Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare carriers, Part A/B Medicare Administrative Contractors (A/B MAC), durable medical equipment regional carriers (DMERC), DME Medicare administrative contractors (DME/MAC), fiscal intermediaries (FI), and/or regional home health intermediaries (RHHI), for the use of infrared therapy devices for treatment of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries

Impact on Providers
This article is based on Change Request (CR) 5421. Effective for services performed on or after October 24, 2006, the Centers for Medicare & Medicaid Services (CMS) has made a National Coverage Determination (NCD) stating the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is noncovered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or nondiabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries.

Background
The use of infrared therapy devices has been proposed for a variety of disorders, including treatment of diabetic neuropathy, other peripheral neuropathy, skin ulcers and wounds, and similar related conditions, including symptoms such as pain arising from these conditions. A wide variety of devices are currently available. Previously there was no NCD concerning the use of infrared therapy devices, leaving the decision to cover or not cover up to local Medicare contractors.

The following requirements are in effect as of October 24, 2006

• Effective for services performed on or after October 24, 2006 , infrared therapy devices, HCPCS codes E0221 (infrared heating pad system) and A4639 (infrared heating pad replacement) are noncovered as DME or PT/OT services when used for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds, and/or ulcers of the skin and/or subcutaneous tissues.
• Claims will be denied with CPT 97026 (infrared therapy incident to or as a PT/OT benefit) and HCPCS E0221 or A4639, if they are accompanied by the following ICD-9-CM codes:
  • 250.60-250.63,
  • 354.4, 354.5, 354.9,
  • 355.1-355.4,
  • 355.6-355.9
  • 356.0, 356.2-356.4, 356.8-356.9,
  • 357.0-357.7,
  • 674.10, 674.12, 674.14, 674.20, 674.22, 674.24,
  • 707.00-707.07, 707.09-707.15, 707.19,
  • 870.0-879.9,
  • 880.00-887.79,
  • 890.0-897.7, or
  • 998.31-998.32.
    
• Note that denial of infrared therapy claims for the indications listed above applies to all settings, and affects Types of bills (TOB) 12X, 13X, 22X, 23X, 34X, 74X, 75X, and 85X.
• If you submit a claim for one of the noncovered services, your patient will receive the Medicare Summary Notice (MSN) message stating “This service was not covered by Medicare at the time you received it.” The Spanish translation is: “Este servicio no estaba cubierto por Medicare cuando usted lo recibió.”
• If you submit a claim for one of the noncovered services you will receive a remittance advice notice that reads: Claim Adjustment Reason Code 50, “These are noncovered services because this is not deemed a ‘medical necessity’ by the payer.”
• Physicians, physical therapists, occupational therapists, outpatient rehabilitation facilities (ORF), comprehensive outpatient rehabilitation facilities (CORF), home health agencies (HHA), and hospital outpatient departments should note that you are liable if the service is performed, unless the beneficiary signs an Advance Beneficiary Notice (ABN).
• DME suppliers and HHA be aware that you are liable for the devices when they are supplied, unless the beneficiary signs an ABN .

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, DMERC, DME/MAC, RHHI, or carrier at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

For complete details regarding this Change Request (CR) please see the official instruction (CR5421) issued to your Medicare A/B MAC, FI, DME MAC, RHHI, or carrier. There are actually two transmittals associated with CR5421. The first is the national coverage determination transmittal, located at http://www.cms.hhs.gov/Transmittals/downloads/R62NCD.pdf on the CMS Web site. In addition, there is a transmittal related to the Medicare Claims Processing Manual revision, which is at http://www.cms.hhs.gov/Transmittals/downloads/R1127CP.pdf on the CMS Web site.

Flu Shot Reminder
As a respected source of health care information, patients trust their doctors’ recommendations. If you have Medicare patients who haven’t yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. – And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5421
Pub. 100-3, Transmittal# R62NCD, CR# 5421
Pub. 100-4, Transmittal# R1127CP, CR# 5421
Related CR Release Date: December 15, 2006
Effective Date: October 24, 2006
Implementation Date: January 16, 2007

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Posted: 12/19/2006

CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.