CMS Pub. 100-04, ch. 32, § 390

Effective for claims with dates of service on or after May 25, 2017, the Centers for Medicare and Medicaid Services

(CMS) will cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the

treatment of symptomatic peripheral artery disease (PAD). Up to 36 sessions over a 12 week period are covered if all of

the following components of a SET program are met:

The 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 physician’s office;

• be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in

exercise therapy for PAD; and

• be under the direct supervision of a physician (as defined in 1861(r)(1)) of the Social Security Act (the Act)),

physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) of (the Act) who

must be trained in both basic and advanced life support techniques.

Beneficiaries must 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.

SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary

attending physician. .

Please refer to the National Coverage Determinations Manual (Publication 100-03, Section 20.35) for more information.

390.1 General Billing Requirements

(Rev. 4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)

Effective for claims with date of services on or after May 25, 2017, contractors shall pay claims for SET for

beneficiaries with IC for the treatment of symptomatic PAD, with a referral from the physician responsible for PAD

treatment.

Medicare Administrative Contractors (MACs) have the discretion to cover SET beyond 36 sessions over 12 weeks and

may cover an additional 36 sessions over an extended period of time. Contractors shall accept the inclusion of the KX

modifier on the claim line(s) as an attestation by the provider of the services that documentation is on file verifying that

further treatment beyond the 36 sessions of SET over a 12 week period meets the requirements of the medical policy.

390.2 Coding Requirements for SET

(Rev. 4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)

• CPT 93668 – Under Peripheral Arterial Disease Rehabilitation

• ICD-10 Codes

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

390.3 Special Billing Requirements for Institutional Claims

(Rev.4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)

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.

Contractors shall pay claims for SET services containing CPT 93668 with revenue codes 096X, 097X, or 098X when billed

on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or the submitted charge.

390.4 Common Working File (CWF) Requirements

(Rev.4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)

CWF shall create a new edit for CPT 93668 to reject claims when a beneficiary has reached 36 SET sessions within 84

days after the date of the first SET session and the KX modifier is not included on the claim or to reject any SET session

provided after 84 days from the date of the first session and the KX modifier is not included on the claim.

CWF shall determine the remaining SET sessions.

The CWF determination, to parallel claims processing, shall include all applicable factors including:

• Beneficiary entitlement status

• Beneficiary claims history

• Utilization rules

CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would

result in a change to the calculation.

CWF shall display the remaining SET sessions on all CWF provider query screens.

The Multi-Carrier System Desktop Tool (MCSDT) shall display the remaining SET sessions in a format equivalent to

the CWF HIMR screen(s).

390.5 Applicable Medicare Summary Notice (MSN), Remittance Advice Remark Codes and

Claim Adjustment Reason Code Messaging

(Rev.4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)

• Contractors shall deny claims for SET when services are provided on other than TOBs 13X and 85X using the

following messages:

MSN 15.20: “The following policies NCD 20.35 were used when we made this

decision.”

Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”

(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1800-633-4227).

Claim Adjustment Reason Code (CARC) 58:

“Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information

REF), if present.

Remittance advice remark code (RARC) N386: This decision was based on a National Coverage Determination

(NCD) 20.35. An NCD provides a coverage determination as to whether a particular item or service is covered.

A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may

contact the contractor to request a copy of the NCD.

Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is

received with a GZ modifier indicating no signed ABN is on file.

• Contractors deny/reject claim lines for CPT 93668 without one of the diagnosis codes listed in 390.2 and use the

following messages:

MSN 15.20: “The following policies NCD 20.35 were used when we made this

decision.”

Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”

(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1800-633-4227).

CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a

coverage determination as to whether a particular item or service is covered. A copy of this policy is available at

www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy

of the NCD.”

Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary if a

claim is received with a GA modifier indicating a signed ABN is on file.

Contractors shall use Group CO (Contractual Obligation) assigning financial liability to the provider, if a claim is

received with a GZ modifier indicating no signed ABN is on file.

• Contractors shall reject claims with CPT 93668 which exceed 36 sessions within 84 days from the date of the

first session when the KX modifier is not included on the claim line OR any SET session provided after 84 days

from the date of the first session and the KX modifier is not included on the claim and use the following

messages:

96- Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject

Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.)

Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

N640 Exceeds number/frequency approved/allowed within time period.

Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line-item is

received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).

• Contractors shall deny/reject claim lines with CPT 93668 when sessions have reached 73 sessions using the

following messages:

MSN 15.20: “The following policies NCD 20.35 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”

(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1800-633-4227).

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a

coverage determination as to whether a particular item or service is covered. A copy of this policy is available at

www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy

of the NCD.”

Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is

received with occurrence code 32 with or without a GA modifier or a claim-line is received with a GA modifier

indicating a signed ABN is on file)

Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line-item is

received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present

• Contractors shall deny claim line-items for SET, CPT 93668, when sessions have reached 73 sessions with or

without the KX Modifier present using the following messages:

MSN 15.20: “The following policies NCD 20.35 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”

(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800- MEDICARE (1800-633-4227).

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a

coverage determination as to whether a particular item or service is covered. A copy of this policy is available at

www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy

of the NCD.”

Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is

received with occurrence code 32 with or without a GA modifier or a claim-line is received with a GA modifier

indicating a signed ABN is on file)

Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line-item is

received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).