EECP^® Therapy Reimbursement

Patients should contact their primary care physician, cardiologist or local EECP^® Therapy center to discuss eligibility for treatment and reimbursement coverage.

CMS - Centers for Medicare and Medicaid Services

Section 20.20 (formerly 35-74) of the Medicare Coverage Issues Manual was revised to provide national Medicare coverage for external counterpulsation (ECP). The Centers for Medicare and Medicaid Services currently covers treatment with EECP^® Therapy/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:

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

Though coverage for congestive heart failure is not currently provided under Medicare, patients with stable congestive heart failure of ischemic etiology maybe covered under the aforementioned policy if they present with concomitant angina pectoris or angina equivalent symptoms as the primary diagnosis. The Centers for Medicare and Medicaid Services provide additional information on reimbursement. You can search for both national and local coverage decisions on the CMS website, including information on the national coverage decision (NCD) for external counterpulsation.

Medicare requires that ECP treatment be performed under the direct supervision of a physician. As defined in 42 CFR 413.65, “direct supervision” means that the physician or nonphysician practitioner must be present on the same campus where the services are being furnished. For services furnished in an off-campus provider based department as defined in 42 CFR 413.65, he or she must be present within the off-campus provider based department. The physician or nonphysician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician or nonphysician practitioner does not have to be present in the room when the procedure is performed.

Private Insurance

Third party commercial insurance carriers offer reimbursement for EECP^® Therapy and have established coverage criteria similar to Medicare. Currently most third-party payers cover EECP^® treatment.

Physician

Code	Procedure	2023 National Average Medicare Payment Rate	Other Information
G0166	HCPCS Level II Code for external counterpulsation, per treatment session	$105.73	G0166 is a Medicare specific code. However, some private payers accept this procedure code and provide reimbursement. Please verify that this code is accepted with private payers before billing it.
G0166-76	Same as above		When a patient receives 2 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 Carrier guidelines.
92971	CPT® Code for Cardioassist-method of circulatory assist - external	Local contractor	Since an individual CPT code has not yet been assigned for EECP, some private payers that do not accept G0166 allow 92971.

Outpatient Hospital

Code	Ambulatory Patient Classification (APC) (Medicare)	Status Indicator	Procedure	2023 Medicare Payment Rate	Other Information
G0166	5734	Q1	Level 4 Minor Procedures	$116.11	Q) Packaged Services Subject to Separate Payment Under OPPS Payment Criteria. 1) Separate APC payment based on OPPS payment criteria.

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