Eli's Rehab Report

Published on Sun Jan 01, 2006 PDF

CMS will not reimburse this modality

You may be one of the many therapy clinics that love this new modality and rave about its success in treating patients with diabetic neuropathy -- but if you are one of these clinics, take note: CMS thinks otherwise.

After going without a finalized national coverage determination for quite some time, now infrared therapy is clearly a nonreimbursable treatment, according to Medicare.

Clear Up Coverage Confusion

This NCD might seem to contradict what you have heard in the past. For example, a lot of miscommunication has been floating around Web sites 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, CHCO, of MJH Consulting, a healthcare reimbursement consulting firm in Denver. In addition, some practices "may have been billing infrared therapy under the infrared CPT code, not realizing that there were individual LCDs out there that addressed it" from the start, she adds.

The facts: Medicare will not cover treatments using infrared therapy devices for diabetic and nondiabetic sensory neuropathy, wounds and ulcers. This includes using infrared therapy to treat related pain. Noncovered therapies include monochromatic infrared energy (MIRE), according to decision memo CAG-00291N.

Inform Your Patients

If you've been using forms of infrared therapy in your facility, you should tell your Medicare patients that they will be responsible for payment. And you will probably want to investigate your private payers as well because "most will follow Medicare's lead eventually," says Meryl Freeman, MS, PT, manager of outpatient rehab at Rex Healthcare in Raleigh, NC.

Options: For your Medicare patients, have a stack of notification forms ready. "It depends on which healthcare lawyer you talk to as to which form would be more appropriate," Hammer says, but you would use the Notice of Exclusions from Medicare Benefits (NEMB), and in some cases the Advance Beneficiary Notice (ABN) form.

The NEMB is an optional form you can use to inform patients of a noncovered benefit, such as acupuncture or therapy treatments above the therapy caps that do not qualify for exceptions. Using that logic, the NEMB would make sense because infrared is now a noncovered treatment for neuropathy, Hammer says.

Depending on the reason you want to use the infrared therapy, however, "you still might be able to squeak in 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 noncovered now, which defeats the purpose of the infrared-plus-PT treatment," which has been one of the few effective treatments for diabetic peripheral neuropathy, Freeman says.

For the full decision memo, visit www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=176.