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Part B Insider (Multispecialty) Coding Alert

Coverage:

Don't Run Out And Invest In Stretta Procedures

Published on Fri Jan 14, 2005 Print Friendly and PDF PDF

Carriers also waver on virtual colonoscopy

Providers may have rejoiced when CPT 2005 included a new code for endoscopic treatment of gastroesophageal reflux disease (GERD), but it appears the party is over.

The new code, 43257, covers the popular Stretta procedure and replaces Category III code 0057T.

But as the CPT disclaimer says, the presence of a code doesn't guarantee reimbursement. And one carrier has already come out with a draft local coverage decision stating that it won't pay for 43257 under any circumstances. Noridian says it will consider the Stretta procedure "not yet proven effective" until more clinical data comes in.

Noridian also won't cover the Bard EndoCinch suturing system, the Plicator, or the Enteryx polymer, all of which are new techniques for treating GERD, the draft policy states.

It's not surprising that carriers are cautious about covering the Stretta procedure, says one coding expert who declined to be quoted. The procedure remains controversial in the medical community because there's no data on long-term effects. Meanwhile, several other draft LCDs also came out:

  •  National Heritage Insurance Co. said it would follow the example of Empire Medicare Services in adding coverage for virtual colonoscopy. (See PBI, vol. 5, no. 38.) NHIC said it would only cover virtual colonoscopy in cases where an "instrument colonoscopy of the entire colon is incomplete." But NHIC won't consider virtual colonoscopy as an alternative when an instrument (or fiberoptic) colonoscopy is possible.

  •  Noridian said in a new draft LCD that it wouldn't cover virtual colonoscopy under any circumstances. Peer-reviewed literature doesn't support its effectiveness, so even if the physician is unable to complete a fiberoptic colonoscopy, a virtual colonoscopy will not be reimbursed.

  •  Noridian said it will cover endoluminal radiofrequency ablation and endoluminal laser ablation for patients with varicose veins. To obtain coverage, patients must have an absence of aneurysm in the target segment, a maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation, an absence of thrombosis or vein tortuosity, and the absence of significant peripheral arterial diseases. Patients must have failed to improve after three months of conservative therapy. Noridian won't cover the treatment of spider veins or "superficial telangiectasis" because those are cosmetic. Noridian won't cover intra-operative ultrasound, but will cover one pre-operative Doppler ultrasound.

  •  But Noridian won't cover nucleoplasty, IDET or other minimally invasive ablative procedures for low back pain. Noridian says the peer-reviewed literature still doesn't support the effectiveness of these services.

    First The Coverage Policy, Then The Audits

    NHIC also said it would cover biofeedback training, anorectal manometry and anal electromyography for perineal muscles and anorectal and urethral sphincters. Biofeedback training of the pelvic muscles (90911) uses an electronic or mechanical device to help the patient become more aware of pelvic floor muscle contractions and learn to control them. Medicare has a national coverage determination for all forms of biofeedback training, including 90911.

    Details: NHIC's policy is more detailed than the national policy and states that the carrier will cover anorectal manometry and EMG studies of the anal or urethral sphincter only for cases of incontinence where the physician needs to rule out urge or stress incontinence, mechanical or functional incontinence, or other types. The results of the test must be used to change the course of therapy for the patient's disease.

    Physicians shouldn't try biofeedback for urinary incontinence unless the patient has failed more conventional treatments such as pelvic muscle exercise training. The patient must have undergone four weeks of an ordered plan of exercises designed to increase periurethral muscle strength, with no significant improvement in urinary continence. Patients must be capable of participating in the treatment, motivated to succeed and lacking an existing condition that would prevent success of the treatment.

    Biofeedback training requires the direct presence of a physician or nonphysician practitioner, who should be supervised by a physician.

    Audits will follow: NHIC is following in the footsteps of First Coast Service Options in laying out detailed coverage criteria for biofeedback, says consultant Jean Acevedo with Acevedo Consulting in Delray Beach, FL. Once you have detailed coverage criteria, the carriers and federal watchdogs usually will start auditing your documentation to make sure you're up to snuff, she warns.

    Biofeedback isn't a treatment per se, but rather a tool to help patients learn to perform pelvic muscle exercises, Acevedo cautions. As with many other treatments, having detailed documentation showing that you tried conservative treatments first is very important.

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