Orthopedic Coding Alert

Look for new codes for plantar fascia shock wave therapy in 2006

If your foot surgeon relies on extracorporeal shock wave therapy to treat plantar fasciitis, you-re in luck this year. CPT 2006 will debut a new code for this service, and coders hope that payment will follow.

For the past three years, you-ve had to use a Category III code (0020T, Extracorporeal shock wave therapy; involving plantar fascia) when your surgeon performs extracorporeal shock wave therapy (ESWT) on the plantar fascia.

You Can Thank 0020T for the New Code

Old way: -The problem with using 0020T is that few insurance companies recognize these codes, or for that matter, paid for them,- says Mary Brown, CPC, CMA, orthopedic coding specialist at OrthoWest PC, a nine-physician practice in Omaha, Neb. -In our office, we would get a -pre-authorization- from the patient's insurance company before performing the procedure, which of course was a hassle.-

But don't think reporting 0020T was completely worthless. The primary purpose of Category III codes is to allow for data collection, which in turn provides information for evaluating the effectiveness of new technologies and the formation of public and private policy.

In other words, Category III codes give insurers and government policy-makers a way to track the effectiveness and usage rate of unproven technologies.
 
New way: ESWT for plantar fasciitis graduates to Category I CPT status with code 28890 (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia). Coders who report ESWT -are going to be very happy that we will finally have a code for this procedure,- Brown says.

ESWT Payment Isn't Guaranteed

Surgeons often reserve ESWT for patients who have failed all other forms of conservative treatment for plantar fasciitis, and can help prevent the patient from requiring -open- surgery, says Susan Vogelberger, CPC, CPC-H, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in Ohio.

During ESWT, surgeons place the patients under anesthetic and apply a special gel to the heel and the treatment head of the instrument, which then delivers shock waves, Brown says. 

Remember: Even though a permanent CPT code for ESWT is definitely a step forward in the pursuit for payment, the handful of payers that have provided reimbursement for ESWT under 0020T suggests that reimbursement still may not be a sure thing come Jan. 1. 

Watch out: Unlike the previous temporary code, the descriptor for 28890 indicates certain clinical demands for reporting. The foot surgeon must use high-energy shock waves and anesthesia -other than local.- These new requirements may nudge surgeons, who had previously been using local anesthesia, to alter their treatment procedures. Surgeons who now use a posterior tibial block and sural nerve block at the ankle level in conjunction with ESWT may find reimbursement difficult.

No Anesthesia, No 28890

Best bet: Check with your individual carrier for its anesthesia criteria before you start coding 28890. 

If your surgeon cannot meet the conditions for 28890, you-ll find yourself back in the realm of Category III codes. CPT 2006 deletes 0020T but keeps the temporary status of all other ESWT codes. Check out these codes (or if your payer prefers, an unlisted-procedure code) if you-re using low-energy ESWT or local anesthesia:

- 0019T--Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy

- 0101T--Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy.

Other obstacles: You will also need to keep an eye on individual carrier requirements for medical necessity and bilateral billing when you report 28890.

For example, some Blue Cross/Blue Shield carriers now require documentation of six months worth of conservative care before they-ll approve ESWT treatment.

And if 0020T guidelines are any indication, payers may also split when it comes to requesting modifier 50 (Bilateral procedure) or RT (Right side) and LT (Left side) for bilateral 28890 claims.