Eli's Rehab Report

2 carriers already say they won't cover new code 28890

Coders rejoiced when CPT 2006 introduced a new code for extracorporeal shock wave therapy: 28890. But just because a procedure has a code, doesn’t mean Medicare will pay you for it.

Find Out When to Report ESWT

ESWT for plantar fasciitis graduated to Category I CPT status with 28890 (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia).

Plantar fasciitis (728.71, Plantar fascial fibromatosis) is an inflammation of the tough connective tissue that stretches from the heel bone, across the arch, and to the base of the toes. This common foot problem produces complaints of deep pain under the heel during the first few steps following prolonged inactivity (such as sleeping or sitting).

Physicians often reserve ESWT for patients who have failed all other forms of conservative treatment for plantarfasciitis. In these cases, ESWT can help prevent the patient from requiring “open” surgical treatment, says Susan Vogelberger, CPC, CPC-H, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in Ohio.

What happens: During ESWT, physiatrists identify the points of maximal tenderness and apply a special gel to the heel and the treatment head of the instrument, which then delivers shock waves, says Mary Brown, coding specialist at OrthoWest in Omaha, Neb.

You’ll find both a high-energy and low-energy form of ESWT, and providers use both forms of shock wave therapy for plantar fasciitis.

The provider gives low-energy shock wave treatments as a series of three or more services, and the low-energy shock waves are not painful. On the other hand, providers give the high-energy shock wave treatments at one session.

High-energy shock wave treatments are quite painful, and the patient often needs some type of anesthesia. The provider will administer either a regional block or a general anesthesia.

Pay attention: The CPT descriptor for 28890 states that the code includes any ultrasound guidance, but also that the procedure requires anesthesia. The descriptor also specifically states that it may not be a local anesthetic. Physiatrists commonly use a heel block (posterior tibial and/or sural nerve injection) before performing ESWT. CPT considers these nerve blocks a “regional” anesthetic rather than a local anesthetic, which meets the code descriptor requirements.

Note: The National Correct Coding Initiative version 12.0 bundles nerve block codes 64415-64417, 64450, 64470 and 64475 into 28890, so you can’t bill separately for the nerve block.

No Anesthesia Means No 28890

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

If your physiatrist cannot meet the conditions for 28890, you’ll find yourself back in the realm of Category III codes. CPT 2006 deleted 0020T (Extracorporeal shock wave therapy; involving plantar fascia) but kept the temporary status of all other ESWT codes.

Check out these codes 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 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.

Get Ready for Limited Reimbursement

Although you may celebrate 28890’s existence, you should prepare yourself for a lack of reimbursement from Medicare carriers. For example, Trailblazer Health Enterprises and HGSAdministrators both put out local coverage determinations stating that ESWT is an “experimental” treatment and therefore noncovered.

So far, only one carrier says it will pay for 28890. CIGNA Government Services says it’ll cover ESWT for plantar fasciitis and lateral epicondylitis.
Keep in mind: The patient must have been symptomatic for at least six months. The condition must not have responded to at least two months of conservative measures, including rest, physical therapy, anti-inflammatory medications, local corticosteroid injections, or orthotics. And ESWT must be the only alternative to surgery.

Take Action With Your Medical Director

If your carrier isn’t one of the three mentioned above, now is the time to contact your carriers’ medical directors and urge them to cover ESWT, experts say.

The fact that there’s a CPT code--and Medicare has assigned 9.44 non-facility relative value units (RVUs) to it--means that the carriers ought to cover the service, Brown says.

Brown had good luck billing for ESWT using an unlisted-procedure code and obtaining prior approval from her carrier, and she’d assumed the new code would make the process easier, not harder.