Chapter 6: Biofeedback, Electrocardiograms (EKG), Electrodiagnostic services, & Extracorporeal shockwave therapy (ESWT)


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



Go Back Return to Billing & Payment Policies


Go Back Return to Fee Schedule Lookup

Effective July 1, 2012

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Payment policies:
Biofeedback
Electrocardiograms (EKG)
Electrodiagnostic services
Extracorporeal shockwave therapy (ESWT)

More info:
Related topics



 

Payment policy: Biofeedback

Prior authorization

Biofeedback treatment requires an attending provider’s order and prior authorization.

The department has the option to require a concurring opinion regarding the relationship of the condition to the industrial injury and/or need for biofeedback treatment.

When the condition is accepted under the industrial insurance claim, the department will authorize biofeedback treatment for:

  • Idiopathic Raynaud's disease,
  • Temporomandibular joint dysfunction,
  • Myofascial pain dysfunction syndrome (MPD),
  • Tension headaches,
  • Migraine headaches,
  • Tinnitus,
  • Torticollis,
  • Neuromuscular reeducation as result of neurological damage in a stroke (also known as “CVA”) or spinal cord injury, and
  • Inflammatory and/or musculoskeletal disorders causally related to the accepted condition.

Link: For more information, see WAC 296-21-280 .

Twelve biofeedback treatments in a 90 day period will be authorized for the conditions listed above when an evaluation report is submitted documenting:

  • The basis for the worker's condition, or
  • The condition's relationship to the industrial injury, or
  • An evaluation of the worker’s current functional measurable modalities (for example, range of motion, up time, walking tolerance, medication intake), or
  • An outline of the proposed treatment program, or
  • An outline of the expected restoration goals.

No further biofeedback treatments will be authorized or paid for without substantiation of evidence of improvement in measurable, functional modalities (for example, range of motion, up time, walking tolerance, medication intake).  Also:

  • Only one additional treatment block of 12 treatments per 90 days will be authorized, and
  • Requests for biofeedback treatment beyond 24 treatments or 180 days will be granted only after file review by and on the advice of the department's medical consultant.

In addition to treatment, pretreatment and periodic evaluation will be authorized.  Follow-up evaluation can be authorized at one, three, six, and 12 months post treatment.

Home biofeedback device rentals are time limited and require prior authorization.

Link: Refer to WAC 296-20-1102 for the insurers’ policy on rental equipment.

Who must perform these services to qualify for payment

Administration of biofeedback treatment is limited to practitioners who:

  • Are certified by the Biofeedback Certification Institute of America (BCIA), or
  • Meet the minimum education, experience, and training qualifications to be certified.

Note: Practitioners must submit a copy of their biofeedback certification or supply evidence of their qualifications to the department or self-insurer to administer biofeedback treatment to workers.

Link: For more information, see WAC 296-21-280 .

Paraprofessionals who aren’t independently licensed must practice under the direct supervision of a qualified, licensed practitioner:

  • Whose scope of practice includes biofeedback, and
  • Who is BCIA certified or meets the certification qualifications.

Note: Also see “Requirements for billing,” below, about paraprofessionals.

A qualified or certified biofeedback provider who isn’t licensed as a practitioner may not receive direct payment for biofeedback services.

Links: For legal definitions of qualified biofeedback provider and certified biodfeedback provider, see WAC 296-21-280 .  For legal definition of licensed practitioner, see WAC 296-20-01002 .

Services that can be billed

CPT® codes 90875 and 90876 are payable to L&I approved biofeedback providers who are clinical psychologists or psychiatrists (MD or DO).

CPT® codes 90901 and 90911 are payable to any L&I approved biofeedback provider.

HCPCS code E0746 is payable to DME or pharmacy providers (for rental or purchase).

Note: Also see “Payment limits,” below, regarding these codes.

Requirements for billing

The supervising licensed practitioner must bill the biofeedback services for paraprofessionals.

When biofeedback is performed along with individual psychotherapy, bill using either CPT® code 90875 or 90876.

Don’t bill CPT® codes 90901 or 90911 with the individual psychotherapy codes.

Use evaluation and management codes for diagnostic evaluation services.

Payment limits

CPT® codes 90901 and 90911 aren’t time limited and only one unit of service per day is payable, regardless of the length of the biofeedback session or number of modalities.

For HCPCS code E0746, use of the device in the office isn’t separately payable for RBRVS providers.

Back to top

Payment policy: Electrocardiograms (EKG)

Service that can be billed

Separate payment is allowed for electrocardiograms (CPT® codes 93000, 93010, 93040, and 93042) when an interpretation and report is included. These services may be paid along with office services.

Services that aren’t covered

EKG tracings without interpretation and report (CPT® codes 93005 and 93041) aren’t payable with office services.

Payment limits

Transportation of portable EKG equipment to a facility or other patient location (HCPCS code R0076) is bundled into the EKG procedure and doesn’t pay separately.

Payment policy: Electrodiagnostic services

Who must perform these services to qualify for payment

Prior to performing and billing for these services, physical therapists (PTs) performing electrodiagnostic testing must provide documentation of proper Department of Health (DOH) licensure to L&I’s Provider Accounts.

PTs who meet the requirements of DOH rules may provide electroneuromyographic tests.

Links: For information on where to send proper license documentation, contact L&I’s Provider Accounts at 360- 902-5140.

To see the DOH rules, refer to WAC 246-915-370.

Services that can be billed

The department or self-insurer covers the use of electrodiagnostic testing, including nerve conduction studies and needle electromyography only when:

  • Proper and necessary, and
  • Testing meets the requirements described in L&I’s “Electrodiagnostic Testing” policy.

Link: The policy for “Electrodiagnostic Testing” is available at www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/ElecTest/default.asp

Note: Performance and billing of NCS (including SSEP and H-reflex testing) and EMG that consistently falls outside of the AANEM recommended number of tests may be reviewed for quality and whether it is “proper and necessary.” Also see "Example: Reasonable limits on units required to determine a diagnosis," below.

Qualified PT providers may bill for the technical and professional portion of the nerve conduction and electromyography tests performed.

Services that aren’t covered

Electrodiagnostic testing isnt covered when:

  • It isn’t proper and necessary (see “Note” and “Link,” below this list), or
  • Performed in a mobile diagnostic lab in which the specialist physician isn’t present to examine and test the patient, or
  • Performed with noncovered devices, including:
    • Portable, and
    • Automated, and
    • "Virtual" devices not demonstrated equivalent to traditional lab based equipment (for example, NC-stat®, Brevio), or
  • Determined to be outside of American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) recommended guidelines without proper documentation supporting that the testing is proper and necessary.

Note: In general, repetitive testing isn’t considered proper and necessary except if:

  • Documenting ongoing nerve injury (for example, following surgery), or
  • Required to provide an impairment rating, or
  • Documenting significant changes in clinical condition.

Link: The legal definition of “proper and necessary” is available at WAC 296-20-01002 .

Requirements for billing

Billing of electrodiagnostic medicine codes must be in accordance with CPT® code definitions and supervision levels.

Link: For the complete requirements for appropriate electrodiagnostic testing, see www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/ElecTest/default.asp

Billing of the technical and professional portions of the codes may be separated.  However, the physician billing for interpretation and diagnosis (professional component) must have direct contact with the patient at the time of testing.

Note: The department may recoup payments made to a provider, plus interest, for NCS and EMG tests paid inappropriately.

Example: Reasonable limits on units required to determine a diagnosis

The table below was developed by the AANEM and summarizes reasonable limits on units required, per diagnostic category, to determine a diagnosis 90% of the time.

Note:Note: As mentioned under “Services that can be billed” (above), review of the quality and appropriateness (whether the test is “proper and necessary”) may occur when testing repeatedly exceeds AANEM recommendations.

Recommended maximum number of studies by indication (from “AANEM Table 1”; recreated and adapted with written permission from AANEM):

Indication Needle EMG
CPT® 95860-
95864, 95867-
95870
NCS
CPT®
95900,
95903,
95904
Other EMG
studies
CPT® 95934,
95936, 95937
# of tests Motor NCS
with and
without Fwave
Sensory NCS H-Reflex Neuromuscular
Junction Testing
(repetitive
stimulation)
Carpal tunnel (unilateral) 1 3 4
Carpal tunnel (bilateral) 2 4 6
Radiculopathy 2 3 2 2
Mononeuropathy 1 3 3 2
Poly/ mononeuropathy
multiplex
3 4 4 2
Myopathy 2 2 2 2
Motor neuronopathy (for example, ALS) 4 4 2 2
Plexopathy 2 4 6 2
Neuromuscular Junction 2 2 2 3
Tarsal tunnel (unilateral) 1 4 4
Tarsal tunnel (bilateral) 2 3 4 2
Weakness, fatigue, cramps, or twitching (focal) 2 3 4 2
Weakness, fatigue, cramps, or twitching (general) 4 4 4 2
Pain, numbness, or tingling
(unilateral)
1 3 4 2
Pain, numbness or tingling
(bilateral)
2 4 6 2

 


Back to top

Payment policy: Extracorporeal shockwave therapy (ESWT)

Services that aren’t covered

The insurer doesn’t cover extracorporeal shockwave therapy because there is insufficient evidence of effectiveness of ESWT in the medical literature.

Link: More information is available at www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/CovMedDev/SpecCovDec/ESWT.asp


If you’re looking for more information about… Then go here:
Administrative rules for biofeedback Washington Administrative Code (WAC) 296-21-280:
http://app.leg.wa.gov/wac/default.aspx?cite=296-21-280
Administrative rules for the definitions of “licensed practitioner” and “proper and necessary” WAC 296-20-01002:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-01002
Administrative rules for the policy on rental equipment WAC 296-20-1102:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-1102
Administrative rules for the requirements on who may provide electroneuromyographic tests WAC 246-915-370:
http://app.leg.wa.gov/wac/default.aspx?cite=246-915-370
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Coverage decision for extracorporeal shockwave therapy L&I’s website:
Coverage decision for extracorporeal shockwave therapy
Fee schedules for all healthcare professional services (including chiropractic) L&I’s website:
http://feeschedules.Lni.wa.gov
Policy for electrodiagnostic testing L&I’s website:
Coverage policy for electrodiagnostic testing
Sending proper license documentation to perform electrodiagnostic services L&I’s Provider Credentialing and Compliance:
360-902-5140

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.