Part B Insider (Multispecialty) Coding Alert

Published on Fri May 12, 2006 PDF

Two carriers already say they won't cover new code 28890

Coders rejoiced when CPT 2006 introduced a new code for extracorporeal shock wave therapy (ESWT): 28890. At last, you no longer have to use an unlisted code or the temporary code 0020T.

But once again, the carriers have proved that just because something has a code doesn’t mean Medicare will pay for it. Two carriers, Trailblazer Health Enterprises and HGSAdministrators, both put out local coverage decisions stating that ESWT is an “experimental” treatment and therefore non-covered.

So far, only one carrier says it’s willing to pay for 28890: CIGNA Government Services says it’ll cover ESWT for plantar fasciitis and lateral epicondylitis. The patient must have been symptomatic for at least six months. The condition must not have responded to at least two months of conservative measures, including rest, physical therapy, anti-inflammatory medications, local corticosteroid injections or orthotics. And ESWT must be the only alternative to surgery.

Urgent: If your carrier isn’t one of the three mentioned above, now is the time to contact your carrier medical director and urge him or her to cover ESWT, say experts.

The fact that there’s a CPT Code , and Medicare has assigned 9.44 non-facility RVUs to it, means that the carriers ought to cover the service, argues Mary Brown, coding specialist at OrthoWest in Omaha, NE.

Brown had good luck billing for ESWT using an unlisted code and obtaining prior approval from her carrier, and she’d assumed the new code would make the process easier, not harder. (Her physician who performed ESWT retired before the new code came along, so she hasn’t billed it.)

Many podiatrists have already given up on billing for ESWT because of problems obtaining payment, says Wendy Linnell, owner of Physician Claim Corp., a podiatry-specific billing service in La Crosse, WI.

Pay attention: The descriptor for 28890 states that the code includes any ultrasound guidance, but also that the physician may not use local anesthetic. Physicians commonly use a heel or sural nerve block before performing ESWT, but CPT doesn’t consider those nerve blocks local anesthetic. Instead, those are “regional” anesthetics, and it’s okay to bill 28890 if your physician performs them.

Note: CCI 12.0 bundled nerve block codes 64415-64417, 64450, 64470, and 64475 into 28890, so you can’t bill separately for the nerve block.