PAD testing in primary care means using a quick, non-invasive test, most often the ankle-brachial index (ABI), to identify peripheral artery disease (PAD) in patients with documented symptoms or signs. It matters because PAD affects more than 10 million U.S. adults over the age of 40, and objective testing on documented indications helps confirm the diagnosis and inform management.
For the independent primary care physician, testing focuses on symptomatic and higher-risk patients, in line with current guidelines. A few minutes of in-office testing provides objective data on a treatable marker of systemic cardiovascular risk. This guide explains what PAD testing in primary care involves, who should be tested, how the ABI works, why diabetes complicates the picture, and how to build the service into a busy practice.
What is PAD testing in primary care?
PAD testing in primary care is the use of a simple bedside test to check whether the arteries carrying blood to the legs are narrowed by atherosclerosis. The workhorse test is the ankle-brachial index, a painless comparison of the blood pressure at the ankle with the blood pressure in the arm. A lower pressure in the ankle signals that blood is not flowing freely to the lower limbs.
It helps to separate two related goals. Diagnosis confirms PAD in a patient who already has symptoms or suggestive exam findings. Screening looks for disease in a patient who has no symptoms; payers treat that differently, and Medicare coverage requires documented medical necessity. Both use the same non-invasive ABI, and both fit inside a standard office visit, with no referral, no imaging suite, and no recovery time required.
How peripheral artery disease presents in primary care
Peripheral artery disease often presents atypically. Classic intermittent claudication, cramping calf pain that appears with walking and eases with rest, is one presentation; others include vague exercise intolerance or joint discomfort. Because presentation varies, documented symptoms and exam signs guide when testing is indicated.
When symptoms or signs of PAD are documented, objective testing helps confirm the diagnosis and inform management. PAD is not just a leg problem. It is a marker of systemic atherosclerosis and a strong, independent predictor of heart attack, stroke, and death. Finding it gives the physician a chance to address a patient’s global cardiovascular risk, not just their legs.
Who should get PAD testing in primary care?
Testing should be risk-based rather than universal. The 2024 ACC/AHA multisociety guideline for lower-extremity PAD recommends a resting ABI to establish the diagnosis in any patient whose history or physical exam findings suggest PAD (a Class 1 recommendation), and states that screening with a resting ABI is reasonable in patients at increased risk of PAD (Class 2a). At the same time, the U.S. Preventive Services Task Force gives an “I” statement, meaning the current evidence is insufficient, for routinely screening asymptomatic adults who have no risk factors. The practical takeaway for primary care is to focus testing on patients who are symptomatic or carry recognized risk.
Consider PAD testing in primary care for patients who have any of the following:
- Diabetes. One of the strongest risk factors, and a group in which foot complications are common.
- Current or past tobacco use. Smoking is a leading driver of lower-extremity atherosclerosis.
- Older age. PAD prevalence rises sharply with each decade of life.
- Hypertension or high cholesterol. The same risk factors that drive coronary disease.
- Known atherosclerosis elsewhere. Coronary, carotid, or renal artery disease raises the odds of PAD.
- Exertional leg symptoms or non-healing foot wounds. Findings that make the ABI a diagnostic, not just a screening, test.
How does the ankle-brachial index (ABI) work?
The ABI is measured by taking blood pressure at both arms and both ankles, usually with a Doppler probe, and dividing the higher ankle pressure by the higher arm pressure. The test is painless, needs no injections or contrast, and takes only a few minutes. The resulting ratio tells the clinician how well blood is reaching the lower limbs.
The American Heart Association and American College of Cardiology use the following interpretation bands. For a deeper walkthrough of the numbers, see our guide to the normal ankle-brachial index.
| ABI value | Interpretation |
|---|---|
| Greater than 1.40 | Non-compressible, calcified arteries; ABI unreliable, so use the toe-brachial index |
| 1.00–1.40 | Normal |
| 0.91–0.99 | Borderline |
| 0.41–0.90 | Mild-to-moderate PAD |
| 0.40 or lower | Severe PAD |
An ABI of 0.90 or lower is generally considered diagnostic of PAD, while a value above 1.40 points to stiff, calcified vessels that the ABI cannot read accurately. That second scenario is common enough that every primary care team should know how to handle it.
Why can the ABI miss PAD in patients with diabetes, and how does the toe-brachial index help?
Diabetes and chronic kidney disease promote calcification of the leg arteries. Calcified vessels resist compression by the blood-pressure cuff, which can push the ABI falsely high, sometimes into the “normal” range or above 1.40, even when significant disease is present. In other words, a reassuring ABI in a person with long-standing diabetes can be misleading.
The toe-brachial index (TBI) solves this problem. The small arteries in the toes rarely calcify, so a toe-pressure measurement can detect occlusive disease that a falsely elevated ABI hides. One study of type 2 diabetes patients found the ABI had a sensitivity of only about 35% for PAD, compared with roughly 82% for the TBI, because the small arteries in the toes rarely calcify. Because a large share of primary care patients have diabetes, the ability to run both an ABI and a TBI is a meaningful advantage for PAD testing in primary care.
7 reasons to add PAD testing in primary care
- Document disease an interview alone cannot confirm. PAD frequently presents atypically, so an objective test in patients with documented symptoms or signs confirms cases an interview alone would not.
- Identify systemic cardiovascular risk. A low ABI flags a patient at elevated risk of heart attack, stroke, and death, information that reshapes their whole care plan.
- Align with current guidelines. The 2024 ACC/AHA guideline positions the resting ABI as the recommended tool to establish a PAD diagnosis.
- Protect diabetic patients’ limbs. Pairing the ABI with a TBI and a thorough diabetic foot exam documents circulation problems so the care team can manage them.
- Fit the visit. A non-invasive test that takes minutes slots into a routine appointment without disrupting the schedule.
- Strengthen patient conversations. Objective numbers give physicians a concrete way to discuss smoking cessation, glucose control, and cardiovascular risk.
- Add a reimbursable ancillary service. In-office ABI testing may be billable when medically necessary and documented; see our ABI CPT code 93923 billing guide and our overview of ancillary revenue for medical practices.
How HealthWright Technologies supports PAD testing in primary care
HealthWright Technologies is a Georgia-based medical device company that helps independent physicians add in-office diagnostics with full training, implementation, and support. Its flagship CMAT Advantage system is an FDA-cleared, non-invasive platform. A complete test takes roughly 7 to 10 minutes and measures the ABI, the toe-brachial index, and autonomic function, including heart rate variability. For a step-by-step view of how one system streamlines non-invasive cardiovascular diagnostics from check-in to signed chart, see our workflow guide.
Running both the ABI and the TBI in a single session is exactly what makes the platform well suited to PAD testing in primary care: it addresses the diabetic non-compressible-vessel problem head-on rather than leaving it to a separate referral. The system is covered by Medicare when testing is medically indicated. To see how it stacks up against older equipment, read our comparison of the CMAT Advantage versus traditional PAD testing devices, our overview of in-office vascular testing, and how the same approach works for PAD testing in podiatry practices.
Frequently asked questions about PAD testing in primary care
What is the best test for PAD testing in primary care?
The resting ankle-brachial index (ABI) is the recommended first-line test. It is non-invasive, painless, takes only a few minutes, and is endorsed by the 2024 ACC/AHA guideline for establishing a PAD diagnosis. In patients with diabetes or calcified arteries, a toe-brachial index should be added because the ABI can read falsely high.
Is PAD testing in primary care covered by insurance?
In-office ABI testing is generally covered by Medicare when it is medically indicated for a patient with documented symptoms or signs. Coverage and coding requirements vary by payer, so verify benefits and documentation before billing; our ABI CPT code 93923 billing guide covers the details.
Which patients warrant PAD testing?
Focus on patients with diabetes, current or past tobacco use, older age, hypertension, high cholesterol, known atherosclerosis in another vascular bed, or leg symptoms and non-healing foot wounds. Guidelines support testing symptomatic and higher-risk patients rather than screening every asymptomatic adult.
How long does an in-office ABI take?
A standalone ABI takes only a few minutes. On an integrated platform such as the CMAT Advantage system, a full assessment that includes the ABI, toe-brachial index, and autonomic measures runs about 7 to 10 minutes, short enough to complete during a routine visit.
Why does diabetes make PAD harder to detect?
Diabetes promotes arterial calcification, which can make leg arteries non-compressible and push the ABI falsely high. Adding a toe-brachial index restores the ability to detect disease the ABI would otherwise miss, because the toe arteries rarely calcify.
How is PAD diagnosed in a primary care office?
Start with the history and a focused exam in a patient who has documented leg symptoms or risk indications, then confirm with an objective test. Ask about claudication, rest pain, and non-healing wounds, check the foot pulses and skin, and measure a resting ankle-brachial index (ABI), the first-line test the 2024 ACC/AHA guideline endorses for establishing a PAD diagnosis. An ABI of 0.90 or lower supports the diagnosis; when diabetes or calcified arteries push the ABI falsely high, add a toe-brachial index. Testing is done in the office on documented indications, not at home.
Bringing PAD testing into your practice
A few minutes of non-invasive testing can change a patient’s trajectory. Offering PAD testing on documented symptoms or signs helps physicians document a major driver of cardiovascular events, support their diabetic patients, and add a reimbursable service that patients value.
To learn how HealthWright Technologies can help your practice add in-office vascular testing, contact us at healthwrighttechnologies.com/contact, email contact@healthwrighttechnologies.com, or call (678) 322-7146. Our office is located at 60 Bear Creek Marina Road, Mansfield, GA 30055.
External references: 2024 ACC/AHA Guideline for Lower-Extremity PAD and the U.S. Preventive Services Task Force ABI recommendation.
Medical & professional disclaimer: This article is intended for licensed healthcare professionals for general educational purposes and is not a substitute for clinical judgment, individualized patient evaluation, or current clinical guidelines. It does not constitute medical advice.
CPT disclaimer: CPT® is a registered trademark of the American Medical Association (AMA). CPT codes, descriptions, and material are copyrighted by the AMA. Coding and coverage requirements change and vary by payer; verify current codes and payer policies before billing. Nothing here guarantees coverage, payment, or a specific reimbursement amount.
If you are weighing equipment options, our guide to choosing an in-office ABI machine walks through what to compare.
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