Orthopedic Coding Alert

2 examples will save you a hassle in the long run

When you report ESWT for patients with epicondylitis or plantar fasciitis, you may find yourself scratching your head, because no national determination from CMS means that Medicare state policies outline varying guidelines. Our two policy examples will help you know what to expect, so you can save yourself a hassle down the road.

Payer Policy #1: Follow Different Guidelines For High- and Low-Energy ESWT

Some carriers differentiate between high-energy and low-energy ESWT and detail separate guiding principles for each.

For example, Montana's Medicare Part B LMRP gives time stipulations for each ESWT energy level.

High-energy ESWT: If the physician provides a single shock wave application (generally referred to as high energy), you should note that Medicare will cover only one treatment per site for a six-month period (or two per calendar year).

Some patients may need repeated treatments. If so, you should have documentation showing the significant improvement of the patient's previous treatment.

Low-energy ESWT: Another patient has multiple applications of the shock wave modality (referred to as low energy). Montana's Medicare will cover no more than three treatments during a six-month period (or six treatments per calendar year).

If the patient reaches her therapeutic goal by the first or second treatment, then Montana's Medicare views subsequent treatments as not medically necessary and would not reimburse a separate payment.

Payer Policy #2: Some Say You Shouldn't Go Beyond 2 ESWT Treatments

Although some payer policies may consider ESWT investigational for both plantar fasciitis and epicondylitis (such as BlueCross BlueShield of California), others may accept either plantar fasciitis or epicondylitis, but not both.

For example, Wellmark, BlueCross BlueShield of Iowa and South Dakota will cover ESWT for plantar fasciitis (728.71) treatment only. Wellmark even allows a second treatment up to 16 weeks after the first ESWT, if the physician finds the results ineffective. However, you shouldn't go beyond that because Wellmark finds a third treatment to be not medically necessary.

In addition, Wellmark's policy describes ESWT as investigational for other musculoskeletal conditions "including but not limited to epicondylitis, tendinopathies including calcific tendonitis of the shoulder, stress fracture, delayed union and nonunion of fractures, and avascular necrosis of the femoral head."