On May 17, 2017, the Centers for Medicare & Medicaid Services (CMS) determined that the evidence was sufficient to 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 hospital outpatient setting, or 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)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) 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.

A number of hospitals have been waiting to understand the payment rate to determine if they will provide this service. In addendum B of the Final OPPS Payment (October 2017), a payment rate was put forth:

Notwithstanding geographic adjustments, let us look at the financial implications:

One patient completing a full program would bring $1,963 net revenue. If the community need supported an average of one referral per week, the annual net revenue would be $102,000.

There are some potential economies of scale. The construct of the program is very similar to Phase Two of Cardiac Rehabilitation. Thus, the space, equipment, and competencies required for the program closely match those in cardiac rehabilitation.

Hospitals should assess their population and determine if this is a service that would meet a need in their community and be in alignment with their overall strategic direction.

If you have questions or would like more information, please contact John Britt at jdbritt@blueandco.com.