Purchasing a Vertebral Axial Decompression Unit  (Reprint of published article)

The question has been repeatedly posed on the efficacy and economic feasibility of incorporating  vertebral axial decompress equipment into the multidisciplinary practice scope. 

 Many practices are acquiring these machines but the most success is on a “cash pay” basis since the  coverage and the billing codes are still a problem.  BC/BS for instance added an “S” code to denote the  “actual procedure” that is being performed. (S9090) 

 There is quite a bit of “new discussion” on this code but it is not a "new"  code.  It was created and  published around 1998 as a "Temporary", Carrier Specific, National Code for Vertebral Axial  Decompression / per session.  It is not a covered code by Medicare.   

 The "S" code section is published in the HCPCS book and are temporary national codes used by the  Blues and the Health Insurance Association to report services and supplies where there is no accurate  CPT or HCPCS  code.  Medicaid occasionally uses them as well.   

 We have had numerous requests for opinions on this matter so we did conduct a full research project on  it for one member in regards to their pending purchase of the DRX unit.  This is what we published on that  project:      

 This is in response to your inquiry on the DRX billing issue. 

 Research performed:  Coding issues 97530 vs 97012 and not otherwise specified procedure. 

 Research sites and data:   

• US FDA – 510(k) approvals for market Dept of HHS Division of General and Restorative Devices.  

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• Medicare / CMS coverage database 

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• AMA – Clinical vignettes 

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• PRN Publications MTG discussion “non surgical decompression” 

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• Medical devise file literature, DRS System as maintained by the Multi-disciplinary Academy of 

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• Affiliated Medical Arts, under Professional Distribution Systems, PDS, Inc. 

 Reference materials / sources employed: 

•  American Medical Association CPT manual – Professional Edition CPT-2004 

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•  American Medical Association Written Opinions CPT Committee 

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•  Current Medicare Coverage Stat us Vertebral Axial Decompression 

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•  Medical equipment literature files, MAAMA 

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•  Medical Advisory Committee opinion 4/25/2003 

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•  Healthcare Common Procedure Coding System (HCPCS) 2000 through 2004 editions. 

 DISCUSSION:   

 Our research reveals that there are several manufacturers of substantially similar technology listed with  the U.S.F.D.A. that have received 510(k) market approvals based on substantial equivalency to their  predicate devices.  Among them are the DRS, Vax-D, Tru-trac 401, DRX 2000 and 9000 and sequences  and the most recent, Spine-med.     

The reported action of each is focused on spinal decompression and represented to the FDA as an  unloading due to distraction and positioning of the intervertebral discs and facet joints which is commonly  viewed as “vertebral axial decompression” for classification purposes.  While the precise action of each  machine is not identical to the predicate equipment the FDA treats each identically in approval for market  and each is registered and approved under Regulation #890.5900 with the actions being similar enough  to be routinely considered as identical.   All of these units are approved for sale in the United States and  classified as “Powered Traction Equipment” (Mechanical Traction units) under Class II – 21CFR Section  890.5900. 

 Summary of FDA research:  All approved units are considered mechanical traction for classification. 

 Accurate Coding for the service by FDA “classification”  would therefore be restricted to the established   CPT™ code 97012 – Mechanical Traction to be 100% accurate.  Medicare however will NOT pay any  code that is billed using one of these units despite their actual FDA classification, so therefore billing the  97012 would be improper.   

 The use of the units became increasingly prevalent in the late 1990’s which prompted the creation of a  HCPCS Temporary National Code (non-Medicare) of S9090.  These “S” codes are used by BCBS and HIAA  to report services for which “there are no national CPT (level I) or standard HCPCS code (level II) to  accurately cover the procedure” for proper claims processing.  The codes are designed to meet the needs  for the private sector and while used by the Medicaid program, they are not payable by Medicare.     

The S9090 code is still listed in the 2007 edition of the HCPCS and has not been replaced with a standard  CPT™ or Medicare National Level II code.   

 Coding Conclusion:  For the Blue Cross / Blue Shield Network and for carriers that are members of the  HIAA and accept the Level III temporary codes, the correct billing for decompression therapy sessions  would be: 

      S9090 Vertebral Axial Decompression, per session.  (one unit) 

 Review of Distributor’s and Manufacturer’s Billing recommendations in their literature: 

The Academy has, on file, literature from several distributors as well as MTG newsletters that were  prepared for the distributors by Peer Review Services.  All the literature suggests billing codes that are of  the “unlisted procedure categories”.  The DRX literature suggests a billing of 64999, Unlisted procedure,  nervous system.  Other literatures suggest 97039 and 97139 as the appropriate code.   

The main conflict in the literature is the addition of codes such as 97140 (manual therapy) and 97530  (Kinetic activities) each being 15 minute sessions per unit billed.  The language however is virtually the  same and is probably overlooked by the physician gleaning the material.  To illustrate, we take the actual  text from the DRX material as published by MTG in their newsletter of November – December 2001     

 CPT Coding:    The CPT code to be used for each treatment would be 64999, Unlisted procedure, nervous system.  The  claim submission MUST include documentation validating the diagnosis (e.g. MRI report) and explaining  the use of the code 64999 (e.g. treatment report). 

 The following services may be billed if performed:   

• Code 97140 – joint mobilization, one or more areas – 1 unit 

• Code 97530 – Kinetic activities, each 15 minutes – 1 o 3 units. 

The key here is that the distributor clearly states that these service may be billed “IF PERFORMED”.  We  did NOT find any reference in any of the literature that stated that the procedure was to be billed under the 97530 code. 

 We have researched the use of the Therapeutic Activities code 97530 on previous occasions and have an  answer to our inquiry from the CPT department of the American Medical Association on file where they  replied on 8/2/99 as follows:     

Code  97530 identifies dynamic activities.  Dynamic activities include the use of multiple parameters such as balance, strength and range of  motion for functional activity.  Examples include lifting stations, closed kinetic chain activity, hand  assembly activity, transfer (chair to bed, lying to sitting, etc.) and throwing, catching or swinging.  

In addition, we offer the description of code 97530 as listed in the coverage issues manual for Medicare.  97530: Therapeutic Activities:   This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching,  catching, and overhead activities) to improve functional performance in a progressive manner.  

The activities are usually directed at a loss or restriction of mobility, strength, balance, or  coordination. They require the professional skills of a provider and are designed to address a   specific functional need of the patient. These dynamic activities must be part of an active  treatment plan and directed at a specific outcome.  

 Medicare coverage: The Medicare coverage issues manual originally classified this treatment as  investigational and experimental.  The topic was changed to “not a covered service” in 2002.  Billing  Medicare for VAD under any code that would normally be paid by Medicare for an otherwise covered  physical therapy service such as 97530, to obtain reimbursement for a VAD session would be considered  to be fraud and abuse and would subject the practice to repayment and possible civil monetary penalties  and potential criminal compliant by the OIG.   

Conclusion and Position:   

The Academy recognizes that a “specific” billing code is needed for this type of treatment however in it’s  absence, we must advise you to bill the sessions under the 97139 (unlisted service) code unless  otherwise directed by the carrier in a pre certification, pre-authorization encounter or after the carrier has  assigned AND published a "temporary local code, like the S9090.    

The use of the 97530, however, without additional service from the Physical Therapist in  keeping with the code description is, in our opinion, improper. 

 We have discussed the problem of coding the VAD therapy with the AMA-CPT committee several times  since these units became prevalent, and each year they tell us that they are considering a level one code  (CPT code).  Perhaps, in light of the HIPAA regulations and use of the standard code sets, they will  address it soon but in the mean time we are still left with this dilemma. 

BC/BS can demand that their "network providers" use their reporting code of S9090 however reporting it  under the 97039, 97139 or any other "not otherwise specified code" would not be considered  misrepresentation since these codes MUST be explained when billed. Likewise billing the use of this equipment under the standard mechanical traction code would also serve to "mislead the carrier" and should NOT be used.  

To refresh your memory on coding:  The CPT manual is published by the AMA and considered "level one" codes for common procedures.  We  are the only country that uses these codes. The rest of the world uses the procedure codes published as  an additional volume of the ICD-9 from the world health organization. 

The HCPCS (Healthcare common procedure coding system) is also published by the AMA and others but  is actually compiled by Medicare and are considered National Level Two codes that are more descriptive  than the CPT codes.  For instance, a TENS unit billed under the CPT code set would be billed as 99070  (supplies) and would need a description entered in field 19 to be payable.  Under the HCPCS system a 2-lead TENS unit would be reported under A0720 which would "accurately describe" the unit dispensed.  

 Medicare uses these codes exclusively for reporting DME products, drugs and supplies and does not  accept the billing of 99070.  Another example is the new "G0283" code used by Medicare to report  unattended electrical stimulation.  CMS instituted this HCPCS reporting code "specifically" to be able to  determine is the e-stim was for anything other than wound healing.  The unattended electrical  stimulation for wound healing were given their own number in the "G028x" section so CMS can tell  what they are being billed for.     

The "S" codes are "published" in the HCPCS manual, as a informational courtesy,  but are "local codes"  (level 3)  that are established for use in the private sector only.  Medicare, with only a few  exceptions, does not accept these local codes for billing purposes.   

 

The hierarchy of coding is that if a level 3 exists your use it to report.  If not, but a level 2 exists, you use  that, if none exist then the level one CPT code is used.  If no code exists in any of these manuals you  report it under a miscellaneous CPT, not otherwise listed code such as the 97139. The confusion on this is what codes will the carrier accept.  You can see just by this situation that BC/BS has codes that no one else universally accepts. 

 

The decision to purchase of the equipment should be made based on the “potential” of developing a  “cash pay basis” patient base.  It is unlikely that you could pay for the equipment within our standard  profitability expectation ratios through insurance billings.  You MAY NOT bill Medicare for the VAD  procedures AT ALL, even under normal traction codes, since the VAD “procedure” is not covered. 

 For now we must advise the following coding scenarios.   

•  S9090 to the carriers who participate in that coding system.   

•  97039 (not otherwise specified, supervised modality)  

•  97139 (not otherwise specified therapeutic procedure)   

All miscellaneous billings require a description that vertebral axial decompression (VAD) is the procedure  being submitted.   We have also developed two separate waivers for our clients to use.  The first is for all Medicare Beneficiaries that is applicable notice that the VAD procedure is excluded from Medicare coverage.  The second form is used for major medical patients where they are notified that VAD is not covered, that it is being used as an adjunctive protocol to their standard therapy regimen and that they are responsible for payment. Use of the forms and inclusion in the record should be "proof positive" to any auditor that no "stealth coding" exists.  

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About the Author:    Ronald L. Ramsdell, Ph.D. is the President of MedCorp Compliance Network, a firm that specializes in  coding and documentation compliance.  Dr. Ramsdell is a Fellow of the American Academy of Forensic Examiners Institute; Board Certified Diplomate of the American  Board of Forensic Examiners, a Certified Forensic Consultant,  Executive Director and a Life Fellow of the  M.A.A.M.A,; a life member of Who’s Who and a long time member of the American Academy of Pain  Management. He has served as a compliance and documentation consultant to hundreds of practices of  all healthcare disciplines and is frequently engaged by health care law attorneys for independent  assessment of their clients Medicare/ Medicaid and overall compliance though comprehensive audit.   Dr. Ramsdell can be reached through his Las Vegas, Nevada office at (702) 838-0054 or by e-mail to  DrR@MAAMA.ORG.