Eli's Rehab Report

Published on Sun Oct 01, 2000 PDF

Health Care Financing Administrations (HCFA) July 31 announcement that Medicare will cover ultrasound stimulation for nonunion fracture healing was great news for practices whose fracture patients are seeking alternatives to repeated surgeries. The announcement also confused some physical medicine and rehabilitation (PM&R) practitioners who have been using ultrasound for deep heat therapy for years to help circulation and reduce pain in their patients.

The codes and billing requirements for these two types of ultrasound stimulation are quite different and billing either of the procedures improperly can cost your practice time and money. PM&R providers, particularly those specializing in joint care or sports medicine, soon may begin treating nonunion of fractures with pulsed, low-intensity ultrasound devices. Knowing the difference between the two codes will make billing for these services more efficient.

Therapeutic Ultrasound CPT 97035

Therapeutic ultrasound (97035, application of a modality to one or more areas; ultrasound, each 15 minutes) is the most familiar form of ultrasound to PM&R providers. Used to treat neuromas, arthritis, muscle spasms, inflammation and other conditions, ultrasound uses deep heat to increase circulation in the affected area, says Douglas Rosario, PT, a practicing physical therapist in Portland, Ore. Its used most often in the acute stages of inflammation to help increase circulation. The heat helps the area get rid of waste products so that any blood accumulated at the site can get back into circulation.

Billing for ultrasound therapy, like all procedures, varies by carrier. Some carriers will cover only 97035 when linked with specific diagnosis codes, and some Medicare carriers may have limitations regarding maximum benefit per year for physical therapy services, says Patricia Niccoli, president of ElectroAge Billing, a medical reimbursement firm in Phoenix. The best approach is to call your carrier for benefits, limitations and filing requirements before starting ultrasound therapy, she advises.

Although Medicare carriers and private payers have differing guidelines for 97035, most Medicare carriers have the same basic limitations on their ultrasound policies. For example, National Heritage Insurance Co., which provides Medicare for California, New Hampshire, Massachusetts, Maine and Vermont, lists the following coverage criteria for 97035:

Documentation must show objective loss of strength, mobility or function (e.g., degrees of motion, strength, function) and estimated duration and goals of treatment.
You should not have to perform any individual procedure for more than 30 minutes (two units) per day any more would be unreasonable.
Any claim submitted for more than two units of 97035 must contain supporting documentation and modifier -22 (unusual procedural services) indicating the medical necessity for more frequent treatments.
Standard treatment is 12 visits per month; anything additional requires documentation supporting the medical necessity of continued treatment.

Most providers also state that 97035 cannot be billed with other heating modalities, such as hot packs (97010), paraffin baths (97018), diathermy (97024), infrared (97026) or contrast baths (97034) on the same day unless documentation can prove medical necessity for both. For example, says Thomas Zapko, PT, a practicing physical therapist in Nashville, Tenn., if a patient with osteoarthritis in his hands (715.14, osteoarthrosis, localized, primary, hand) is getting a paraffin bath to relieve joint inflammation and pain, he may be treated with ultrasound for an ankle sprain (845.01, sprains and strains of ankle and foot; deltoid [ligament], ankle) on the same day. The paraffin would be treating a deep joint problem, says Zapko, which you would bill with the osteoarthritis diagnosis. The ultrasound is for the more superficial problem of an ankle sprain, Zapko continues, and you could charge for that with its own diagnosis code.

Ultrasound for Fracture Healing 20979

HCFAs July Decision Memorandum CAG-00022 announced Medicares national coverage decision for nonunion of fractures that have failed at least one surgical intervention attempt at treatment. A nonunion is when the fracture healing has ceased, and yet bony continuity has not been restored, says Carl Brighton, MD, PhD, a faculty member at the University of Pennsylvanias McKay Orthopedic Research Laboratory in Philadelphia, and one of the first physicians to treat a fracture with electric and magnetic fields (EMFs). Instead of one bone, the patient now has two, and sometimes even surgery cant help fuse the bones together again.

In cases where two sets of x-rays, taken at least 90 days apart, along with a physicians report, can prove that a patient has not achieved any clinically significant evidence of fracture healing and a surgical attempt at treating the fracture has failed HCFA will cover ultrasound stimulation (20979) using an ultrasonic osteogenic stimulator (E0760, osteogenesis stimulator, low intensity ultrasound, noninvasive).

HCFAs coverage policy does not allow ultrasound for treating nonunions of the skull, vertebrae or those that are tumor-related. In addition, Medicare will not cover ultrasound stimulation for fresh fractures. Coverage guidelines for Medicare may be vastly different from the coverage criteria of many private insurers.

Blue Cross and Blue Shield of Massachusetts, an independent insurance company, (BCBSMA - Policy 157) states that ultrasound treatment, as an adjunct to conventional management (such as closed reduction and cast immobilization), is covered for treating fresh, closed fractures in skeletally mature individuals. BCBSMAs policy states that it does not cover ultrasound fracture healing for delayed unions or fracture nonunions. Therefore, you must verify this procedure with a patients insurer before beginning treatment because coverage may vary greatly between Medicare and private carriers.