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Charlene Posted Tue 16th of February, 2016 13:01:51 PM

What is the CPT for prolotherapy?

If there isn't a CPT, which code would it be comparable to?

SuperCoder Answered Wed 17th of February, 2016 07:18:05 AM


There is no CPT code and only HCPCS code M0076 for Prolotherapy.
PFB details for billing Prolotherapy-
• Prolotherapy has an "N" status code in the Medicare Fee Schedule, meaning it's a noncovered service. Therefore, it is not recommended to submit these services to Medicare for consideration unless the patient asks to do so. Also link modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to indicate that it's a noncovered service.
• If the patient is happy with the prolotherapy, have the patient pay for it. Also, have the patient sign a waiver form stating he or she will pay for prolotherapy if the insurer rejects it. Write in the patients records that you did prolotherapy and send a bill to Medicare for the prolotherapy. If the patient signs the waiver, and you submit the claim to Medicare, you should bill M0076 with modifier -GA (waiver or liability statement on file). The payment should go straight to the patient if Medicare reimburses the bill.
• Other practitioners ask the patients to file insurance on their own. I always request payment for prolotherapy up front. They give patients receipts so that they can submit the claims themselves if they want to, but not many insurers cover it.
• Some practitioners report trigger point injection codes 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles) for prolotherapy, reasoning that prolotherapy is relatively similar to trigger point injections, but this coding practice is incorrect. Remember that although prolotherapy is simply an injection rather than surgery, coding it as a trigger point injection is wrong.
• Never bill prolotherapy to insurance since it is a non-covered benefit. A few self-funded insurances are known exceptions. Work comp can only be billed if you are specifically referred for prolotherapy with reimbursement at time of service similar to X-rays or other pain procedures.

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