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New developments on Medicare coverage of ESWT...

Posted by Ed Davis, DPM on 5/21/03 at 15:56 (119543)

Medicare Part B
Extracorporeal Shock Wave Therapy Clarification and Expansion of Coverage
This article will replace the article previously published in Medicare B News, Issue No. 188, March 15, 2001, and will cover both the use of this therapy for plantar fasciitis AND lateral epicondylitis.

For Treatment of Plantar fasciitis:

On October 12, 2000, the FDA approved a device that, much like the lithotripsy device which breaks up kidney stones, delivers extracorporeal shock waves to the heel with the aim of resolving pain from chronic proximal plantar fasciitis. This treatment claims to 'promote revascularization, which promotes healing'. This Carrier will allow payment for this service when the following guidelines are followed.

Indications (all three must be present):

Proximal plantar pain for at least six months
Failure to respond to two courses of physical therapy, e.g., stretching, massage
Failure to respond to pharmacological therapy, e.g., cortisone injections, NSAIDs
Contraindications:

Previous proximal plantar fascia surgery
Other foot or ankle pathology, e.g., osteomyelitis, recent fracture
Neurological or vascular disease that has affected the foot
History of plantar fascia rupture

Retreatment: This Carrier will allow a second treatment at 14-16 weeks after the first, if response is not acceptable. We will not allow a third treatment.

Billing:

This service should be billed with the Category III code 0020T, appending modifiers LT (left) or RT (right) to indicate the site. If the indications listed above are met, ICD-9-CM 728.71, chronic proximal plantar fasciitis, should be used. Reimbursement will currently be $375.00 and includes all follow-up care for 90 days. Anesthesia services may be billed separately, as appropriate.

Re: New developments on Medicare coverage of ESWT...

Ed Davis, DPM on 5/21/03 at 15:58 (119546)

I cannot give any more details than what is printed here. I feel that it is a significant precedent to be set by a carrier (Noridian) representing a national program.
Ed

Re: New developments on Medicare coverage of ESWT...

BrianG on 5/21/03 at 19:28 (119561)

If you don't mind me asking, will the doctor settle for the Medicare payment, $375? Or will the patient have to come up with the rest of the money for a typical treatment?

Regards
BrianG

Re: New developments on Medicare coverage of ESWT...

Ed Davis, DPM on 5/21/03 at 20:38 (119570)

Brian:

When a doctor accepts assignment on a Medicare claim, the patient cannot be balanced billed for the difference. The doctor may decide that he cannot afford to provide treatment at a particular rate and, as such, refuse to offer the treatment. It is fairly common for Medicare to set reimbursement rates at below the cost price for a number of procedures.
A provider then can take a loss assuming that it will be made up by those procedures which have an adequate profit margin (depends on the specialty), refuse to offer the procedure or, at times stop taking Medicare patients altogether. Most of the family doctors in my town have stopped accepting new Medicare patients.

Ed

Re: clarification

Ed Davis, DPM on 5/21/03 at 20:44 (119572)

Medicare allows a specific amount for a procedure, then pays 80% of what it allows, less any outstanding patient deductible. The patient or the patient's co-insurance is responsible for the 20%. If a doctor is not a participating provider than a premium of about 10% (changed several times so I don't know what the current % is) can be charged to patients above the allowed amount.

A small percentage of physicians have completely opted out of the Medicare system. Such providers would provide services to Medicare beneficiaries on a cash basis but the patient could recieve no reimbursement from Medicare. This scenario may be difficult for many to understand but a number of physicians feel that they cannot offer an adequate levle of quality within the constraints of the system.
Ed

Re: New developments on Medicare coverage of ESWT...

elliott on 5/22/03 at 08:25 (119606)

Dr. Ed, I'm not claiming that every doc does equally well under Medicare, bnut just in the past few weeks, a few acquaintences have claimed Medicare is by far their best payor--an eye doc and a neurologist. Let's also not forget we spend more on helath care than any other country by far, and Medicare has long-term solvency issues to deal with.

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Re: New developments on Medicare coverage of ESWT...

Ed Davis, DPM on 5/22/03 at 09:06 (119610)

Elliott:

Opthamologists do better under Medicare than most specialties. The solvency issues Medicare faces are due to a number of factors but two major ones include benefit design and the failure to institute needs testing for benefits, in my opinion.

Ed

Re: clarification

john h on 5/22/03 at 09:55 (119633)

My family clinic of 25 years will no longer accept new Medicare patients. Of course those of us who have been there will be accpted as long as we live my Doctor told me.

As a Medicare patient I get a form that shows what the Doctor bills and what Medicare pays for that treatment. It is amazing. When I had litotripsy for the removal of a kidney stone I think the total charges for the machine, operating room and staff, anathesiaologist, Urologist, etc was on the order of $12,000. Medicare approved and paid around $3000 and my suppliment picked up the 20% Medicare does not pay. Many procedures I see the Doctor is not paid anything and they cannot bill the patient back.
One of my wife's doctors requires she pay up front and then the Doctor files the Medicare paper work and we are reimbursed directly.

Re: New developments on Medicare coverage of ESWT...

john h on 5/22/03 at 10:02 (119634)

Brian that $375 would easily cover your ESWT in Australia and you could have enough left over for a Big Mac.

Re: New developments on Medicare coverage of ESWT...

elliott on 5/22/03 at 10:50 (119644)

With benefit design, there will always be winners and losers. Have to disagree about needs testing for Medicare. The way it is currently set up, people pay taxes into Medicare all their lives expecting to receive non-needs-tested benefits when they retire. It is what makes the system palatable. Those who earned more all those years also payed more into it, since they paid a fixed percentage of their salary. So they are getting less of a return benefit than they are in social security, where at least they get back a bit more if they contributed more. I don't trust politicians to come up with a 'fair' needs-testing system; there ends up being no end to how they stretch that when they are desperate. It would also penalize savers and encourage wasters.

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Re: New developments on Medicare coverage of ESWT...

Ed Davis, DPM on 5/22/03 at 14:52 (119669)

Elliott:

We could probably spend a day discussing this issue. I agree with the concept that patients, to an extent, that patients have the right to a certain level of benefits from medicare after spending a 'lifetime' paying into the system. But, from an actuarial standpoint, are we not paying out a greater level of benefits than what was paid in? There are very few Americans who have a policy with as low a deductible as Medicare Part B. Now, I realize that there are many seniors who could not afford to pay a higher deductible and I would like to see some adjustment made for that group. But, as it stands now, Warren Buffett and Bill Gates will have the same low deductible as a poor senior citizen.

One problem with benefit design is that I see a lot of 'politics' in the design as opposed to logic. A prime example in my profession is that Medicare gives me a strong incentive to do minor surgical procedures in the hospital or surgicenter -- procedures that I could do in my office at a fraction of the cost. Medicare pays docs the fee for the procedure but refuses to pay costs of supplies and staffing. If I do the procedure at a hospital my only overhead is the gas in my car to drive there. I realize that one way docs have gotten around that is to open Medicare certified surgicenters.

You are absolutely correct about the difficulties inherent in needs testing, particularly in light of the influence of politics. I am not sure that that reason is sufficiently compelling to give up on the concept though, particularly when one considers the need to preserve the system for the future. My suggestion (which goes against my libertarian leanings) is to completley federalize Medicaid, eliminating state to state inconsistencies in the program and turn it into a Medicare Part C. We already needs test Medicaid recipients. Deductible should be raised for Medicare Part B but the critieria to get onto part C would be somewhat liberalized. Non-seniors of working age would be expected to pay into part C unless they are completely disabled. I readily admit that this is a minefield subject to politicization. Nevertheless, I would just turn the project over to H. Ross Perot ;)
Ed

Ed

Re: New developments on Medicare coverage of ESWT...

elliott on 5/22/03 at 15:39 (119673)

Dr. Ed:

Sure they get back more on average than they pay into the system; it's currently over 2:1, and this even includes the employers' share (although a tremendous chunk is spending in one's last year of life). But people don't view it that way. I might add that 3/4 of Part B is paid for out of general revenues (read: taxes on the working), so they're really paying more. A case can be made that our society sees the need to offer a health care safety net for people in their retirement, and the way to do that is to charge a fixed percentage and give equal benefits. The Buffet/Gates analogy is a catchy one, of course, but ignores that they already paid in far more than they'll ever get out, and also that your typical middle-to-upper-middle-class recipient who spent a lifetime saving could find himself just as poor as someone not needs-tested after the politicians are done.

Supplies have always been a thorn, but there have always been iregularities in charging for supplies too. Let's not ignore, either, that while doctors are no doubt loving and caring healers, they have, even as whole, historically been rather creative in maximizing their profits in response to any well-intentioned legislation trying to curb their excesses.

Medicare Part C? You want 3 programs heading toward insolvency instead of 2? :-) Such an idea would eliminate legitimate cost-cutting efforts. And some states have a better grasp on things than others. San Francisco has historically had very low medical utilization without undertreating patients, other cities ridiculously high. Such a formal program would standardize at an inefficient level. Take your idea to an extreme (nationalized health care), and you'll have what they have in Europe, not all rosy by Americans' standards.

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Re: New developments on Medicare coverage of ESWT...

BrianG on 5/22/03 at 18:12 (119689)

I guess it will be a lot like dental care in my state, Ma. This year we have no coverage, but last year only extractions were covered. I needed an extraction last year, and called around to find a dentist taking the Medicaid. Forget about it !!!! The few who advertised were booked up months in advance, and were not taking any new patients. I did find a dentist, by word of mouth, who took some Medicade cses, but only a few, and he did not advertise.

I was able to get in, but he was quicker than any Army, or Navy, dentist I ever saw. He gave me the shot, and was gone for about 10 minutes. When he came back in, he had it (molar) pulled in less than 3 minutes, and was on to the next patient!!!!! I could see why he had to hustle, as I know he was paid less than a third of what the other local doctors wanted.

How the heck are the Pod's going to cut the ESWT time, in order to make a profit? I'm doubting very many doctors will be accepting Medicare patients, as long as private patients are willing to pay retail. We'll see !!!!!

BrianG

Re: New developments on Medicare coverage of ESWT...

Ed Davis, DPM on 5/23/03 at 15:03 (119755)

Elliott:

Part of the problem is that part B presupposes indigence. It is based on giving coverage to those least able to pay. If that presupposition can be removed from the design of part B, then it has a good chance at solvency. The only way to do this fairly is to have a program that can deal effectively with those who don't have the ability to pay. We have a hodgepodge of Medicaid programs, of which, a lot of federal dollars are flowing to anyway. Why not take the best program, perhaps San Francisco, and use that as a model for a uniform federal system. As a pseudo-libertarian, I would also like to assume that the worst will happen but we really cannot do so -- it is the equivalent of throwing in the towel.

It really does not matter how creative docs get with billing supplies -- one will never come close to the amount paid to hospitals for procedures that could have been performed in the office.

Ed

Re: New developments on Medicare coverage of ESWT...

Ed Davis, DPM on 5/23/03 at 15:05 (119756)

John:

Australia does not have the FDA to contend with.

Ed