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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAlabama Medicaid ESWL Coverage & Payment Policy | …
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    CurrentAlabama MedicaidPolicy N/A

    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.

    Policy Summary
    PayerAlabama Medicaid
    PolicyExtracorporeal Shock Wave Lithotripsy (ESWL) reimbursement
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 13, 1987
    Next Review DateN/A
    Key ActionFacilities must have a signed ESWL contract with Alabama Medicaid to receive reimbursement for ESWL treatment.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    renal pelvis/UPJ/upper ureterAnatomic sites covered
    bladder/lower ureterAnatomic sites excluded
    1.5xBilateral same-period multiplier
    0.5xRepeat within 90 days multiplier
    separateAnesthesiologist billing

    ESWL Coverage and Payment Rules

    ESWL coverage and payment criteria

    Covered when the following location, payment, billing, and participation conditions are met:

    Anatomic site: ESWL is covered for treatment of kidney stones located in the renal pelvis, the uretero-pelvic junction (UPJ), or the upper one-third of the ureter.

    From Rule No. 560-X-39-.01.

    Exclusion: ESWL is not a covered service for urinary stones of the bladder or stones in the lower two-thirds of the ureter.

    From Rule No. 560-X-39-.01.

    Facility participation: The facility must have a signed ESWL contract with the Alabama Medicaid Agency to be eligible for facility reimbursement for ESWL treatment.

    From Rule No. 560-X-39-.02.

    ALL of the following

    Policy Summary
    PayerAlabama Medicaid
    PolicyExtracorporeal Shock Wave Lithotripsy (ESWL) reimbursement
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 13, 1987
    Next Review DateN/A
    Key ActionFacilities must have a signed ESWL contract with Alabama Medicaid to receive reimbursement for ESWL treatment.
    SourceLink
    On This Page
    ESWL Coverage and Payment RulesReimbursement, Modifiers, and Coding RulesProvider Enrollment, Contracts, and Billing ResponsibilitiesAnatomic Sites and Reimbursement Scope

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    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.
  1. 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.

    2. 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.
    Facility rate inclusions and exclusions: The ESWL facility reimbursement rate is all-inclusive for the encounter and includes services rendered in conjunction with treatment (e.g., lab, x-ray, observation), except that physician and anesthesiologist fees are not included.

    From Rule No. 560-X-39-.02.

    Anesthesiologist billing: Anesthesiologist services are not included in the facility's or physician's reimbursement rate and can be billed separately.

    From Rule No. 560-X-39-.04.

    Provider enrollment requirements: To participate as an ESWL provider, submit a written request for enrollment, documentation that the lithotripsy machine is FDA approved, and documentation showing the machine is operated under the authority of a valid Certificate of Need (CON) — either the CON itself or a contract with the CON holder.

    From Rule No. 560-X-39-.05.

    Reimbursement, Modifiers, and Coding Rules

    Reimbursement modifiers and rulesmixed
    Facility: both kidneys same treatment periodfacility reimbursed at 1.5x regular reimbursement rate
    Facility: repeat treatment within 90 daysfacility reimbursed at 0.5x regular reimbursement rate
    Physician/Surgeon: both kidneys same treatment periodsurgeon reimbursed at 1.5x regular reimbursement rate for the surgical procedure
    Physician/Surgeon: repeat treatment within 90 dayssurgeon reimbursed at 0.5x regular reimbursement rate for the surgical procedure
    Anesthesiologist servicesnot included in facility's or physician's reimbursement rate; billable separately
    Facility participation requirementfacility must have a signed ESWL Contract with the Alabama Medicaid Agency to be reimbursed
    Provider enrollment requirementssubmit 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 rateESWL 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 siteskidney stones in the renal pelvis, uretero-pelvic junction, and the upper one-third of the ureter
    Excluded anatomic sitesurinary stones of the bladder and the lower two-thirds of the ureter are not covered
    Repeat treatment window (inv-03)
    Repeat treatment window90 days — repeat ESWL treatments on the same recipient within a ninety-day period are reimbursed at half the regular rate
    Reimbursement adjustment for repeatsFacility and surgeon reimbursement reduced to 0.5x for repeats within 90 days
    Reference ruleRule No. 560-X-39-.02(3) and 560-X-39-.03(2)

    Provider Enrollment, Contracts, and Billing Responsibilities

    Documentation Required

    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).
    Prior Authorization

    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

    Covered sites (inv-06)
    Covered anatomic sitesRenal pelvis
    Covered anatomic sitesUretero-pelvic junction (UPJ)
    Covered anatomic sitesUpper one-third of the ureter
    Excluded sites (inv-07)
    Excluded anatomic sitesBladder (urinary stones of the bladder)
    Excluded anatomic sitesLower two-thirds of the ureter
    Coverage statusNot a covered service for these locations per Rule No. 560-X-39-.01(2)
    All-inclusive facility rate (inv-08)
    All-inclusive facility rateESWL facility reimbursement is an all-inclusive rate for each encounter and includes ancillary services (e.g., lab, x-ray, observation)
    Exceptions to all-inclusive ratePhysician and anesthesiologist fees are excluded from the facility all-inclusive rate and may be billed separately
    Regulatory referenceRule No. 560-X-39-.02(4) and 560-X-39-.04(1)