Introduction

  • Low frequency, non-contact, nonthermal ultrasound (UltraMIST) has its own unique CPT code, 97610
  • UltraMIST has nationwide Medicare coverage at a national average reimbursement rate of $168.95
  • UltraMIST Therapy is reimbursed in the HOPD, under APC 5051
  • UltraMIST Therapy performed in the physician office or by a therapist is reimbursed under the MPFS at a national average reimbursement rate of $136.44
  • Medical necessity is documented with progression and changes in wound (reduction in size, pain, or necrotic tissue and/or an increase in granulation tissue) and expectation is patient will be seen 2-3x per week

The Venous Leg Ulcers (VLU) Algorithm

UltraMIST Therapy has clinical evidence to support improvement in the microenvironment of the wound bed which promotes wound healing in addition to standard of care.

Mean % VLU Area Reduction at 4 Weeks

Subjects with VLUs randomized to MIST Therapy® and standard care (SC) vs. SC (per guidelines) alone. MIST Therapy® SC out-performed SC alone regardless of the age of the ulcer, the size of the ulcer, or complex comorbidities.

Gibbons GW et al. Ostomy and Wound Management 2015; 61(1): 16-29

Coding for UltraMIST Therapy: 97610

Low frequency, non contact, non thermal ultrasound (UltraMIST) including topical application(s) when performed wound assessment, and instruction(s) for ongoing care per day.

  • Placed in the “Active Wound Management” codes in the CPT Coding Manual
  • Designated a “sometimes therapy” code

Documentation for UltraMIST Therapy

Medical necessity is documented with wound progression and changes in one or more of the following:

  • Wound type
  • Wound size
  • Co-morbidities
  • Pain
  • Description of the wound bed, i.e. necrotic tissue, granulation tissue, drainage

Low-Frequency, Non-Contact, Non-Thermal Ultrasound (MIST Therapy) is considered reasonable and necessary wound therapy and therefore eligible for coverage by Medicare when provided for any of the following clinical conditions:

  • Wounds and ulcers which are too painful for sharp or excisional debridement and have failed conventional debridement with documentation supporting the same, or
  • Wounds and ulcers meeting Medicare coverage for debridement but with documented contraindications to sharp or excisional debridement, or
  • Wounds and ulcers meeting Medicare coverage for debridement but with documented evidence of no signs of improvement after 30 days of standard wound care
  • MIST Therapy is typically required to be performed 2-3 times per week to be considered “reasonable and necessary”
  • Observable, documented improvements in the wound(s) should be evident after 2 weeks of 4-6 MIST treatments
  • Continuing MIST treatments for wounds demonstrating no improvement after six (6) treatments may be considered NOT reasonable and necessary

MAC Coverage for UltraMIST

  • 100% coverage for Medicare recipients
  • Prior authorizations is recommended for commercial payers

Payment for UltraMIST (97610) Based on the VLU Algorithm

National Average Reimbursement HOPD
$168.95
MD Office / PT
$136.44
MIST Generator Costs $5.00 $5.00
MIST Applicator $55.00 $55.00
Dressing / Compression $12.00 $12.00
Net Revenue / Visit $96.95 $64.44
  • National average in HOPD – APD 5051 = $168.95
  • National average MPFS = $136.44

Case Study

Progress of a 14 month old VLU, 14.4cm2 in size, treated with MIST + Standard of Care.
Complete healing was observed in five weeks (12 MIST treatments total).

Pre-MIST
Post Two Weeks
Six Mist Treatments
Post Four Weeks
12 MIST Treatments
Post Five Weeks
Healed