Business Briefs: Reimbursement for Outpatient Biophysical Procedures and Equipment

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   As discussed by Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA; and Luther Kloth, PT, MS, FAPTA, CWS, FACCWS in “E-Stimulation: An Effective Modality to Facilitate Wound Healing” on page 28, manufacturers have developed equipment to provide biophysical treatments in outpatient settings and by patients at home. Physicians who believe these treatments are necessary to manage chronic wounds and accompanying pain must understand affiliated coding, Medicare payment, and coverage guidelines (ie, indications, limitations, documentation requirements, etc.).   As we have discussed in this column, the “devil is in the details” when it comes to reimbursement for biophysical procedures and equipment. Providers should read pertinent Medicare National Coverage Determinations (NCDs), their Medicare contractor’s pertinent Local Coverage Determinations (LCDs), and the medical policies from the top 20 private payers in their wound care practice. This column will provide a brief coding, Medicare payment (see tables 1 and 2), and coverage overview of the most commonly ordered biophysical technologies. CAUTION: If you choose to use any of these biophysical technologies, you must thoroughly read the pertinent NCDs, LCDs, and medical policies. Those specific policies may have differing coverage guidelines than provided in this overview.

BIOPHYSICAL TECHNOLOGIES USED IN OUTPATIENT SETTINGS

  97024 Diathermy (ie, microwave)   Medicare NCDs are written for diathermy and pulsed wave diathermy.   Indications for Diathermy and Pulsed Wave Diathermy:     • Osteoarthritis, rheumatoid arthritis, or traumatic arthritis     • Strain or sprain     • Acute or chronic bursitis     • Traumatic injury to muscle, ligament, or tendon resulting in functional loss     • Joint dislocation or subluxation     • Treatment for a post-surgical functional loss     • Adhesive capsulitis     • Joint contracture.   Limitations for Diathermy and Pulsed Wave Diathermy:     • Asthma     • Bronchitis     • Any other pulmonary condition.   Utilization Guidelines for Diathermy and Pulsed Wave Diathermy:     • Only 1 unit is covered per date of service, per discipline.     • If no objective and/or subjective improvements are noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented, or documentation should include the rationale for continued diathermy.   Documentation Guidelines:   Documentation must clearly support the need for diathermy for more than 12 visits.   Documentation for each diathermy/pulsed wave diathermy should include:     • Rationale for use of modality     • Area(s) being treated     • Response of patient to treatment     • Objective clinical findings/measurements to support the need for a deep-heat treatment     • Subjective findings to include pain ratings, pain location, activities that increase or decrease pain, effect on function, etc.     • Functional progress at reassessment and discharge. If there’s no progress, a reason and/or an alternative treatment strategy should be documented.   97026 Infrared Therapy Devices (to one or more areas)   A Medicare National Non-Coverage Determination states the Centers for Medicare & Medicaid Services have determined the use of infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin, and/or subcutaneous tissues.   If physicians order this treatment for their patients, they should inform the patients that the treatment is not covered by Medicare and that the patient will be responsible for the cost of the treatment.   97028 Ultraviolet (to one or more areas)   Most Medicare contractors address this technology in their LCDs.   Indications:     • Ultraviolet treatment is generally used for patients requiring the application of a drying heat.     • A patient having an open wound; minimal erythema     • Severe psoriasis, limiting range of motion   Limitations:   Most Medicare contractors do not cover this modality for pressure ulcers.   Utilization Guidelines:   Only 1 unit is covered per date of service, per discipline.   Documentation Guidelines:     • Rationale for use of modality     • Area(s) being treated     • Objective clinical findings/measurements to support the need for ultraviolet     • Minimal erythema dosage     • Response of patient to treatment.   97032 Electrical Stimulation (manual) (to one or more areas), each 15 minutes   Most Medicare contractors address this technology in their LCDs.   97032 is a constant attendance electrical stimulation (ES) modality that requires direct (one-on-one) manual patient contact by a qualified professional/auxiliary personnel.   Because the use of a constant, direct-contact ES modality is less frequent, documentation should clearly describe the type of ES provided as well as the medical necessity of the constant contact to justify billing 97032 versus G0283 (only used if ES unit is placed on the patient by the provider and does not require the continued presence and direct, one-on-one contact by the provider once setup is completed). Devices delivering high-voltage stimulation may require one-on-one patient contact.   ES that may require constant attendance and should be billed as 97032 when continuous presence by the qualified professional/auxiliary personnel is required includes:     • Direct motor point stimulation delivered via a probe     • Instructing a patient in the use of a home transcutaneous electrical nerve stimulation (TENS) unit. Once a trial of TENS has been done in the clinic over 1-2 visits and the patient has had a favorable response, the patient can usually be taught to use a TENS unit for pain control in 1-2 visits. Consequently, it is inappropriate for a patient to continue treatment for pain with a TENS unit in the clinic setting.   Indications:     • Documented dependent peripheral edema with an accompanying reduction in the ability to contract muscles     • Documented reduction in the ability to contract muscles or in the strength of the muscle contraction     • Documented condition that requires an educational program for self-stimulation of denervated muscles     • Documented condition that requires muscle re-education involving a training program (ie, functional ES)     • Treatment of disuse atrophy using a specific type of neuromuscular electrical stimulator.   Limitations:     • Treatment of facial nerve paralysis, commonly known as Bell’s palsy     • Treatment of motor function disorders such as multiple sclerosis     • Treatment of strokes when it is determined there is no potential for restoration of function     • When ES is the only intervention utilized for strengthening of a muscle with at least “fair-graded” strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities.   Utilization Guidelines:     • No more than 4 units per code, per day, per discipline     • If no objective and/or subjective improvement in swelling and/or pain are noted after 6 visits, a change in treatment plan (alternative strategies) should be implemented or documentation should support need for continued use of this modality.     • For swelling and pain control, the efficacy of this modality should be met in 10-12 visits, at most.   Documentation Guidelines:     • Type of ES used (Do not limit the description to “manual” or “attended.”)     • Area(s) being treated     • If used for muscle weakness, objective rating of strength and functional deficits     • If used for pain, include pain rating, location of pain, effect of pain on function     • Must support the need for continued treatment for > 12 visits.   G0281 ES (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care   A Medicare NCD covers this technology.   Indications:     • Chronic stage III and stage IV pressure ulcers     • Arterial ulcers     • Diabetic ulcers     • Venous stasis ulcer.   Limitations:     • Stage I or stage II wounds     • As an initial treatment modality     • Measurable signs of healing have not been demonstrated within a 30-day period of treatment     • Wounds that demonstrate a 100 percent epithelialized wound bed     • Treatment used in an unsupervised setting, as this has not been found to be medically reasonable and necessary.   Utilization Guidelines:     • When covered ulcers do not demonstrate measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care     • Only 1 unit is covered per date of service, per discipline.     • Wounds must be evaluated periodically (no less than every 30 days) by the treating physician.   Documentation Guidelines:     • Etiology and duration of wound     • Type of prior treatments by a physician, non-physician, nurse, and/or therapist that failed, including the duration of the failed treatment     • Stage of wound     • Description of wound: length, width, depth, grid drawing, and/or photos     • Amount, frequency, color, odor, type of exudate     • Evidence of infection, undermining, or tunneling     • Nutritional status     • Comorbidities (eg, diabetes mellitus, peripheral vascular disease)     • Pressure support surfaces in use     • Patient’s functional level     • Skilled plan of treatment, including specific frequency of the modality     • Changing plan of treatment based on clinical judgment of the patent’s response or lack of response to treatment     • Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session).   G0329 Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care   A Medicare NCD covers this therapy.   Indications:     • Chronic stage III and stage IV pressure ulcers     • Arterial ulcers     • Diabetic ulcers     • Venous stasis ulcers.   Limitations:     • Stage I or stage II wounds     • ES when used as an initial treatment modality     • Continued treatment if measurable signs of healing have not been demonstrated within any 30-day period of treatment     • Wounds that demonstrate a 100 percent epithelialized wound bed     • A patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.   Utilization Guidelines:     • When covered ulcers do not demonstrate measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care     • Only 1 unit is covered per date of service, per discipline.     • Wounds must be evaluated periodically (no less than every 30 days) by the treating physician.   Documentation Guidelines:     • Etiology and duration of wound     • Type of prior treatments by a physician, non-physician, nurse, and/or therapist that failed, including the duration of the failed treatment     • Stage of wound     • Description of wound: length, width, depth, grid drawing, and/or photographs     • Amount, frequency, color, odor, type of exudate     • Evidence of infection, undermining, or tunneling     • Nutritional status     • Comorbidities (eg, diabetes mellitus, peripheral vascular disease)     • Pressure support surfaces in use     • Patient’s functional level     • Skilled plan of treatment, including specific frequency of the modality     • Changing plan of treatment based on clinical judgment of the patent’s response or lack of response to treatment     • Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session).   97035 Ultrasound (to one or more areas)   Most Medicare contractors address this technology in their LCDs.   Indications:     • Limited joint motion that requires an increase in extensibility     • Symptomatic soft-tissue calcification     • Neuromas.   Limitations:     • Asthma, bronchitis, or any other pulmonary condition     • Conditions for which the ultrasound can be applied by the patient without the need for a therapist or other professional to administer, and/or for extended period of time     • Wounds.   Utilization Guidelines:     • No more than 2 units per code, per day, per discipline     • Non-thermal ultrasound for wound healing may be indicated for non-necrotic wound(s) only after documented standard wound care has been used for a minimum of 30 days with no measurable signs of healing.     • If no objective and/or subjective improvements are noted after 6 treatments, change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.   Documentation Guidelines:     • Rationale for use of modality     • Area(s) being treated     • Frequency and intensity of ultrasound and time applied     • Response of patient to treatment     • Objective clinical findings, such as measurements of strength, range of motion, and functional deficits/limitations to support need for ultrasound     • Subjective findings to include pain ratings, pain location, effect on function     • Functional progress at reassessment and/or discharge. If there’s no progress, a reason and/or alternative treatment strategy should be documented.     • Must support the need for continued treatment with this modality for > 12 visits.   NOTE: Some Medicare contractors do not cover this modality for wound care.   0183T Low-frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day   Some Medicare contractors address this technology in their LCDs. Some cover it per the guidelines below. Others do not separately cover this technology and state that it is included in the payment for evaluation and management or other concurrent wound care services.   Indications:     • Nonhealing wounds of > 1 month of conservative care with documented TCO2 of > 20, with evidence of inflammation, infection, or significant yellow slough, fibrin, or tissue exudates     • Wounds, burns, and ulcers meeting Medicare coverage for debridement that are too painful for sharp or excisional debridement     • Wounds, burns, and ulcers meeting Medicare coverage for debridement, but with documented contraindications to sharp or excisional debridement     • Wounds, burns, and ulcers meeting Medicare coverage for debridement but with documented evidence of no signs of improvement after 30 days of standard wound care.   Utilization Guidelines:     • No more than 3 times per week     • Once epithelialized wound bed occurs, therapy should be discontinued     • No ongoing use after 1 month unless specific conditions, such as improving wound measurement, drainage reduction, and increase in granulation tissue is noted.   Documentation Guidelines:     • Reduction in pain, necrotic tissue, wound size     • Improved and increased granulation tissue

BIOPHYSICAL TECHNOLOGIES AT HOME

  TENS   A Medicare NCD provides coverage guidelines for TENS.   Indications:     • Chronic, intractable pain     • Acute post-operative pain.   Utilization Guidelines:     • Pain must have been present for at least 3 months. Other appropriate treatment modalities must have been tried and failed. The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy.     • When used for the treatment of chronic, intractable pain, the TENS unit must be used by the patient on a trial basis for a minimum of 1 month (30 days), but not to exceed 2 months. The trial period will be paid as a rental. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. The physician’s records must document a re-evaluation of the patient at the end of the trial period, must indicate how often the patient used the TENS unit, the typical duration of use each time, and the results.     • For coverage of a purchase, the physician must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.     • The physician ordering the TENS unit must be the attending or consulting physician for the disease or condition resulting in this need.   Documentation Guidelines:     • Location of the pain     • Duration of time patient had pain     • Presumed etiology of the pain     • Treatment modalities that have been tried and failed.   Although few patients with chronic wounds would meet coverage criteria for use of a TENS unit at home, Table 2 shows HCPCS codes that durable medical equipment suppliers must use when they supply TENS units for patient use at home. Table 2 also shows the 2012 national average Medicare payment rate and the patient’s coinsurance responsibilities. Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. She can be reached by emailing: kathleendschaum@bellsouth.net or calling 561-964-2470.