Neurology & Pain Management Coding Alert

News: CMS no longer pays for 97026.

Pain management specialists sometimes prescribe infrared therapy for patients diagnosed with diabetic neuropathy (357.2, Polyneuropathy in diabetes). If you see orders for the service, keep an important thing in mind for your Medicare claims: CMS classifies infrared therapy as a non-reimbursable treatment (see Medicare NCD 270.6, Infrared Therapy Services).

Clear Up Coverage Confusion

This national coverage determination might seem to contradict what you have heard in the past. For example, a lot of miscommunication has been floating around websites such as supplier sites or diabetes sites that say infrared is covered if a physical therapist is treating the patient, experts say.

In addition, some providers may have been billing infrared therapy under the infrared CPT^® code, not realizing that there were also individual Medicare LCDs out there that addressed this therapy from the start. The code these groups are mistakenly reporting for this situation is 97026 (Application of a modality to one or more areas; infrared).

The facts: Medicare will not cover treatments using infrared therapy devices for diabetic and non-diabetic sensory neuropathy, wounds, and ulcers. This includes using infrared therapy to treat related pain. Non-covered therapies include monochromatic infrared energy (MIRE), according to decision memo CAG-00291N.

Keep Patients Informed

If you’ve been using forms of infrared therapy in your facility for treatment of diabetic neuropathy, you should tell your Medicare patients that they will be responsible for payment. You’ll also want to clarify your private payers’ stances because “most will follow Medicare’s lead eventually,” says Meryl Freeman, MS, PT, manager of outpatient rehab at Rex Healthcare in Raleigh, N.C.

Tip: For your Medicare patients, have the Advance Beneficiary Notice (ABN) form ready. Depending on the reason you want to use the infrared therapy, you might want to use an ABN.

Reason: The ABN is a required Medicare notice for a service that Medicare will most likely not cover (as opposed to a service that it never covers). Because the coverage determination specifically prohibits coverage of infrared therapy for neuropathy, perhaps a therapist would have luck submitting an ABN for infrared treatments not related to neuropathies. Remember that if the provider uses infrared therapy to treat covered conditions, however, you won’t need to complete an ABN.

Don’t miss: Medicare will still cover actual physical therapy treatments, if the diagnosis is medically necessary, Freeman says. “The challenge will be that home units are also non-covered now, which defeats the purpose of the infrared-plus-PT treatment,” which has been one of the few effective treatments for diabetic peripheral neuropathy, she adds.