How to submit document during first claim submission - detailed review - PWK segment

PWK allows documentation to be submitted with an initial claim

Effective October 1, 2012, First Coast Service Options Inc. (First Coast) implemented the PWK (paperwork) segment of the X12N version 5010. PWK allows for voluntary submission of supporting documentation with a 5010 version electronic claim.

PWK is a segment within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions that provides the link between electronic claims and additional documentation. PWK allows providers to submit electronic claims that require additional documentation and, through the dedicated PWK process, have the documentation imaged to be available during the claims adjudication. Eliminating the need for costly development and allowing providers and Medicare contractors to utilize efficient, cost-effective Electronic Data Interchange or EDI technology will create a significant cost savings.

Although PWK ultimately will allow electronic submission of additional documentation, the October implementation only allows for submission of additional documentation via mail and fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier, respectively).

First Coast has made available a fax/mail coversheet that providers or trading partners shall use to submit the unsolicited additional documentation. The First Coast fax/mail coversheet is an interactive form posted to our website. Providers or trading partners may complete required data elements and are then able to print a hardcopy of the form to mail or fax with their documentation. Modifications to the fax/mail coversheet are not permitted. Separate forms are provided for Part A and B for Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast has also provided secure faxination numbers for those providers or trading partners who elect to fax the additional documentation.

PWK Fax/mail coversheets

First Coast is requiring the following section of the form to be completed with valid information to ensure the paperwork documentation is appended to the pending claim in our system: ACN (Attachment Control Number (submitted in the PWK06 segment)), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, Billing provider's name and NPI (national provider identifier).

First Coast will return PWK coversheets with missing or inaccurate data. The coversheet will be returned based on how it was received (fax or mail).

• Note: First Coast will not return any paperwork documentation that accompanies a rejected PWK coversheet; nor will the documentation be used for adjudication of the claim.

PWK documentation may not be submitted prior to submission of a claim. Submitters must send all relevant PWK data at the same time for the same claim. Thus, if the claim was submitted with multiple PWK iterations, all PWK data for the claim must be submitted together under one coversheet.

If the PWK segment is completed and additional documentation is needed for adjudication, First Coast will allow seven calendar "waiting" days (from the claim date of receipt) for the paperwork documentation to be faxed or ten calendar waiting days to be mailed. The seven and ten day waiting periods apply to claims for both Part A and Part B.

If the PWK data is not received within the waiting timeframe and additional documentation is needed, a development request will be sent. If documentation is received after the timeframe has elapsed, the documentation will not be used for adjudication of the claim. Thus, the paperwork will need to then accompany our request for additional documentation to prevent possible claim denials.

Claims submitted with a PWK segment, that would not otherwise suspend for review and/or require additional development, will process routinely and will not be held for the seven or ten day waiting period.

Faxination numbers

First Coast has provided designated faxination lines to expedite receipt of the PWK coversheets/attachments, depending on the provider’s line of business and location (Part A or Part B; Florida, Puerto Rico, or the U.S. Virgin Islands.

Each fax/mail coversheet includes the appropriate First Coast return mailing address and faxination number, based on the provider's selection.

Handling Incomplete or Invalid Submissions - Medicare claim tips

The following provides additional information detailing submissions that are considered incomplete or invalid.

The matrix in Chapter 25 specifies whether a data element is required, not required, or conditional. (See definitions in §70.2 above.) The status of these data elements will affect whether or not an incomplete or invalid submission (hardcopy or electronic) will be returned to provider (RTP). FIs should not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction. (See §80.3.1 for Definitions.)

The FIs should take the following actions upon receipt of incomplete or invalid submissions:
• If a required data element is not accurately entered in the appropriate field, RTP the submission to the provider of service.

• If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission.

• If a conditional data element (a data element which is required when certain conditions exist) is not accurately entered in the appropriate field, RTP the submission to the provider of service.


• If a submission is RTP for incomplete or invalid information, at a minimum, notify the provider of service of the following information:
o Beneficiary’s Name;
o Health Insurance Claim (HIC) Number;
o Statement Covers Period (From-Through);
o Patient Control Number (only if submitted);
o Medical Record Number (only if submitted); and
o Explanation of Errors.

NOTE: Some of the information listed above may in fact be the information missing from the submission. If this occurs, the FI includes what is available.

• If a submission is RTP for incomplete or invalid information, the FI shall not report the submission on the MSN to the beneficiary. The notice must only be given to the provider or supplier.

The matrix in Chapter 25 specifies data elements that are required, not required, and conditional. These standard data elements are minimal requirements. A crosswalk is provided to relate CMS-1450 (UB-04) form locators used on paper submissions with loops and data elements on the ANSI X12N 837 I used for electronic submissions.
The matrix does not specify loop and data element content and size. Refer to the implementation guide for the current HIPAA standard version of the 837I for these specifications. If a claim fails edits for any one of these content or size requirements, the FI will RTP the submission to the provider of service.

NOTE: The data element requirements in the matrix may be superceded by subsequent CMS instructions. The CMS is continuously revising instructions to accommodate new data element requirements. The matrix will be updated as frequently as annually to reflect revisions to other sections of the manual.

The FIs must provide a copy of the matrix listing the data element requirements, and attach a brief explanation to providers and suppliers. FIs must educate providers regarding the distinction between submissions which are not considered claims, but which are returned to provider (RTP) and submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected and re-submitted.

Electronic claim process in Medicare overview

Electronic Claims


As of October 16, 2003, all providers and suppliers must submit claims electronically via Electronic Data Interchange (EDI) in the Health Insurance Portability and Accountability Act format, except in limited situations.

Electronic versions of Centers for Medicare & Medicaid Services (CMS) claim forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp on the CMS website. Each provider or supplier must complete a CMS Standard EDI Enrollment Form and send it to the Medicare Contractor prior to submitting electronic media claims (EMC). A sender number, which is required in order to submit electronic claims, will then be issued. An organization that is comprised of multiple components that have been assigned Medicare provider identifiers may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these identifiers have been assigned.


Where to Find Additional Information About Electronic Billing and Electronic Data Interchange Transactions
Additional information about electronic billing and EDI transactions is available at http://www.cms.hhs.gov/ElectronicBillingEDITrans on the CMS website. The EDI Enrollment Form is available from Medicare Contractors.

Electronic Media Claims Submissions
Claims are electronically transmitted to the Medicare Contractor’s system, which verifies claim data. This information is then electronically checked or edited for required information. Claims that pass these initial edits, also called front-end or pre-edits, are processed in the claims processing system according to Medicare policies and guidelines. Claims with inadequate or incorrect information may:

Be returned to the provider or supplier for correction;

Be suspended in the Contractor’s system for correction; or

Have information corrected by the system (in some cases).

A confirmation or acknowledgment report, which indicates the number of claims accepted and the total dollar amount transmitted, is generated to the provider or supplier. This report also indicates the claims that have been rejected and reason(s) for the rejection.



Electronic Media Claims Submission Alternatives


Providers and suppliers who do not submit electronic claims using EMC may choose to alternatively submit claims through an electronic billing software vendor or clearinghouse, billing agent, or by using Medicare’s free billing software. Providers and suppliers can obtain a list of electronic billing software vendors and clearinghouses as well as billing software from Medicare Contractors.

How to submit electronic claim

Electronic Health Care Claims

How to Submit Claims: Claims may be electronically submitted to a Medicare carrier, Durable Medical Equipment Medicare Administrative Contractor (DME MAC), or a fiscal intermediary (FI) from a provider's office using a computer with software that meets electronic filing requirements as established by the HIPAA claim standard and by meeting CMS requirements contained in the provider enrollment & certification category area of this web site and the EDI Enrollment page in this section of the web site. Providers that bill FIs are also permitted to submit claims electronically via direct data entry screens.

Providers can purchase software from a vendor, contract with a billing service or clearinghouse that will provide software or programming support, or use HIPAA compliant free billing software that is supplied by Medicare carriers, DME MACs and FIs. Medicare contractors are allowed to collect a fee to recoup their costs up to $25 if a provider requests a Medicare contractor to mail an initial disk or update disks for this free software. Medicare contractors also maintain a list on their providers' web page that contains the name of vendors whose software is currently being used successfully to submit HIPAA compliant claims to Medicare. This is done for the benefit of providers interested in purchasing electronic billing software for the first time or in changing their current software.

How Electronic Claims Submission Works: The claim is electronically transmitted in data "packets" from the provider's computer modem to the Medicare contractor's modem over a telephone line. Medicare contractors perform a series of edits. The initial edits are to determine if the claims in a batch meet the basic requirements of the HIPAA standard. If errors are detected at this level, the entire batch of claims would be rejected for correction and resubmission. Claims that pass these initial edits, commonly known as front-end edits or pre-edits, are then edited against implementation guide requirements in those HIPAA claim standards. If errors are detected at this level, only the individual claims that included those errors would be rejected for correction and resubmission. Once the first two levels of edits are passed, each claim is edited for compliance with Medicare coverage and payment policy requirements. Edits at this level could result in rejection of individual claims for correction, or denial of individual claims. In each case, the submitter of the batch or of the individual claims is sent a response that indicates the error to be corrected or the reason for the denial. After successful transmission, an acknowledgement report is generated and is either transmitted back to the submitter of each claim, or placed in an electronic mailbox for downloading by that submitter.

Electronic claims must meet the requirements in the following claim implementation guides adopted as national standard under HIPAA:

 
• Providers billing an FI must comply with the ASC X12N 837 Institutional Guide (004010X096A1).
• Providers billing a Carrier or DME MAC (for other than prescription drugs furnished by retail pharmacies) must comply with the ASC X12N 837 Professional guide (004010X098A1).
• Providers billing a B DME MAC for prescription drugs furnished by a retail pharmacy must comply with the National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard 5.1 and Batch Standard Version 1.1.

 

CPT 97014 / G0283 , 97032, G0281, G0282, G0295 - Electosimulation

CPT/HCPCS Codes

Group 1 Codes:

64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH

Group 2 Paragraph: Note: Use of the following Physical Medicine and Rehabilitation CPT/HCPCS Codes for these treatments is inappropriate:

97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES

97139 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY)

G0282 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0281


G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE

 Electric stimulation - CPT 97014/G0283, CPT 97032, 97033

Electric stimulation. Three codes exist that relate to electric stimulation — CPT 97014/G0283, supervised electric stimulation; CPT 97032, attended manual electric stimulation; and CPT 97033, iontopheresis. average fee amount - $12 - $18

CPT 97014/G0283 is appropriate for pad-based e-stim, which requires supervision only. Although this is not a time-based service, accepted protocols require 15 minutes to as much as 30 minutes of treatment.

97014 Application of a modality to one or more areas; electrical stimulation (unattended) is an invalid code for Medicare.

* For unattended electrical stimulation, HCPCS G0281 and G0283 have replaced CPT code 97014.
* For attended electrical stimulation, please refer to CPT 97032.

CPT 97032 can only be used when stimulation is manually applied. The requirement for constant attendance is derived from the manual-application requirement.

Usually a probe or other hand-held device is used and must be held for the entire therapy. This is a time-based service reported in 15-minute units.

97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes


Background

Nerve blocks, injections of local anesthetic solutions, cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks.

There are also early studies using electrostimulation with or without nerve blocks for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases.

Limitations

The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary. Medical management using systemic medications is clinically indicated for the treatment of these conditions.

At present, the literature and scientific evidence supporting the use of peripheral nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases, is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases.

This modality includes the following types of electrical stimulation:

* Transcutaneous electrical nerve stimulation (TENS) is used primarily for pain control. No more than a single office session will be allowed for the purpose of training for in-home use.

* Neuro-muscular stimulation: Used for retraining weak muscles following surgery or injury.

* Muscle stimulation: This type of stimulation is taken to the point of visible muscle contraction.

* High voltage pulsed current, also called electrogalvanic stimulation, may be useful for reducing swelling and control of pain.

* Interferential current/medium current: These units use a frequency that allows the current to go deeper. IFC is used to control swelling and pain.

* These uses may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures (e.g., 97110) to effect continued improvement.

* Electrical stimulation is typically used in conjunction with therapeutic exercises. A limited number of visits without a therapeutic procedure may be medically necessary for treatment of muscle spasm and swelling.

* Treatment would not be expected to exceed 4 treatments per week no longer than one month when used as adjunctive therapy or for muscle retraining.

* When electrical stimulation is used for muscle strengthening or retraining, the nerve supply to the muscle must be intact. It is not medically necessary for motor nerve disorders such as Bell’s Palsy (Ref: Medicare National Coverage Determination Manual, Pub. 100-3, Section 160.15 and 150.4; formerly CIM 35-72 and 35.77). It is not medically necessary when there is limited potential for restoration of function.

* Microamperage E-stimulation (MENS) has not been proven effective and will be denied as such. It is inappropriate to use the CPT code 97032 for MENS therapy. Please refer to the procedure code 97799 for further instructions.

* E-Stim (Vital Stim) has not been proven effective and will be denied as such. It is inappropriate to use the CPT code 97032 for E-Stim (Vital Stim). Please refer to the procedure code 97799 for further instructions.

Electrical stimulation (HCPCS code G0283; CPT code 97032) is considered not reasonable and necessary and is excluded from Medicare coverage for the following:

a. motor nerve disorders such as Bell’s Palsy. (ICD-9 code 351.0)

b. TENS treatments and related services (i.e. CPT code 64550), furnished in physicians/NPP or therapist’s office. (See CMS Pub.100-2 Ch.16 §180, CMS Pub.100-3 §160.3)

c. Electrical Stimulation is not medically necessary for the treatment of strokes when there is no potential for restoration of function.



 CPT CODE G0283 - Billing and Coding Guidelines

97014 -- electrical stimulation unattended (NOTE: 97014 is not recognized by Medicare. Use G0283 when reporting unattended electrical stimulation for other than wound care purposes as described in G0281 and G0282.)


Key Points

This Special Edition article outlines the method that is in place to remedy the error as follows:

• The modifier indicator for the 92526/G0283 code pair will be corrected and changed to a "1" with the OPPS OCE July 2006 Release.

• On July 3, 2006, the "1" indicator will permit the use of modifier -59 with G0283 for reporting of this service with CPT 92526 when performed by different therapy disciplines in outpatient providers of Part B therapy services.

• In addition to the OPPS hospitals (billing with bill types 12X and 13X), this edit was effective on January 1, 2006, for the following providers:

• Skilled nursing facilities (bill types 22X and 23X)

• Comprehensive outpatient rehabilitation facilities (bill types 75X)

• Outpatient physical therapy and speech language pathology service providers (74X)

• Home health agencies (bill type 34X)


Note: After the implementation of the July 2006 OPPS OCE, FIs and RHHIs shall begin to reprocess claims where payment for HCPCS G0283 was rejected based on the “0” indicator. Until the OPPS OCE is updated in July 2006, providers should continue to bill this code pair as the CCI indicates—without a modifier—and .should NOT hold claims.

If I am providing untimed estim (G0283) or diathermy (97024) to multiple placements on the patient, how many times can I bill the code for the day? 

You can only bill the above codes once. Your daily documentation would reflect the sites the modality was applied to the patient for the treatment day. 

• 97032 Scenarios: 

- When using a manual probe (Neuroprobe), bill for the whole time the e-stim is applied to the patient

- 30 minutes of e-stim was administered in water while instructing the patient in ROM and/or fine motor manipulation activities.

¾ Code 30 minutes using the e-stim code OR therapeutic activities (97530) OR therapeutic exercise (97110) OR code the set-up time usually 5 minutes to G0283 and 25 minutes to one of the timed codes.

- 30 minutes of e-stim is applied to the quads while a patient is performing therapeutic exercise with verbal cues

¾ Split time between (97032) and (97110) OR code 30 minutes to e-stim (97032) OR code 30 minutes therapeutic exercise (97110) OR code set-up time to (G0283) and the rest of the time to a timed therapeutic procedure code. 

- 30 minutes of e-stim (PENS/neuro re-ed) is applied while observing, instructing and/or providing hand-over-hand guidance with the patient, using PNF movement patterns during motor recruitment cycle of the e-stim

¾ Split the time between 97032 and 97112 or code 30 minutes using neuro re-ed code (97112) OR 30 minutes e-stim (97032) OR code set-up time to (G0283) and the rest to another timed therapeutic procedure code (97110 or 97112) 

• G0283 Scenarios:

- Any time you apply estim to a patient and you are not spending one-on-one time with the patient (Pain management)

- 20 minutes of e-stim (PENS) is applied to a patient’s elbow extensors while the patient is doing sit-to-stand push-ups from the arms of the chair during the extension phase of the e-stim ¾ Code the first 5 minutes (set-up time) to (G0283) and 15 minutes to therapeutic exercise (97110)

¾ Combo unit application, which includes estim and ultrasound: Split the time between supervised e-stim (G0283) and ultrasound 97035 for the application time (remember 97035 must show at least 8 minutes to be billed).

Reimbursement Guidelines

Optum will not reimburse for CPT code 97014. Unattended electrical stimulation will remain a reimbursable service however providers utilizing this modality will not be reimbursed for CPT code 97014. In accordance with CMS National Coding Policy, providers should submit the appropriate HCPCS G-code which more accurately represents the service rendered.


In December of 2002, the Federal Register was updated to reflect the addition of three new G-codes. The purpose of the G-code additions was to:

** Provide CMS more accurate tracking, trending, and data retrieval ability relative to provider specific use of electrical stimulation.

** Provide more specificity to the generalized CPT 97014 electrical stimulation code definition to better enable more accurate tracking, trending, and data retrieval ability relative to provider specific use of electrical stimulation.

** Provide language which details indication for electrical stimulation in the treatment of wound care management - stages lll and lV only, 30 days of documented failed trial of conventional care, etc.



Coding:

There are no specific CPT codes describing interferential current stimulation. The following CPT codes might be used: 64550, 97014

The following HCPCS code might also be used:

G0283: Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.

The G-codes more accurately describe electrical stimulation application. Per the AMA CPT coding instructional which can be referenced in the Introduction section of the CPT manual, "select the name of the procedure or service that accurately identifies the service being performed. Do not select a CPT code that merely approximates the service provided."

Effective with CMS National Coding Policy, January 1, 2003, CPT 97014 unattended electrical stimulation was cross-walked to new G codes.


The evidence base for the use of electrotherapy as practiced by PT’s is robust and insurance generally covers its use. In a fee-for-service payment structure either CPT code 97032 (attended electrical stimulation; in 15 minutes increments) or CPT code 97014 (unattended electrical stimulation; untimed; Medicare requires CPT code G0283 to be used instead) is used.





CPT 97033 is appropriate only when iontopheresis — the introduction of ions of soluble salts into the body by an electric current — is applied. Applying topical gels to the skin prior to application of the electric stimulation pads is not considered iontopheresis.

Although the pads used in this treatment are similar to those used in supervised e-stim, constant attendance is required because of the potential for burning the patient’s skin during therapy.


97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes

* Because there is no convincing evidence from published, controlled clinical studies demonstrating the efficacy of this as a physical medicine modality, this service will be denied as not proven effective. An Advance Beneficiary Notice (ABN) should be obtained when iontophoresis is utilized.


CPT 97014 – Electrical stimulation (unattended) (to one or more areas)

CPT 97014 is not a Medicare recognized code. See HCPCS code G0283 for electrical stimulation (unattended).

CPT 97032 – electrical stimulation (manual) (to one or more areas), each 15 minutes

Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.

97032 is a constant attendance electrical stimulation modality that requires direct (one-on-one) manual patient contact by the qualified professional/auxiliary personnel. Because the use of a constant, direct contact electrical stimulation modality is less frequent, documentation should clearly describe the type of electrical stimulation provided, as well as the medical necessity of the constant contact to justify billing 97032 versus G0283. Devices delivering high voltage stimulation may require one-on-one patient contact (e.g., MicroVas, when applied in a high voltage mode).


• If providing an electrical stimulation modality that is typically considered supervised (G0283) to a patient requiring constant attendance for safety reasons due to cognitive deficits, do not bill as 97032. This type of monitoring may be done by non-skilled personnel.

•Non-Implantable Pelvic Floor Electrical Stimulation (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.)


Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.

* The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus  frequency and other parameters are chosen based on the patient's clinical diagnosis.

* Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.

* A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

* The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training.


Code G0283 is classified as a “supervised” modality, even though it is labeled as “unattended.” A supervised modality does not require direct (one-on-one) patient contact by the provider. Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation  (Russian stimulation).

Documentation must clearly support the need for electrical stimulation more than 12 visits. Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training (which may be billed as 97032). Once training is completed, code G0283 should not be billed as a treatment modality in the clinic.




Non-Implantable Pelvic Floor Electrical Stimulation

(CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.) Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature.

Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.



The charges for the electrodes are included in the practice expense portion of code G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality.

Do not bill Medicare for unattended electrical stimulation using code 97014.

Supportive Documentation Requirements (required at least every 10 visits) for G0283

Horizontal Therapy

• This service should be coded using 97014.
• The unit of service is limited to one, regardless of the time spent or the number of areas treated.
• When electrical stimulation 97014 and ultrasound 97035 are performed at the same time, using the same machine, only one modality should be billed.
• The electrodes and other supplies used to administer any modality are content of service of the modality.

EXAMPLES OF RED FLAGS:

• Duplicative services
• Misuse of CPT codes
• Billing/use of 97124 and 97140 for the same body part on the same DOS
• # of units / treatment greater than BCBSKS policy allowable
• Billing/use of 97002 for DOS before Jan. 1, 2017 or 97164 for DOS after Jan. 1, 2017 on each DOS billed
• Upcoding (e.g. 97032 instead of 97014)
• Use of unlisted procedure and modality codes
• Billing/use of two or more superficial heating modalities to the same body part –Use of 97010, 97014, 97035 same body part, same session with no documented rationale and objective data to support necessity for each modality
• Continued use of modalities for periods greater than 10 treatment sessions with no documented rationale and objective data to support patient improvement and ongoing treatment.

Utilization Guidelines and Maximum Billable Units per Date of Service

Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.

The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied: 97001, 97002, 97003, 97004, 97012, 97016, 97018, 97022, 97024, 97028, 97150, 97597, 97605, 97606, G0281, G0283, G0329. 

Nationally Covered Indications (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 270.1): Electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds are considered adjunctive therapies, and will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Chroniculcers are defined as ulcers that have not healed within 30 days of occurrence. ES or electromagnetic therapy will be covered only after appropriate standard wound therapy has been provided

• electrical stimulation or electromagnetic therapy when used as an initial treatment modality;

• continued treatment with ES or electromagnetic therapy if measurable signs of healing have not been demonstrated within any 30-day period of treatment;

• wounds that demonstrate a 100% epithelialized wound bed;


• a patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.

• Etiology and duration of wound

• Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment

• Stage of wound

• Description of wound: length, width, depth, grid drawing and/or photographs

• Amount, frequency, color, odor, type of exudate

• Evidence of infection, undermining, or tunneling

• Nutritional status

• Comorbidities (e.g., diabetes mellitus, peripheral vascular disease)

• Pressure support surfaces in use

• Patient’s functional level

• Skilled plan of treatment, including specific frequency of the modality

• Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment

• Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session) 30 days and there are no measurable signs of healing. This 30-day period may begin while the wound is acute.

Billing - CPT Codes: Not Permitted

In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients.

Examples include:


a. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);

b. Any CPT code for modalities requiring constant attendance (CPT codes 97032 - 97039) with the group therapy CPT code (97150). For example: group therapy (97150) with ultrasound (97035);

c. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)

Carrier Billing Instructions Applicable HCPCS Codes

• G0281 - Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care.

• G0282 - Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281 (Not covered by Medicare) Short descriptor: Elect stim wound care not pd

• G0295 - Electromagnetic stimulation, to one or more areas (Not covered) Short descriptor: electromagnetic therapy one

 97014 -- electrical stimulation unattended. (NOTE: 97014 is not recognized by  Medicare. Use G0283 when reporting unattended electrical stimulation for other than wound care purposes as described in G0281 and G0282.)

97032 -- Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes. (NOTE: 97032 should NOT be reported for wound care of any sort because electrical stimulation for wound care does not require constant attendance.)

97014 -  This code is one or more areas so the unit of service is limited to one regardless of the time spent or the number of areas treated. Use this code for Horizontal Therapy.

When electrical stimulation 97014 and ultrasound 97035 are performed at the same time using the same machine, only one modality should be billed.

The electrodes and other supplies used to administer any modality are content of service of the modality.

Billing of electrodes

The electrodes and other supplies used to administer any modality are content of service of the modality and should not be billed to the patient.

ICD-10 CODE DESCRIPTION

A52.15 Late syphilitic neuropathy
E08.40 - E08.43 - Opens in a new window Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified - Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E09.40 - E09.43 - Opens in a new window Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified - Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy
E10.40 - E10.43 - Opens in a new window Type 1 diabetes mellitus with diabetic neuropathy, unspecified - Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.40 - E11.43 - Opens in a new window Type 2 diabetes mellitus with diabetic neuropathy, unspecified - Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.40 - E13.43 - Opens in a new window Other specified diabetes mellitus with diabetic neuropathy, unspecified - Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
G13.0 Paraneoplastic neuromyopathy and neuropathy
G56.40 - G56.92 - Opens in a new window Causalgia of unspecified upper limb - Unspecified mononeuropathy of left upper limb
G57.70 - G57.92 - Opens in a new window Causalgia of unspecified lower limb - Unspecified mononeuropathy of left lower limb
G58.7 - G65.2 - Opens in a new window Mononeuritis multiplex - Sequelae of toxic polyneuropathy
M05.50 - M05.59 - Opens in a new window Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site - Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M34.83 Systemic sclerosis with polyneuropathy
M79.2 Neuralgia and neuritis, unspecified
M79.601 - M79.676 - Opens in a new window Pain in right arm - Pain in unspecified toe(s)

EDI and PC - ACE PRO 32 - billing software

ELECTRONIC DATA INTERCHANGE (EDI)

The Administrative Simplification Compliance Act (ASCA) requires that providers submit claims to Medicare electronically to be considered for payment, with a limited number of exceptions. If a provider meets one of the exceptions, the provider is waived for a period of two years.
Exceptions to this requirement, include:

•Small providers, defined as a physician, practitioner, or supplier with less than 10 full time equivalent employees

• Roster billers of Medicare covered mass immunizations

• Claims for payment under Medicare demonstration projects when information is required that cannot be submitted electronically

• Claims where Medicare is the tertiary payer to two (or more) primary payers , and

• Dental claims.

More EDI information is available on the WPS Medicare Website at http://www.wpsmedicare.com/part_b/business/edi_hipaa.shtml.

PC-ACE PRO 32 ELECTRONIC BILLING SOFTWARE

PC-Ace Pro32 is a free, stand-alone software package that creates a patient database and allows your office to electronically submit most WPS Medicare Part B claims electronically. PC-Ace has many built in features to lighten your office's workload. The software provides you with the ability to enter patient information, claim information, procedure file information, and creates a summary report of the claims you submit electronically.

If you are interested in using PC-Ace Pro-32 in your office, visit the WPS Website at http://www.wpsic.com/edi/pcacepro32.shtml or call our Electronic Data Interchange (EDI) department at (866) 503-9670.