Knowledge Base Article

Regardless of where you stand politically – conservative, liberal, or moderate – you must admit that sometimes a conservative approach is best.  This can be true with medical treatments. Medicare coverage policies often require conservative treatments be tried and fail before more aggressive and invasive treatments are covered. There are at least two benefits to this – conservative treatments usually cost less and save Medicare dollars if they are successful and there are fewer medical risks to the patient than with the more invasive procedures. Sometimes Medicare can be slow in following their own advice.  Despite years of high-quality research illustrating the effectiveness of supervised exercise therapy (SET) to treat intermittent claudication associated with peripheral vascular disease (PAD), more invasive treatment options (i.e., endovascular revascularization) have continued to increase. This may be due to lack of Medicare coverage and limited access to SET programs.  Hopefully this will change with the new Medicare National Coverage Determination (NCD).

On February 7, 2018, MLN Matters Article MM10295 was released explaining the new coverage and claims processing requirements for Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).  Intermittent claudication is aches, cramps, numbness or a sense of fatigue, usually in the calf muscle, during mild exertion, such as exercise or walking, that is relieved by a short period of rest.  It is the most common symptom experienced by people with PAD. 

Under the new NCD 20.35, Medicare will cover SET for up to 36 sessions over 12 weeks, with the option of coverage for another 36 sessions at the discretion of the Medicare Administrative Contractor(MAC) when the services are reported with the KX modifier, attesting the medically necessary need for additional sessions. SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest and is recommended as the initial treatment for patients suffering from IC.  Coverage is effective for services performed on or after May 25, 2017. Other Medicare requirements for coverage of SET for PAD include:

• 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, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques,
• Patients must have a face-to-face visit with the physician responsible for PAD treatment to
• Obtain the referral for SET and
• Receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.

Coding

Report SET for symptomatic PAD with CPT code 93668 (Peripheral arterial disease (PAD) rehabilitation, per session) and with one of the following ICD-10 codes for atherosclerosis of extremities with intermittent claudication: I70.211 – right leg; I70.212 – left leg; I70.213 – bilateral legs; I70.218 – other extremity; I70.311 – right leg; I70.312 – left leg; I70.313 – bilateral legs; I70.318 – other extremity; I70.611 – right leg; I70.612 – left leg; I70.613 – bilateral legs; I70.618 – other extremity; I70.711 – right leg; I70.712 – left leg; I70.713 – bilateral legs.

In other coverage news this month, Palmetto GBA announced the coverage Articles unrelated to LCDs that will become effective for the newly transitioned Jurisdiction J on February 26, 2018 (the date the JJ Part B transition occurs; JJ Part A transitioned to Palmetto on January 29, 2018).  To see the announcement, including the list of articles, click here.  The LCDs for JJ Part A became effective upon their transition on January 29, 2018.  Those articles are now listed on the Medicare Coverage Database for Palmetto JJ.  You can also see a discussion of the LCDs selected for JJ and JM and a crosswalk here.  The crosswalk (link at bottom of the page) includes tabs for Palmetto LCDs that are new for Jurisdiction J and Cahaba policies that were adopted and are new for providers in Jurisdiction M. All the information providers need to know about the LCD changes can be found in the article and the crosswalk.