Orthopedic Coding Clinic: Pull the Plug on PRP Injection Denials
Posted on 22. Jun, 2009 by Editor in Hot Coding Topics
Here’s where 86999 comes in.
If your orthopedist is performing platelet rich plasma (PRP) injections with surgical reconstructions and you’re looking for a way to report this, you may be making your life more difficult than it should be. Most likely, you should consider this inherent to the surgical procedure.
That’s not what most coders and physicians want to hear. “This is currently a great challenge for our physicians who are performing this procedure with excellent outcomes — yet they are being told they should not be paid for it,” laments Gloria Caballero, director of finance at OED Orthopaedics in Warrenville, Ill.
But take heart: In one situation, you might be able to get away with an unlisted procedure code to reflect the additional work.
To minimize denials and save precious time, discover what PRP involves, what you should report, and what codes you should avoid.
What Is PRP?
In the past seven years, PRP has taken off in orthopedic medicine. These treatments focus on healing joints: ligaments, tendons, and cartilage. A primary problem is that there is little blood flow in the joint tissues compared with muscle tissues. PRP stimulates blood flow to the area which allows for the breakdown of unhealthy tissue and the creation of new, healthy tissue. Patients heal faster.
Benefit: The primary advantage of PRP is that the orthopedist places blood platelets involved in healing damaged connective tissue into the area — rather than wait for the body to do so on its own. By using one’s own blood platelets, which the body quickly replaces, rejection is not an issue.
“PRP addresses surgical healing and tendonitis,” says Connie Treonze, practice...
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Dana Waegele
04. Feb, 2010
there is a new code released Jan 1, 2010 which will be effective July 1, 2010 for PRP injections 0232T published by the AMA. This will have final publication in the CPT 2011 Manuel however effective on July 1,2010
Judy Lax
08. Mar, 2010
I have been told my torn rotator cuff could be repaired with the PRP injection. My insurance company requires that my doctor contact them regarding pre-approval, noting that it should be covered if it was a necessary medical procedure. However, my doctor’s office said they would not file the claim and they refused to contact my insurance company for pre-approval. I asked my insurance company if I could file and they told me I could not because they needed necessary medical information. Can you offer any suggestions for what I can do? I guess approval for surgery would be easier to obtain than this injection.
Editor
10. Mar, 2010
Hi, Judy: It’s puzzling to me that your doctor’s billing office is “refusing” to contact the carrier for pre-approval, since that is a standard task most billing offices do. (It helps *them* get their reimbursement too, after all.) Did they give you a reason why? Did you talk to the billing office’s supervisor or the practice manager?
Erin Lang Masercola, PhD, CPC
Ross
14. Apr, 2010
I am a member of GHP coventry medical insurance. My PRP injections have recently been denied ( My physician is aware of this new cut off that GHP just put in as well). However, I am able to get the injections done at a different physicians office and its covered. I would prefer to go the one which my insurance does not cover. Im guessing its a matter of how the two offices bill and what codes they use. Does anyone know what I can do to get covered. This sux because I just switched from Blue Cross which covered them with no problem.
Barbara
06. May, 2010
Ross, If one physician’s office is getting paid for the PRP injections they may be doing something wrong. I work for orthopaedic surgeons. No insurance company that I know of, including Medicare, is covering PRP injections. Every one that we have turned in has been denied by every company as “experimental”. Most carriers have written policys that keep them from paying for this, because it is a new technology. If one doctors office is getting paid by insurance, they may not be telling the whole truth to the carrier, and turning the PRP injections in as somthing other than what they are. The doctor who is not getting paid is probably turning in the correct code. If the injections are doing a good job for you, just pay for them yourself and keep your doctor out of harm’s way. Not everything is covered by insurance.
Patti
11. May, 2010
PRP has also shown significantly successful outcomes in non-healing wound care but hardly anyone uses it because of coding issues. How would a wound care center get reimbursed for using PRP to heal pressure ulsers or diabetic non healing wounds? What codes can they use?
Michelle
03. Jun, 2010
In response to Barbara, I’m on Workers Comp and they are paying for my PRP Injection. Without any problems. Less recovery time than surgery. Faster I get healed and no pain, the faster I get back to work.
David Spirt
12. Jun, 2010
Although there have been reimbursement issues surrounding PRP injections and the intraoperative application of PRFM for orthopedic and podiatric procedures,the results have been nothing short of dramatic and amazing.Most co.’s that provide the systems that prepare the PRP/PRFM have reimbursement helplines,which assist with precertification.Precertification is not a guarantee of full reimbursement.Workers comp has traditionally been the best at adopting and paying for cutting edge/breakthrough technology;especially if it offsets other costs and gets patients back to work.PRP injections efficacy is also enhanced with the use of ultra sound guidance.PRFM which is prepared with the Cascade system has been helpful in sports medicine tendon to bone procedures such as rotator cuff repairs,achilles repairs,etc. and woundcare applications for chronic ulcers of various sizes, depths and locations and association with recalcitrant/resistant diseases.The creation of and acceptance of the new code is a logical and long awaited step in the use of these preparations and expanding their use and including them as a logical step in the algorithm of treatment in the specialties it relates to.The facts are these preparations are no longer a novel idea but an actual “silver bullet” in their efficacy and variety of applications.More information is constantly being revealed anecdotaly and through clinical studies/publications from the U.S. and Europe.”Keep on spinning”.