Knowledge Base Article

It is no secret that physical activity and exercise are good for you. For most healthy adults, the Department of Health and Human Services recommends at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity a week, or a combination of the two. Medicare patients with certain conditions can participate in structured exercise programs as a benefit through Medicare. For example, there are cardiac and pulmonary rehabilitation programs for patients who meet certain cardiac and obstructive pulmonary criteria and in 2017 Medicare approved supervised exercise therapy for patients with symptomatic peripheral artery disease.

On February 1, 2019, CMS issued a new transmittal that clarified the payment rules and expanded the list of covered diagnosis codes for supervised exercise therapy (SET). Here are some things providers need to know about SET:

• On May 25, 2017, CMS issued a National Coverage Determination (NCD) to cover SET for Medicare beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD).
• Claudication is pain in the thigh, calf, or buttocks that occurs when walking. Intermittent claudication (IC) is the most common symptom experienced by people with PAD.
• SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC.
• SET consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication.
• It must be performed in an outpatient hospital setting or a physician’ s office.
• It must be delivered by qualified auxiliary personnel trained in exercise therapy for PAD and under the supervision of a physician or non-physician practitioner (PA, NP, or CNS).
• Medicare covers up to 36 sessions over a 12-week period with the option, at the discretion of the Medicare Administrative Contractor (MAC), to cover an additional 36 sessions (up to 72 sessions) over an extended period of time. Providers should append the KX modifier to sessions beyond the initial 36 to attest documentation is on file verifying that further treatment is medically necessary and meets the policy requirements.
• Patients must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the patient must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments. Be sure there is documentation of this visit in your SET records to support coverage.
• SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary attending physician.
• SET is reported with CPT code 93668 and an appropriate diagnosis code is required for coverage. Please see the ICD-10 diagnosis code table in the transmittal for covered diagnoses.

People should start their own exercise regimen while they are healthy and before health conditions qualify them for one of Medicare’s exercise programs. An ounce of prevention is worth a pound of cure.