93668
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$15.36
Non-Facility
$15.36
Documentation Required
- ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim.
- The submitted medical record must document and support the use of the selected ICD-10-CM code(s) and the medical necessity for supervised exercise therapy.
- The submitted CPT/HCPCS code must accurately describe the service performed.
- A physician referral is required for the initial course of supervised exercise therapy and the second 36-session course; the second referral must meet the same requirements as the initial referral.
Key Coverage Criteria
- Supervised exercise therapy is covered for beneficiaries with peripheral arterial disease (PAD) presenting with symptomatic lower-extremity intermittent claudication when documented with appropriate ICD-10-CM diagnosis code(s).
- Supervised exercise therapy (SET) is covered for beneficiaries with a diagnosis of peripheral arterial disease (PAD) of the lower extremities who have symptomatic intermittent claudication (IC).
- Coverage requires documented activity limitations in mobility that are attributable to IC and a therapeutic goal of improving those activity limitations.
- Beneficiary must be referred to SET by a physician after a face-to-face encounter that documents PAD as the diagnosis being treated and that the patient can reasonably tolerate SET (measured against potential benefits and harms) in accordance with NCD 20.35.
- A formal plan of care signed by the treating physician for PAD must be established before initiating SET, describing baseline functional status, treatment goals, exercise program, projected frequency and duration, and plans to assess benefits and harms.
- SET must be delivered under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist credentialed and trained in basic and advanced life support, with their name and credentials legible in the record and an indication of direct supervision per 42 CFR §410.32(b)(3)(ii).
3 Active Policies
AETNA-CPB-0458 — Peripheral Vascular Rehabilitation Programs
A56384 — Billing and Coding: Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication
L37774 — Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication
Related Codes
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