Healthcare Fraud Shield’s Latest Article: Let’s Talk about Modifier -AT – Active Treatment

How many of us went to a chiropractor only once? How often did you go when you first initiated chiropractic treatment vs. months later? Do you know if you are undergoing active or maintenance treatment? Active treatment basically means a condition is being treated that will improve within a reasonable or expected period of time. Maintenance treatment is meant to “prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition.”¹

Billing for Active Treatment

According to CMS, the -AT modifier should be included on Current Procedural Terminology (CPT) codes 98940-98942 (Chiropractic manipulative treatment -CMT codes) and should ONLY be included for services treating acute or chronic conditions. If providers are performing maintenance therapy, then the -AT modifier should not be used as these services are not covered by Medicare and most commercial payers.  Check your respective plan policies for additional information.^2,3

Documentation Guidelines

According to CMS, documentation of history is required for all visits.   In addition, all services ordered rendered must have a signature. Ever heard of SFPMQOAP – Some Fine People May Quibble Over Apple Pie? CMS laid out documentation requirements along with this handy phrase to help us remember. ⁴

S – Symptoms causing patient to seek treatment

F – Family history, if relevant

P – Past health history

M – Mechanism of trauma

Q – Quality and character of symptoms/problems

O – Onset, duration, intensity, frequency, location and radiation of symptoms

A – Aggravating or relieving factors

P – Prior interventions, treatments, medications, and secondary complaints

What schemes to look out for?·      

Providers billing Active Treatment for an extended period of time

Cookie Cutter billing patterns – patients with the same diagnoses/treatment modalities

Providers resubmitting claims that were previously denied and adding the modifier

Look for providers who submit all or most of their claims with modifier -AT

Do not forget to check your respective plan policies, reimbursement guidelines, provider contracts and member evidence of coverage documents.   

If you have any questions or comments, please reach out to SIU@hcfraudshield.com. 

REFERENCES

1        https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1602.pdf

2        https://www.paramounthealthcare.com/assets/documents/medicalpolicy/PG0150_Chiropractic_Services_and_Spinal_Manipulation.pdf

3        https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1602.pdf

4        https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/31862_17/Chiropractic_FactSheet09.18.14.pdf

Healthcare Fraud Shield’s Latest Article: Understanding Wheelchair Management

Most people need a little tutorial on how to use new equipment. This also applies to patients who need new wheelchairs. Enter the service of wheelchair management. In this service, the provider assesses a patient’s need for a wheelchair and/or teaches a patient wheelchair maneuvering skills. CPT code 97542 is the correct procedure code for wheelchair management. The units measure one unit per 15-minute increment¹

According to CMS²:This service trains the patient, family and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. Consider the following points when providing wheelchair management services.

Practice makes perfect! Most wheelchair users will need to practice a bit, but typically no more than a few days of training is enough. Regardless of whether the training took one day or four, the service needs to be documented.³ The medical record should include the following: 

• the recent event that prompted the need for a skilled wheelchair assessment;
• any previous wheelchair assessments have been completed, such as during a Part A SNF stay;
• most recent prior functional level;
• if applicable, any previous interventions that have been tried by nursing staff, caregivers or the patient that may have failed, prompting the initiation of skilled therapy intervention;
• functional deficits due to poor seating or positioning;
• objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone;
• the response of the patient or caregiver to the fitting and training.

Since it is a timed code, the practitioner should record the time for the visit from start to finish in the notes.  As of April 2021, the Medically Unlikely Edits (MUE)⁴ show the maximum number of units per day is 8 (2 hours of time). Additionally, only a Practitioner or Facility Outpatient Services can bill for this service, not DME Supplier Services.

What to look for?
When assessing this service for any potential fraud, waste and abuse (FWA), you should look for the following:

• Excessive units in a given day/compared to other providers;
• More than 8 units in a day;
• Patients who don’t have any other wheelchair related claims;
• Excessive number of dates of service per patient/compared to other providers;
• Look for services unbundled from CPT 97542 (Per CMS CCI – 36591, 36592, 96523)⁵

If you have any questions or comments, please reach out to SIU@hcfraudshield.com. 

REFERENCES

1,5 https://www.aapc.com/codes/cpt-codes/97542

2, 3 Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)

4 https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE

DRG and Clinical Validation Audits: Demystifying the Difference

Medical record auditing is an excellent tool for payers to ensure that hospitals are appropriately reimbursed for services rendered. The Office of Inspector General’s (OIG) Audit Work Plan [1] for Fiscal Year 2021 has identified the improvement of the prevention, detection, and recovery of improper payments as a management challenge making the use of DRG and clinical validation audits that much more important in the success of payment integrity operations.

There are two types of medical record audits that can assist in the validation of hospital inpatient claims: Diagnosis related-group (DRG) and clinical validation (CV) audits. Although similar in that both types of audits utilize the medical record, the difference lies in the extent of the review.

DRG

“DRG” is an abbreviation for diagnosis-related groups and is a payment methodology adopted by the Centers for Medicare and Medicaid Services (CMS) in the early 1980’s that classifies patients with similar healthcare resource consumption allowing hospitals to monitor resource usage while focusing on quality of care.

The Centers for Medicare and Medicaid Services (CMS) defines the purpose of DRG validation as ensuring the medical record supports coded diagnostic and procedural information. [2] DRG audits are performed by coding professionals who follow official coding guidelines as they evaluate the hospital claim against the medical record to substantiate coded elements such as principal and secondary diagnoses, surgical procedures, present on admission indicators and discharge disposition as documented by the physician. DRG audits can be performed concurrently and retrospectively. Working DRGs are often established shortly after admission, modified during the patient’s hospitalization, and finalized upon discharge.  

Clinical Validation

Clinical validation takes the DRG audit a step further by confirming if the clinical indicators presented in the medical record validate a diagnosis documented by a physician or physician extender.  Clinical validation audits are retrospective reviews because all documented clinical criteria (emergency department notes, history & physical, discharge summary, nursing notes, laboratory results, vital signs, diagnostic test results, etc.) must be available to perform an accurate validation.  According to Richard D. Pinson MD, FACP[3], clinical validation utilizes accepted clinical criteria to substantiate documented and coded medical diagnoses.  The applied clinical criteria are based on evidence-based medical guidelines.  Clinical validation must be performed by a licensed clinician and requires an in-depth review of the medical record to validate the medical diagnoses coded.  Some of the common diagnoses that are a focus of clinical validation audit programs include sepsis, renal failure, malnutrition, and encephalopathy because of their frequent abuse.

When clinical validation became more mainstream, questions arose regarding coders performing outside of their scope because coders are not clinicians. ICD-10-CM Official Coding Guideline I.A.19 “Code Assignment and Clinical Criteria” caused further confusion by stating code assignment is not based on clinical criteria but rather the provider’s diagnostic statement. Coding Clinic Fourth Quarter 2016 pages 147-149 effective with discharges October 1, 2016 provided clarification by confirming clinical validation is not a coding review but rather a clinical review that must be performed by a clinician (RN, CMD, or therapist). [4]

Bottom Line

DRG and clinical validation audits although different in their scope of audit are both effective tools in payment integrity endeavors to minimize payment of erroneous claims and possibly detect and deter potential healthcare fraud.

Want to learn more about DRGs? Listen to our webinar on April 28^th. Register HERE.

If you have any questions or comments, please reach out to SIU@hcfraudshield.com. 

REFERENCES

1 Audit Work Plan Fiscal Year 2021 | Office of the Inspector General, SSA

2 Medicare Program Integrity Manual (cms.gov)

3 What is clinical validation? | ACP Hospitalist

4 2021 ICD-10-CM Guidelines (cdc.gov)

Healthcare Fraud Shield’s Latest Article: Billing for COVID-19 Time and Supplies

We are in a new year, but will see the impact of code changes from 2020 for months to come.   There are many new codes directly related to COVID-19, in addition to the normal code changes. One code we want to focus on for this article, is Current Procedural Terminology (CPT) code 99072 (Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency (PHE), as defined by law, due to respiratory-transmitted infectious disease)¹.  This code became effective September 8, 2020. 

There is a similar code, CPT 99070, (Supplies and materials,except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided); however, in the CPT Assistant Special Edition², the AMA clarifies the difference between 99070 and 99072. CPT 99072 is used only during a PHE and only for supplies supporting a safe environment.   CPT 99072 also accounts for additional time needed by the clinical staff in order to provide a safe environment.    This potentially could include the use of masks or sanitizing supplies. 

What to look for:

• Since CPT 99072 is to be billed once per in-person visit, look for anyone billing it more than once or excessively per patient. 
• Look for providers billing for other time-based codes in an attempt to bill for the time spent related to CPT 99072. The time spent for the services related to CPT 99072 should not be calculated in any other time-based service during the same visit.

Check your respective plan policies for information regarding reimbursement and documentation requirements as they may vary.  In addition, the PHE is currently set to expire on January 20, 2021, however, be on the lookout for additional extensions.  Once the PHE has ended, the code will no longer be accepted for reimbursement. 

If you have any questions, please do not hesitate to reach out to SIU@hcfraudshield.com.

REFERENCES:

1.      https://www.ama-assn.org/press-center/press-releases/ama-announces-new-cpt-codes-covid-19-advancements-expand

2.      https://www.ama-assn.org/system/files/2020-09/cpt-assistant-guide-coronavirus-september-2020.pdf

Healthcare Fraud Shield’s Latest Article: Changes to Prolonged Services

 

Healthcare Fraud Shield wrote an article in 2013 explaining the use of prolonged service codes. Well, back in 2013 we said time is money and in 2020, the times have changed.  Just a refresher – what are Prolonged Services? Prolonged Service codes are used when the healthcare professional performs “beyond the usual service.”1 Providers are able to bill for three types of prolonged service codes:   1.   Prolonged service with direct patient contact, 2.   Prolonged services without direct patient contact, 3.   Providers providing direct supervision of clinical staff delivering a prolonged service    Providers billing these codes typically receive added reimbursement in addition to payment for the base evaluation and management code. As a result, these services may be prone to fraudulent and/or abusive billing. So what’s new in 2021 for Prolonged Services?  Effective January 1, 2021, there is a new Current Procedural Terminology (CPT) code, 99417.2 Per the AMA, CPT 99417 is defined as a: Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). In addition to the new code, changes were made to existing prolonged services. For example: CPT 99354 and 99355 underwent some changes as well: ·     Both codes are described now as prolonged services as opposed to “prolonged evaluation and management or psychotherapy service(s)” ·     Office was removed or other outpatient was removed from the description and now it’s just outpatient setting ·     The codes can no longer be reported with new patient or established patient evaluation and management (e/m) codes (99202-99215) ·     99354 is to be used in conjunction with 90837, 90847, 99241-99245, 99324-99337, 99341- 99350, 99483 only The American Academy of Family Physicians3 provided an example of the use of 99417: “the multiple current codes will become a single CPT code, 99417, which you can bill in 15-minute increments when total time exceeds a level 5 visit. So, a visit of 55-69 minutes with an established patient would require 99215 plus a single 99417 prolonged services code. A visit of 70-84 minutes with an established patient would take a 99215 plus two 99417 prolonged services codes, and so on” What to look for? ·     Any outlier billing patterns related to prolonged services by specialty, diagnoses, line of business and more ·     What percentage of a provider’s overall claims contain these codes? ·     Check policies and verify with your respective plans how time is to be calculated.4  If you have any questions, feel free to email us at info@hcfraudshield.com. REFERENCES: 1,2 AMA CPT Book 3 AAFP 4 CMS – Prolonged Services

Healthcare Fraud Shield’s Latest Article: Federal Laws Related to COVID-19

In response to the public health emergency and after consulting with public health officials, HHS Secretary Alex Azar, officially signed a renewal of determination extending the COVID-19 public health emergency designation up to 90 days, effective July 25th. This was the second time for the determination renewal, the first being in April.

The Secretary exercising his authority under section 1135 of the SSA (1135 waiver), may temporarily waive or modify certain Medicare, Medicaid, CHIP, and HIPAA requirements in an emergency area during an emergency period.
Examples of requirements that may be temporarily waived or modified include:

• Sanctions and penalties arising from noncompliance with HIPAA privacy regulations
• Deadlines and timetables for performance of required activities
• Sanctions under section 1877(g) (Stark) relating to limitations on physician referral under such conditions and in such circumstances as the Centers for Medicare & Medicaid Services (CMS) determines appropriate.
• Requirements that physicians and other healthcare professionals hold licenses in the state in which they provide services if they have an active and valid license from another state
• Certain conditions of participation, certification requirements, program participation, or similar requirements for individual healthcare providers or types of healthcare providers, and pre-approval requirements.

With the COVID-19 addition of waivers, modifications and relaxed rules and regulations, it opens a pandora’s box for people attempting to commit fraud! The five Federal fraud laws that pertain to physicians participating in Medicaid and/or Medicaid programs are:

1) False Claims Act or FCA, both Civil and Criminal penalties, protects the government from being overcharged or sold inferior goods or services.
2) Anti-Kickback Statute or AKS, Criminal law that prohibits the knowing and payment of remuneration (anything of value) to induce or reward patient referrals or the generation of business
3) Physician Self-Referral Law or The Stark Law, prohibits physicians from referring patients for designated health services from entities the physician or an immediate family member has a financial relationship with, unless an exception applies
4) Exclusion Authorities, exclude from participation in all Federal health care programs individuals and entities convicted of the specific types of criminal offenses
5) Civil Monetary Penalties Law or CMPL, applies civil monetary penalties and sometimes exclusion for various violations

Let’s take a look at these five laws and how they may relate to the current Public Health Emergency or PHE that is COVID-19.

False Claims Act (FCA)
• Providers billing for higher reimbursed covid-lab tests than what was actually rendered
• Submission of tests that never occurred
• Submitting telemedicine claims with a higher-level code than what was actually rendered
• Billing home services at the physician’s rate but services were performed by a visiting nurse.

Anti-Kickback Statute (AKS)
• Provider is receiving a percentage of the profit every time they refer a patient for a covid test at XXXX laboratory
• Drug Rep offers a provider an all-expense paid trip to XXXX for only prescribing their label to their patient population
• DME supplier approaches a provider and offers a gift card for steering patients their direction for PPE
• Respiratory Specialist approaches a General Practitioner (GP) and offers a monetary reward for every patient they refer to their specialty practice

Physician Self-Referral Law or The Stark Law
• A physician sees a patient that is having difficulty breathing possibly related to COVID-19, the physician sends the patient for a chest x ray at XXXX Imaging, that they share ownership of
• A Physician refers his patients for COVID-19 tests only to XXXX laboratory which is owned by his daughter
• A physician who is a GP only refers their patients to their spouse’s rehabilitation facility

Exclusion Statute
• A physician illegally prescribes drugs to his/her friends and family
• Provider submitted multiple telemedicine claims for patients without actually providing the services
• Provider negligently dismissed a patient’s complaint of shortness of breath after contact with a suspected COVID-19 person
• Physician continuously billing COVID-19 tests for patients he/she has never seen

Civil Monetary Penalties Law (CMP)
• A provider wanting to cash in on the increasing number of COVID-19 patients, made false statements on his application to participate in Federal Healthcare Programs
• A Psychiatrist misrepresented that he provided therapy sessions requiring 30 or 60 minutes of face-to-face time with the patient, when he had provided only medication checks for 15 minutes or less.
• A lab billed only high-throughput molecular diagnostic tests due to the higher reimbursement

Healthcare Fraud Shield has rules in place that recognize and alert our clients when suspicious activity is detected.

If you have any questions or comments, please contact SIU@hcfraudshield.com.

References:

https://oig.hhs.gov/compliance/index.asp

https://oig.hhs.gov/compliance/physician-education/01laws.asp

 

If you would like to learn more about Healthcare Fraud Shield’s AIShield or PostShield Shared Analytics, contact us at info@hcfraudshield.com.

 

Healthcare Fraud Shield’s Latest Article: Finding the Dysfunction in Autonomic Nervous System Testing

What is the autonomic nervous system?

The autonomic nervous system (ANS) regulates a wide variety of body system processes that take place without having to think about it, such as heartbeat, breathing, body temperature, metabolism, blood circulation, and digestion to name a few. The ANS consists of three parts: the sympathetic, parasympathetic, and enteric (the digestive system only). The sympathetic division regulates the Fight or Flight response, increasing the availability of energy, heart rate, and dilating eye pupils. The parasympathetic division helps to protect and recover normal body functions, slowing the heart rate and reducing pupils. The sympathetic and parasympathetic systems have opposite functions, responding and recovery after a response.

 

What causes problems with autonomic nervous system?

Autonomic disorders can be caused by damage to the autonomic nerves, and parts of the brain that control body systems. Some common disorders that cause damage include diabetes, peripheral nerve disorders, and Parkinson disease. Less common: Autonomic neuropathies, spinal cord disorders, some viral infections, and injury to nerves in the neck.

 

What kinds of tests are used to diagnose autonomic nervous system disorders?

 

Cardiovagal function Test: Measuring heart rate variability, heart rate response to deep breathing and Valsalva maneuver.

Vasomotor Adrenergic Function Test: Measuring blood pressure response to standing, Valsalva maneuver, hand grip, and with a tilt table.

Tilt Table Test: The patient is strapped to a motorized table that moves into an upright position while measuring changes in the patient’s blood pressure and heart rate.

Quantitative Sudomotor Axon Reflex Test (QSART): This test measures autonomic nerves that control sweating by utilizing mild electrical stimulation on the skin by iontophoresis. Measuring the volume of sweat produced.

Thermoregulatory Sweat Test (TST): The core body temperature is raised. The degree and extent of sweat production is then visualized with an indicator dye.

Who can perform autonomic nervous system testing?

 

Per the American Academy of Neurology (AAN): “We strongly recommend that only physicians with the appropriate training perform and interpret clinical autonomic test results. The United Council of Neurologic Subspecialties has established a board examination as one potential method to certify those individuals with expertise in autonomic disorders.”[1] 

How is this testing billed?

The American Medical Association (AMA) Current Procedural Terminology (CPT) assigns the following procedure codes to ANS testing:

95921: Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio. 

95922: Vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt. (Do not report 95922 in conjunction with 95921) 

95923: Sudomotor, including one or more of the following quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential.

95924: combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt. (Do not report 95924 in conjunction with 95921 or 95922 ) 

95943: Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change. (Do not report 95943 in conjunction with 93040, 95921, 95922, 95924?

What should I look for?

Per the AAN: “A number of automated testing devices have been developed over the past several years and advertised directly to non-neurologists and general practitioners who do not have training or expertise in the autonomic nervous system. Some of these automated devices may also generate patient-specific recommendations for treatment. As a result, physicians who do perform full autonomic testing have seen a large increase in the number of patients erroneously diagnosed with an autonomic disorder. Most physicians without training in the autonomic nervous system do not know enough about many of the rare autonomic disorders to integrate the information supplied by automated devices into the clinical history of the individual in front of them.” [2]

These automated testing devices often do not meet the coding requirements. These codes also require physician interpretation and report, which without the right training may not be diagnostically accurate or meet medical necessity and coding requirements. Most payors will have guidelines around provider qualifications and testing requirements. Make sure to be familiar with your carrier’s policies.

If you have any questions or comments, please contact SIU@hcfraudshield.com.

References:

---

[1] Autonomic Testing Model Coverage Policy, American Academy of Neurology

[2] Autonomic Testing Model Coverage Policy, American Academy of Neurology

Healthcare Fraud Shield’s Latest Article: Opioid Crisis in America and FWA

Opioid abuse and overdose deaths are at epidemic levels in the United States. Opioids, sometimes called narcotics, are a type of drug used to treat moderate to severe pain. They include strong prescription pain relievers, such as oxycodone, hydrocodone, fentanyl, and tramadol. The illegal drug heroin is also an opioid. Some opioids are made from the opium plant, and others are synthetic (man-made). Most opioids are classified as Schedule II controlled substances. Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.

Opioid fraud schemes and networks of pill mill clinics can not only be a multimillion-dollar business, but endangers lives and costs the healthcare system billions of dollars each year. By identifying and mitigating potentially fraudulent, abusive, or wasteful activities related to opioids, we play an important role in dismantling the epidemic.

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What type of schemes should you look for?

• Pharmacies filling prescriptions for highly abused prescription-drug cocktails especially for long-distance patients
• A pharmacy excessively dispensing opioid prescriptions for multiple members of the same family
• The pharmacy dispensing controlled-substance prescriptions for patients engage in doctor/pharmacy shopping
• Pharmacy receiving dinners, cash, rebates and discounts from drug companies
• Pharmacies hiring marketing firms to hire recruiters to find patients
• Pharmacies offering physicians a percentage of insurance reimbursement to write scripts and send them to your pharmacy 

If suspicious behavior or predication exists, conduct audits and analysis of the following:

Prescriber Audits

• Are Medication Management visits provided in line with Controlled Substance requirements
• Writing excessive prescriptions for controlled substances
• Claims with only one visit from several patients
• High percentages of patients with diagnosis of chronic pain
• Is this prescriber allowed to prescribe these medications?
• Is the prescriber utilizing the Prescription Drug Monitoring Programs (PDMPs) to determine concurrent opioid use?
• Is the prescriber performing urine drug test screening to test for concurrent illicit drug use?

 Pharmacy Audits

• High dollar average claim amounts
• Quantity dispensed versus the days supplied
• Confirm the pharmacies dispensing is in line with FDA guidelines
• Quantity dispensed versus prescription drug program limitations
• Look for excessive claim reversals
• Compounding (high claim amounts billed or average ingredient cost too high)
• Excessive amounts of Controlled Substances being dispensed compared to peers
• Invalid DEA, NPI, or state board license number in the incorrect NCPDP field
• Submitting smaller package sizes for large quantities of medications
• Dispensing prescriptions written by an excluded provider
• Excessive early refill overrides
• Counterfeit prescription pads 

Member Audits

• Review claim history for member filling prescriptions at several different pharmacies
• Review history for members seeing several different physicians
• Review history for excessive Emergency Department visits
• Diagnosis of chronic pain
• Insurance denials paid by cash
• Requests for early refills
• Auto refills
• Prescriptions filled 100 miles or more from residence, or located in a different state
• Physician visits 100 miles or more from residence, or located in a different state

If you have any questions or comments, please contact SIU@hcfraudshield.com.

References:

1) DEA

Healthcare Fraud Shield’s Latest Article: The Stimulating Billing of P-Stim devices!

 

We all want to be pain free right? What if I told you that you could experience relief of chronic pain using a minimally invasive technique with virtually no side effects? You would probably say sign me up, right? At least that’s what the makers of P-Stim devices like ANSiStim and Stivax are advertising. What is P-Stim? Point-Stimulation Therapy or P-Stim is a non-narcotic approach to pain management. P-Stim is a miniaturized electro-acupuncture device worn by the patient that administers continuous pulses of a low-level electrical current at the ear over several days. Electrical pulses are emitted through three selectively positioned acupuncture needles. Some examples of the devices include: AcuStim (S.H.P. International) P-Stim™ System (NeuroScience Therapy) E-pulse® (AMM Marketing) Electro Auricular Device – EAD (Key Electronics) P-Stim (Biegler Gmbh) ANSiStim® (DyAnsys) Stivax System (Biegler Gmbh) Who should use a P-Stim? Makers of the PStim devices advise that using P-Stim can be highly effective in relieving chronic pain for conditions such as:1 Peripheral Vascular Disease Neuropathy Post-amputation Pain Herpetic Neuralgia Trigeminal Neuralgia Reflex Sympathetic Dystrophy (RSD) Migraines Occipital Neuralgia Peripheral Artery Disease (PAD) Back and Neck Pain Post-Surgical Pain Complex Regional Pain Syndrome (CRPS) Diabetic Peripheral Neuropathy Lateral Femoral Cutaneous Neuropathy Traumatic Nerve Injuries Can anyone place a P-Stim device? Check your respective state guidelines and internal policies, but typically only licensed medical providers may apply this device. How is it billed? S8930-Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient. The Potential Scheme Medicare does not reimburse for acupuncture or for acupuncture devices such as P-Stim, nor does Medicare reimburse for P-Stim as a neurostimulator or as implantation of neurostimulator electrodes. Medicare considers Electrical stimulation of auricular acupuncture not medically necessary and not covered for all indications, including but not limited to chronic and acute pain.2 P-Stim is sometimes incorrectly billed as a surgically implanted neurostimulator (HCPCS code L8679). The American Medical Association defines code L8679 as an “Implantable Neurostimulator, Pulse Generator.”  P-stims are applied as devices employing acupuncture needles attached to electrodes that are being applied to a patient’s ear through simple bandages and therefore does not qualify as “implantable”. Implantation of a Percutaneous Neurostimulator Pulse Generator is typically performed in an outpatient or Ambulatory Surgical Center (ASC) setting while P-stims can generally be performed in an office environment. Auditors and investigators should: 1)      Review claims to determine the place of service and if an implantable neurostimulator is being billed without an accompanying surgical code as this might imply the provider is incorrectly reporting P-Stim. 2)      Look for excessive billing of L8679 3)      Look for S8930 with a place of service for ASC. If you have any questions or comments, please contact SIU@hcfraudshield.com. REFERENCES [1,]P-Stim [2]Medicare/DOJ If you would like to learn more about Healthcare Fraud Shield’s PostShield Shared Analytics, contact us at info@hcfraudshield.com.

Healthcare Fraud Shield’s Latest Article: Controlling the Uncontrollable?

Do you ever use Fitbit’s Relax feature which provides guided breathing sessions? While in this mode, the user can concentrate on clearing his/her mind, lowering the heart rate and as the feature suggests, just relaxing.     Certain bodily functions such as your heart rate, blood pressure, skin temperature are controlled involuntarily by our nervous system.   Using the Fitbit or other similar devices to help control some of these areas is akin to what we know in the medical field as biofeedback.   According to WebMD¹:

 

The idea behind biofeedback is that, by harnessing the power of your mind and becoming aware of what’s going on inside your body, you can gain more control over your health.

 

How is Biofeedback performed?

Although methods vary slightly, typically a biofeedback therapist will attach electrodes or sensors to the skin to monitor things such as blood pressure, heart rate, skin temperature, peripheral vasomotor activity and more. The therapist utilizes a variety of techniques such as deep breathing, progressive muscle relaxation, guided imagery and mindful medication.²

 

Why is Biofeedback performed?

A variety of conditions may warrant utilizing biofeedback including, but not limited to:

• Constipation
• Incontinence
• Migraines
• Neuromuscular rehabilitation for patients who had a stroke

How is it billed?

These are the codes that can currently be used:

• E0746 – Electromyography (EMG), biofeedback device
• 90901 – Biofeedback training by any modality
• 90911 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry

CPT 90911 will be deleted effective 12/31/2019 and replaced with two codes:

• 90912- Biofeedback Training, Perineal Muscles, Anorectal Or Urethral Sphincter, Including Emg And/Or Manometry, When Performed; Initial 15 Minutes Of One-On-One Physician Or Other Qualified Health Care Professional Contact With The Patient
• +90913 – Biofeedback Training, Perineal Muscles, Anorectal Or Urethral Sphincter, Including Emg And/Or Manometry, When Performed; Each Additional 15 Minutes Of One-On-One Physician Or Other Qualified Health Care Professional

Is Biofeedback a covered service?

Typically, biofeedback is covered by health insurance when performed by a licensed provider for a limited number of conditions such as:

• Chronic constipation
• Fecal incontinence
• Stress urinary urgency
• Migraine and tension headaches
• Muscular re-education after a stroke

It is considered experimental, investigational and unproven for conditions such as:

• Autism
• ADHD
• Spasmodic torticollis
• Epilepsy, etc.³

What to look for?

• Inappropriate medical diagnoses to support the service
• Excessive time submitted for the new add-on code
• Providers hiding these services under other codes when performing them for the for conditions that are considered investigational.⁴

If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

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[1,2] Biofeedback

[3]   Medical Policy

[4]   List of Providers