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Orthopedic Coding Alert

Using ESWT? You May Finally Be Able to Collect

Published on Sat Oct 09, 2004

But payer coverage varies, so check your carriers' policies

If your orthopedist uses extracorporeal shock wave therapy (ESWT) to treat plantar fasciitis or elbow epicondylitis, you may be in luck. Insurers have slowly started issuing positive coverage policies for this emerging technology, but most policies have hitches. Your best bet? Research your payers' policies scrupulously to determine whether your carriers cover these therapies, and if so, whether you need to jump through hoops to collect your rightful reimbursement.

Because the CMS has not issued a national coverage policy regarding ESWT, many state carriers offer a slew of different policies. Our expert advice will help you combat denials and win the reimbursement battle.

ESWT Encompasses More Than 1 Code

Most insurers request that you report 0020T (Extracorporeal shock wave therapy; involving plantar fascia) for your plantar fasciitis (728.71) patients, and G0279 (Extracorporeal shock wave therapy; involving elbow epicondylitis) when you treat tennis elbow (726.31-726.32) patients.

"Some private payers may request 24999 (Unlisted procedure, humerus or elbow) for epicondylitis patients or 28899 (Unlisted procedure, foot or toes) instead," says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. Therefore, you should check your specific carriers' policies to learn which codes they prefer and whether your patient meets the carrier's criteria - and some insurers are extremely specific when it comes to paying ESWT claims.

For example, Blue Cross and Blue Shield of Montana, a Part B carrier, will reimburse ESWT claims if your plantar fasciitis/elbow epicondylitis patients meet the following criteria:

  • The patient has been symptomatic for at least six months

  • There has been a lack of response for at least the last two months to conservative measures, including rest, physical therapy, anti-inflammatory medications, local corticosteroid injections (as applicable), or heel orthotics or forearm sleeve (as applicable).

    3 Tips Help Win the Reimbursement Battle

    When you code for ESWT, keep the following three tips in mind and you'll have a better chance of collecting reimbursement.

    Tip #1: The three FDA-approved ESWT devices require that the practitioner administer anesthesia (such as local or regional blocks), but payers will bundle this service into the ESWT procedure code itself, so you should not separately report the anesthesia. Also, if your physician performs an ultrasound, many carriers may include payment for that service with the fee for the procedure.

    Tip #2: Don't forget to assign your modifiers. Both Healthnow and Empire Medicare, among other insurers, request that you use modifiers -LT (Left side) and -RT (Right side) to designate which of the patient's limbs is affected, Corcoran says.

    Tip #3: Know that insurers will be manually processing your ESWT claims, so payment may take a little longer than usual. "Each of our payers said that they would have to individually screen each case that came through," says Brad Colvard, business analyst for the department of orthopedics at the University of North Carolina in Chapel Hill. "The patient has to meet certain guidelines."

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