Part B Insider (Multispecialty) Coding Alert

Published on Sun Nov 21, 2004 PDF

But you can improve your chances of payment with savvy documentation

Sometimes it seems the "G" in "G" codes stands for "good luck getting paid" - especially when it comes to new technology.
 
The Centers for Medicare & Medicaid Services introduced two new "G" codes for extracorporeal shock wave therapy (ESWT) for musculoskeletal problems such as elbow epicondylitis. But many of the carriers won't cover ESWT for such problems, claiming the procedure is experimental.
 
The new codes are: G0279 (ESWT; involving elbow epicondylitis) and G0280 (ESWT; involving other than elbow epicondylitis or plantar fasciitis). (Two Category III codes, CPT 0019T and 0020T, cover ESWT for general musculoskeletal problems and plantar fasciitis, respectively.)
 
Several carriers, including HGSA, Aetna and Palmetto GBA, have issued non-coverage policies for ESWT for musculoskeletal problems. Cigna Medicare and HealthNow NY both say they'll cover ESWT for those conditions, however.
 
Cigna says that for techniques involving a single application of high-energy shock waves on a site, it'll only cover the treatment once per site in any six-month period. For techniques involving multiple applications of low-energy shock waves per site, Cigna will cover no more than three treatments per six-month period. Cigna won't pay for ultrasound or anesthesia separately.
 
HealthNow says that since plantar fasciitis and elbow epicondylitis both have a 70-percent to 90-percent success rate with more conservative treatments, you should try those first before going for broke with ESWT. Your documentation should reflect that you tried more conservative treatments "thoroughly" first.

Payors Would Rather Try Surgery

Few private payors will cover ESWT for plantar fasciitis, complains Martha Cintron, office manager with Advanced Foot Care & Laser Center in Portland, ME. Even the plans that used to cover it have changed their policies. Some payors will cover the technical component but not the professional component for ESWT.
 
"They'd rather have the patient do surgery than a non-invasive procedure," Cintron complains. "It's rough on the patient."
 
When payors deem a procedure such as ESWT experimental, that sets up a huge hurdle in the way of coverage, says Alameda, CA podiatrist Anthony Poggio. You can't even prove medical necessity until you prove a procedure isn't experimental.
 
Once a payor has accepted that ESWT isn't experimental for musculoskeletal problems, you must document a laundry list of other treatments you tried, says Poggio. These treatments can include rest, plus "anti-inflammatory medicines, injections, physical therapy, orthotics or other forms of immobilization such as a cam walk or night splints," says Poggio.
 
It's not enough to give a patient a pill, try a different pill three months later, and then decide after six months that neither pill has done the trick, says Poggio. Payors want to see "an algorithm" of conservative treatments in which you tried a number of things, not just a couple of attempts.
 
Also, you should submit a letter from the physician, chart notes and an operative report to back up the medical necessity of ESWT, says Giuliana DeFilippi, office manager with the Foot & Ankle Institute in Beverly Hills, CA. She's had good luck obtaining reimbursement from private payors in California, but
hasn't yet billed Medicare.
 
ESWT is a cash-only procedure for most patients, says David Gurvis, a podiatrist with Avon Podiatry in Avon, IN. He charges $500 for one heel and $750 for both, and occasionally an insurance company will cover the procedure.  
 
Usually he'll try anti-inflammatories, orthotics, and corticosteroid injections, often in combination with physical therapy and stretching exercises.