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Insurance Billing
 

by Michael D. Miscoe JD*, CPC, CASCC, CUC, CCPC, CHCC, CRA

1032 Peninsula Dr
Central City, PA 15926
Office: 1-814-754-1857


PP notes:

Michael Miscoe is a CPT coding specialist attorney and his advice was sought regarding giving advice to practitioners regarding CPT coding.

You may offer his services to clients at their expense should they require a personal opinion based on their unique circumstance.



CPT Coding Insurance Billing for SCENAR Treatment.



Where therapy is applied in the handheld mode (manual application thereby requiring constant attendance) the correct code according to AMA CPT coding principles is:

CPT 97032

Where self-sticking pads are used such that the therapy is not delivered manually (hand held) and where constant attendance is therefore not required, the appropriate code is:

CPT 97014


Notes: Medical/health practitioners must due their own due diligence any advice provided by NuGen Medical to you and in turn to them is based on generic advice and should not be relied upon as a one size fits all answer. The advice will vary from Insurer to Insurer.

According to the AMA,

"Biofeedback identifies the use of training to help an individual gain some element of voluntary control over autonomic body functions".

It is based on the learning principle that a desired response is learned when some type of information is received (such as a recorded increase in skin temperature [feedback] that indicates a specific thought process or action has produced the desired physiological response (paraphased from Stedman's Medical Dictionary, 26th Edition).

This is accomplished with various biofeedback monitoring equipment, which may vary from one session to another depending on the presenting symptomatology.

This may include placement of temperature or EMG sensors to relevant musculature.

Verbal and visual instruction may also be given to the patient to show how to interact with biofeedback information. The patient also receives directions for appropriately reducing tension in the targeted areas of treatment. Since various methods of biofeedback exist, the type of procedure employed is dependent on the needs of the patient.

The service components for biofeedback include reviewing the history/chart, preparing the equipment for use, placing electrodes, reading responses (including galvanic skin responses), and working with the patient to monitor and control/change muscle responses.

American Medical Association, CPT Assistant Coding Communication, Biofeedback Services, p.5 (June 1999).

IF YOU ARE CODING SCENAR AS A BIOFEEDBACK TREATMENT IT IS ADVISABLE TO INCLUDE TRAINING REGARDING OBTAINING A VOLUNTARY RESPONSE FROM THE PATIENT IN ORDER TO BE ABLE TO BILL AS BIOFEEDBACK. FOR EXAMPLE: ASKING THEM TO THINK ABOUT WHERE THE CHANGES ARE HAPPENING AND VISUALIZING THE CHANGE IN THE BODY.

Unless there is this type of training while using SCENAR then it can't be billed as biofeedback.

SCENAR as a therapeutic device using electrical stimulation to achieve its intended effect, the use of this device would be described in CPT as a modality, which is defined as follows:

Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.

American Medical Association, Current Procedural Terminology (4th ed., 2010).

There is a diagnostic mode where the SCENAR measures impedance of the skin and other factors and uses this data to modulate the waveform as a means of gaining a better therapeutic result.

The SCENAR diagnostic aspect of the service would not be separately re portable for a number of reasons.

First, it is a necessary aspect of performing the therapy.

Second, even if this was not true, the analysis would not be separately re portable in any event. Where a physician performed this therapy, the analysis would be subsumed within the provider evaluation/management service, which is necessarily bundled into the therapy.

Where a non-physician practitioner such as a physical therapist was providing the service, even if the diagnostic aspect of the service were considered separate from the therapy, it is subsumed within the PT/OT/AT re-evaluation service, which cannot be routinely billed in addition to therapy.

While the information supplied describes an interesting waveform, which causes a different biologic change than other forms of electrical stimulation, the specific type of biologic change is irrelevant when selecting the appropriate modality code.

Only the physical agent used and the degree of contact required to deliver the therapy are relevant.

Clearly, the physical agent at issue is electricity. When the SCENAR therapy is delivered in a hand-held mode, the appropriate code is CPT 97032, which is defined as follows:

Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Ibid.

In the SCENAR hand-held configuration, the constant attendance of the physician or therapist is required and the therapy is no doubt delivered manually.

I do, however, not the option to use point electrodes as well as (presumably) stick on electrodes.

Where a probe is used, the CPT code does not change as the therapy is still administered manually, and constant attendance must be maintained.

Where a stick on electrode(s) or the healing blanket is/are used, however, the correct code is CPT 97014 given that only supervision is required and there is no need for manual contact during the performance of the service.

CPT 97014 is described as follows:

Application of a modality to 1 or more areas; electrical stimulation (unattended). Ibid.

By carefully evaluating the descriptions of these codes, a significant difference becomes evident. Where CPT 97032 is correctly reported, the provider of the service may report the service on the basis of time.

Where performed sufficiently, the service may be billed in multiple units based on the time rules applicable to the particular insurance carrier being billed.

Only the time is relevant. The number of areas treated with SCENAR in the handheld mode is not relevant.

Where CPT 97014 / G0283 is correctly reported, neither time nor the number of areas treated is relevant. As a result, in a SCENAR non-handheld mode using stick-on conductive pads or sleeves or by any method not requiring manual delivery (for the entire time) and/or constant attendance of the skilled provider, this service may ONLY be billed in a single unit of service.

The appropriateness of the above CPT codes is based on the presumption that the insurance carrier being billed will concur that the service meets their definition of medical necessity and will not conclude that the therapy is experimental / investigational.

US insurance carriers have nearly unfettered discretion to determine what interventions are or should be considered experimental / investigational and for what conditions (if any) the application of SCENAR therapy would be approved.

That said, most carriers do provide coverage for these CPT codes although it is not clear that they would pay for the service if they knew what it was.

For that reason, providers who do report the CPT accurately as addressed above could face post payment liability based on the insurance carriers after the fact determination that the service is experimental / investigational.

Even those subject to class action settlement agreements can declare a service to be experimental / investigational on the basis that it is not commonly used in the industry or where there is a lack of peer reviewed literature or well designed (RCT, Cohort) study data supporting the effectiveness of the service.

Ultimately, it will be up to individual insurance carriers to define whether the services performed with the SCENAR device are considered to be medically necessary.

It is recommended that prior to reporting these services, that the providers seek pre-authorization from the carrier medical director.

Given the scope of conditions your customer/provider's may potentially attempt to treat, I would suggest obtaining such an opinion for each condition.

The final concern exists regarding whether skilled application is required. I note that, RITM SCENAR and LET Medical markets a device that provides (I presume) a substantively similar electrical waveform as the professional device.

Since this is an option and since some of the literature provided suggests that the device decides how to modulate the waveform, a carrier might conclude that there is no need for in-office performance.

Certainly, there are areas of the body that a patient could not self-treat; however, where a device could be provided and a family trained in its use, coverage of in-office administration might be denied on this basis.

This is not intended to suggest that the carrier would necessarily cover the SCENAR as an item of DME either.

Please advise if DME applications are being considered and if you need additional analysis relative to that application.

How does one determine if a practitioner, such as a physician, dentist or chiropractor (for example) in the State of Florida is licensed by law to use or order the use of SCENAR class 2 medical device?

Essentially, each type of physician or practitioner has their scope of practice defined by statute as well as through implementing regulations that are developed by the individual licensing boards.

You should note that just because a physician or practitioner can legally use or order the SCENAR device, this has no bearing on whether an insurance carrier has an obligation to pay for the service/device as described above.

As medical doctors (M.D.) and doctors of osteopathy (D.O.) have plenary licenses, they certainly could use this device (if performed personally) or order a home unit.

Licensed Doctors of Chiropractic (D.C.) and physical therapists (L.P.T.) also have this type of electrical therapy as a service within their scope of practice.

As non-physician practitioners, LPT's usually must have the use certified as necessary by an MD/DO. There may be others such as naturopaths, psychiatrists, psychologists that may appropriately use this device.

Also, nurse practitioners, and/or physicians assistants operating under the supervision of an MD/DO could likely personally perform the service.

Be sure to check the appropriate licensure statutes/regulations for the specific type of provider.