Extracorporeal Shock Wave Lithotripsy (ESWL) reimbursement
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This document governs Alabama Medicaid coverage, provider participation, and reimbursement rules for ESWL procedures, including facility, physician, and anesthesiologist billing, and applies to providers participating in Alabama Medicaid.
No material clinical or coverage changes in this revision.
ESWL Coverage and Payment Rules
ESWL coverage and payment criteria
Covered when the following location, payment, billing, and participation conditions are met:
From Rule No. 560-X-39-.01.
From Rule No. 560-X-39-.01.
From Rule No. 560-X-39-.02.
ALL of the following
- If ESWL is performed to both kidneys during the same treatment period, Medicaid will reimburse the facility at one-and-a-half (1.5) times the regular reimbursement rate for the procedure.
- Repeat ESWL treatments on the same recipient within a ninety (90)-day period will be reimbursed at one-half (0.5) the regular reimbursement rate for the procedure.
ALL of the following
- If ESWL is performed to both kidneys during the same treatment period, Medicaid will pay the surgeon one-and-a-half (1.5) times the regular reimbursement rate for the surgical procedure.
- For repeat ESWL treatments on the same recipient within a ninety (90)-day period, Medicaid will reimburse the surgeon at one-half (0.5) the regular reimbursement rate for the surgical procedure.
From Rule No. 560-X-39-.02.
From Rule No. 560-X-39-.04.
From Rule No. 560-X-39-.05.
Reimbursement, Modifiers, and Coding Rules
| Facility: both kidneys same treatment period | facility reimbursed at 1.5x regular reimbursement rate |
| Facility: repeat treatment within 90 days | facility reimbursed at 0.5x regular reimbursement rate |
| Physician/Surgeon: both kidneys same treatment period | surgeon reimbursed at 1.5x regular reimbursement rate for the surgical procedure |
| Physician/Surgeon: repeat treatment within 90 days | surgeon reimbursed at 0.5x regular reimbursement rate for the surgical procedure |
| Anesthesiologist services | not included in facility's or physician's reimbursement rate; billable separately |
| Facility participation requirement | facility must have a signed ESWL Contract with the Alabama Medicaid Agency to be reimbursed |
| Provider enrollment requirements | submit written request for enrollment; documentation that lithotripsy machine is FDA approved; documentation of valid Certificate of Need or contract with CON holder |
| All-inclusive facility rate | ESWL reimbursement is an all-inclusive rate for each encounter and includes services such as lab, x-ray, and observation (physician and anesthesiologist fees excluded) |
| Covered anatomic sites | kidney stones in the renal pelvis, uretero-pelvic junction, and the upper one-third of the ureter |
| Excluded anatomic sites | urinary stones of the bladder and the lower two-thirds of the ureter are not covered |
Provider Enrollment, Contracts, and Billing Responsibilities
ESWL provider enrollment requirements
To participate in Alabama Medicaid as an ESWL provider, submit a written request for enrollment; provide documentation that the lithotripsy machine is FDA approved; and provide documentation that the machine is operated under the authority of a valid Certificate of Need (CON) — either a copy of the CON or a copy of the contract between the provider and the CON holder.
- Submit written request for enrollment.
- Submit documentation that the lithotripsy machine is FDA approved.
- Provide documentation of a valid Certificate of Need (copy of CON or contract with CON holder).
Signed facility ESWL contract required for reimbursement
Facilities must have a signed ESWL Contract with the Alabama Medicaid Agency to be reimbursed for ESWL treatment.
- Obtain and maintain a signed ESWL Contract with the Alabama Medicaid Agency prior to billing for ESWL facility services.
Anatomic Sites and Reimbursement Scope
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