Get Set for SET: Supervised Exercise Therapy

Newly covered treatment offers promising relief for sufferers of condition tied to poor blood circulation in the legs.

 The main symptom of peripheral arterial disease (PAD) is intermittent claudication. This is an aching, cramping, tired, and sometimes burning sensation in the legs that comes and goes – it typically occurs when walking and goes away with rest – that arises due to poor circulation of blood in the arteries of the legs.

In severe claudication, the pain is also felt at rest. Intermittent claudication may occur in one or both legs and often continues to worsen over time. However, some patients complain only of weakness in the legs when walking or a feeling of “tiredness” in the buttocks. The usually intermittent nature of the pain is due to narrowing of the arteries that supply the leg with blood, limiting the supply of oxygen to the leg muscles: a limitation that is felt especially when the oxygen requirement of these muscles rises with exercise.

Intermittent claudication can be due to temporary artery narrowing due to vasospasm (spasm of the artery), permanent artery narrowing due to atherosclerosis, or complete occlusion (closure) of an artery to the leg. The condition is quite common, more so in men than women. It affects 1-2 percent of the population under 60 years of age, 3-4 percent of persons age 60 to 70, and over 5 percent of people over 70.

The prognosis of intermittent claudication is generally favorable because the condition often stabilizes or improves in time. Conservative therapy is advisable. Walking often helps increase the time that the patient can go without symptoms. A program of daily walking for short periods, and stopping for pain or cramping, often helps improve function by encouraging the development of collateral circulation, that is, the growth of new small blood vessels that bypass the area of obstruction in the artery. It is essential to stop smoking, avoid applications of heat or cold on legs, and to avoid tight shoes. Good advice from the Mayo Clinic.

Effective May 25, 2017, but to be fully implemented July 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD).

Related change request (CR) number: 10295.

Make sure your coding and billing staffs are aware of these changes.

SET involves the use of intermittent walking exercise, which alternates periods of walking to alleviate moderate-to-severe claudication with rest. SET has been recommended as the initial treatment for patients suffering from IC. Because patients have had limited access to SET, per CMS discussion, endovascular revascularization procedures such as PTA, stenting, and atherectomies have continued to increase. 

CMS issued the aforementioned NCD to cover SET for beneficiaries with IC for the treatment of symptomatic PAD. There are limitations for how many such treatments will be allowed. This change request allows up to 36 sessions over a 12-week period. If all of the following components of a SET program are met, the beneficiary will be covered:

A SET Program MUST:

• Consist of 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 that benefits exceed harms, and who are trained in exercise therapy for PAD.
• Be coordinated under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act) who must be trained in both basic and advanced life support techniques.

Beneficiaries must also have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.

Coding Requirements for SET

Providers should use Current Procedural Terminology (CPT®) code 93668 (under peripheral arterial disease rehabilitation) to bill for these services, along with the appropriate ICD-10 code as follows:

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

I70.718 – other extremity

Program Note:

Listen to Terry Fletcher report on SET on Talk Ten Tuesdays during this morning’s broadcast, as well as more on this topic and expanded Medicare coverage details that may affect your reimbursement.

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