I had been suffering from metatarsal pain in my right foot for several months despite trying everything I could think of. My associate adjusted me, did myofascial work, e-stim and ultrasound.
I was beginning to resign myself to a future of chronic foot pain when a colleague I was teaching a neurology course with suggested low-level laser therapy (LLLT.) I knew very little about laser therapy and was extremely skeptical, but I trusted my friend, and he had been teaching classes on laser, so I knew he was informed. I was also not interested in spending thousands of dollars on a new toy at the height of the recession. He suggested I have a sales rep come and show me a machine.
A few days later I met with the salesman, arms folded across my chest, daring him to convince me of efficacy. He asked if I had a patient on whom he could demonstrate. "Yeah, me," I replied. Undeterred, he commenced to skillfully wield the laser wand and in less than two minutes, he was done. I didn't notice any difference at all - until the next morning, when all my pain had disappeared. In fact, it has yet to come back after four months.
Being an "evidence-based" practitioner, I did my homework and searched the scientific literature regarding efficacy for laser. In a couple of weeks, I bought my own Class IV machine. Now I needed to find a way to pay for it.
Fortunately, as a past chairman of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP,) I knew a thing or two about the importance of guidelines and chiropractic evidence. As luck would have it, Drs. Howard Vernon and Michael Schneider had recently published a literature synthesis for CCGPP on conservative treatment of myofascial pain syndromes and myofascial trigger point (MFTrP) therapies. They looked at a wide variety of treatments for myofascial problems, including manual therapies, ultrasound, magnets and yes, laser therapy. They reviewed a huge volume of research evidence, graded it for quality and distilled out what works, and what doesn't. Care to guess the only form of therapy that received an "A" grade?
I have a pretty diverse practice, seeing patients referred by their medical doctors, friends, or their employers for work-related injuries. Here in California, all care delivered for workers' compensation injuries has to meet treatment guideline standards or it won't be reimbursed. Fortunately, the legislature saw fit to add a provision that allows us to "controvert" the guidelines by demonstrating that the proposed treatment is "in accordance with other evidence-based medical treatment guidelines that are generally recognized by the national medical community and are scientifically based." That is exactly why CCGPP was created, and what those of us who have worked on guidelines for the past 15 years intended them to be used for.
Needless to say, most guidelines do not yet recognize LLLT as a "recommended" (read: reimbursed) treatment. Hopefully that will change soon. In the meantime, the CCGPP paper by Drs. Vernon and Schneider (available at www.ccgpp.org)1 has enabled me to get paid for myofascial and overuse syndromes. Other papers (Chow, et al.)2 substantiate efficacy for both acute and chronic neck pain (PI, anyone?).
There is still no specific code for LLLT under the CPT coding system, though the HCPCS system uses S8948. The code under CPT that most closely matches is probably 97799 (unlisted modality or procedure). While there are never any guarantees in terms of reimbursement, the following steps have allowed me to be paid my full fee:
- Document the clinical condition (e.g., myofascial pain and/or trigger points in terms of location, radiation and severity).
- Send a copy of the CCGPP paper (or other supporting documentation).
- Be willing to appeal! In California, we have to ask first for authorization. I have never been approved for laser on the first try; but I have never been denied if I persisted. Why? The science is on my side, thanks to CCGPP!
References
- Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature. J Manip Physiol Ther, 2009;32:14-24.
- Chow RT, Johnson MI, Lopes-Martins RAB, Bjordal JM. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet, 2009;347:1897-1908.
Dr. Wayne Whalen, is a 1986 graduate of Palmer College of Chiropractic West. He is a past president of the California Chiropractic Association and past chairman of the Council on Chiropractic Guidelines and Practice Parameters. He is board certified in chiropractic neurology and was named a Fellow of the International College of Chiropractors.