Documenting and Coding Peripheral Artery Disease

Documenting and Coding Peripheral Artery Disease

Peripheral arterial disease occurs in the arteries of the circulatory system. Read about the diagnosis, treatment and prevention of this condition.

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Peripheral artery disease (PAD) refers to diseases of the blood vessels (located outside the heart and brain) that occur in the arteries of the circulatory system. Also known as peripheral arterial or peripheral vascular disease, the condition is most often caused by a buildup of plaque (fatty deposits) in the arteries. This buildup of plaque (fatty deposits) 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.

The pain usually improves with rest. With proper documentation, physicians can rely on outsourced medical billing and coding services to report peripheral artery disease diagnosis and treatment.

Reports suggest that an estimated 8.5 million people in the United States have peripheral artery disease, affecting approximately 12-20 percent of Americans above 60 years (2018 statistics). 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. Atherosclerosis is a gradual process in which a fatty material builds up inside the arteries. Other less 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 and cholesterol, habit of smoking, family history of heart disease, and excess levels of C-reactive protein or homocysteine.

Symptoms As many people with peripheral artery disease experience mild or in some cases no symptoms, around half of the people do not even know whether they suffer from this condition. One of the most common symptoms includes leg pain when walking (claudication). Intermittent claudication (IC) 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 –

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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 your toenails Shiny skin on your legs Numbness in the legs Erectile dysfunction (impotence in men, problems achieving or sustaining an erection) Difficulty in finding a pulse in the leg or foot Coldness in your lower leg or foot, especially when compared with the other side Brittle toenails 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 be so severe that it may disrupt sleep.

Diagnosis and Treatment If you are suffering from any of the above symptoms of PAD, then it is important to talk to your physician so that the treatment can be initiated as soon as possible. Early detection of PAD symptoms is crucial so that the right treatment modalities can be provided before the disease becomes severe leading to heart attack or stroke.

Primary care doctors may treat people who have mild PAD. However, for advanced PAD, vascular specialists or a cardiologist may be involved. Initial diagnosis may begin with a detailed physical examination and previous medical history and 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 weak or absent pulses. They may also check the pulses in the leg arteries for an abnormal whooshing sound called a bruit (using a stethoscope) which 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 that may be signs of PAD. A wide range of diagnostic tests like - Ankle-brachial index, Doppler and ultrasound (Duplex) imaging, Computed Tomographic angiography (CT), Magnetic Resonance Angiography (MRA), Ultrasound scan and blood tests may be performed to accurately diagnose peripheral artery disease.

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Treatment modalities for PAD aims to alleviate leg pain (in order to resume normal physical activities) and stop the progression of atherosclerosis throughout your body (to reduce the risk of heart attack and stroke).

Treatment options include medicines to control or lower cholesterol, high blood pressure; prevent blood clot and other medications for relief. If the any of these treatments (mentioned above) 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. In addition to medications or surgery, physicians will also prescribe a supervised exercise therapy (SET) to improve the symptoms of PAD. Documenting PAD In order to correctly document Peripheral artery disease (PVD), 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 rest pain Laterality (left, right, or bilateral) and specify if one or both sides are affected by complicating conditions of atherosclerosis.

Medicare Coverage The Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD). SET involves the use of intermittent walking exercise - which alternates periods of walking to moderate-to-maximum claudication, with rest. This exercise therapy has been recommended as the initial treatment for patients suffering from intermittent claudication (IC) - the most common symptom experienced by people with PAD. •

Medicare coverage is offered for supervised exercise therapy (SET) for beneficiaries with intermittent claudication for the treatment of symptomatic 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 -

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 Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication  Sessions must be conducted in a hospital outpatient setting or a physician’s office  Sessions must be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD  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 PAD treatment to obtain the referral for SET. 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.

In addition, 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. A second referral is required for these additional sessions.

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

Coding Requirements for SET Providers should use Current Procedural Terminology (CPT) 93668 (Under PAD Rehabilitation) to bill for these services with appropriate ICD-10 codes.

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

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 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

Prevention of PAD 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 green leafy vegetables and fruits. Overweight and obese patients should engage in regular exercise (for at least 30-40 minutes per day) to maintain a healthy weight. As regular smokers are four times more likely to develop PAD than non-smokers, people should quit the habit of smoking permanently. Other prevention steps include keeping blood pressure, diabetes and cholesterol levels under control.

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Clinicians dealing with the challenges of treating and preventing peripheral arterial disease (PAD) can rely on an experienced medical billing and coding company to submit claims on time and get accurate reimbursement.

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