Eli's Rehab Report

Published on Sun Oct 12, 2003 PDF

You can't benefit from reporting the trigger point injection codes to garner prolotherapy reimbursement from Medicare, but you can increase your prolotherapy reimbursement odds if you secure preapproval from workers' compensation payers that cover it - and ask all other patients to pay you up-front for these services.

Confirm Covered Diagnoses First

Physiatrists use prolotherapy - also known as nonsurgical ligament reconstruction or joint sclerotherapy - to treat many different types of musculoskeletal pain. CPT does not include a code for prolotherapy, so you should always report it using the HCPCS Code M0076 (Prolotherapy). Unfortunately, a quick perusal of HCPCS offers a "heads up" on why coding for prolotherapy is no fun: Following the descriptor for M0076, HCPCS includes the note "The therapeutic efficacy of prolotherapy and joint sclerotherapy has not been established."
 
Prolotherapy has an "N" status code in the Medicare Fee Schedule, meaning it's a noncovered service, says Susan Turney, MD, FACP, medical director of reimbursement with Marshfield Clinic in Marshfield, Wis. "Therefore, we don't submit these services to Medicare for consideration unless the patient asks us to do so," she says. "In that event, we link modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to indicate that we know it's a noncovered service."

ABNs Aren't Necessary

Contrary to popular belief, Medicare patients are responsible for paying you for their prolotherapy services regardless of whether they've signed an advance beneficiary notice (ABN). According to CMS' information sheet regarding the -GY modifier, ABNs "are not an issue for these services" because "there are no ABN requirements for statutory exclusions." In other words, because prolotherapy is statutorily excluded from Medicare, an ABN is not necessary.
 
Most coding consultants recommend that you should still ask your patients to sign a statement explaining that prolotherapy is not covered by insurance and that the patient is responsible for payment.
 
So why submit prolotherapy claims to Medicare at all? First, submitting the claim ensures that the insurer will notify the patient that prolotherapy is not a benefit of his or her policy. Some patients prefer to see the denial in writing so they can submit the claim to a secondary insurer, or just so they can confirm that they should pay you directly.
 
Other practices submit prolotherapy claims to insurers to lay the groundwork for future reimbursement. Julie Mace, office manager with Mark Hines, MD, in Charlotte, N.C., says, "If the doctors want to lobby for coverage, they have to show that the procedure is being done. They don't have that backup if we haven't been filing claims. Plus, carriers are more likely to consider it for coverage if they see more and more claims for it."

Do Not Report 20552-20553

Some practitioners report trigger point injection codes 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles) for prolotherapy, reasoning that prolotherapy is relatively similar to trigger point injections, but this coding practice is incorrect. Remember that although prolotherapy is simply an injection rather than surgery, coding it as a trigger point injection is wrong.
 
Most carriers specifically state that you cannot report the trigger point injection codes for prolotherapy. The local medical review policy for Blue Cross and Blue Shield of Arkansas, for example, states, "Prolotherapy is not covered by Medicare. Its billing under the trigger point injection code is misrepresentation of the facts and is considered a fraudulent practice."
 
The fact that HCPCS already includes a prolotherapy code is a positive sign in many practitioners' minds. Once physicians start documenting and performing outcome studies that prove prolotherapy is a worthwhile service for some patients, a CPT code for it should follow.
 
In the meantime, you should obtain prior authorization when performing prolotherapy on non-Medicare patients, because some workers' compensation payers do reimburse for prolotherapy.