS Addendum B.

Table 2 ─ Peripheral Artery Disease (PAD) Rehabilitation

CPT Code

Long Descriptor

OPPS SI

OPPS APC

Medicare Payment

93668

Peripheral arterial disease (pad) rehabilitation, per session

 

S

 

5733

 

$54.55

 

CMS Decision Memo for Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N)

  1. The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD).  Up to 36 sessions over a 12 week period are covered if all of the following components of a SET program are met:

The SET program must:

    • consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
    • be conducted in a hospital outpatient setting, or a physician’s office;
    • be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and
    • be under the direct supervision of a physician (as defined in 1861(r)(1)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) who must be trained in both basic and advanced life support techniques.

Beneficiaries must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET.  At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.

  1. Medicare Administrative Contractors (MACs) have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time.  A second referral is required for these additional sessions.
  2. SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary physician.

For more information on this recent NCD, refer to the “Decision Memo on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N),” which is available at:

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=287