Medicare Compliance & Reimbursement

Medicare non-coverage could reduce your PPS payment rates by thousands unless you know the ropes.

Medicare won't cover infrared therapy for diabetic neuropathy, but that doesn't mean you have to abandon the practice--especially in the home health setting where many patients have enjoyed the benefits of home devices.

The Centers for Medicare & Medicaid Services (CMS) issued an Oct. 26, 2006 coverage decision memo spelling out that Medicare won't cover monochromatic infrared energy (MIRE) therapy to treat diabetic neuropathy.

Home health agencies (HHAs) billing infrared therapy under Part B outpatient therapy can bill the patient for the treatment using proper notice, but agencies furnishing MIRE under a home health plan of care aren't as sure what to do.

"The non-coverage decision has caused a significant amount of confusion," says physical therapist Cindy Krafft, consultant with UHSA. HHAs billing Part B use a CPT code for infrared therapy, so it's clear that service isn't billable to Medicare.

But agencies under the Medicare home health prospective payment system don't use CPT codes and thus aren't sure how the non-coverage decision affects them, Krafft acknowledges.

Some agencies think they can't furnish the therapy at all to Medicare patients. Others think the coverage decision only affects them if they bill Part B, says Debbie Thompson with the Home Care Association of Louisiana.

Beware: The truth is somewhere in the middle, experts say. And not knowing the answer can cost you $2,000 per episode.

For a visit to count toward the 10-visit therapy threshold or the five-visit LUPA threshold, "you must provide a skilled service that is covered," explains attorney Lisa Selman-Holman with Selman-Holman & Associates in Denton, TX. Thanks to the coverage decision, infrared therapy can't be that covered service that makes the visit count.

However, it's highly unlikely that you will furnish a visit that has MIRE therapy as its only skilled service, expects PT Roger Herr. "This goes against ... PT education," says Herr, past president of the Home Health Section of the American Physical Therapy Association (APTA). "We are taught to [use] modalities as adjunct treatments to supplement the functional and physical mobility of clients."

If you furnish any other skilled service along with the infrared therapy, you can bill and count the visit toward the therapy or LUPA threshold. "As long as the visits are about more than the infrared"--for example, gait training or therapeutic exercises--"the visits should count," advises Krafft, who is also vice president of APTA's Home Health Section.

In other words, MIRE "can be provided as an incidental service," Selman-Holman explains.

Example: Think of infrared therapy like using hot packs, Krafft counsels. "We cannot bill for hot packs. If we only put one on and removed it and tried to call that a visit, we would be denied," Krafft tells Eli. "We have not abandoned the use of hot packs; rather they are incorporated into the larger plan of care."

Don't forget: That means that like other incidental services, infrared therapy will require doctor's orders, Krafft reminds providers.

Beef Up Documentation To Ward Off Denials

Hot spot: And you had better make sure your documentation for the other skilled services offered during the visit is up to snuff, Krafft says.

Intermediaries have a big financial incentive to deny therapy visits. "In the current environment, careful attention to the documentation to support the plan of care is critical," Krafft stresses.

Herr hopes agencies won't abandon the use of MIRE just because Medicare doesn't cover it at the moment. Many clinicians have case studies supporting use of the therapy, he tells Eli.

And agencies can gather more data to prove the therapy's effectiveness if they continue using the treatment, Herr notes. That could help CMS change its mind about coverage down the road.

Note: The decision memo (CAG-00291N) is at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=176.