Reimbursement Overview

Medicare

Medicare Guidelines for ECP Treatment1

The Centers for Medicare and Medicaid Services currently covers treatment with ECP systems for patients who have been diagnosed with disabling stable angina (Class III or IV Canadian Cardiovascular Society or equivalent classification), who in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention because:

  • Their condition is inoperable, or at high risk of operative complications or postoperative failure;
  • Their coronary anatomy is not readily amenable to such procedures; or
  • They have co-morbid states, which create excessive risk.

Patients with stable congestive heart failure of ischemic etiology are covered under the aforementioned policy if they present with concomitant angina pectoris or angina equivalent symptoms. Coverage for congestive heart failure of idiopathic etiology is not currently provided under Medicare.

Reimbursement1

  • Main revenue code for ECP treatment for Medicare is: G0166
  • ECP devices are cleared by the FDA for use in treating chronic stable angina. The use of ECP to treat cardiac conditions other than stable angina pectoris is not covered.
    • CPT code for stable angina is: 413.9
  • Reimbursement on average is $143.93 per treatment session in an outpatient setting.
  • Reimbursement on average is $99.49 per treatment session in a hospital setting. Allowed treatments are approved as 35 one-hour treatments, typically administered multiple times per week.
    • Patients may have treatment approved more than once
  • Private insurance/private pay reimbursement on average is typically higher than Medicare.
 

Reimbursement Codes1

Code Procedure 2013 National Average
Medicare Payment Rate
Other Information
G0166 HCPCS Level II
Code for external
counterpulsation, per
treatment session
$143.92 G0166 is a Medicare specific code. However, some private payers accept this procedure code and will cover reimbursement. Payment verification is recommended prior to treatment and billing.
G0166-76 Same as above $143.92 per hour When a patient receives two, one-hour sessions in one day, then the suffix – 76 is typically used for clarification.
93799 CPT Code for unlisted cardiovascular service or procedure Local Contractor Some Medicare Carriers require the use of this code with G0166 when two treatments are administered to a patient on the same day of service. Consult local Medicare guidelines.
G0166 06378 External counterpulsation, per treatment session Private payer classification and payment is likely variable and may be dependent on a negotiated contract. A patient co-pay may be required.