Local Coverage Article Billing and Coding

Billing and Coding: Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication

A56384

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Contractor Information

Article Information

General Information

Article ID
A56384
Article Title
Billing and Coding: Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication
Article Type
Billing and Coding
Original Effective Date
03/14/2019
Revision Effective Date
10/17/2019
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process that claim.

 

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication.

After the initial 36 treatment sessions or 12 weeks (whichever comes first) beneficiaries may be eligible for another 36 treatment sessions with another referral from a physician. The requirements of this second referral are the same as for the initial referral. All claims submitted for additional sessions after the first 36 sessions or the initial 12 week period must append modifier -KX to the CPT code for this service in order to attest that those requirements have been fulfilled.

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

Any diagnosis submitted must have documentation in the patient’s record to support coverage and medical necessity.

The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

The CPT codes are considered medically necessary when the Indications of Coverage are met.

Part A:

Contractors shall pay claims for SET services containing CPT code 93668 on Types of Bill (TOBs) 13X under OPPS and 85X based on reasonable cost.

Part B:

Claims for CPT 93668 are limited to be billed in POS 11 only in Part B.

Group 1 Codes
CodeDescription
93668 PERIPHERAL ARTERIAL DISEASE (PAD) REHABILITATION, PER SESSION

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET

ICD-10-CM Codes that Support Medical Necessity

Group 1

(24 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg
I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs
I70.218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity
I70.311 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg
I70.312 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg
I70.313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.318 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, other extremity
I70.411 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg
I70.412 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, left leg
I70.413 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.418 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, other extremity
I70.511 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, right leg
I70.512 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, left leg
I70.513 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.518 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, other extremity
I70.611 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, right leg
I70.612 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, left leg
I70.613 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.618 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, other extremity
I70.711 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, right leg
I70.712 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, left leg
I70.713 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.718 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, other extremity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All other ICD-10-CM codes not listed under “ICD-10-CM Codes that Support Medical Necessity” will be denied as not medically necessary.

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
013x Hospital Outpatient
085x Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Part A:

Contractors shall not pay claims for SET services containing CPT 93668 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II


CodeDescription
096X Professional Fees - General Classification
097X Professional Fees - Laboratory
098X Professional Fees - Emergency Room Services

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/17/2019 R3

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of the related Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication L37774 LCD and placed in this article. Under Article Title changed title from “Billing and Coding for Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication” to “Billing and Coding: Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication”. Under CPT/HCPCS modifiers section added modifier KX.

07/01/2019 R2

Under Revenue Codes: Codes the description changed for Revenue code 0964. This revision is due to the 2019 Annual NUBC Code Update and is effective for dates of service on or after 7/1/2019.

03/14/2019 R1

Under Bill Type Codes added 013x and 085x. Under Revenue Codes: Paragraph added the verbiage “ Part A: Contractors shall not pay claims for SET services containing CPT 93668 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II”. Under Revenue Codes: Codes added 096x, 097x, and 098x. Under CPT/HCPCS Codes Group 1: Paragraph added the verbiage “Part A: Contractors shall pay claims for SET services containing CPT code 93668 on Types of Bill (TOBs) 13X under OPPS and 85X based on reasonable cost. Part B: Claims for CPT 93668 are limited to be billed in POS 11 only in Part B.” Under ICD-10 Codes that Support Medical Necessity Group# 1: Codes added I70.411, I70.412, I70.413, I70.418, I70.511, I70.512, I70.513, and I70.518 due to Change Request #11022.

This Article will be effective on 3/14/19 and revision 1 has a retroactive effective date of 5/25/17.

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/08/2019 10/17/2019 - N/A Currently in Effect You are here
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Keywords

  • SET
  • PAD