Reimbursement for Outpatient Biophysical Procedures and Equipment

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Kathleen D. Schaum, MS

    • If no objective and/or subjective improvements are noted after 6 treatments, change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.

  Documentation Guidelines:
    • Rationale for use of modality

    • Area(s) being treated

    • Frequency and intensity of ultrasound and time applied

    • Response of patient to treatment

    • Objective clinical findings, such as measurements of strength, range of motion, and functional deficits/limitations to support need for ultrasound

    • Subjective findings to include pain ratings, pain location, effect on function

    • Functional progress at reassessment and/or discharge. If there’s no progress, a reason and/or alternative treatment strategy should be documented.

    • Must support the need for continued treatment with this modality for > 12 visits.

  NOTE: Some Medicare contractors do not cover this modality for wound care.

  0183T Low-frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day
  Some Medicare contractors address this technology in their LCDs. Some cover it per the guidelines below. Others do not separately cover this technology and state that it is included in the payment for evaluation and management or other concurrent wound care services.

  Indications:
    • Nonhealing wounds of > 1 month of conservative care with documented TCO2 of > 20, with evidence of inflammation, infection, or significant yellow slough, fibrin, or tissue exudates

    • Wounds, burns, and ulcers meeting Medicare coverage for debridement that are too painful for sharp or excisional debridement

    • Wounds, burns, and ulcers meeting Medicare coverage for debridement, but with documented contraindications to sharp or excisional debridement

    • Wounds, burns, and ulcers meeting Medicare coverage for debridement but with documented evidence of no signs of improvement after 30 days of standard wound care.

  Utilization Guidelines:
    • No more than 3 times per week

    • Once epithelialized wound bed occurs, therapy should be discontinued

    • No ongoing use after 1 month unless specific conditions, such as improving wound measurement, drainage reduction, and increase in granulation tissue is noted.

  Documentation Guidelines:
    • Reduction in pain, necrotic tissue, wound size

    • Improved and increased granulation tissue

BIOPHYSICAL TECHNOLOGIES AT HOME

  TENS
  A Medicare NCD provides coverage guidelines for TENS.

  Indications:
    • Chronic, intractable pain

    • Acute post-operative pain.

  Utilization Guidelines:
    • Pain must have been present for at least 3 months. Other appropriate treatment modalities must have been tried and failed. The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy.

    • When used for the treatment of chronic, intractable pain, the TENS unit must be used by the patient on a trial basis for a minimum of 1 month (30 days), but not to exceed 2 months. The trial period will be paid as a rental. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. The physician’s records must document a re-evaluation of the patient at the end of the trial period, must indicate how often the patient used the TENS unit, the typical duration of use each time, and the results.

    • For coverage of a purchase, the physician must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.

    • The physician ordering the TENS unit must be the attending or consulting physician for the disease or condition resulting in this need.

  Documentation Guidelines:
    • Location of the pain

    • Duration of time patient had pain

    • Presumed etiology of the pain

    • Treatment modalities that have been tried and failed.

  Although few patients with chronic wounds would meet coverage criteria for use of a TENS unit at home, Table 2 shows HCPCS codes that durable medical equipment suppliers must use when they supply TENS units for patient use at home. Table 2 also shows the 2012 national average Medicare payment rate and the patient’s coinsurance responsibilities.

Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. She can be reached by emailing: kathleendschaum@bellsouth.net or calling 561-964-2470.


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