Home Health & Hospice Week

CMS says no to this modality.

If you furnish provide infrared therapy, beware.

You may be one of the many therapy providers that love this new modality and rave about its success in treating patients with diabetic neuropathy--but the Centers for Medicare & Medicaid Services thinks otherwise.

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

CMS came to the decision despite strong opposition. More than 4,800 health care professionals and patients commented on the NCD, notes Tampa, FL-based infrared therapy device maker Anodyne Therapy. "These included comments from 17 Professional Associations and clinicians from 11 teaching institutions," Anodyne says in a statement on its Web site. And "15 members of the Senate and House of Representatives wrote strong letters to CMS supporting coverage for infrared therapy devices."

Clear Up Coverage Confusion

This national coverage decision 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 or diabetes sites that say infrared is covered if a physical therapist is treating the patient, points out Marvel Hammer of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

In addition, some providers "may have been billing infrared therapy under the infrared CPT code, not realizing that there were individual [local coverage determinations] out there that addressed it" from the start, Hammer adds.

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

Inform Your Patients

If you've been furnishing forms of infrared therapy, you should tell your Medicare patients they will be responsible for payment. And you probably will want to investigate your private payers as well because "most will follow Medicare's lead eventually," notes therapist Meryl Freeman, 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 health care lawyer you talk to as to which form would be more appropriate," Hammer says.

HHAs furnishing outpatient therapy under Part B could use the Notice of Exclusions from Medicare Benefits (NEMB) and in some cases the general Advance Beneficiary Notice (ABN) form. Anodyne recommends using the NEMB, according to the company's Web site.

The NEMB is an optional form you can use to inform patients of a non-covered benefit, such as acu-puncture 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 non-covered 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 believes.

Reason: The general ABN, not to be confused with the home health-specific HHABN, 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 suggests.

HHAs Should Use The HHABN, Expert Says

But home care providers should really use the home health ABN to notify patients of the non-coverage, counsels attorney Robert Markette Jr. with Gilliland, Markette & Milligan in Indianapolis.

"The revised HHABN supersedes the old NEMB," Markette explains. The transmittal CMS issued implementing the HHABN "basically says HHAs always use the new HHABN," he adds.

"In this case, they would issue the HHABN using option box 1, because the care is continuing, but is no longer covered," Markette advises. "The beneficiary then can choose to pay privately or point the agency to other insurance."

Billing upshot: The non-coverage shouldn't affect HHA billing, Anodyne maintains. That's because agencies don't bill separately for services like infrared, electrical stimulation or ultrasound.

"In addition, home care agencies provide non-reimbursed services such as Telemedicine," Anodyne CEO Craig Turtzo says on the site. "Therefore, this NCD does not affect current PPS billing practices."

Watch out: But agencies that want to count an infrared-related therapy visit toward the 10-visit therapy threshold may not be able to do so, experts say. That could mean a $2,000 difference in episode payment level.

Don't miss: Medicare will still cover actual physical therapy treatments, provided that the diagnosis is medically necessary, Freeman says. "The challenge will be that home units are also non-covered 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.

Note: Email editor Rebecca Johnson at rebeccaj@eliresearch.com with "Infrared Therapy NCD" in the subject line for a copy of the decision.