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  1. #1
    Default Prolotherapy
    Medical Coding Books
    Does anyone have any info on how to code properly for prolotherapy? What CPT codes do we use? Thanks.
    Last edited by dballard2004; 01-15-2009 at 09:20 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P

  2. #2
    North Carolina
    For Medicare purposes, you would report M0076; although, I don't think Medicare reimburses for this. I have seen other offices submit 20550 for the other carriers.

    Ok...found Medicare's policy. The policy is in alpha order once you open the link.

    "The medical effectiveness of the above therapies has not been verified by scientifically controlled studies. Accordingly, reimbursement for these modalities should be denied on the ground that they are not reasonable and necessary as required by §1862(a)(1) of the Act."
    Last edited by RebeccaWoodward*; 01-15-2009 at 07:06 AM.

  3. #3
    Thanks. We were wondering if we could even bill this or not. I have done some research on this that seems to indicate that this service is not covered but many plans. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P

  4. #4
    One other the code M0076 only for Medicare use or can we report this to commercial insurance. If Medicare does not cover this service, then why do they have a code for it?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P

  5. #5
    North Carolina
    1) I think this will become carrier specific. I looked at some of carriers and they do not accept M0076.

    Aetna considers prolotherapy (also known as proliferant therapy or proliferation therapy) experimental and investigational for any indications because there is inadequate evidence of its effectiveness.

    BCBSNC does not provide coverage for Prolotherapy because it is considered investigational. BCBSNC does not cover investigational services.

    UHC-Coverage Rationale
    The use of prolotherapy for any musculoskeletal indications such as chronic low back pain and osteoarthritis of the knee, thumb, and finger joints is unproven due to inadequate clinical evidence of safety and/or efficacy in published peer-reviewed medical literature.

    2) As for Medicare, sounds like to me it's for reporting purposes yet it allows the provider to invoice the patient with a completed ABN. I look at this way...UHC doesn't pay for the XSTOP procedure (0171T). They recognize it but they consider it experimental; yet they do allow the provider to bill the patient with proper notification. M0076 is recognized by Medicare but not proven to be effective.

    Anyone else?

  6. #6
    Thanks so vey much!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P

  7. Default Livi Rizo, CPC
    Our Doctor has been using this procedure on many of our patients, the majority of them work comp. I have been using the 20550. I'm not sure if this is correct. I believe this is like a trigger point injection...right?

  8. #8
    Sioux Falls South Dakota
    Quote Originally Posted by bebe View Post
    Our Doctor has been using this procedure on many of our patients, the majority of them work comp. I have been using the 20550. I'm not sure if this is correct. I believe this is like a trigger point injection...right?

    Although Prolotherapy is a "series of trigger point injections", you should not use the trigger point injection codes to bill it; and since most work comp requires pre-approval for procedures, visits, etc, you should not be performing prolotherapy when you have approval for trigger point injections. Also, 20550 is not a trigger point injection but a tendon sheath or ligament injection. The codes for trigger point injections are 20552 and 20553.

    The big difference is in what is injected. In prolotherapy, "proliferative" solutions are injected into various trigger points, to irritate or inflame the area and supposed induce the production of addition collagen, strengthening the area. Some of the solutions include phenol and morrhuate sodium. Trigger point injections, on the other hand, involve injecting a therapeutic agent such as Depo-Medrol.

    The therapeutic efficacy of prolotherapy has not been established; evidence is only anecdotal so far.

    I hope this helps,
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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