Stay Away From Denials by Applying UHC's Latest Thermal Policy
If your practice participates with United Health Care (UHC)
, you will want to take note of UHC's recent policy update on ablative treatment of spinal pain. Even though UHC has a limited coverage policy for a number of spinal pain and facet joint pain procedures, you have some chance of reimbursement if you are aware of the rules.
Ablation method and frequency matter
Among the changes are a revised coverage policy for how often thermal radiofrequency ablation (RFA) can be carried out and reimbursed. According to the policy, thermal RFA is covered when carried out at three months or greater frequency, provided there has been a 50 percent or greater documented reduction in pain.
Reimbursement difficult for Thermal RF treatment
UHC's policy toward thermal radiofrequency ablation can seem disheartening at first glance. The policy's coverage rationale points out a number of conditions for which treatment for spinal or orthopedic pain is not covered.
Fluoroscopic guidance called for
One guideline is the necessity of fluoroscopic guidance when a doctor carries out these procedures. The image guidance requirement makes sense. Per medical care standards, providers should not carry out the thermal destruction procedures blind' or anatomically guided'.
Pulsed radiofrequency, other ablations not covered
Practices that make use of emerging techniques to treat chronic spinal pain will also be in for some disappointments. The updated UHC policy considers pulsed RF therapy, cryoablation, alcohol ablation, and laser ablation to be unproven for spinal/facet joint pain and, as such, not covered.
However the coverage climate could be changing. If future studies demonstrate the safety and efficacy of alternative methods of destructive neurolysis, it's possible that third-party payers may reconsider their non-coverage decision. The fast growth of these kind of procedures using a variety of methods is leading more payers to examine the published medical evidence for a particular method, with subsequent revision of prior coverage policies.
If your practice makes use of pulsed radiofrequency ablation, you'll need to turn to an unlisted code.
Reasoning: Some people will try to bill the pulsed RFA using the normal
CPT codes used for thermal RFA. The policy is stating it should be an unlisted code, and they don't cover it.
The
CPT manual also sets the following guideline in the Destruction by Neurolytic Agent' section. For therapies that are not destructive for the target nerve, report 64999. A
CPT Assistant August 2005 article echoes that, suggesting you report 64999 when pulsed radiofrequency is carried out on any anatomic region and on any nerve.
Stay Away From Denials by Applying UHC's Latest Thermal Policy
By: James Smith
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