Eli's Rehab Report

Published on Wed Sep 08, 2004 PDF

But what payers cover varies, so watch out
 
Many physicians use extracorporeal shock wave therapy (ESWT) for renal and biliary stones, but did you know that some Medicare payers approve of ESWT for musculoskeletal conditions?
 
Because the Centers for Medicare and Medicaid Services (CMS) has not issued a national coverage policy regarding ESWT, many state carriers offer a slew of different policies. Our expert advice and five tips will help you combat denials and win the reimbursement battle.

You Won't Use All ESWT Cat III and G Codes

Although two category III or "T" codes and two G codes exist for ESWT, you won't be using them all. The range of possible codes include:
 

0019T - Extracorporeal shock wave therapy; involving musculoskeletal system
 

0020T - Extracorporeal shock wave therapy; involving plantar fascia
 

G0279 - Extracorporeal shock wave therapy; involving elbow epicondylitis
 

G0280 - Extracorporeal shock wave therapy; involving other than elbow epicondylitis or plantar fasciitis.

"Most payers now prefer that you bill ESWT with the G codes, G0279 and G0280, instead of the T codes (0019T-0020T)," says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. But as always, you should check with your specific carriers' policies to learn which codes they prefer.
 
Another tactic: "As a policy, we ask all ESWT patients to pay for each treatment up front because this is truly an elective procedure," says Brad Colvard, business analyst for the department of orthopedics at UNC Chapel Hill. "We will file their insurance for them, and if we get paid by their insurance, we'll refund the patient's money."

Five Tips Help Win the Reimbursement Battle

When you code for ESWT, keep the following five tips in mind and you'll have a better chance at receiving reimbursement.
 
Tip #1: The three FDA-approved ESWT devices require that the provider give the patient anesthesia such as local or regional blocks, but this service will be bundled into the procedure code itself. You should not report them separately. Also, if your physician performs an ultrasound, many carriers may include payment for that service with the fee for the procedure.
 
Tip #2: Don't neglect your modifiers. Both Healthnow and Empire Medicare request that you use modifiers -LT (Left side) and -RT (Right side) to designate the affected limb, Corcoran says.
 
Tip#3: The HCPCS descriptor for G0280 states that you should use this code only for conditions other than epicondylitis or plantar fasciitis - but now, most carriers do not cover any other conditions. "The device that we are using is only FDA-approved in the United States for chronic lateral epicondylitis, but North Carolina Medicare Part B's LMRP states that they will cover the ESWT treatment for both lateral epicondylitis and plantar fascial fibromatosis," Colvard says.
 
Tip #4: APMA and ACFAS warn in their joint statement that you should not report lithotripsy code 50590 (Lithotripsy, extracorporeal shock wave) in place of the EWST code.
 
Tip #5: Make sure your documentation matches up. "Each of our payers said that they would have to individually screen each case that came through," Colvard says. "The patient has to meet certain guidelines."

Join the Rising Numbers of ESWT Procedures

If a patient has plantar fasciitis or lateral epicondylitis (tennis elbow) and fails two of the following - either four weeks of physical/occupational therapy, a four-week course of nonsteroidal anti-inflammatory medications (NSAIDS), or local steroid injection(s) - he may find relief from the noninvasive ESWT.
 
A December 2003 statement from the American Podiatric Medical Association (APMA) and the American College of Foot and Ankle Surgeons (ACFAS) acknowledges EWST as a viable treatment for plantar fasciitis. This statement also points out that physicians perform more ESWT procedures because of the "effectiveness of the treatment, fewer complications, and the availability of the technology."
 
"Our physicians are more aware of this device and how it works, so they're starting to educate their patients on the effectiveness of ESWT in treating chronic lateral epicondylitis and plantar fasciitis," Colvard says.
 Because payer determination contains a broad range of stipulations and guidelines, it remains unclear when or whether these codes will no longer be temporary.
 
Most carriers, such as Aetna and Regence Group of Idaho, consider ESWT experimental for either plantar
fasciitis or epicondylitis or both because of the lack of evidence supporting the effectiveness of ESWT for these musculoskeletal conditions.
 
"I periodically contact the company that makes the ESWT machines that we currently use and ask when to expect the release of a CPT Level I code," Colvard says. "The longer it takes to establish a CPT Level I code, the better it is for the company and the provider, because the more data and research that's out there, there's a better chance the RVUs will be higher."