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OhioBWC - Basics: (Policy library) - File

InfoStation Document

TENS and NMES

 

The intent of this policy is to implement minimum standards for all vendors supplying TENS/NMES units to Ohio’s injured workers and to establish standardized criteria for the medical indications for the use of TENS/NMES.

 

TENS:  A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patient’s perception of pain by inhibiting the afferent pain nerve impulses and/or stimulating the release of endorphins.

 

NMES: A device which transmits an electrical stimulus to muscle groups and causes the muscle to contract.

 

Required Criteria for TENS/NMES Units

These criteria apply to all vendors supplying TENS/NMES units to Ohio’s injured workers.

 

BWC Minimum Technical and Educational Criteria

 

1) TENS and NMES units

Requirement: Device must produce constant current.

Rationale: Constant current maintains waveform as it is driven through the skin. It allows the current to be delivered in a uniform pattern, increasing the comfort level for the patient. Breakdown of the waveform may result in increased skin irritation and burning.

 

2) Electrodes

Requirements: a.) Impedance must be no greater than 75 ohms. Ideal impedance is 30-60 ohms. b) Re-usable electrodes must be able to be reused 10-15 times depending on skin condition.

Rationale: a.) Increased ohms cause the need for higher current levels for maximum functioning. b.) Re-use of electrodes provides for increased efficiency and decreased costs.

 

3) Instruction/Education

Requirement: TENS and NMES units must be personally fitted and face to face instruction given by a direct employee of the billing provider within 5 business days of the request for the unit, payable one time per injured worker.

Rationale: Injured workers are more apt to use the TENS or NMES unit correctly and to have fewer problems and increased pain relief if given face to face instruction rather than if given written or telephonic instruction.

 

4) Supplies

Requirement: Prior authorization is required to obtain monthly supplies. Claimants who have TENS units must complete and submit to the TENS provider a monthly written request for specific supplies needed in the following month.  The written request must be initiated and signed by the claimant and received by the TENS provider prior to delivery of supplies and/or equipment. The MCO shall provide education to the injured worker and parties to the claim on the injured worker signature requirement for monthly TENS supplies when a C-9 is authorized for TENS supplies.  The TENS provider will provide education to the injured worker on the signature requirement for monthly TENS supplies. The TENS provider shall then deliver the supplies and bill the BWC, MCO, QHP or self-insuring employer after the claimant’s written request is received. The provider shall retain the original written request for supplies in accordance with the time frames set forth in 4123-6-45.1 of the Administrative Code. The bill must indicate the actual date of service, reflecting the date that services or supplies were provided. The BWC, MCO, QHP or self-insuring employer may adjust bills upon audit if the audit disclosed that provider’s failure to comply with 4123-6-43 of the Administrative Code.

Monthly phone calls must be placed by the vendor to each injured worker to gather usage information, to offer additional instruction, gather supply quantity information and to inform the injured worker that a written request for the following month’s supplies is required. 

 

The MCO shall monitor the vendor for provision of a monthly progress report including Physician of Record documentation.

 

Rationale: Appropriate amounts of medically necessary supplies for the following month will be provided.  Billing provider will not issue supplies unless the injured worker has provided a signed written request and the supplies are necessary and authorized.

 

BWC Medical Necessity Criteria

 

1) TENS for Chronic Pain

Prior authorization by BWC, MCO, or self-insured employer is required for TENS rental or purchase. Payment for a transcutaneous electrical nerve stimulator (TENS) is covered for the treatment of patients with chronic, intractable pain who meet the following criteria:

·         Documentation from the physician of chronic pain that has been present for three months;

·         Documentation from the physician of the location of pain, duration of time patient has had pain, and the presumed cause of the pain;

·         Documentation from the physician of other modalities that have been tried and failed;

·         Trial rental period of only one month to determine the effectiveness of TENS unit.

 

For purchase of a TENS unit for chronic pain, the following documentation must be present in the physician’s records at the conclusion of the 30 day trial:

·         Frequency and duration of use of TENS;

·         Results of TENS units modulating  pain

 

2) TENS for Acute Post-operative Pain

TENS rental is generally limited to 30 days beyond surgery. For reimbursement beyond 30 days, the physician must provide medical documentation for justification.

 

3) Neuromuscular Stimulators (NMES)

A NMES device provides an electrical stimulus directly to the muscle or motor nerve of the muscle, causing the muscle to contract.  The goal is to stimulate denervated muscle to prevent atrophy or degeneration and to strengthen/train healthy muscles that are at risk of atrophy from immobilization or disuse due to injury.  Prior authorization by BWC, MCO, or self-insured employer is required prior to NMES rental or purchase.

 

The MCO Medical Director or an MCO physician consultant is required to review each request for home rental or purchase of NMES based on medical necessity and BWC NMES criteria.

 

Reimbursement of NMES devices for home use for the treatment/prevention of muscle atrophy requires the following conditions be met:

·         The patient has suffered partial or complete loss of function in one or more muscles because of an injury to a peripheral nerve or nerve root, and

·         Denervation is substantiated by EMG confirming the nerve injury.  The EMG must demonstrate positive waves and/or fibrillation in the affected muscles.

 

BWC/MCOs will reimburse NMES and also Functional Electrical Stimulation (FES) to enhance walking of injured workers with spinal cord injuries (SCI) who meet all the following criteria:

·         Diagnosis of paraplegia of both lower limbs (ICD-9 344.1);

·         Willingness to use the device on a long-term basis;

·         High motivation, commitment and cognitive ability to use the device for   walking;

·         Completion of a physical therapy training program of a minimum of 30 sessions with the NMES unit  over  a 3 month period;

·         Intact lower motor units (L1 and below) both muscle and peripheral nerve;

·         Demonstration of brisk muscle contraction to NMES and sensory perception of electrical stimulations sufficient for muscle contraction;

·         Muscle and joint stability for weight bearing at upper and lower extremities with demonstration of balance and control to maintain an upright support posture independently;

·         Ability to transfer independently and demonstration of standing independently for at least 3 minutes;

·         Demonstration of hand and finger function to manipulate controls;

·         Minimum of 6-month post recovery spinal cord injury and restorative surgery;  and

·         Absence of hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis

 

The appropriate Level I CPT® code to be billed to MCO/BWC for the required physical therapy with the NMES unit is 97116-gait training.

 

NMES/FES for walking is contraindicated for SCI injured workers with any of the following:

·         Cardiac pacemakers or cardiac defibrillators;

·         Severe scoliosis or severe osteoporosis;

·         Irreversible contracture;

·         Autonomic dysreflexia: or

·         Skin disease or cancer at the area of stimulation

 

ORC 4123-6-43  Payment of TENS and NMES

 

Payment will be approved for a TENS unit for treatment of allowed conditions in a claim directly resulting from an allowed industrial injury or occupational disease, as provided in this rule.

 

·         Prior authorization is required for TENS units and supplies.

·         Each claimant who requires a TENS unit will be provided only one unit at a time.

·         For each TENS there is a trial period of no more than 30 days.  This trial period is to evaluate the medical necessity and effectiveness of the TENS treatment.

·         TENS treatment will be discontinued at the end of 30 days if it has not proven to be medically necessary or effective.

·         Reimbursement of rental costs will be considered only for the trial period that the TENS unit was actually used before treatment was discontinued.

·         BWC shall apply all rental payments previously made to the purchase price of the TENS unit.

·         A TENS unit, furnished and purchased for the claimant, is not the personal property of the claimant, but remains the property of BWC, or self-insuring employer.

·         BWC or self-insuring employer, reserves the right to reclaim and recover the TENS unit from the claimant at the completion of the course of TENS treatment.

·         Once a TENS unit is purchased, BWC, or self-insuring employer will reimburse for repair or replacement of the unit upon the submission of request from the physician of record or treating provider that includes medical documentation substantiating the continued medical necessity and effectiveness of the unit.

 

The TENS provider shall maintain the following records and make them available for audit upon request:

·         The injured worker’s signed monthly written requests;

·         Records of the provider’s wholesale purchase of TENS supplies or equipment; and,

·         Records of delivery of supplies to injured workers and the delivery or return of TENS units.

 

Upon request, the provider shall supply copies of the record information to the requester at no cost. Failure to provide the requested records will result in denial or adjustment of bills related to these records.

 

Note:  The above criteria listed in ORC 4123-6-43 Payment of Transcutaneous Electrical Nerve Stimulators, is being applied to the payment neuromuscular units (NMES) effective March 1, 2004.

 

TENS/NMES coding and reimbursement

BWC will reimburse for TENS and NMES units and supplies at the current fee schedule rates.

 


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