National Coverage Determination (NCD) for External Counterpulsation (ECP) Therapy for Severe Angina (20.20) 1
Nationally Covered Indications
The Centers for Medicare and Medicaid Services (CMS) provides coverage for the use of ECP for patients who have been diagnosed with disabling stable angina (Class III or Class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass, because:
- Their condition is inoperable, or at high risk of operative complications or post-operative failure;
- Their coronary anatomy is not readily amenable to such procedures; or
- They have co-morbid states which create excessive risk.
A full course of therapy usually consists of 35 one-hour treatments, which may be offered once or twice daily, usually 5 days per week. The patient is placed on a treatment table where their lower trunk and lower extremities are wrapped in a series of three compressive air cuffs which inflate and deflate in synchronization with the patient's cardiac cycle.
National Non-Covered Indications
All other cardiac conditions not otherwise specified as nationally covered for the use of ECP remain nationally non-covered.
Private Insurance Coverage
Most private payers refer to Medicare’s National Coverage Determination (20.20) for coverage. Some payers may consider additional treatments after 35 if certain conditions have been met. Others may require prior authorization before treatment can begin. Please consult with your plan before proceeding with treatment.
ECP-Related Codes and Medicare Reimbursement
To report ECP services use:
G0166: External counterpulsation, per session (required by Medicare and private payers)
G0166-76 : Use modifier 76 when a patient receives more than one treatment per day
76 – Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
2019 National Average Medicare Payment: $116.05
- https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx. Website accessed 03 Sep 2019