The Journal for Nurse Practitioners 18 (2022) 608e610

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The Journal for Nurse Practitioners

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The 6-Minute Walk Test: Indications and Guidelines for Use in

Outpatient Practices
Evelyn J. Kammin

a b s t r a c t
Keywords: The 6-Minute Walk Test (6MWT) is a standardized tool used to measure lung impairment. It is used in
6-minute walk test (6MWT) outpatient primary and pulmonary practices to objectively assess functional exercise capacity and hypoxemia
chronic lung disease
in patients with chronic lung disease. Screening for functional decrease in exercise tolerance and hypoxemia
coding
COVID-19
aids in initiating and maintaining the use of oxygen supplementation to improve functional improvement in
documentation chronic lung patients. It has new applications for recovering COVID-19 pneumonia patients to assess for
exercise clinical compromise. Discussion includes elements and guideline recommendations for 6MWT, indications
functional exercise capacity for use, appropriate patient populations appropriate, safety, coding, and current reimbursement insurance
hypoxemia guidelines.
outpatient © 2022 Elsevier Inc. All rights reserved.
oxygen
primary
pulmonary
reimbursement

Chronic hypoxemia has long been recognized as a hallmark of definitions, elements, and documentation required for recognition
chronic cardiac and lung disease. The need for oxygen supple- and reimbursement by insurance providers allows optimal benefit
mentation to treat hypoxemia is often assessed in primary and while minimizing out-of-pocket costs for patients and providers.
pulmonary outpatient clinics through use of a standardized The first element of provider evaluation is initial oxygen deter-
objective measuring tool recognized by the Centers for Medicare mination assessment and is based on the results of a clinical test
and Medicaid (CMS).1-4 This recognition is used to reimburse that has been ordered and evaluated by the treating practitioner.6-8
practices and patients both in utilization of the tool and in the Two methods for this assessment include a preferred method,
issuance of oxygen for home use by patients with documented which is the arterial blood gas, specifically the partial pressure of
hypoxemia.2,5-7 oxygen in arterial blood (PO2) or an ear or pulse oximetry ordered
The purpose of this article is to familiarize providers, predomi- by the treating practitioner and performed under their supervision
nantly in the primary and pulmonary outpatient arenas, of the or when performed by a qualified provider or supplier of lab
definitions, requirements, and documentation for the purposes of services.6
prescribing oxygen for patients for use with activity to prevent The second element required for CMS determination of oxygen
hypoxemia and its associated clinical signs and symptoms. This need is the time of need, further defined as “during the patient’s
report discusses hypoxemia and oxygen determination needs based illness when the presumption is that the provision of oxygen in the
on a standardized tool, the 6-minute walk test (6MWT) for use in home setting will improve the patient’s condition.”5,6 In inpatient
practice for providers that is recognized as valid by CMS and private settings, this must be done within 2 days of discharge. For outpa-
insurance companies for the purposes of reimbursement. tient settings, the time of need is during the time period when the
treating practitioner documents signs and symptoms of illness that
Indications and Guidelines for Management can be relieved by oxygen in the patient who is to be treated at
home.6,7
Hypoxemia and oxygen need are defined by the CMS and The third element includes clinical criteria for oxygen use as
include provider evaluation, timing of determination of oxygen determined by CMS. This is defined by 2 subgroups. The first sub-
need, and supporting clinical criteria.6,7,13,15,18 In an era of limited group includes those patients with an arterial PO2
55 mmHg, or
health care anddoften limited personal resourcesdappropriate an arterial saturation
88%, taken at rest and breathing room air or
use and burden of cost need to be addressed to provide maximum taken during exercise using a formal exercise test while breathing
benefit to the patient and practices involved. Awareness of the room air.6 Additional elements in this category are listed in the

https://doi.org/10.1016/j.nurpra.2022.04.013
1555-4155/© 2022 Elsevier Inc. All rights reserved.
 E.J. Kammin / The Journal for Nurse Practitioners 18 (2022) 608e610 609

criteria that do not pertain to the discussion in this report but may reflect space limitations in practice.1,2,4,6,15,16 Continuous walks in
prove to be of benefit to providers. In these instances, oxygen can various shapes (circular, oval, or square) layouts resulted in greater
be provided to those patients to improve the hypoxemia demon- walk distances than noncontinuous according to Agarwala and
strated during exercise on room air. The second subgroup includes Salzman.2 Treadmills offer an advantage in compact space re-
those patients with arterial PO2 is 56e69 mm Hg or whose arterial quirements, but lack of familiarity with the machine could influ-
blood oxygen saturation is
89% if there is either dependent edema ence walk length and are not considered interchangeable.2,16 Verbal
suggesting congestive heart failure; patients with pulmonary hy- encouragement is a tool that is used to promote participation by the
pertension or cor pulmonale as determined by measurement of patient. The scripted instructions in the guideline state that stan-
pulmonary artery pressure in cardiac testing, such as cardiac dardized encouragement phrases are to be exclusively used at 1-
catheterization or echocardiogram; or patients with eryth- minute intervals because frequency of encouragement can also
rocythemia with a measured hematocrit greater than 56%.1,6 affect walk distance.1,2 Table 1 provides a summary of procedural
guidelines.
Tool Development
Coding and Reimbursement
The 6MWT was developed by the American Thoracic Society,
and it was officially introduced in 2002 with a comprehensive Primary and pulmonary practices that use tools such as the
guideline. It was originally designed to help in the assessment of 6MWT require the support of staff; additional time for patient visits
the patient with cardiopulmonary issues and has since been to use the tool; and, when properly coded and billed, allow for
introduced for use in numerous other conditions. The 6MWT is a those practices to be reimbursed for the cost of use. The American
low-intensity, submaximal exercise test used to assess aerobic ca- Medical Association developed the current procedural terminology
pacity and endurance and oxygen saturation.1,8 A subsequent (CPT), which provides identification codes for uniform reporting of
literature review and technical standard update by a joint European medical services and procedures.2,6 The CPT codes in current use
Respiratory Society and American Thoracic Society collaboration in are 5-digit codes and can have the addition of 2-digit codes as
2014 that endorsed its continued use in clinical settings.3,9 modifiers to attach to a visit. CMS and other insurance payers
The focus of this report is to discuss the role of the 6MWT in recognize the technical component of the test, such as cost of
oxygen prescribing and use for patients with documented hypox- technicians, equipment, and space requirements and is indicated by
emia with exercise. The 6MWT is considered unencouraged and a technical component (TC) modifier. The current 6MWT code was
self-paced, occurring at a lower exercise level. The patients decide updated in 2018 and is now current CPT code 94618.5,7 This code
their own effort intensity, which more accurately reflects each can be used for pulmonary stress testing, which covers the 6MWT.
person’s everyday activities. The 6MWT is recognized at a national Reimbursement is based on CMS guidelines; require proper use of
and global levels for evaluation of aerobic activity and oxygen coding, including the additional use of modifier to support addi-
determination and does not specify the source of the limitation. tional services performed during a visit, such as a 6MMWT, and
Current clinical uses of the 6MWT are for patients with chronic subsequent medical needs for home oxygen; and is, at time of
obstructive lung disease, idiopathic pulmonary fibrosis, and pul- writing of this brief, approximately $35 for Medicare and Medicaid
monary artery hypertension.1,2,4,5 A newer application of the patients.2,5
6MWT is noted for patients who have had COVID-19 pneumonia
with prolonged respiratory symptoms.11-14
Safety Considerations

Test Procedure The 6MWT is a safe test with rare complications.17,18 It is a

practical, simple test that requires, in ideal circumstances, a 100-
Standardization of a 6MWT is essential for reproducible and foot hallway, no exercise equipment, and no advanced training
reliable results. The 6MWT is to be performed along a minimally for technicians. Walking is a daily activity for all but severely
trafficked flat, straight corridor ideally 30 m in length to be impaired patients and so can be used by most patients in a practice.
consistent with established reference equations. Reference equa- Patient involvement is based on voluntary participation, is self-
tions exist for shorter tracks, including 20- and 10-m lengths, to directed, and is easily terminated in the event of a complication.

Table 1
Procedural Guidelines for 6-Minute Walk Test1,2,6

Starting point is marked with tape and every 3 m.

Turn around points are clearly marked with cone or tape.
Patients should be wearing comfortable clothing and use their usual walking aids.
Patients should be using their prescribed oxygen therapy device and manage their own oxygen delivery devices if already utilizing oxygen. (If this is not possible, the
assessor is to walk slightly behind to avoid setting the pace.)
Notations made if patient is assisted, and repeat tests are done in a similar fashion.
Oxygen is not to be titrated during the walk.
The patient is to be at rest for 10 minutes before walk.
Documentation of blood pressure, heart rate, oxygen saturation, and baseline dyspnea done at rest.
Continuous SpO2 should be used to capture nadir SpO2 because it does not always correlate with end test SpO2.
If the patient stops during testing, the timer is not stopped, but a notation on the time of stopping and restarting should be noted.
Reason for premature cessation of testing by patient documented (e.g., chest pain, intolerable dyspnea, joint, or back or leg pain).
Assessor can terminate testing based on patient appearance or if oxygen saturation is <80%.
Walk distance is measured by counting the number of full laps and rounding up to the nearest meter for the partial final lap.
Repeat the parameters measured pretest at time of cessation.
Safety considerations include, but are not limited to the following:
Assessors should be certified in basic life support and cardiopulmonary resuscitation.
Access to emergency equipment should be available. This can include a crash cart, sublingual nitroglycerin, and bronchodilators.
610 E.J. Kammin / The Journal for Nurse Practitioners 18 (2022) 608e610

Table 2 clinical care or increase awareness of the need for further testing
Absolute and Relative Contraindications to the use of the 6-Minute Walk Test1 and follow-up at an outpatient pulmonary practice for patients
Contraindication Absolute Relative who meet the guideline qualifications for testing. The 6MWT is
Unstable angina in past 30 days X
used as a clinical basis for prescribing oxygen for home use. The
Myocardial infarction in past 30 days X principal goal for provider care is accurate assessment of client or
Resting heart rate >120 X patient needs, and provision of care based on such assessment. The
Systolic blood pressure >180 X 6MWT is a useful tool for patients with chronic pulmonary
Diastolic blood pressure >100 X
compromise.

Safety considerations when administering the 6MWT include References

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Chest pain
Intolerable dyspnea
Leg cramps Evelyn Kammin, DNP, FNP-BC, CCRN, Governors State University, University Park, IL
Staggering and can be contacted at evelyn.kammin@gmail.com
Diaphoresis
In compliance with standard ethical guidelines, the author reports no relationships
Pale or ashen appearance
with business or industry that would pose a conflict of interest.