Medicare Compliance & Reimbursement

Beware of buying equipment before you're sure of reimbursement.

You've heard other offices rave about the latest equipment that treats intractable conditions--but you could be stuck with denials if you make a purchase without doing your homework first.

Warning: Manufacturers' sales reps may make vague promises about Medicare reimbursement. For example, they'll promise that Medicare will cover a new technology in most parts of the country. But you walk on dangerous ground if you go solely by the manufacturer's general guidelines.

Find out whether your own Medicare carrier covers a new technology, says Robin Roach, president of Health Data Solutions in Charleston, WV. Check on your top 10 private payors as well, Roach urges. With new technologies, your carrier may wait until the evidence is overwhelming before jumping on the bandwagon, Roach warns.

Even if you find out that your Medicare contractor will reimburse, read the fine print too--most payers will only reimburse in limited cases, such as systemic conditions.

Don't take a manufacturer's coding advice as the final word either. Many manufacturers honestly seek to inform their buyers of the latest coding updates, but you're still never 100 percent sure until you check with your carrier or fiscal intermediary (FI) first-hand.

Example: Anodyne Infrared Therapy Systems will instruct you to bill the infrared code, 97026 (Application of a modality to one or more areas; infrared), for its circulation-boosting treatment. The manufacturer acknowledges that other reimbursable codes may exist, but claims 97026 is the most widely accepted code.
 
However, "our carrier, Palmetto, does not recognize Anodyne as infrared," Roach says. Although Palmetto doesn't cover Anodyne, it requires 97799 (Unlisted physical medicine/rehabilitation service or procedure) for a denial, not 97026.

Do this: You should take the manufacturer's recommendation as a starting point, but look through your coding book for other options. Where possible, you should seek the final word from your payors, advises Arnold Beresh, a podiatrist with Peninsula Foot and Ankle Specialists in Hampton, VA.

Watch out: A new therapy may have a code assigned, but the reimbursement amount may be zero, warns Beresh. Or, like Anodyne, some carriers pay less than $5 per treatment.