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Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)TECHNICAL REQUIREMENTS For Medicare & Medicare Advantage Coverage Sequence of Events: 2012 = Science: CLEVER study completed & published in Circulation; compelling evidence. 2012-2017 = Lobbying Congress for Medicare coverage by AHA, Vascular Society, etc. 5/25/2017 = “Effective”: Medicare Decision Memo released by CMS to signal that coverage is now approved * 2/01/2018 = “Active”: Notice received from most Medicare Administrative Contractors (MACs) for mid-Atlantic states that their computers are now ready to receive/process SET charges 2/02/2018 = “Technical instructions” sent by CMS to MACs re: how to process SET claims Spring 2018 = Completion of above steps means SET program can now “GO LIVE”! Description of Coverage: *“Research has shown supervised exercise therapy (SET) to be an effective, minimally invasive method to alleviate the most common symptom associated with peripheral artery disease (PAD) – intermittent claudication (IC). SET has been shown to be significantly more effective than unsupervised exercise and could prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients. SET has also been shown to perform at least as well as more invasive revascularization treatments that are covered by Medicare”. (National Coverage Determination (NCD), CMS pub.no. 100-3, section 20.35; February 2018). Patient requirements Medicare/Medicare Advantage beneficiaries with intermittent claudication (IC) NO particular diagnostic testing requirements MUST have medical record proof of current/recent IC Recently seen (face-to-face) & referred by physician treating PAD No absolute contraindications to exercise per that physician: NOTE: consider both cardiovascular and extremity contraindications Program REQUIREMENTS Components Up to 36 sessions over 12 weeks = NO roll-overs or extensions 30-60 minutes of exercise = moderate to maximal pain level Conducted in hospital outpatient setting or physician’s office = ONLY approved sites Delivered by qualified personnel to ensure benefit exceeds harm = trained in exercise therapy for PAD Be under direct supervision by a physician, physician assistant, or nurse practitioner = MUST be trained in both BLS & ACLSCoding: ICD-10 Diagnostic codes Referral MUST be accompanied by appropriate diagnosis = one of 16 codes as shown on attached sample referral form. PLEASE NOTE: contrary to earlier advice, ICD-10 code I 73.9Peripheral Vascular Disease, unspecifiedNOT a covered diagnosis!because it does not specify “intermittent claudication”, which is required. .Billing: Revenue code = 943, Cardiovascular Services One new billing code = CPT 93668 Medicare reimbursement = $55.96 (national average); incudes $11.20 patient co-pay. Coding additions/precautions An initial stress test (Gardner protocol) is recommended & when done would be billed through the stress lab A 6 Minute Walk Test (6MWT) can be done & billed by rehab program = billed as 94618 “simple pulmonary stress test” Only 1 session can be billed per day, not 2 as in Cardiac & Pulmonary RehabAs in Pulmonary Rehab, there is a lifetime limit of 72 visits = 2nd round of SET requires a separate order at a separate time Any/every visit from # 37 on, requires a KX modifier to signal to Medicare that adequate proof of medical necessity is contained in the patient’s file Physician rolesNO Medical Director required by Medicare, but recommended by AACVPR Office visit MUST be completed by physician treating the patient’s PAD = rehab should retrieve that visit note to confirm that “the beneficiary received information regarding cardiovascular disease & PAD risk factors reduction”, along with a referral to SET. “Direct supervision” by a physician, physician assistant, or nurse practitioner, who is trained in both BLS & ACLS. NOTE: the addition of NP/PA daily coverage is unique to the SET program & does not, at the present time, extend to CR or PR. Staffing requirements NO specific discipline required, but: “be delivered by qualified personnel auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD”. Documentation NOT RequiredRequiredRecommendedITPs!!30-day reports Telemetry strips Education classes Referral signed by a physician Note of recent face-to-face physician - patient visit Daily exercise notes = to provide evidence of: service delivery, including 30-60 minutes if exercise moderate claudication during exercise Initial assessment, including foot inspection Pre-post outcome data: Stress test or 6MWT Exercise time or MET-minutes Quality of Life Depression status Risk factors: Tobacco useDiabetic status Blood pressure Symptomatic reports, especially signs of CAD Staff Training CompetenciesReferencesAnkle-Brachial Index (ABI) Doppler pulses in legs PAD Medications PAD Exercise Training Toolkit, Clever study results, Circulation, January 2012 AHA/ACC 2016 PAD Guidelines ................
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