Learn About Peripheral Artery Disease (PAD) and Its Coding

Hello everyone and welcome to our podcast series! My name is Natalie Tornese and I’m a Senior Solutions Manager at Outsource Strategies International (OSI). I wanted to take this opportunity to talk about Peripheral artery disease (PAD). Peripheral artery disease refers to diseases of the blood vessels located outside the heart and brain that occur in the arteries of the circulatory system. It is also known as peripheral arterial or peripheral vascular disease. It is the condition that is most often caused by a buildup of plaque in the arteries. This buildup of plaque occurs gradually and if allowed to progress, blood flow in that artery can become limited or blocked all together. The condition affects or narrows the arteries serving the legs, stomach, arms and head. However, it most commonly causes pain and fatigue, often in the legs, and especially during exercise. This pain is usually improved with rest. Reports suggest that an estimated 8.5 million people in the U.S. have peripheral artery disease. This means that it affects approximately 12 to 20 percent of Americans above 60 years old. It is estimated that men are slightly more likely to develop PAD than women. The condition is a major risk factor for heart attack and stroke. One of the most common causes of PAD is atherosclerosis. Other common causes include – blood clots in the arteries, injury to the limbs, and unusual anatomy of the muscles and ligaments. There are several risk factors that directly contribute to PAD which include – obesity, diabetes, high blood pressure, high cholesterol, habit of smoking, family history of heart disease, and excess levels of C-reactive protein. Many people with peripheral artery disease experience mild or in some cases no symptoms, around half of the people do not even know if they suffer from this condition. One of the most common symptoms include leg pain when walking, which is called claudication. Intermittent claudication symptoms include severe muscle pain or cramping in your legs or arms that is triggered by activity, such as walking, but disappears after a few minutes of rest. Severe claudication can make it hard for people to walk or do other types of physical activity. The location and severity of pain depends on the location of the clogged or narrowed artery. Other additional symptoms include –

• Hair loss on the feet and legs
• Sores or ulcers on the legs and feet that take a long time to heal (or never heal)
• Slower growth of toenails
• Shiny skin on your legs
• Numbness in your legs
• Erectile dysfunction
• Difficulty in finding a pulse in the leg or foot
• Coldness of your lower leg or foot, especially when compared with the other side
• Brittle toenails and
• A change in the color of your legs

As PAD progresses, pain may even occur when a person is at rest or when he/she is lying down. The pain may at times be so severe that it may disrupt your sleep. Early detection of PAD symptoms is crucial so that the right treatment modalities can be provided before the disease becomes severe leading to a heart attack or stroke. Primary care doctors may treat people who have mild PAD. But, for advanced PAD, you would need a vascular specialist or a cardiologist. Initial diagnosis may begin with a detailed physical exam and a previous medical history and a risk factor review. During the physical exam, the physician may check the blood flow in the legs or feet to see whether the patient has a weak or absent pulse. They may also check the pulses in the leg arteries for an abnormal whooshing sound called a bruit. This is done using a stethoscope. If this is heard, it may be a warning sign of a narrowed or blocked artery. In addition, physicians may also check for blood pressure and poor wound healing or any changes in the hair, skin, or nails. A wide range of diagnostic tests like an Ankle-brachial index, Doppler, ultrasounds, CT, angiographies, Magnetic Resonance Angiographies, blood tests these may all be performed to accurately diagnose peripheral artery disease. The treatment modalities aim to alleviate leg pain and stop the progression of atherosclerosis throughout your body. Treatment options include medication to control or lower cholesterol, medication to lower high blood pressure; prevent blood clots and even provide relief. If any of these treatments do not help, the physician may advise the surgical unblocking or repair of a blood vessel. Surgical options include – angioplasty, bypass surgery and Thrombolytic therapy. But in addition to medications or surgery, physicians can also prescribe supervised exercise therapy, known as SET to improve the symptoms of PAD. In order to correctly document Peripheral artery disease, it’s important to include the following components –

• Location of vein/artery affected
• Whether the vein/artery is native or a graft (and type of graft if known)
• Complications such as intermittent claudication, ulceration or pain at rest and
• If the condition or the pain is at the left, right, or bilateral

Medicare issued a National Coverage Determination to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC). Supervised Exercise Therapy involves the use of intermittent walking exercises – which alternates periods of walking, with rest. This exercise therapy has been recommended as the initial treatment for patients suffering from intermittent claudication.

• Medicare coverage is offered for supervised exercise for the treatment of symptomatic PAD. It’s up to 36 sessions over a 12-week period are covered if all of the following components are met.
  • The Supervised Exercise Therapy program must –
  • Consist of sessions lasting 30-60 minutes
  • The sessions must be conducted in a hospital outpatient setting or in a physician’s office
  • Sessions must be under the direct supervision of a physician/physician assistant/nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques
• Medicare beneficiaries must have a face-to-face visit with the physician responsible for the treatment to obtain the referral for Supervised Exercise Therapy. During 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.
• Medicare may also cover Supervised Exercise Therapy beyond 36 sessions over 12 weeks and may actually cover an additional 36 sessions over an extended period of time. However, a second referral is required for these additional sessions.
• Supervised Exercise Therapy is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary care physician.

I will include a transcript along with this podcast outlining coding requirements for the Supervised Exercise Therapy.
CPT Code

• 93668 – Peripheral arterial disease (PAD) rehabilitation, per session

ICD-10 Codes

• I70.21 – Atherosclerosis of native arteries of extremities with intermittent claudication
  • I70.211 …… right leg
  • I70.212 …… left leg
  • I70.213 …… bilateral legs
  • I70.218 …… other extremity
  • I70.219 …… unspecified extremity

• I70.31 – Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication
  • I70.311 …… right leg
  • I70.312 …… left leg
  • I70.313 …… bilateral legs
  • I70.318 …… other extremity
  • I70.319 …… unspecified extremity

• I70.61 – Atherosclerosis of non-biological bypass graft(s) of the extremities with intermittent claudication
  • I70.611 …… right leg
  • I70.612 …… left leg
  • I70.613 …… bilateral legs
  • I70.618 …… other extremity
  • I70.619 …… unspecified extremity

• I70.71 – Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication
  • I70.711 …… right leg
  • I70.712 …… left leg
  • I70.713 …… bilateral legs
  • I70.718 …… other extremity
  • I70.719 …… unspecified extremity

• I73.9 – Peripheral vascular disease, unspecified

• • I73.89 – Other specified peripheral vascular diseases

The best way to prevent claudication is to maintain a healthy lifestyle. Incorporate a healthy eating plan that is low in fat and sodium. Eat plenty of leafy green vegetables and fruits. Overweight and obese patients should engage in regular exercise (for at least 30-40 minutes per day) and maintain a healthy weight. Regular smokers are four times more likely to develop PAD than non-smokers. So people should quit the habit of smoking permanently. Other prevention steps include keeping your blood pressure, glucose and cholesterol levels under control. I hope this helps. But always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed. Thank you for listening!