Beware of medical device companies selling spinal decompression tables with the promise that Medicare and private payers will reimburse the services. At least 1,000 of the physical therapy tables are in operation nationwide. They're often sold with the assurance they can generate hundreds of thousands in annual revenue, in part from insurance reimbursement.
But Medicare and most private insurers don't cover the therapy, a fact many coders and doctors don't know. So practices bill for the services anyway, using codes meant for physical therapy and in some cases, surgery.
The claims they wrongly submit for payment could cost the Medicare program and private insurance companies more than $67 million this year, according to an exclusive Coder's Pink Sheet analysis.
Private payers have launched probes into the billing practices of offices that own the tables. And if recent audits and carrier updates are any indication, Medicare is more interested in the tables today than it was a year ago. Pain practices that bill for the services run the risk of expensive Medicare audits, repayments, penalties, and even criminal prosecution, the Coder's Pink Sheet investigation found. Our whole focus here is not to go on witch hunts, but to identify people who are trying to beat the system, says Karl Krieger, a Montana Blue Cross Blue Shield investigator. The Montana BC/BS investigative unit recently issued a fraud alert. for physicians who use any code besides S9090 (vertebral axial decompression) when billing therapy services with the VAX-D, DRS, DRX-9000, LORDEX or Accu-Spina decompression tables. The insurer denies payment for this code.
In August, federal prosecutors in Georgia indicted two chiropractors on health care fraud charges after they allegedly used inapplicable codes to submit $1 million in claims to BC/BS for patients who used the VAX-D spinal decompression machine.
The Centers for Medicare & Medicaid Services issued a coverage decision denying payment for vertebral axial decompression (VAX-D) in 1997, based on an informal discussion at a federal advisory committee meeting.
But as new devices hit the market, CMS never updated its policy, leading to confusion over whether it applies to one trademarked device or a type of therapy.
Still, CMS officials say decompression therapy is not reimbursable. It is absolutely not supposed to be billed, a CMS spokesperson says.
But three quarters of practices that answered a Coder's Pink Sheet survey say they were given advice on how to bill Medicare when they purchased the tables, which can cost as much as $150,000. The device companies all deny wrongdoing, saying they don't give out specific codes to bill. The coding advice often comes from third-party contractors who say they are working on behalf of the vendors, the Coder's Pink Sheet found. Customers say
they receive faxes, letters and even phone calls about how to bill for the procedures, either before they buy the table or after they sign the sales contract. In Florida, attorney Robert Rappel of Rappel & Rappel, Vero Beach, says he has been contacted by 10 doctors across the country who purchased machines after being told by vendors that Medicare would cover spinal decompression services. Much to their surprise, their claims are being rejected. They're upset at the companies that are selling the machines, says Rappel, who is an osteopathic physician as well as an attorney. It's fraudulent inducement, he alleges. (Rappel is also defending a former independent sales agent of the DRX-9000 decompression table, who was sued by the manufacturer in October.) Dubbed VAX-D or spinal decompression , the therapy consists of a month's worth of daily physical therapy sessions on a computercontrolled table. It treats back pain by alternating between cycles of tension and relaxation, which supposedly decompress damaged vertebral discs and release pressure on spinal nerves.
According to the CMS's Coverage Issues Manual (35-97) and National Coverage Determinations Manual (160.16), There is insufficient scientific data to support the benefits of this technique. Therefore, spinal decompression is not covered by Medicare.
Major private payers, including Aetna, Cigna, Oxford, Wellpoint and the BC/BS Assn., have also issued national policies calling the therapy investigational, and not medically necessary, regardless of the name of the particular device used.
"For efficiency's sake, we consider them similar," explains Robert McDonough MD, senior medical director of Aetna's Clinical Policy Unit, Hartford, Conn. "There may in fact be differences between the machines, but it's the burden of manufacturers to prove those differences. We're at a point where none of them have that evidence."
The Coder's Pink Sheet investigation, which was launched after a coding inquiry from a subscriber, found that some vendors are distributing information that appears to disregard those policies. The investigation included interviews with lawyers, doctors, insurers and vendors and a review of lawsuits, audits, internal companydocuments and correspondence, and government records obtained through the Freedom of Information Act.
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In Comparison, all procedures done at Goodwin Chiropractic (initial exam, x-rays & spinal adjustments) are covered by insurance.
