Outpatient Facility Coding Alert

Published on Wed Mar 20, 2013 PDF

Heed what CMS says about reimbursing 97026.

Providers with some therapy clinics tend to lean toward using infrared therapy to treat patients with diabetic neuropathy (357.2, Polyneuropathy in diabetes), but keep one thing in mind before submitting those claims: CMS doesn’t take the same stance.

After going without a finalized national coverage determination (NCD) for quite some time, now infrared therapy is clearly a non-reimbursable treatment, Medicare says.

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, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver.

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, she adds. 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.

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,” Hammer says.

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 new 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, Hammer says.

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.