Knowledge Base Article

The first weekend in September marked the return of college football for another season.  Football is a rough sport that requires a lot of padding to prevent and lessen injuries, so football pads are a good thing.  If you have ever done home projects that require working on your knees, you quickly realize the value of knee pads.  And for long-winded speakers, you hope your chair has a comfortable pad.  All of these are good “pads,” but some pads are not so welcome.  The extra padding of weight gain and aging is not so good – for example those extra “pads” around your eyes.  Peripheral artery disease, abbreviated PAD, is another pad that is bad.  The October 2017 update of the Outpatient Prospective Payment System addresses ways Medicare handles these examples of bad “pads.”

Supervised Exercise Therapy (SET) for Peripheral Artery Disease (PAD)

Under a new National Coverage Determination (NCD) effective May 25, 2017, Medicare will pay for supervised exercise therapy (SET) for beneficiaries with intermittent claudication for the treatment of symptomatic peripheral artery disease. The October OPPS update provides details of the requirements and CPT coding for this service.

The Medicare requirements for coverage of SET for PAD are:

• A therapeutic-exercise training program consisting of 30-60 minute sessions,
• Generally up to 36 sessions over 12 weeks,
• Referral from the physician responsible for PAD treatment,
• Contractor discretion for an additional 36 sessions over an extended period of time with a second referral,
• Performed in a hospital setting or physician’s office,
• Delivered by personnel trained in exercise therapy for PAD and who ensure benefits outweigh harms,
• Direct supervision by a physician or non-physician practitioner trained in both basic and advanced life support techniques,
• Patient has no absolute contraindications to exercise as determined by their primary physician, and
• A face-to-face visit with the physician responsible for PAD treatment to obtain:
• The referral for supervised exercise therapy, and
• Information regarding cardiovascular disease and PAD risk factor reduction, such as education, counseling, behavioral interventions, and outcome assessments.

Peripheral artery disease (PAD) rehabilitation is reported with CPT code 93668 for each session.  This service is paid under OPPS with a status indicator of “S” (separate APC payment, not discounted when multiple).

Upper Eyelid Blepharoplasty and Blepharoptosis Repair

CMS is revising their policy on blepharoplasty and blepharoptosis when performed together.  Before addressing the revision, let’s review the differences in these procedures and the prior policy.  Blepharoplasty is removing “pads” (excess fat or skin) around the eye. This is often a cosmetic procedure to improve appearance and cosmetic procedures are not covered by Medicare.  Medicare may cover blepharoplasty if there is medical need, such as an injury or the excess skin interferes with vision.  Ptosis repair tightens muscles around the eye to raise the height of a drooping eyelid.  Medicare’s prior policy, as clarified in the July 2016 OPPS Update, was that any removal of upper eyelid tissue (blepharoplasty) performed in conjunction with a ptosis repair of the same eye was considered a part of the blepharoptosis repair and could not be billed separately to Medicare or to the patient.

Effective October 1, 2017, CMS is revising this policy to allow either cosmetic or medically necessary blepharoplasty to be performed in conjunction with a medically necessary upper eyelid blepharoptosis surgery.  This means both procedures can be billed when performed together on the same eye – medically necessary procedures to Medicare and procedures performed for cosmetic reasons to the patient.  Patients should be made aware of their financial obligations for cosmetic procedures per Advance Beneficiary Notice (ABN) instructions.  If both the ptosis repair and the blepharoplasty are medically necessary and billed to Medicare, the payment for the blepharoplasty is bundled into the comprehensive APC payment for the blepharoptosis. In other words, when Medicare covers both procedures, there is no separate payment for the blepharoplasty.

The article also includes a list of practices related to blepharoplasty and blepharoptosis that are not appropriate for separate payment under Medicare, such as procedures performed on different dates.  Please refer to the October 2017 OPPS Update for the full list.  You can also find additional information on the original policy clarification in a prior article on this subject.

When billing Medicare for exercise therapy for PAD or blepharoplasty procedures, you need to grab your pad of paper and your favorite padded ink pen, sit in your most comfortable padded chair, and make notes on Medicare’s rules about “pads.”