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  • CMS Will Cover Supervised Exercise Therapy for Peripheral Artery Disease

    Calling the supporting evidence "at least equivalent to already covered therapies" for intermittent claudication (IC), the US Centers for Medicare and Medicaid Services (CMS) announced that it will extend Medicare coverage for supervised exercise therapy (SET) to treat peripheral artery disease (PAD).

    The expansion, announced in a May 25 coverage decision, will cover physician-referred SET for up to 36 30 to 60-minute sessions over a 12-week period. The sessions must be conducted in a physician's office or outpatient facility, and must be delivered by "qualified auxiliary personnel" that includes physical therapists (PTs), nurses, and exercise physiologists. Supervision will be conducted by a physician or "non-physician practitioner"—a physician assistant, or nurse practitioner/clinical nurse specialist.

    "Trials showed that SET decreases mortality, reduces cardiovascular risk factors, increases exercise capacity, and increases quality of life in older adults," CMS states. "While in general exercise capacity alone, which was an endpoint in a number of studies, would not be an appropriate outcome, it is a meaningful outcome for IC due to symptomatic PAD since there is a well-established evidence link to all-cause mortality."

    To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit must also include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.


    • For physical therapists providing supervised exercise therapy (SET) for these patients, are there any differences in documentation or billing procedures compared to other diagnoses? For example, is the physician signed care plan required? Are functional treatment goals required? Are any specific diagnosis codes, CPT codes, or modifiers required on claim forms?

      Posted by Tony on 5/31/2017 4:39 PM

    • So where are outpatient PTs NOT working in the hospital covered? So when did exercise physiologists become reimbursable professionals in the Medicare program? Will this be coded as 97110? Will the 36 visits be subject to the CAP?

      Posted by Bobbie Hurt -> >HT^? on 5/31/2017 4:54 PM

    • What the typical Bill be therapeutic exercise and is it reimbursed the same as that code currently.

      Posted by Renee frank on 6/1/2017 8:21 AM

    • Exercise physiologists working incident to the physician have always been covered under cardiac rehab in the Medicare system. SET is realistically just an extension of those services since the exercise for PAD patients may not always approach the need for skilled therapies. This ruling requires PTs be directly supervised and answerable to a MD which opens up the potential abuse of physician owned PT practices taking this on as a way to get 36 visits. The reimbursement will be key as it may be counterproductive for PT to provide this service. I would advise looking at AACVPR's interpretation of this ruling.

      Posted by JL Carter on 6/1/2017 9:57 AM

    • I agree with Bobbie's questions and would like them answered. So now, MD's will hire LVN's to supervise exercise in their offices? Why stop at PAD?

      Posted by Mistie McBride on 6/1/2017 10:17 AM

    • When did nurses become exercise specialists?

      Posted by Donna Woods on 6/1/2017 11:59 AM

    • God Medicare is dumb "Supervised" exercise "therapy." Supervised by a physician or extender. When were they trained to supervise exercise or physical therapists? Where's the evidence to support their competence and the additional benefit of having that "supervision"? Medicare is lost in the 50's....

      Posted by Burton Ford on 6/2/2017 7:53 PM

    • A SET program must be conducted in a hospital outpatient setting or in a physician’s office and under the direct supervision of a physician, or physician assistant, nurse practitioner, or clinical nurse specialist who must be trained in both basic and advanced life support techniques. Physical therapists not practicing in these settings are not covered at this time. The requirements of the SET program are available at the link below. https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx Currently, CPT Code 93668 covers Peripheral Arterial Disease Rehabilitation. At this point we are unsure whether a new code will be developed or code 93668 will be revised. We are expecting more information when CMS releases the final National Coverage Determination contractor instructions and will share that information as it becomes available.

      Posted by APTA Staff on 6/9/2017 5:39 AM

    • Anyone know of Medicare/medical insurance covered supervised pool/water based exercising sessions? It would be easier on a patient (such as myself) who experiences excruciating pain and oft times have my feet collaspe out from underneath me causing more problems. Thank you .ap

      Posted by A. Pankratz on 8/7/2017 8:20 AM

    • Great. Medicare now pays for exercise therapy for PAD. Problem is I can't find a facility in Queens NY that is offering such a program. Does anyone know of where I can get this program?

      Posted by Sal on 8/27/2017 12:10 PM

    • It says that service must be provided in physicians office or hospital outpatient setting. Does anyone know if they have specifically prohibited private practices in providing these services?

      Posted by Shirley Reed -> ?GY[=H on 9/28/2017 2:16 AM

    • @Shirley Reed; Thanks for your question. Unfortunately, the NCD for SET for PAD limits coverage of SET to therapy provided in a physician’s office or a hospital outpatient setting. This precludes coverage of services that are provided in a private practice setting for a physical therapist. APTA urged CMS to reconsider this limitation.

      Posted by PT in Motion News on 9/28/2017 2:04 PM

    • what will this code reimburse the hospitals

      Posted by debra may on 10/23/2017 11:19 AM

    • Where can I find the NCD for SET?

      Posted by Magean Whaley on 11/14/2017 2:01 PM

    • CMS has not yet finalized the NCD contractor instructions guiding SET for PAD, but you can take a look at a CMS decision memo for guidance until the NCD is finalized. That memo can be found at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=287

      Posted by APTA STaff on 11/15/2017 8:34 AM

    • 1. Please define: “be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD” 2. Are there specific training programs that credential "qualified auxiliary personnel” or does CMS specify a structured training protocol? 3. Is the CPT Code 93668 covered for a Medicare Independent Diagnostic Testing Facility (IDTF)?

      Posted by Robert R. Ross, PA-C, BLS, ACLS, ATLS on 12/4/2017 7:21 AM

    • Do we have any additional updates on this article?

      Posted by chris on 1/4/2018 5:15 PM

    • Thanks for the question Chris. CMS has not yet published the final National Coverage Determination (NCD) contractor instructions within the NCD Manual. APTA staff have contacted CMS staff to request a status update of when we might expect the final NCD to be released.

      Posted by APTA Staff on 1/5/2018 11:22 AM

    • How is 93668 billed? Is it a timed or untimed code?

      Posted by Anamarie c. on 2/27/2018 3:34 PM

    • For an outpatient dept, Can you bill 93668 with the revenue code of 943, the dept it is being performed in on a ub04 claim? Everything I read indicated the pt revenue codes. Thank you for your help.

      Posted by Debbie Miller on 3/2/2018 11:53 AM

    • Do the charges that are used for this service, apply to the PT/SLP cap/threshold?

      Posted by Lori Sweet -> =KP_? on 3/29/2018 7:50 PM

    • @Lori - Thanks for the question! Services furnished under the outpatient therapy services benefit – including SLP, OT, and PT – are subject to the financial limitations. In order to accrue incurred expenses to the correct therapy cap, the use of one of the three therapy modifiers (GN, GO, or GP) is required on a certain set of Healthcare Common Procedure Coding System (HCPCS) codes in order to identify when each outpatient therapy service is furnished under an SLP, OT, or PT plan of care, respectively. For more information: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10176.pdf Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy and publishes this list as an Annual Update on the Therapy Services. The list of codes subject to the therapy cap tracking requirements can be found on the CMS website here: https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html CPT 93668 is not currently on the list of therapy codes subject to the therapy limits. It is recommended this list be checked annually to determine what codes CMS may have added or deleted.

      Posted by APTA Staff on 3/30/2018 8:30 AM

    • Are Co-pays and Deductible payments waived or must the patient pay the Co-pays and Deductible payments?

      Posted by Robert Ross on 9/1/2018 7:53 AM

    • @Robert: The beneficiary copayment and deductible continue to apply.

      Posted by APTA Staff on 9/4/2018 8:10 AM

    • Is there such a program for PAD in Queens NY?

      Posted by Salvatore Liggieri on 11/23/2018 12:57 PM

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