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Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.
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     Voluntary Termination

    According to 42 CFR 489.52, a provider that wishes to terminate its agreement to participate in the Medicare program may do so by: (1) filing with CMS a written notice stating its intention to terminate its agreement; and (2) informing CMS of the date upon which it wishes the termination to take effect. The CMS may approve the date proposed by the provider or set a different date no later than six months after the date of the provider’s notice.

    The effective date of termination may be less than six months following CMS’ receipt of the provider’s notice of its intention to terminate if CMS determines that termination on that date would not:

    • Unduly disrupt the furnishing of services to the community; or

    • Otherwise interfere with the effective and efficient administration of the Medicare program.

    If a provider sends the FI a written notice of its intention to terminate its agreement, the FI should forward the notice to the CMS RO. The date of receipt of the notice by the FI will be considered the date of filing in determining the date of termination.

    The RO promptly notifies the FI when it learns from other sources that a provider wishes to terminate its participation in the program, and keeps the FI informed of the status of the provider’s request. It is the responsibility of the FI, as necessary, to make preliminary arrangements for filing of the cost report, and to adjust any interim payments, accelerated payments, of current financing payments to avoid overpayments. Final notice of termination of the provider’s agreement is formally given to the FI by the RO via Form CMS-2007.

    As soon as the termination date is established, the RO instructs the provider to notify the public that it is voluntarily terminating its provider agreement. The public notice should be published in the local newspapers with the largest circulation, as soon as possible, but not less than l5 days before the effective termination date. A provider that wishes to terminate its provider agreement should also file a Form CMS-855A with the FI requesting a voluntary termination of its Medicare billing number.

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    Required Data Element Requirements

    The following Medicare-specific, return as unprocessable requirements in this section and the following two sections are in addition to requirements established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Regulations implementing HIPAA require the use of National Provider Identifiers (NPIs) by covered health care providers and health plans. Although not required by HIPAA, CMS is extending the requirement to include the NPI on electronic claims to paper claims submitted on the Form CMS-1500 (8/05). Carriers are referred to the Health Care Claims Professional 837 Implementation guide for requirements for professional claims subject to HIPAA, including the NPI reporting requirements.

    Carriers must return a claim as unprocessable to a provider of service or supplier and use the indicated remark code, or select and use another appropriate remark code, if the claim is returned through the remittance advice or notice process. In most cases, reason code 16, "Claim/service lacks information that is needed for adjudication", will be used in tandem with the appropriate remark code that specifies the missing information.

    Carriers shall return a claim as unprocessable:

    1. If a claim lacks a valid Medicare Health Insurance Claim Number (HICN) in item 1a. or contains an invalid HICN in item 1a. (Remark code MA61.)

    2. If a claim lacks a valid patient’s last and first name as seen on the patient’s Medicare card or contains an invalid patient’s last and first name as seen on the patient’s Medicare card. (Remark code MA36.)

    3. If a claim does not indicate in item 11 whether or not a primary insurer to Medicare exists. (Remark code MA83 or MA92.)

    4. If a claim lacks a valid patient or authorized person’s signature in item 12 or contains an invalid patient or authorized person’s signature in item 12. (See “Exceptions,” bullet number one. Remark code MA75.)

    5. If a claim lacks a valid “from” date of service in item 24A or contains an invalid “from” date of service in item 24A. (Remark code M52.)
    6. If a claim lacks a valid place of service (POS) code in item 24B or contains an invalid POS code in item 24B, return the claim as unprocessable to the provider or supplier. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, if a claim contains more than one POS (other than Home – 12), for services paid under the MPFS and anesthesia services.

    Effective January 1, 2011, for claims processed on or after January 1, 2011 on the Form CMS-1500, if a claim contains more than one POS, including Home – 12, (or any POS contractors consider to be Home), for services paid under the MPFS and anesthesia services.


    (Remark code M77.)

    7. If a claim lacks a valid procedure or HCPCS code (including Levels 1-3, “unlisted procedure codes,” and “not otherwise classified” codes) in item 24D or contains an invalid or obsolete procedure or HCPCS code (including Levels 1-3, “unlisted procedure codes,” and “not otherwise classified” codes) in item 24D. (Remark code M20 or M51.)

    NOTE: Level 3 HCPCS are not valid under HIPAA after Dec 31, 2003.

    8. If a claim lacks a charge for each listed service. (Remark code M79.)

    9. If a claim does not indicate at least 1 day or unit in item 24G (Remark Code M53.) (Note: To avoid returning the claim as “unprocessable” when the information in this item is missing, the carrier must program the system to automatically default to “1” unit).

    10. If a claim lacks a signature from a provider of service or supplier, or their representative. (See “Exceptions,” bullet number one; Remark code MA70 for a missing provider representative signature, or code MA81 for a missing physician/supplier/practitioner signature.)

    11. If a claim does not contain in item 33:

    a. A billing name, address, ZIP Code, and telephone number of a provider of service or supplier. (Remark code N256 or N258.)

    AND EITHER

    b. A valid PIN number or, for DMERC claims, a valid National Supplier Clearinghouse number (NPI in item 33a. of the Form CMS-1500 (8/05) when the NPI is required) for the performing provider of service or supplier who is not a member of a group practice. (Remark code N257)

    OR

    c. A valid group PIN (or NPI when required) number or, for DMERC claims, a valid National Supplier Clearinghouse number (NPI in item 33a. of the Form CMS-1500 (8/05), when the NPI is required) for performing providers of service or suppliers who are members of a group practice. (Remark code N257)

    12. If a claim does not contain in Item 33a., Form CMS 1500 (08-05), the NPI, when required, of the billing provider, supplier, or group. (Remark Code N257 or MA112.)

    13. Effective May 23, 2008, if a claim contains a legacy provider identifier, e.g., PIN, UPIN, or National Supplier Clearinghouse number. (Remark Code N 257)

    NOTE: Claims are not to be returned as unprocessable in situations where an NPI is not required (e.g., foreign claims, deceased provider claims, other situations as allowed by CMS in the future) and legacy numbers are reported on the claim. Such claims are to be processed in accordance with the established procedures for these claims.

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    1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants

    Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the costs of the following services:

    • National Marrow Donor Program fees, if applicable, for stem cells from an unrelated donor;

    • Tissue typing of donor and recipient;

    • Donor evaluation;

    • Physician pre-procedure donor evaluation services;

    • Costs associated with harvesting procedure (e.g., general routine and special care services, procedure/operating room and other ancillary services, apheresis services,etc.);

    • Post-operative/post-procedure evaluation of donor; and

    • Preparation and processing of stem cells.

    Payment for these acquisition services is included in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the hospital outpatient setting, and in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment. Recurring update notifications describing changes to and billing instructions for various payment policies implemented in the OPPS are issues annually.

    Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are obtained from a donor (other than the recipient himself or herself). Acquisition charges do not apply to autologous transplants (transplanted stem cells are obtained from the recipient himself or herself), because autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the hospital may bill and receive payment (see Pub. 100-04, chapter 3, §90.3.1 and §231.10 of this chapter for information regarding billing for autologous stem cell transplants).



    2. Billing for Acquisition Services

    The hospital bills and shows acquisition charges for allogeneic stem cell transplants based on the status of the patient (i.e., inpatient or outpatient) when the transplant is furnished. See Pub. 100-04, chapter 3, §90.3.1 for instructions regarding billing for acquisition services for allogeneic stem cell transplants that are performed in the inpatient setting.

    When the allogeneic stem cell transplant occurs in the outpatient setting, the hospital identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants separately in FL 42 of Form CMS-1450 (or electronic equivalent) by using revenue code 0819 (Other Organ Acquisition). Revenue code 0819 charges should include all services required to acquire stem cells from a donor, as defined above, and should be reported on the same date of service as the transplant procedure in order to be appropriately packaged for paymentpurposes.

    The transplant hospital keeps an itemized statement that identifies the services furnished, the charges, the person receiving the service (donor/recipient), and whether this is a potential transplant donor or recipient. These charges will be reflected in the transplant hospital's stem cell/bone marrow acquisition cost center. For allogeneic stem cell acquisition services in cases that do not result in transplant, due to death of the intended recipient or other causes, hospitals include the costs associated with the acquisition services on the Medicare cost report.

    In the case of an allogeneic transplant in the hospital outpatient setting, the hospital reports the transplant itself with the appropriate Procedure  code, and a charge under revenue center code 0362 or another appropriate cost center. Selection of the cost center is up to the hospital.

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    Medicare Credit Balance Report – Provider Instructions


    General

    The Paperwork Burden Reduction Act of 1995 was enacted to inform you about why the Government collects information and how it uses the information.  In accordance with sections 1815(a) and 1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program.

    In addition, section 1866(a)(1)(C) of the Act requires participating providers to furnish information about payments made to them, and to refund any monies incorrectly paid. In accordance with these provisions, all providers participating in the Medicare program are to complete a Medicare Credit Balance Report (CMS-838) to help ensure that monies owed to Medicare are repaid in a timely manner.

    The CMS-838 is specifically used to monitor identification and recovery of “credit balances” owed to Medicare. A credit balance is an improper or excess payment made to a provider as the result of patient billing or claims processing errors. Examples of Medicare credit balances include instances where a provider is:

    • Paid twice for the same service either by Medicare or by Medicare and another insurer;

    • Paid for services planned but not performed or for non-covered services;

    • Overpaid because of errors made in calculating beneficiary deductible and/or coinsurance amounts; or

    • A hospital that bills and is paid for outpatient services included in a beneficiary’s inpatient claim. Credit balances would not include proper payments made by Medicare in excess of a provider’s charges such as DRG payments made to hospitals under the Medicare prospective payment system. For purposes of completing the CMS-838, a Medicare credit balance is an amount determined to be refundable to Medicare.

    Generally, when a provider receives an improper or excess payment for a claim, it is reflected in their accounting records (patient accounts receivable) as a “credit.” However, Medicare credit balances include monies due the program regardless of its classification in a provider’s accounting records. For example, if a provider maintains credit balance accounts for a stipulated period; e.g., 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider must identify and repay all monies due the Medicare program.

    Only Medicare credit balances are reported on the CMS-838. 

    To help determine whether a refund is due to Medicare, another insurer, the patient, or beneficiary, refer to the sections of the manual [each provider manual will have the appropriate cite for that manual] that pertain to eligibility and Medicare Secondary Payer (MSP) admissions procedures.

    Submitting the CMS-838

    Submit a completed CMS-838 to your fiscal intermediary (FI) within 30 days after the close of each calendar quarter. Include in the report all Medicare credit balances shown in your accounting records (including transfer, holding or other general accounts used to accumulate credit balance funds) as of the last day of the reporting quarter.

    Report all Medicare credit balances shown in your records regardless of when they occurred. You are responsible for reporting and repaying all improper or excess payments you have received from the time you began participating in the Medicare program. Once you identify and report a credit balance on the CMS-838 report, do not report the same credit balance on subsequent CMS-838 reports.

    Completing the CMS-838

    The CMS-838 consists of a certification page and a detail page. An officer (the Chief Financial Officer or Chief Executive Officer) or the Administrator of your facility must sign and date the certification page. Even if no Medicare credit balances are shown in your records for the reporting quarter, you must still have the form signed and submitted to your FI in attestation of this fact. Only a signed certification page needs to be submitted if your facility has no Medicare credit balances as of the last day of the reporting quarter. An electronic file (or hard copy) of the certification page is available from your FI.

    The detail page requires specific information on each credit balance on a claim-by-claim basis. This page provides space to address 17 claims, but you may add additional lines or reproduce the form as many times as necessary to accommodate all of the credit balances that you have reported. An electronic file (or hard copy) of the detail page is available from your FI.

    You may submit the detail page(s) on a diskette furnished by your contractor or by a secure electronic transmission as long as the transmission method and format are acceptable to your FI. Segregate Part A credit balances from Part B credit balances by reporting them on separate detail pages.

    NOTE: Part B pertains only to services you provide which are billed to your FI. It does not pertain to physician and supplier services billed to carriers.

    Begin completing the CMS-838 by providing the information required in the heading area of the detail page(s) as follows:

    • The full name of the facility;

    • The facility’s provider number. If there are multiple provider numbers for dedicated units within the facility (e.g., psychiatric, physical medicine and rehabilitation), complete a separate Medicare Credit Balance Report for each provider number;

    • The month, day and year of the reporting quarter; e.g., 12/31/02;

    • An “A” if the report page(s) reflects Medicare Part A credit balances, or a “B” if it reflects Part B credit balances;

    • The number of the current detail page and the total number of pages forwarded, excluding the certification page (e.g., Page 1 of 3); and

    • The name and telephone number of the individual who may be contacted regarding any questions that may arise with respect to the credit balance data.

    Complete the data fields for each Medicare credit balance by providing the following information (when a credit balance is the result of a duplicate Medicare primary payment, report the data pertaining to the most recently paid claim):

    Column 1 - The last name and first initial of the Medicare Beneficiary, (e.g., Doe, J.).

    Column 2 - The Medicare Health Insurance Claim Number (HICN) of the Medicare Beneficiary.

    Column 3 - The multiple-digit Internal Control Number (ICN) assigned by Medicare when the claim is processed.

    Column 4 - The 3-digit number explaining the type of bill; e.g., 111 - inpatient, 131 - outpatient, 831 - same day surgery. (See the Uniform Billing instructions, [each provider manual has the appropriate cite for the manual].)

    Columns 5/6 - The month, day and year the beneficiary was admitted and discharged, if an inpatient claim; or “From” and “Through” dates (date service(s) were rendered), if an outpatient service. Numerically indicate the admission (From) and discharge (Through) date (e.g., 01/01/02).

    Column 7 - The month, day and year (e.g., 01/01/02) the claim was paid. If a credit balance is caused by a duplicate Medicare payment, ensure the paid date and ICN number correspond to the most recent payment.

    Column 8 - An “O” if the claim is for an open Medicare cost reporting period, or a “C” if the claim pertains to a closed cost reporting period. (An open cost report is one where an NPR has not yet been issued. Do not consider a cost report open if it was reopened for a specific issue such as graduate medical education or malpractice insurance.)

    Column 9 - The amount of the Medicare credit balance that was determined from your patient/ accounting records.

    Column 10 - The amount of the Medicare credit balance identified in column 9 being repaid with the submission of the report. (As discussed below, repay Medicare credit balances at the time you submit the CMS-838 to your FI.)

    Column 11 - A “C” when you submit a check with the CMS-838 to repay the credit balance amount shown in column 9, an “A” if a claim adjustment is being submitted in hard copy (e.g., adjustment bill in UB-92 format) with the CMS-838, and a “Z” if payment is being made by a combination of check and adjustment bill with the CMS-838. Use an “X” if an adjustment bill has already been submitted electronically or by hard copy.

    Column 12 - The amount of the Medicare credit balance that remains outstanding (column 9 minus column 10). Show a zero (“0”) if you made full payment with the CMS-838 or a claim adjustment had been submitted previously, including electronically.

    Column 13 - The reason for the Medicare credit balance by entering a “1” if it is the result of duplicate Medicare payments, a “2” for a primary payment by another insurer, or a “3” for “other reasons.” Provide an explanation on the detail page for each credit balance with a “3.”

    Column 14 - The Value Code to which the primary payment relates, using the appropriate two digit code as follows: (This column is completed only if the credit balance was caused by a payment when Medicare was not the primary payer. If more than one code applies, enter the code applicable to the payer with the largest liability. For code description, see [each provider manual has the appropriate cite for that manual].)

    12 – Working Aged

    13 – End Stage Renal Disease

    14 – Auto/No Fault

    15 – Workers’ Compensation

    16 – Other Government Program

    41 – Black Lung

    42 – Department of Veterans Affairs (VA)

    43 – Disability

    44 – Conditional Payment

    47 – Liability


    Column 15 - The name and billing address of the primary insurer identified in column 14.

    NOTE: Once a credit balance is reported on the CMS-838, it is not to be reported on a subsequent
     period report.


    Payment of Amounts Owed Medicare

    Providers must pay all amounts owed (column 9 of the report) at the time the credit balance report is submitted.

    Providers must submit payment, by check or adjustment bill.

    • Payments by check must also be accompanied by a separate adjustment bill, electronic or hard copy, for all individual credit balances that pertain to open cost reporting periods. The FI will ensure that the monies are not collected twice.

    • Submission of the detail information on the CMS-838 will not be accepted by the FI as an
     adjustment bill.


    • Claim adjustments, whether as payment or in connection with a check, must be submitted as adjustment bills (electronic or hard copy). If the claim adjustment was submitted electronically, this must be shown on the CMS-838 (see instructions for column 11).

    • There is a limited exception for MSP credit balances. Federal regulations at 42 CFR 489.20(h) state that “if a provider receives payment for the same services from Medicare and another payer that is primary to Medicare…” the provider must identify MSP related credit balances in the report for the quarter in which the credit balance was identified, even if repayment is not required until after the date the report is due. If the provider is not submitting a payment (by check or adjustment bill) for an MSP credit balance with the CMS-838 because of the 60-day rule, the provider must furnish the date the credit balance was received. Otherwise, the FI must assume that the payment is due and will issue a recovery demand letter and accrue interest without taking this 60-day period into consideration.

    • If the amount owed Medicare is so large that immediate repayment would cause financial hardship, you may contact your FI regarding an extended repayment schedule.

    Records Supporting CMS-838 Data


    Develop and maintain documentation that shows that each patient record with a credit balance (e.g.,
     transfer, holding account) was reviewed to determine credit balances attributable to Medicare and the   amount owed, for the preparation of the CMS-838. At a minimum, your procedures should:


    • Identify whether the patient is an eligible Medicare beneficiary;
    • Identify other liable insurers and the primary payer;
    • Adhere to applicable Medicare payment rules; and
    • Ensure that the credit balance is due and refundable to Medicare.

    NOTE: A suspension of Medicare payments may be imposed and your eligibility to participate in the Medicare program may be affected for failing to submit the CMS-838 or for not maintaining documentation that adequately supports the credit balance data reported to CMS. Your FI will review your documentation during audits/reviews performed for cost report settlement purposes. Provider Based Home Health Agencies (HHAs) Provider-based HHAs are to submit their CMS-838 to their Regional Home Health Intermediary even though it may be different from the FI servicing the parent facility.

    Exception for Low Utilization Providers

    Providers with extremely low Medicare utilization do not have to submit a CMS-838. A low utilization provider is defined as a facility that files a low utilization Medicare cost report as specified in PRM-I, section 2414.4.B, or files less than 25 Medicare claims per year.

    Compliance with MSP Regulations

    MSP regulations at 42 CFR 489.20(h) require you to pay Medicare within 60 days from the date you receive payment from another payer (primary to Medicare) for the same service. Submission of the CMS-838 and adherence to CMS’ instructions do not interfere with this rule. You must repay credit balances resulting from MSP payments within the 60-day period.

    Report credit balances resulting from MSP payments on the CMS-838 if they have not been repaid by the last day of the reporting quarter. If you identify and repay an MSP credit balance within a reporting quarter, in accordance with the 60-day requirement, do not include it on the CMS-838; i.e., once payment is made, a credit balance would no longer be reflected in your records.

    If an MSP credit balance occurs late in a reporting quarter, and the CMS-838 is due prior to expiration of the 60-day requirement, include it in the credit balance report. However, payment of the credit balance does not have to be made at the time you submit the CMS-838, but within the 60 days allowed.



    What is a CMS-838 Credit Balance Report?

    Medicare credit balance is an amount determined to be refundable to Medicare. Generally, when a provider receives an improper or excess payment for a claim, it is reflected in their accounting records (patient accounts receivable) as a “credit.” 

    The CMS -838 report is specifically used to monitor identification and recovery of “credit balances” owed to Medicare. A credit balance is an improper or excess payment made to a provider as the result of patient billing or claims processing errors. 

    Completing and Submitting the CMS-838 Quarterly Credit Balance Report

    Credit Balance Forms

    • Finding the Credit Balance forms
    • Submitting the forms and payments
    Common rejection reasons and Helpful Hints on completing the 838 forms. 

    CMS-838 Credit Balance Reports

    This concludes the webcast on CMS-838 Credit Balance Report submission. 


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    Why is Ohio Medicaid requiring Ordering, Referring, and Prescribing Providers (ORP Providers) to enroll as Ohio Medicaid providers?

    This is being done in order to comply with program integrity provisions of the Affordable Care Act (ACA), specifically section 6401 which is found in the Code of Federal Regulations: 42 CFR § 455.410(b): “The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan in the fee-for-service program to be enrolled as participating Medicaid providers.” As a result, ORP providers will undergo a screening process to improve  program integrity and reduce fraud, waste and abuse. This screening process includes a review of federal exclusion lists and other databases that would prohibit an excluded healthcare professional from being associated with Medicare or Medicaid.
    What are the requirements for ORP**

    There are three basic requirements:

    ** The physician or non-physician practitioner who wrote the order, referral or prescription must be enrolled as either a Medicaid billing provider or as an ORP-only (non-billing) provider and their NPI and NAME must be included on claims submitted to the department.

    ** The provider's NPI must be for an individual physician or non-physician practitioner (not an organizational NPI).

    ** The physician or non-physician practitioner must be of a specialty type that is eligible to order, refer, or prescribe.

    Does the Ohio Department of Medicaid have a list of provider types that are eligible to be ORP providers**

    Currently, the list of eligible OPR Providers includes:

    ** Licensed Doctors of Medicine/Osteopathy – (Provider Type 20)
    ** Licensed Doctors of Chiropractic – (Provider Type 27)
    ** Licensed Doctors of Dental Medicine/Surgery- (Provider Type 30)
    ** Licensed Doctors of Podiatric Medicine- (Provider Type 36)
    ** Licensed Doctors of Optometry- (Provider Type 35)
    ** Licensed Physician Assistants- (Provider Type 24)
    ** Licensed Nurse Practitioners- (Provider Type 72)
    ** Licensed Clinical Nurse Specialists- (Provider Type 65)
    ** Licensed Certified Nurse Midwifes- (Provider Type 71)
    ** Licensed Clinical Psychologists- (Provider Type 42)

    Note: Organizational providers are prohibited from ordering, referring, or prescribing medications

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    Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program. (f) Maintaining and providing access to documentation.

    (1) A provider or a supplier who furnishes covered ordered DMEPOS or referred home health, laboratory, imaging, or specialist services is required to maintain documentation for 7 years from the date of service and, upon the request of CMS or a Medicare contractor, to provide access to that documentation. The documentation includes written and electronic documents (including the NPI of the physician who ordered the home health  services and the NPI of the physician or the eligible professional who ordered or referred the DMEPOS, laboratory, imaging, or specialist services) relating to written orders and requests for payments for items of DMEPOS and home health, laboratory, imaging, and specialist services.

    (2) A physician who ordered home health services and a physician and an eligible professional who ordered or referred items of DMEPOS or laboratory, imaging, and specialist services is required to maintain documentation for 7 years from the date of the order, certification, or referral and, upon request of CMS or a Medicare contractor, to provide access to that documentation. The documentation includes written and electronic documents (including the NPI of the physician who ordered the home health services and the NPI of the physician or the eligible professional who ordered or referred the DMEPOS, laboratory, imaging, or specialist services) relating to written orders or requests for payments for items of DMEPOS and home health, laboratory, imaging, and specialist services.

    The Office of the Inspector General (OIG) U.S. Department of Health and Human Services provides physician educational resources on physician relationships with payers and vendors. These resources are found here: http://oig.hhs.gov/compliance/physician-education/index.asp. The educational information discusses maintaining and providing documentation as well as the importance of legitimate prescriptions for patients.

    As a billing provider/supplier, if you are asked and/or required to pay for or refused documentation by a referring/ordering physician, please report the incident as potential fraud and/or abuse. As a referring/ordering physician, if you are asked to sign or write prescriptions for Medicare beneficiaries by a provider/supplier for unnecessary services/items or for patients you do not know, please report the incident.

    Executive Summary

    When physicians believe their patients may require the expertise of another physician, effective, timely and informative communication between all physicians is essential to ensure appropriate use of specialty care services. The results of physician surveys indicate a lack of informative referral communication exists in Canada. Significant variation exists in referral request processes*. This is contributing to the poor access to specialty care that many patients are experiencing.

    Some of this variation is necessary, however, which means that a single, standardized solution to improve the entire referral and consultation process is not feasible. Nonetheless, while communication processes and information requirements for referral requests vary considerably, the communication and information needs in consultant responses is essentially the same for all referring physicians. Unfortunately, provision of this information is often lacking. This problem can be addressed through standard communication protocols because all referring physicians benefit from receiving the same types of information in response to referral requests; for example, acknowledgement of referral receipt or patient consult reports.

    Furthermore, when referrals are initiated, specific types of requests can benefit from standardization of communication methods and information requirements. Such activities are already underway in Canada in select areas. These successful initiatives, used together as complementary approaches to address the varying needs of referral requests, should be adopted throughout the country.

    RECOMMENDATIONS

    ** All stakeholders, especially physicians, but also, where appropriate, office assistants, nurses, other health care providers as well as patients, must be engaged in an early and meaningful way regarding any initiative that has a goal to improve referral or consultation processes.

    ** There is no single best way to access specialist expertise; as a result, a combination of complementary initiatives (e.g., formal consultation systems, standardized referral processes with central intake systems and/or physician directories) should be implemented to reduce variation in the approaches that are used and to facilitate more timely access to specialty care for patients.

    ** While acknowledging the referring physician’s ability to interpret certain test results, the referral must be accompanied by appropriate information to allow the consulting specialist to fully assess the request, and the referring physician must be informed of what is “appropriate”.

    ** The referring physician (and family physician if different), as well as the patient, should be kept informed, in a timely fashion, of the status of the referral request, using standardized procedures, minimum information requirements and timelines.

    ** Physician and/or physician practices should receive compensation and support in recognition of the time and effort undertaken to communicate appropriate information regarding referral requests as well as to conduct electronic or real-time consultations.

    The most appropriate method of communication differs depending on the degree of specialist involvement that is required. There are no standards about which method of communication is the most appropriate or effective, or what information is required, for each situation. Referral request processes† vary significantly; not only across specialties but among specialists within a particular specialty and even within a geographic region.

    Examples of this variation include: some consulting specialists will accept referrals only if the referring physician has used their specific referral form; others accept referrals using only one particular communication method (e.g., by fax); and others accept referrals on just one day each month. Such variation creates inefficiencies because referring physicians must familiarize themselves with each request process that is required by each consulting specialist.

    The range and quality of information provided in a referral request also varies considerably; for example, too little information (i.e. no reason for referral provided), insufficient information (i.e. out-of-date or a lack of lab or imaging tests), or to too much information (i.e. noncontributory family history).

    This lack of standardization is problematic. In this context, standardization means simplification rather than obligation. Standardized processes facilitate communications for referrals by removing ambiguities about which method is most appropriate for each situation.

    Communication methods and the types of information that are transferred between referring physicians and consulting specialists vary based on numerous factors, ranging from those beyond the control of physicians such as regulations and available technology, to those completely within their control such as their own individual preferences.

    An effective way to facilitate appropriate and timely access to specialty care that is within the control of the health care profession is to explore the rationale behind these varying communication and information preferences and address these variations by developing, with meaningful participation and approval from physicians and their administrative staff, standard processes for requesting a specialist referral and for communicating back to the referring physician.


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    Procedure  Codes and Description

    Group 1 Paragraph: Note: The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web. For CPT code long descriptors, refer to the current version of CPT.

    Group 1 Codes:

    88182Cell marker study
    88184Flowcytometry/ tc 1 marker
    88185Flowcytometry/tc add-on
    88187Flowcytometry/read 2-8
    88188Flowcytometry/read 9-15
    88189Flowcytometry/read 16 & >


    Coverage Indications, Limitations, and/or Medical Necessity

    Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis.

    A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation.

    When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components.

    Indications
    Cytopenias and Hypercellular Hematolymphoid Disorders

    Hematolymphoid neoplasia can present with cytopenias (anemia, leucopenia and/or thrombocytopenia) or elevated leukocyte counts. If medical review and preliminary laboratory testing fails to reveal a cause, bone marrow aspiration and biopsy are indicated to rule out an infiltrative process or a stem cell disorder. FCM is essential to evaluate hematolymphoid lineages. Although anemia commonly occurs in nonneoplastic diseases, anemia alone should not automatically trigger FCM.

    FCM may be useful in hypercellular hematolymphoid disorders to differentiate reactive conditions from neoplastic conditions. In the absence of blasts, neutrophilic leukocytosis is not generally an indication for FCM. Isolated polycythemia and basophilia are not sufficient to warrant FCM.

    Lymphomas 

    In the current WHO classification, all non-Hodgkin lymphomas (NHLs) are distinct clinicopathologic entities defined by their clinical features, morpholology, immunophenotype and, where appropriate, their genetic abnormalities. Immunophenotyping by FCM allows multiparameter evaluation of single cells and the ability to work on very small samples.

    Most new cases of suspected NHL undergo initial immunophenotypic analysis as part of the routine handling of a specimen. A standard lymphoma panel is designed to identify abnormal populations of B cells, T cells and/or NK cells. A standard lymphoma panel might include a combination of markers from the following categories: T cells (CD2, CD3, CD4, CD5, CD7, CD8); B cells (CD19, CD20, CD23); Kappa and lambda surface immunoglobulins light chains; plasma cells (CD38 and CD138); CALLA (CD10); CD45; CD56: FMC-7, CD103, CD11b, CD13, CD14, CD15, CD16 and CD34.

    The immunophenotypes of lymphomas are widely known and FCM allows appropriate classification of most cases. However, atypical patterns occur and pose significant diagnostic difficulties where aberrant antigen expression patterns must be reconciled with morphology. Additional markers may be required to characterize the abnormal population of cells including markers of immature cells (HLA-DR), B cells (CD22) and myeloid cells (CD14, CD15, CD33, CD64, CD117).

    Acute Leukemia

    The diagnosis and management of acute leukemia depend on the detection, identification and characterization of leukemic cells. The identification of leukemic cells is straightforward in most occasions. However, each acute leukemia subgroup has heterogeneous biologic characteristics, many of which are associated with a different response to therapy.

    As part of a routine diagnostic workup, most suspected acute leukemia cases undergo initial multiparameter immunophenotypic analysis, combined with morphology, cytochemistry, cytogenetics, and molecular biology.

    A standard acute leukemia FCM panel is designed to determine whether leukemic blasts are of myeloid or lymphoid origin, and then to further classify the neoplastic cells (myeloid blasts, B lymphoblasts, abnormal promyelocytes, monoblasts, etc). An acute leukemia panel might include a combination of cell markers from the following categories: stem cell lineage (CD34), immature cell lineage (HLA-DR, CD 10); T cell (CD2, CD3, CD4, CD5, CD7 and CD8); B cell (CD19, CD20); myeloid cell (CD13, CD14, CD15, CD 33, CD 64 and CD17); CD38, CD45, and CD56.

    When the routine panel is insufficient to characterize the leukemic cells, additional antibodies including erythroid markers (CD71 and glycophorin A), megakaryocytic markers (CD41, CD61) or cytoplasmic markers may be indicated.

    Chronic Lymphocytic Leukemia (CLL) & Other Chronic Lymphoproliferative Diseases (CLPD)

    The history, physical exam (lymphadenopathy, splenomegaly and/or hepatomegaly) laboratory findings (lymphocytosis, granulocytopenia, anemia, thrombocytopenia), and lymphocyte morphology are suggestive of CLL. The diagnosis is established by paradoxical co-expression of CD5 on peripheral lymphocytes that express B cell markers (CD19, CD20, CD21 and CD 23) with Kappa or lambda immunoglobulin light chain restriction. Additional markers such as CD38 and ZAP70 may provide important prognostic information.

    FCM can distinguish CLL, the peripheral counterpart of small lymphocytic lymphoma, often diagnosed in lymph node biopsies, from other indolent lymphocytic malignancies including prolymphocytic leukemia, Waldenstrom’s macroglobulinemia, leukemic phase of lymphomas, hairy cell leukemia, T-cell CLL, adult T-cell leukemia, large granulocytic leukemia and cutaneous T-cell lymphoma and natural killer (NK) disorders including KIR expression.


    Plasma Cell Disorders

    Plasma cell disorders are often identified through a combination of clinical, laboratory studies (urine or serum gamma globulins), morphologic, and radiologic findings. FCM immunophenotyping is useful to identify abnormal plasma cells, and the distinction between lymphoid and plasma cell neoplasms, and between reactive plasma cells and neoplastic plasma cells.

    The initial FCM workup for a plasma cell disorder may include the basic lymphoma panel markers with additional markers such as CD28 and CD117.

    Myelodysplastic Syndromes (MDS)

    The gold standard for an MDS diagnosis is assessment of bone marrow smears for dysplastic changes. FCM may assist in MDS determination through the identification of abnormal maturing myeloid cells. An abnormal phenotype by FCM is a minimal diagnostic MDS criteria to establish a definitive diagnosis.

    MDS has a definite risk and rate of progression to acute leukemia. Standard FCM leukemia panels are indicated to evaluate progression and onset of leukemia.

    Chronic Myeloproliferative Disorders (CMPD)

    Although genetic (Philadelphia chromosome and BCR/abl) and molecular studies (Jak 2) are the accepted cornerstone for the identification and classification of CMPDs, FCM may assist in the distinction from reactive hematopoietic proliferations and is important in the enumeration of blasts in the distinction from acute leukemia and an accelerated phase of CMPD.

    CMPD also has a definite risk and rate of progression to acute leukemia. Standard FCM leukemia panels are indicated to evaluate progression and onset of leukemia.

    Mast Cell Neoplasms

    Mast cell neoplasms are uncommon disorders. Mast cells coexpress multiple markers including CD9, CD33, CD45, CD68, CD117, but also lack several myelomonocytic antigens including CD14, CD15, CD16 and most T- and B- cells antigens. Neoplastic mast cells have a similar antigen profile, but also can coexpress CD2 and CD25, which helps in distinguishing malignant mast cells from mastocytosis.

    Paroxysmal hemoglobinuria (PNH)

    PNH is a rare clonal hematopoietic disorder of stem cells. This condition is caused by genetic mutation that results in the absence of over a dozen surface antigens on red and white blood cells. FCM can diagnose PNH by assessing both the red and white blood cells for the absence of these antigens.

    Minimal Residual Disease (MRD)

    FCM analysis for MRD must identify phenotypic features characteristic of the disease of interest. The MRD flow analysis should not rely on an exact match between the phenotype of the residual disease and the original diagnostic specimen because phenotypes can change over time and with treatment. The antibody combinations should be chosen to maximize detection of disease, limit the impact of phenotypic variation, and permit detection of disease following antibody directed therapy.

    HIV Infection

    HIV-1 infection causes significant changes in the number of CD4 and CD8 positive lymphocytes. CD4 count falls roughly 30% while CD8 count increases within 6 months after seroconversion, causing a decrease in the CD4/CD8 ratio

    Following HIV-1 diagnosis, FCM should include enumeration of mature T cells (CD3), helper T cells (CD4) and suppressor T cells (CD8) to ensure all major T cell subsets are accounted for (the sum of helper CD4 and suppressor CD8 T cells is roughly close to the total number of CD3 positive T cells). This ensures that the absolute CD4 is not artificially decreased due to sample degradation or other artifact.

    A WBC count with differential also needs to be performed to calculate the absolute CD4 count (absolute lymphocyte count times CD4%).

    Organ Transplants

    In order to differentiate early rejection, immunosuppressive therapy toxicity or infection, FCM may be indicated to monitor postoperative organ transplants. CD3 is useful to monitor the effectiveness of certain immunosuppressive therapies. When the transplant patient demonstrates symptoms for the above conditions, repeated analysis may be required.

    DNA Analysis

    Carcinoma, Non-hematolymphoid Tumors
    DNA analysis of tumor for ploidy and percent S-phase cells may be necessary for a few selective patients with carcinomas. When the obtained prognostic information will affect treatment decisions in patients with low stage (localized) disease, FCM results are useful.

    Molar Pregnancy

    FCM is useful to evaluate molar and partial molar pregnancies. Using a method to quantify DNA, similar to that used for evaluation of carcinomas, partial moles (triploid), can be distinguished from normal placenta and complete molar (diploid) pregnancies.

    Primary Immunodeficiencies(PIDS)

    PIDs are rare disorders that reflect inherited abnormalities in the development and maturation of cells responsible for immune function. More than 120 inherited immunodeficiency disorders are currently recognized. Affected individuals are prone to repeated infections, allergies, autoimmune disorders, and malignancies. Diagnosis typically occurs at an early age.

    FCM may be indicated for diagnostic purposes and is usually limited to T (CD3, CD4, CD8), B (CD20) and NK cell (CD56) markers. Additional disease specific markers may be indicated.

    Primary Platelet Disorders, Non-neoplastic

    FCM is used for platelet analysis in quantitative and qualitative disorders such as Glanzmann Thrombasthenia (GT) and Bernard-Soulier Disease (B-S). GT is a rare inherited or acquired platelet disorder. Hereditary GT is defined by platelets with decreased expression or absence of the GPIIa/GPIIIb receptor. This receptor is responsible for the initial platelet plug at the site of endothelial injury. Absence if the receptor may result in increased bleeding.

    Acquired GT is likely an autoimmune phenomenon with the presence of GPIIb/GPIIIa blocking antibodies. FCM may be used to determine the functional effect and identity the molecular targets of these antibodies.

    B-S is another rare inherited disorder that prevents the initial binding of platelets at the site of endothelial injury by absence of or presence of abnormal surface GPIa/V/IX receptor. Abnormalities of this receptor prevent attachment of platelets to subendothelial or free von Willebrand’s factor with subsequent tendency to bleed.

    FCM may be used to measure antibodies directed at specific loci of the GPIa/V/IX receptor, which include GPIb (CD42b), GPIX (CD42a), and GPV (CD42d). FCM is also used to assess the size of platelets in the initial evaluation of B-S disease. In B-S disease, platelets are generally larger than normal. FCM can distinguish B-S platelets from fragmented RBCs and debris by antibodies directed to the GPIb/IX/V receptor.

    Red Cell and White Cell Disorders, Non-neoplastic

    FCM is a valuable tool to establish abnormal or defective red blood cell, leukocyte and lymphocyte surface receptors, transmembrane molecules, and intracellular DNA.
    It may be used in acquired and congenital red cell conditions such as in quantifying fetomaternal hemorrhage and hereditary spherocytosis, hereditary elliptocytosis, and hereditary persistence of fetal hemoglobin in the context of compound hemoglobinopathy syndromes.

    FCM is a sensitive and specific method to identify leukocyte receptor abnormalities for the diagnosis of chronic granulomatous disease and CD11b deficiency.
    It is an efficient method to identify lymphocytes HLA B27 associated with uveitis, ankylosing spondylitis, Reiter’s syndrome and sacroiliitis.

    Limitations:

    Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated.

    The flow report must document the specific indication for each marker over the 24 marker limit.

    The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied.


    Bill Type Codes:

    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    012xHospital Inpatient (Medicare Part B only)
    013xHospital Outpatient
    014xHospital - Laboratory Services Provided to Non-patients
    018xHospital - Swing Beds
    021xSkilled Nursing - Inpatient (Including Medicare Part A)
    022xSkilled Nursing - Inpatient (Medicare Part B only)
    023xSkilled Nursing - Outpatient
    071xClinic - Rural Health
    077xClinic - Federally Qualified Health Center (FQHC)
    085xCritical Access Hospital

    Revenue Codes:

    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

    0300Laboratory - General Classification
    0302Laboratory - Immunology
    0309Laboratory - Other Laboratory



    Group 2 Paragraph: Quantitative Codes in immunology section:


    Group 2 Codes:

    86355B cells total count
    86356Mononuclear cell antigen
    86357Nk cells total count
    86359T cells total count
    86360T cell absolute count/ratio
    86361T cell absolute count
    86367Stem cells total count



    ICD-10 Codes that Support Medical Necessity


    ICD-10 CODEDESCRIPTION

    A18.01Tuberculosis of spine
    B20Human immunodeficiency virus [HIV] disease
    B97.33Human T-cell lymphotrophic virus, type I [HTLV-I] as the cause of diseases classified elsewhere
    B97.34Human T-cell lymphotrophic virus, type II [HTLV-II] as the cause of diseases classified elsewhere
    B97.35Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere
    C15.3Malignant neoplasm of upper third of esophagus
    C15.4Malignant neoplasm of middle third of esophagus
    C15.5Malignant neoplasm of lower third of esophagus
    C15.8Malignant neoplasm of overlapping sites of esophagus
    C16.0Malignant neoplasm of cardia
    C16.1Malignant neoplasm of fundus of stomach
    C16.2Malignant neoplasm of body of stomach
    C16.3Malignant neoplasm of pyloric antrum
    C16.4Malignant neoplasm of pylorus
    C16.8Malignant neoplasm of overlapping sites of stomach
    C17.0Malignant neoplasm of duodenum
    C17.1Malignant neoplasm of jejunum
    C17.2Malignant neoplasm of ileum
    C17.8Malignant neoplasm of overlapping sites of small intestine
    C18.0Malignant neoplasm of cecum
    C18.1Malignant neoplasm of appendix
    C18.2Malignant neoplasm of ascending colon
    C18.3Malignant neoplasm of hepatic flexure
    C18.4Malignant neoplasm of transverse colon
    C18.5Malignant neoplasm of splenic flexure
    C18.6Malignant neoplasm of descending colon
    C18.7Malignant neoplasm of sigmoid colon
    C18.8Malignant neoplasm of overlapping sites of colon
    C19Malignant neoplasm of rectosigmoid junction
    C20Malignant neoplasm of rectum
    C21.1Malignant neoplasm of anal canal
    C21.2Malignant neoplasm of cloacogenic zone
    C21.8Malignant neoplasm of overlapping sites of rectum, anus and anal canal
    C22.0Liver cell carcinoma
    C22.2Hepatoblastoma
    C22.3Angiosarcoma of liver
    C22.4Other sarcomas of liver
    C22.7Other specified carcinomas of liver
    C22.9Malignant neoplasm of liver, not specified as primary or secondary
    C23Malignant neoplasm of gallbladder
    C24.0Malignant neoplasm of extrahepatic bile duct
    C24.1Malignant neoplasm of ampulla of Vater
    C25.0Malignant neoplasm of head of pancreas
    C25.1Malignant neoplasm of body of pancreas
    C25.2Malignant neoplasm of tail of pancreas
    C25.7Malignant neoplasm of other parts of pancreas
    C25.8Malignant neoplasm of overlapping sites of pancreas
    C26.1Malignant neoplasm of spleen
    C26.9Malignant neoplasm of ill-defined sites within the digestive system
    C30.0Malignant neoplasm of nasal cavity
    C30.1Malignant neoplasm of middle ear
    C31.0Malignant neoplasm of maxillary sinus
    C31.1Malignant neoplasm of ethmoidal sinus
    C31.2Malignant neoplasm of frontal sinus
    C31.3Malignant neoplasm of sphenoid sinus
    C31.8Malignant neoplasm of overlapping sites of accessory sinuses
    C32.0Malignant neoplasm of glottis
    C32.1Malignant neoplasm of supraglottis
    C32.2Malignant neoplasm of subglottis
    C32.3Malignant neoplasm of laryngeal cartilage
    C32.8Malignant neoplasm of overlapping sites of larynx
    C33Malignant neoplasm of trachea
    C34.01Malignant neoplasm of right main bronchus
    C34.02Malignant neoplasm of left main bronchus
    C34.11Malignant neoplasm of upper lobe, right bronchus or lung
    C34.12Malignant neoplasm of upper lobe, left bronchus or lung
    C34.2Malignant neoplasm of middle lobe, bronchus or lung
    C34.31Malignant neoplasm of lower lobe, right bronchus or lung
    C34.32Malignant neoplasm of lower lobe, left bronchus or lung
    C34.81Malignant neoplasm of overlapping sites of right bronchus and lung
    C34.82Malignant neoplasm of overlapping sites of left bronchus and lung
    C37Malignant neoplasm of thymus
    C38.1Malignant neoplasm of anterior mediastinum
    C38.2Malignant neoplasm of posterior mediastinum
    C38.4Malignant neoplasm of pleura
    C38.8Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
    C40.01Malignant neoplasm of scapula and long bones of right upper limb
    C40.02Malignant neoplasm of scapula and long bones of left upper limb
    C40.11Malignant neoplasm of short bones of right upper limb
    C40.12Malignant neoplasm of short bones of left upper limb
    C40.21Malignant neoplasm of long bones of right lower limb
    C40.22Malignant neoplasm of long bones of left lower limb
    C40.31Malignant neoplasm of short bones of right lower limb
    C40.32Malignant neoplasm of short bones of left lower limb
    C40.81Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
    C40.82Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
    C41.0Malignant neoplasm of bones of skull and face
    C41.2Malignant neoplasm of vertebral column
    C41.3Malignant neoplasm of ribs, sternum and clavicle
    C41.4Malignant neoplasm of pelvic bones, sacrum and coccyx
    C44.01Basal cell carcinoma of skin of lip
    C44.02Squamous cell carcinoma of skin of lip
    C44.09Other specified malignant neoplasm of skin of lip
    C44.112Basal cell carcinoma of skin of right eyelid, including canthus
    C44.119Basal cell carcinoma of skin of left eyelid, including canthus
    C44.122Squamous cell carcinoma of skin of right eyelid, including canthus
    C44.129Squamous cell carcinoma of skin of left eyelid, including canthus
    C44.192Other specified malignant neoplasm of skin of right eyelid, including canthus
    C44.199Other specified malignant neoplasm of skin of left eyelid, including canthus
    C44.212Basal cell carcinoma of skin of right ear and external auricular canal



    0 0

    Procedure codes and Description

    J1459INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

    J1556INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG

    J1557INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON-
    LYOPHILIZED (E.G., LIQUID), 500 MG

    J1561INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E.G., LIQUID), 500 MG

    J1566INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., POWDER), NOT OTHERWISE SPECIFIED, 500 MG

    J1568INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

    J1569INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E.G., LIQUID), 500 MG

    J1572INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

    J1599INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG



    Coverage Indications, Limitations, and/or Medical Necessity

    Note: Providers should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor's discretionary coverage related to this drug.

    IVIg is a solution of human immunoglobulins specifically prepared for intravenous infusion. Immunoglobulin contains a broad range of antibodies that specifically act against bacterial and viral antigens.

    There may be acceptable off-label uses for IVIg in rare patient populations or in rare individual patient clinical scenarios which are not covered by this LCD. In such instances, a request for an individual patient consideration by the Medical Director should accompany the appeal of any denied claim.

    There are several off-label uses for IVIg, especially in neurological disorders. There is good scientific evidence that supports use in a few of the disorders; in others, however, the evidence is either poor or absent. This policy addresses the off-label uses of IVIg in certain neurological conditions, and idiopathic thrombocytopenic purpura (ITP) in pregnancy. It also clarifies the conditions under which certain FDA-approved uses may be covered. This policy does not address the use of IVIg in any condition covered by a National Coverage Determination (NCD) or CMS manual instruction. (See attached article)

    Idiopathic Thrombocytopenic Purpura (ITP) in Pregnancy:

    Pregnant women with this disease are at risk for delivering thrombocytopenic infants. Protection of the fetus becomes an important consideration in management of a pregnant woman with immune thrombocytopenic purpura. IVIg may be recommended in the following:

    1. Pregnant women who have previously delivered infants with autoimmune thrombocytopenia;
    2. Pregnant women who have platelet counts less than 75,000/mm3 during the current pregnancy; or
    3. Pregnant women with past history of splenectomy


    In the presence of one of the above indications, the use of IVIg may be covered if one of the following situations is present:

    Failure of or contraindications to other therapy; and/or

    Rapidly progressive form of the disease;

    All the conditions listed below (see Neurological Disorders) for Medicare coverage are met.

    Neurological Disorders:
    The use of IVIg in some neurological conditions has been associated with demonstrable clinical benefit. Studies with acceptable methodological bases have shown that IVIg may halt and/or reverse disease progression in Myasthenia Gravis, Guillain-Barre Syndrome and Chronic Inflammatory Demyelinating Neuropathy (CIDP). In a few neurological conditions, such as Polymyositis, Multiple Myeloma, Multifocal Motor Neuropathy (MMN), Dermatomyositis and Lambert-Eaton myasthenic syndrome, IVIg may be of benefit.

    Medicare may provide coverage for the use of IVIg use in the above disease conditions if the following requirements are met.

    For Guillain-Barre, Myasthenia Gravis, Acute or Chronic Inflammatory Demyelinating Neuropathy (see CIDP below for additional criteria), Dermatomyositis, and Relapsing-Remitting Multiple Sclerosis (MS), the use of IVIg may be covered if one of the following scenarios is present:

    Failure of or contraindications to other therapy (absolute requirement for Dermatomyositis and MS); and/or

    Rapidly progressive form of the disease.


    The diagnosis of the disorder must be reasonably certain, based on a thorough history and examination as well as, when necessary, electromyography (EMG), spinal fluid tests, serum tests and biopsy findings.

    The clinical record must document the medical necessity to initiate IVIg therapy, and the ongoing need as long as treatment continues. The reasons for prescribing IVIg must be clear and include all required information. For example, previous treatment failures must be recorded.

    Once treatment is initiated, documentation of progress must be meticulous. If there is initial improvement and continued treatment is necessary, then some type of quantitative assessment to monitor and document the progress is required. Quantitative monitoring may include any accepted metric assessment such as MRC scale and activities of daily living (ADL) measurements. Changes in these measures must be clearly documented. Subjective or experiential improvement alone is insufficient to either continue IVIg or to expect coverage.

    Clinical monitoring takes precedence over laboratory monitoring. If significant clinical improvement is evident, then laboratory monitoring, solely to guide IVIg therapy, is not medically necessary.

    When improvement has occurred, attempts to decrease/wean the dosage must be made and documented. Following dosage reduction, if improvement is sustained, an attempt to discontinue IVIg must be made. If documentable improvement does not occur with IVIg administration, then infusions should not continue.

    Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) and its variants (multifocal motor neuropathy, multifocal acquired demyelinating polyneuropathy, multifocal motor neuropathy, pure sensory CIDP).

    CIDP is an autoimmune disorder caused by an attack on peripheral nervous system myelin. Clinically CIDP follows a subacute onset of weakness and/or sensory loss, evolving progressively, or in a stepwise fashion, over several months. Reflexes are usually decreased or absent. Electrodiagnostic testing (EDX) reveals the classic features of demyelination, with prolonged distal latencies, conduction slowing, prolonged F-waves, conduction block, and temporal dispersion in most cases. Most patients have an elevated spinal fluid protein level. (Jonathan S. Katz, MD, Dept. of Neurology, Stanford University)

    Chronic progressive painful peripheral sensory neuropathy, which is common with diabetes mellitus or toxins, may eventually show demyelinating features on electrodiagnostic testing. Typically, these cases have progressed for more than one year prior to electrodiagnostic testing. Many patients with CIDP are not seen until several years into their illness.

    In patients with sensory or sensorimotor polyneuropathies, when a CIDP diagnosis is uncertain, a response to a therapeutic trial of prednisone (e.g. 30-60 mg/d or perhaps 50-100 mg/d for 2-4 months with a taper) should be helpful to increase the specificity of the diagnosis in order to help assure that IVIg will be effective. In the absence of other supporting information, a subjective response to a therapeutic trial of IVIg is not sufficient to validate the diagnosis of CIDP. The principal goal of the treatment is to improve motor function in most patients.

    If a diagnosis of multifocal motor neuropathy is suspected, a trial of IVIg is recommended since this condition does not respond to prednisone.

    Specific diagnostic criteria for CIDP should include:

    In typical CIDP, symmetrical muscle weakness affects proximal and distal muscles of all four limbs. Sensory loss may affect the distal limbs and usually involves large fiber modalities. The clinical evolution tends to be gradually progressive, evolving over periods of more than 8 weeks although patients typically present to clinicians within 6 months of onset. Decreased or absent reflexes in affected nerve distributions occur in nearly all CIDP presentations, and develop during the acute phase typically within 8 weeks of symptom onset. The patient should have a neurologic function assessment score of at least 3 or greater on the Rankin Scale at the time of initial therapy. However, IVIg can be used in patients with rapidly worsening weakness regardless of the Rankin score.

    A multifocal variant of CIDP (multifocal acquired demyelinating sensory and motor neuropathy or MADSAM) leads to sensory and motor dysfunction in multiple individual nerve distributions (for example, ulnar or median). Weakness may affect the upper or lower limbs, but it most commonly affects distal musculature and is more common in the hands. Progression tends to be step-wise with episodes of weakness compiling over time to cause gradually increasing debility.

    Multifocal motor neuropathy (MMN) is a purely motor syndrome that tends to affect the hands. Like MADSAM, the weakness affects the distribution of individual nerves and tends to progress in a step-wise fashion over time. Patients may have subjective sensory complaints but objective sensory findings are not present. The diagnosis is generally made using motor and sensory nerve conduction studies. MMN responds to IVIg but not to Prednisone. Therefore, Prednisone is never indicated in this condition.

    Occasionally, a patient with CIDP may have only sensory symptoms. The sensory loss may affect the upper or lower limbs and tends to be relatively symmetrical. Like more common sensory-motor CIDP presentations, patients typically seek medical attention within 6-9 months from onset. The sensory loss may begin relatively acutely and progresses in a stepwise or gradual fashion. The sensory distribution is usually not simply limited to the feet or in a stocking distribution, but takes on unusual patterns involving the trunk, arms, or proximal legs. The condition is rare compared with the relatively common purely sensory neuropathies such as distal diabetic, toxic, alcoholic, and idiopathic neuropathies. Pure sensory CIDP also must be distinguished from distal demyelinating neuropathies associated with an IgM paraprotein, which is not responsive to IVIg or prednisone.

    Laboratory evidence of CIDP includes:


    oConduction block at sites not prone to nerve compression.

    oMotor nerves characteristically show segmental conduction slowing and increased distal latencies consistent with a demyelinating polyneuropathy. This is present in typical CIDP, MADSAM, MMN, and purely sensory CIDP.

    oConduction slowing from a demyelinating neuropathy should be distinguished from conduction slowing secondary to moderate to severe axonal loss.

    oCytoalbuminologic dissociation in more than 90% of cases.

    Serum tests may show:

    oAn IgG monoclonal gammopathy (e.g. on immunofixation electrophoresis); however, an IgM monoclonal gammopathy places the diagnosis in question.

    oAn elevation of a specific antibody to GM-1 increases the likelihood of MMN. Antibodies to myelin associated glycoprotein (MAG) or sulfatide may occur in patients with demyelinating neuropathies besides CIDP and place the diagnosis in question.

    No other explanation for the diagnosis, such as

    oHIV disease;

    oDistally predominant diabetic neuropathy;

    oDiabetic amyotrophy;

    oDiabetic cachectic neuropathy;

    oDistal acquired demyelinating symmetric neuropathy with an IgM paraprotein; or

    No evidence of another treatable cause of the polyneuropathy;

    No evidence of hereditary demyelinating neuropathy.

    Special consultation recommendations for IVIg use for CIDP, CIDP variants, and MMN:

    Before beginning the initial treatment (i.e. the induction dose) for CIDP, or, for patients currently on treatment for CIDP within 3 months of the effective date of this policy, a consultation is expected from a neurologist or rheumatologist who is an expert in the field of CIDP. This will help validate the diagnosis is correct and the IVIg treatment is reasonable and necessary. The consultation should include a comprehensive history and examination as defined in the CPT book, validate the diagnosis of CIDP, and clarify the need for IVIg treatment. The consultation should set forth the recommended treatment regimen, appropriate measures of therapeutic benefit, and any recommendation for follow-up consultation.

    If the indication for IVIg treatment is principally for pain control in a patient with presumed CIDP predominantly affecting the sensory nerves, before beginning the initial treatment (i.e. the induction dose), the patient should have shown a measurable response to a therapeutic trial of prednisone. In addition, the consultation from a neurologist or rheumatologist who is an expert in the field of CIDP is expected. This consultation should help validate the need for IVIg treatment for pain control as opposed to other pain treatment options that do not include IVIg.

    IVIg for CIDP following the initial treatment regimen:

    Once treatment is initiated, the benefit of treatment must be measured. Quantitative monitoring may use any accepted metric as MRC scale and activities of daily living (ADL) measurements.

    Subsequent treatment with IVIg will be covered only when the patient demonstrates significant improvement in clinical condition and, when relevant, a reduction in the level of sensory loss. For long-term treatment of stable patients, the dose must be periodically reduced or withdrawn, and the effects measured, in order to validate continued use.

    There is no reimbursement for the use of IVIg in the treatment of the following neurological disorders: epilepsy, Amyotrophic Lateral Sclerosis (ALS), paraneoplastic neurological syndromes, undiagnosed neuropathy or weakness and malignancies with no casual link to coexisting neurological dysfunctions.

    The use of IVIg should be reserved for patients with serious defects of antibody function. The goal is to provide immune globulin to those who lack it. The following are certain FDA approved indications for IVIg, which are covered by Noridian.

    Acute ITP:

    Management of acute bleeding due to severe thrombocytopenia (platelet counts less than 30,000/mm3);

    To increase platelet counts prior to invasive major surgical procedures (splenectomy); or

    In patients with severe thrombocytopenia (platelet counts less than 20,000/mm3) considered to be at risk for intracerebral hemorrhage.


    Chronic Refractory ITP:

    First line treatment

    oPediatric ITP;
    oIn combination with steroids if rapid platelet response justified or to avoid splenectomy; or
    oContraindications to steroids

    Second line treatment

    oFollowing treatment with corticosteroids with splenectomy; or
    oPlatelet counts persistently at or below 20,000/mm 3.

    Symptomatic Human Immunodeficiency Virus (HIV):

    Indications for intravenous immunoglobulin would include:

    1. Patients less than 13 years of age;
    2. Entry CD4+ lymphocyte counts greater than or equal to 200/mm3; and
    3. Clinically symptomatic or asymptomatic, but immunologically abnormal

    Other Disorders:

    a. Chronic Lymphocytic Leukemia with associated hypogammaglobulinemia. To initiate IVIg for this disease, the IgG level should be less than 600 mg/dl or there should be evidence of specific antibody deficiency and the presence of repeated bacterial infections.
    b. Bone Marrow/Stem Cell Transplantation

    oTransplantation must have been for a Medicare covered indication;

    oPatients 20 years of age or older;

    oCytomegalovirus (CMV) seropositive before transplantation; or

    oCytomegalovirus (CMV) seronegative, had seropositive marrow donors, and were undergoing allogenic transplantation for hematologic neoplasms.

    c. Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)
    d. Transplantation rejection, kidney or stem cell, antibody-mediated.
    e. Autoimmune retinopathy (limited to three months unless there is improvement on therapy).

    Immunoglobulin Deficiencies:
    Individuals with agammaglobulinemia or hypogammaglobulin need lifelong antibody replacement, however, Ig replacement is unlikely to be necessary until the IgG levels fall below 200 mg/dl.


    Bill Type Codes:
    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    012xHospital Inpatient (Medicare Part B only)
    013xHospital Outpatient
    022xSkilled Nursing - Inpatient (Medicare Part B only)
    023xSkilled Nursing - Outpatient
    085xCritical Access Hospital

    Revenue Codes:
    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
    The Section titled “Does the 'CPT 30% Rule' Apply?” needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual.
    0636Pharmacy - Drugs Requiring Detailed Coding





    ICD-10 Codes that Support Medical Necessity


    Group 1Codes

    ICD-10 CODEDESCRIPTION
    B20*Human immunodeficiency virus [HIV] disease
    B25.0Cytomegaloviral pneumonitis
    B25.1Cytomegaloviral hepatitis
    B25.2Cytomegaloviral pancreatitis
    B25.8Other cytomegaloviral diseases
    C90.00Multiple myeloma not having achieved remission
    C90.02Multiple myeloma in relapse
    C91.10Chronic lymphocytic leukemia of B-cell type not having achieved remission
    C91.11Chronic lymphocytic leukemia of B-cell type in remission
    C91.12Chronic lymphocytic leukemia of B-cell type in relapse
    D59.0Drug-induced autoimmune hemolytic anemia
    D59.1Other autoimmune hemolytic anemias
    D61.01*Constitutional (pure) red blood cell aplasia
    D69.3Immune thrombocytopenic purpura
    D69.42Congenital and hereditary thrombocytopenia purpura
    D69.49Other primary thrombocytopenia
    D80.0Hereditary hypogammaglobulinemia
    D80.1Nonfamilial hypogammaglobulinemia
    D80.5Immunodeficiency with increased immunoglobulin M [IgM]
    D81.0Severe combined immunodeficiency [SCID] with reticular dysgenesis
    D81.1Severe combined immunodeficiency [SCID] with low T- and B-cell numbers
    D81.2Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
    D81.6Major histocompatibility complex class I deficiency
    D81.7Major histocompatibility complex class II deficiency
    D81.89Other combined immunodeficiencies
    D81.9Combined immunodeficiency, unspecified
    D82.0Wiskott-Aldrich syndrome
    D83.0Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
    D83.2Common variable immunodeficiency with autoantibodies to B- or T-cells
    D83.8Other common variable immunodeficiencies
    D83.9Common variable immunodeficiency, unspecified
    G25.82Stiff-man syndrome
    G35Multiple sclerosis
    G60.3Idiopathic progressive neuropathy
    G61.0Guillain-Barre syndrome
    G61.81*Chronic inflammatory demyelinating polyneuritis
    G61.82Multifocal motor neuropathy
    G65.0Sequelae of Guillain-Barre syndrome
    G70.00Myasthenia gravis without (acute) exacerbation
    G70.01Myasthenia gravis with (acute) exacerbation
    G70.81Lambert-Eaton syndrome in disease classified elsewhere
    G73.1Lambert-Eaton syndrome in neoplastic disease
    G73.3Myasthenic syndromes in other diseases classified elsewhere
    M30.3Mucocutaneous lymph node syndrome [Kawasaki]
    M31.1Thrombotic microangiopathy
    M33.00Juvenile dermatopolymyositis, organ involvement unspecified
    M33.01Juvenile dermatopolymyositis with respiratory involvement
    M33.02Juvenile dermatopolymyositis with myopathy
    M33.09Juvenile dermatopolymyositis with other organ involvement
    M33.10Other dermatopolymyositis, organ involvement unspecified
    M33.11Other dermatopolymyositis with respiratory involvement
    M33.12Other dermatopolymyositis with myopathy
    M33.19Other dermatopolymyositis with other organ involvement
    M33.20Polymyositis, organ involvement unspecified
    M33.21Polymyositis with respiratory involvement
    M33.22Polymyositis with myopathy
    M33.29Polymyositis with other organ involvement
    M33.90Dermatopolymyositis, unspecified, organ involvement unspecified
    M33.91Dermatopolymyositis, unspecified with respiratory involvement
    M33.92Dermatopolymyositis, unspecified with myopathy
    M33.99Dermatopolymyositis, unspecified with other organ involvement
    M34.83Systemic sclerosis with polyneuropathy
    M36.0Dermato(poly)myositis in neoplastic disease
    T86.01Bone marrow transplant rejection
    T86.02Bone marrow transplant failure
    T86.09Other complications of bone marrow transplant
    T86.11Kidney transplant rejection
    T86.12Kidney transplant failure
    T86.19Other complication of kidney transplant
    T86.5Complications of stem cell transplant
    Z48.22Encounter for aftercare following kidney transplant
    Z94.0Kidney transplant status
    Z94.81Bone marrow transplant status
    Z94.84Stem cells transplant status
    Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *B20 is only payable for children under 13 years of age.
    *D61.01 is only to be used when patient has failed all first line therapies.
    *G61.81 is not payable when associated with diabetes mellitus, dysproteinemias, renal failure, or malnutrition.
    Showing 1 to 74 of 74 entries in Group 1
    FirstPrevCurrently Selected1NextLast


    ICD-10 Codes that DO NOT Support Medical Necessity

    Group 1 Paragraph: Any diagnosis codes other than those listed in the covered ICD-10-CM codes of this policy and those in the attached article will be denied as not reasonable and necessary and will be denied provider liable unless a non-coverage notice has been issued to the beneficiary prior to the test. Screening diagnoses will be denied as routine services.

    Group 1 Codes: N/A




    Additional ICD-10 Information
    N/A

    0 0

    Procedure Codes and Description

    Group 1 Paragraph: Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural (CPT) codes.

    Group 1 Codes:
    82306VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED
    82652VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED

    Coverage Indications, Limitations, and/or Medical Necessity

    Vitamin D is called a "vitamin" because of its exogenous source, predominately from oily fish in the form of vitamin D 2 and vitamin D 3. It is more accurate to consider fat-soluble Vitamin D as a steroid hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. Clinical disorders related to vitamin D may arise because of altered availability of the parent vitamin D, altered conversion of vitamin D to its predominant metabolites, altered organ responsiveness to dihydroxylated metabolites and disturbances in the interactions of the vitamin D metabolites with PTH and calcitonin. Normal levels of Vitamin D range from 20 – 50 ng/dl. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for the lab assay.

    Indications:

    Measurement of 25-OH Vitamin D, CPT 82306, level is indicated for patients with:

    chronic kidney disease stage III or greater

    cirrhosis

    hypocalcemia

    hypercalcemia

    hypercalciuria

    hypervitaminosis D

    parathyroid disorders

    malabsorption states

    obstructive jaundice

    osteomalacia

    osteoporosis if
    i. T score on DEXA scan ii. History of fragility fractures or
    iii. FRAX > 3% 10-year probability of hip fracture or 20% 10-year probability of other major osteoporotic fracture or
    iv. FRAX > 3% (any fracture) with T-score v. Initiating bisphosphanate therapy (Vit D level should be determined and managed as necessary before bisphosphonate is initiated)

    osteosclerosis/petrosis

    rickets

    vitamin D deficiency on replacement therapy related to a condition listed above; to monitor the efficacy of treatment.

    Measurement of 1, 25-OH Vitamin D, CPT 82652, level is indicated for patients with:

    unexplained hypercalcemia (suspected granulomatous disease or lymphoma)

    unexplained hypercalciuria (suspected granulomatous disease or lymphoma)

    suspected genetic childhood rickets

    suspected tumor-induced osteomalacia

    nephrolithiasis or hypercalciuria

    Limitations:

    Testing may not be used for routine or other screening.

    Both assays of vitamin D need not be performed for each of the above conditions. Often, one type is more appropriate for a certain disease state than another. The most common type of vitamin D deficiency is 25-OH vitamin D. A much smaller percentage of 1,25 dihydroxy vitamin D deficiency exists; mostly, in those with renal disease. Documentation must justify the test(s) chosen for a particular disease entity. Various component sources of 25-OH vitamin D, such as stored D or diet-derived D, should not be billed separately.

    Once a beneficiary has been shown to be vitamin D deficient, further testing may be medically necessary only to ensure adequate replacement has been accomplished. If Vitamin D level is between 20 and 50 ng/dl and patient is clinically stable, repeat testing is often unnecessary; if performed, documentation most clearly indicate the necessity of the test. If level 60 ng/dl, a subsequent level(s) may be reimbursed until the level is within the normal range.20>


    Bill Type Codes:

    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    012xHospital Inpatient (Medicare Part B only)
    013xHospital Outpatient
    014xHospital - Laboratory Services Provided to Non-patients
    018xHospital - Swing Beds
    022xSkilled Nursing - Inpatient (Medicare Part B only)
    023xSkilled Nursing - Outpatient
    085xCritical Access Hospital

    Revenue Codes:

    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

    0300Laboratory - General Classification
    0301Laboratory - Chemistry
    0309Laboratory - Other Laboratory





    ICD-10 Codes that Support Medical Necessity


    ICD-10 CODEDESCRIPTION

    E20.0Idiopathic hypoparathyroidism
    E20.8Other hypoparathyroidism
    E20.9Hypoparathyroidism, unspecified
    E21.0Primary hyperparathyroidism
    E21.1Secondary hyperparathyroidism, not elsewhere classified
    E21.2Other hyperparathyroidism
    E21.3Hyperparathyroidism, unspecified
    E41Nutritional marasmus
    E43Unspecified severe protein-calorie malnutrition
    E55.0Rickets, active
    E55.9*Vitamin D deficiency, unspecified
    E67.3Hypervitaminosis D
    E83.30Disorder of phosphorus metabolism, unspecified
    E83.31Familial hypophosphatemia
    E83.32Hereditary vitamin D-dependent rickets (type 1) (type 2)
    E83.39Other disorders of phosphorus metabolism
    E83.50*Unspecified disorder of calcium metabolism
    E83.51Hypocalcemia
    E83.52Hypercalcemia
    E89.2Postprocedural hypoparathyroidism
    E89.820Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure
    E89.821Postprocedural hematoma of an endocrine system organ or structure following other procedure
    E89.822Postprocedural seroma of an endocrine system organ or structure following an endocrine system procedure
    E89.823Postprocedural seroma of an endocrine system organ or structure following other procedure
    K74.1Hepatic sclerosis
    K74.2Hepatic fibrosis with hepatic sclerosis
    K76.9Liver disease, unspecified
    K90.0Celiac disease
    K90.1Tropical sprue
    K90.2Blind loop syndrome, not elsewhere classified
    K90.3Pancreatic steatorrhea
    K90.41Non-celiac gluten sensitivity
    K90.49Malabsorption due to intolerance, not elsewhere classified
    K90.89Other intestinal malabsorption
    K90.9Intestinal malabsorption, unspecified
    K91.2Postsurgical malabsorption, not elsewhere classified
    M81.0Age-related osteoporosis without current pathological fracture
    M81.8Other osteoporosis without current pathological fracture
    M83.0Puerperal osteomalacia
    M83.1Senile osteomalacia
    M83.2Adult osteomalacia due to malabsorption
    M83.3Adult osteomalacia due to malnutrition
    M83.4Aluminum bone disease
    M83.5Other drug-induced osteomalacia in adults
    M83.8Other adult osteomalacia
    M83.9Adult osteomalacia, unspecified
    M85.80Other specified disorders of bone density and structure, unspecified site
    M85.88Other specified disorders of bone density and structure, other site
    N18.3Chronic kidney disease, stage 3 (moderate)
    N18.4Chronic kidney disease, stage 4 (severe)
    N18.5Chronic kidney disease, stage 5
    N18.6End stage renal disease
    N25.81Secondary hyperparathyroidism of renal origin
    Q78.2Osteopetrosis
    Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: E55.9* If more than one LCD-listed condition contributes to Vit. D deficiency in a given patient and/or is improved by Vit. D administration, coders should use: ICD-10 E55.9 UNSPECIFIED VITAMIN D DEFICIENCY.This code should not be used for any other indication.

    E83.50* Use only for HYPERCALCIURIA
    t

    Group 2 Paragraph: The following ICD-10-CM codes support the medical necessity of CPT code 82652

    Group 2 Codes:
    Show entries for Group 2 ICD-10 Codes that Support Medical Necessity:
    Search Group 2 ICD-10 Codes that Support Medical Necessity textbox:
    Search By:Group 2 ICD-10 Codes that Support Medical Necessity radio button CodeGroup 2 ICD-10 Codes that Support Medical Necessity radio button DescriptionSearch Group 2 ICD-10 Codes that Support Medical Necessity Submit buttonSEARCH GROUPSearch Group 2 ICD-10 Codes that Support Medical Necessity Clear buttonCLEAR SEARCH
    Group 2Codes

    ICD-10 CODEDESCRIPTION
    E55.0Rickets, active
    E55.9Vitamin D deficiency, unspecified
    E83.50*Unspecified disorder of calcium metabolism
    E83.52*Hypercalcemia
    M83.0Puerperal osteomalacia
    M83.1Senile osteomalacia
    M83.2Adult osteomalacia due to malabsorption
    M83.3Adult osteomalacia due to malnutrition
    M83.4Aluminum bone disease
    M83.5Other drug-induced osteomalacia in adults
    M83.8Other adult osteomalacia
    M83.9Adult osteomalacia, unspecified
    N20.0Calculus of kidney
    N20.1Calculus of ureter
    N20.2Calculus of kidney with calculus of ureter
    N20.9Urinary calculus, unspecified
    N22Calculus of urinary tract in diseases classified elsewhere
    Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation: M83.9* Use only for tumor-induced osteomalacia
    E83.50* Use only for unexplained hypercalciuria
    E83.52* Use only for unexplained hypercalcemia
    Showing 1 to 17 of 17 entries in Group 2
    FirstPrevCurrently Selected1NextLast


    Additional ICD-10 Information
    N/A-1>-2>

    0 0

    CPT/HCPCS Codes

    Group 1 Paragraph: N/A

    Group 1 Codes:

    G0398HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND OXYGEN SATURATION

    G0399HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION

    G0400HOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3 CHANNELS

    Group 2 Paragraph: CPT/HCPCS Codes Not Covered:


    Group 2 Codes:

    95803ACTIGRAPHY TESTING, RECORDING, ANALYSIS, INTERPRETATION, AND REPORT (MINIMUM OF 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING)

    95811POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BILEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST



    Coverage Indications, Limitations, and/or Medical Necessity

    Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Such clinics are for diagnosis, therapy, and research. Sleep disorder clinics may provide some diagnostic or therapeutic services which are covered under Medicare. These clinics may be affiliated either with a hospital or a freestanding facility. Whether a clinic is hospital-affiliated or freestanding, coverage for diagnostic services under some circumstances is covered under provisions of the law different from those for coverage of therapeutic services. (CMS publication 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 70)

    The physician services related to home sleep testing are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patient’s condition, meets all other Medicare requirements, and the physician who performs the service has sufficient training and experience to reliably perform the service.

    A home sleep test is covered only when it is performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.

    Home sleep testing is not covered for persons with comorbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure).

    Home Sleep studies are only covered for the diagnosis of Obstructive Sleep Apnea. They are not covered for any other sleep disorders (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy) or for screening asymptomatic persons.


    A. Medical Conditions for Which Testing is Covered

    Sleep Apnea- Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. This is a potentially lethal condition where the patient stops breathing during sleep. Three types of sleep apnea have been described (central, obstructive, and mixed). The nature of the apnea episodes can be documented by appropriate diagnostic testing.(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).

    Obstructive Sleep Apnea (OSA) is the collapse of the oropharyngeal walls and the obstruction of airflow occurring during sleep.

    CMS PUB 100-03 NCD; 240.4.1 – Sleep Testing for Obstructive Sleep Apnea (OSA) finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA:

    B. Covered Home Sleep Testing Devices

    1. Type II sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA.
    Type II monitors have a minimum of 7 channels (e.g., EEG, EOG, EMG, ECG-heart rate, airflow, breathing/respiratory effort, SaO2)-this type of device monitors sleep staging, so AHI can be calculated).

    2. Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA.
    Type III monitors have a minimum of 4 monitored channels including ventilation or airflow (at least two channels of respiratory movement or respiratory movement and airflow), heart rate or ECG, and oxygen saturation.

    3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA.

    Type IV devices may measure one, two, three or more parameters but do not meet all the criteria of a higher category device.

    Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab
    facility or attended in a sleep lab facility.


    C. Physician and Technician Requirements for Home Sleep Testing:

    The physician performing the service must meet one of the following:
    be a diplomate of the American Board of Sleep Medicine (ABSM) and
    Board Certified Pulmonologist, or a Board Certified Neurologist or

    has a Sleep Certification issued by one of the following Boards:
    American Board of Internal Medicine (ABIM),
    American Board of Family Medicine (ABFM),
    American Board of Pediatrics (ABP),
    American Board of Psychiatry and Neurology (ABPN),
    American Board of Otolaryngology (ABOto),
    American Osteopathic Board of Neurology and Psychiatry (AOBNP),
    American Osteopathic Board of Family Medicine, (AOBFP)
    American Osteopathic Board of Internal Medicine, (AOBIM)
    American Osteopathic Board of Ophthalmology and Otorhinolaryngology (AOBOO), or

    be an active staff member of an accredited sleep center or laboratory. The sleep facility accreditation must be from the American Academy of Sleep Medicine (AASM), inpatient or outpatient, or the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation for Ambulatory care sleep centers.


    Technician Credentials

    The technician performing the service must meet one of the following:

    American Board of Sleep Medicine (ABSM)
    Registered Sleep Technologist (RST)

    Board of Registered Polysomnographic Technologists (BRPT):
    Registered Polysomnographic Technologist (RPSGT)

    National Board for Respiratory Care (NBRC):
    Certified Pulmonary Function Technologist (CPFT)
    Registered Pulmonary Function Technologist (RPFT)
    Certified Respiratory Therapist (CRT)
    Registered Respiratory Therapist (RRT)

    All centers billing sleep studies must maintain proper certification/ accreditation documentation as defined above, which include: Accreditation of sleep centers to include—AASM, or Joint Commission.


    D. Actigraphy Testing:

    Actigraphy measures movement of a limb. It can be measured as part of a sleep test but will not be paid for separately.

    E. Home Sleep Testing (HST) is not covered in the following situations:

    for the diagnosis of patients with chronic insomnia;
    to preoperatively evaluate a patient undergoing a laser assisted uvulopalatopharyngoplasty without clinical evidence that obstructive sleep apnea is suspected;
    to diagnose chronic lung disease (Nocturnal hypoxemia in patients with chronic, obstructive, restrictive, or reactive lung disease is usually adequately evaluated by oximetry. However, if the patient's symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography is considered medically necessary);
    in cases where seizure disorders have not been ruled out;
    in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated
    for patients with epilepsy who have no specific complaints consistent with a sleep disorder
    for patients with symptoms suggestive of the periodic limb movement disorder or restless leg syndrome unless symptoms are suspected to be related to a covered indication
    for the diagnosis of insomnia related to depression
    for the diagnosis of circadian rhythm sleep disorders [i.e., rapid time-zone change (jet lag), shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non 24-hour sleep wake disorder].

    Criteria for Coverage of Diagnostic Tests

    All reasonable and necessary diagnostic tests given for the medical conditions listed in subsection B are covered when the following criteria are met:

    The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician;

    Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s orders; and

    The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests.

    Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not reasonable and necessary under §1862(a)(1)(A) of the Act.


    Home sleep studies/home sleep test may be considered medically necessary in adult patients (>18years of age) who are at high pre-test probability for moderate to severe obstructive sleep apnea (OSA), when ALL of the following criteria are met:

    Patients considered high pre-test probability for moderate to severe OSA must have at least two of the following:
    *Habitual snoring or gasping/choking episodes associated with awakenings;
    *Observed apneas;
    Excessive daytime sleepiness as evidenced by one of the following:
    Questionnaires (Epworth Sleepiness Scale >10, Berlin, Wisconsin, STOP or STOP BANG)
    Inappropriate day time napping (e.g. during driving, conversation or eating), or
    sleepiness that interferes with daily activities not explained by other conditions;
    A body mass index > 30 kg/m2;
    Increased neck circumference >17 inches for men or >16 inches in women;
    Morning headaches;
    Sleep fragmentation or frequent unexplained arousals from sleep;
    Decreased concentration/memory loss;
    Treatment resistant hypertension/unexplained hypertension.
    *If no bed partner is available to report snoring or observed apneas, the patient must still meet the criteria as it relates to other signs and symptoms suggestive of OSA.

    AND

    In addition, those patients eligible for an unattended home sleep study must have no evidence of a co-morbid medical condition including but not limited to any of the following as they might alter ventilation or require alternative treatment;
    Moderate to Severe Pulmonary Disease
    Congestive Heart Failure
    Obesity hypoventilation syndrome
    Neuromuscular disease (Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis).


    AND

    Must not be suspected of having other sleep disorders including but not limited to the following;
    Central sleep apnea
    Periodic limb movement disorder
    Restless leg syndrome
    Insomnia
    Parasomnias
    Narcolepsy.


    AND

    Any one of the following sleep monitoring devices;
    sleep monitoring using a Type II device; or
    sleep monitoring using a Type III device; or
    sleep monitoring using a Type IV(A) device, which must measure a minimum of three channels and must provide measurement of apnea-hypopnea index (AHI).

    Unsupervised (unattended) home sleep studies/home sleep testing for an asymptomatic individual is considered not medically necessary.

    Sleep studies using devices that do not provide a measurement of apnea-hypopnea index (AHI) and oxygen saturation are considered not medically necessary because they do not provide sufficient information to prescribe treatment.


    Notes

    See Description information above for a full description of sleep monitoring devices.
    Respiratory disturbance index (RDI) may be used in place of apnea/hypopnea index (AHI) in unattended sleep studies.

    Unsupervised (unattended) home sleep study/home sleep test is typically performed over multiple nights with a single interpretation and is considered a single sleep study for purposes of reimbursement.

    When a diagnosis of OSA is established following a home sleep study/home sleep test (portable study), home titration to determine a fixed CPAP pressure can be effectively completed using auto-titrating positive airway pressure. Evidence from several well-designed trials demonstrates that home PAP titration using APAP compared to in-facility titration results in similar outcomes in terms of improvement in AHI, Epworth Sleepiness scores, and CPAP acceptance and adherence. Therefore laboratory CPAP titration following unattended or home sleep testing is not considered medically necessary.


    Repeat unsupervised (unattended) home sleep studies/home sleep testing may be considered medically necessary in adult patients for any of the following reasons;

    To assess efficacy of surgery or oral appliances/devices.
    A non-diagnostic home study within the past 3 months (e.g. technical complications or negative test with a high pretest probability of OSA).
    Failure of resolution of symptoms or recurrence of symptoms during treatment.
    To re-evaluate the diagnosis of OSA and need for continued PAP therapy (e.g. if there is a significant change in weight or change in symptoms suggesting that PAP therapy should be adjusted or possibly discontinued).



    Revenue Codes:

    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
    N/A


    ICD-10 Codes that Support Medical Necessity


    ICD-10 CODEDESCRIPTION

    G47.10Hypersomnia, unspecified

    G47.13Recurrent hypersomnia

    G47.14Hypersomnia due to medical condition

    G47.19Other hypersomnia

    G47.30Sleep apnea, unspecified

    G47.33Obstructive sleep apnea (adult) (pediatric)


    0 0

    CPT/HCPCS Codes

    Group 1 Paragraph: N/A

    Group 1 Codes:

    96360Hydration iv infusion init
    96361Hydrate iv infusion add-on



    Coverage Indications, Limitations, and/or Medical Necessity



    Indications

    The clinical manifestations of dehydration or volume depletion are related to the volume and rate of fluid loss, the nature of the fluid that is lost, and the responsiveness of the vasculature to volume reduction. Rehydration with fluids containing sodium as the principal solute preferentially expands the extracellular fluid volume; a 1-liter infusion of normal saline may expand blood volume by about 300 ml. In general, an imbalance of less than 500 ml of volume is not likely to require intravenous rehydration.

    Hydration services are indicated:

    In documented volume depletion.

    When performed in conjunction with chemotherapy, these CPT codes are covered only when infusion is prolonged and done sequentially [done hour(s) before and/or after administration of chemotherapy], and when the volume status of a patient is compromised or will be compromised by side effects of chemotherapy or an illness.

    In some endocrine conditions with findings such as hypercalcemia, prolonged hydration can be medically necessary.

    As an adjunct to the treatment of hypotension.
    Limitations

    Rehydration with the administration of an amount of fluid equal to or less than 500 ml is not reasonable and necessary.

    These CPT codes are not to be used for routine IV drug injections.

    Hanging of D5W or other fluid just prior to administration of chemotherapy is not hydration therapy and should not be billed with these codes.

    When the sole purpose of fluid administration is to maintain patency of the access device, these infusion CPT codes should not be billed as hydration therapy.

    Administration of fluid in the course of transfusions to maintain line patency or between units of blood product is not to be separately billed as hydration therapy.

    Fluid used to administer drug(s) is incidental hydration and is not separately payable.

    Rehydration via hydration therapy of extensively dehydrated patients can be accomplished in hours; therefore, the medical necessity of hydration beyond 12 hours must be documented in the medical record.

    These CPT codes require the direct supervision of the physician or non-physician practitioner for the initiation of the service.




    Bill Type Codes:

    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    N/A



    Revenue Codes:

    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

    N/A




    ICD-10 Codes that Support Medical Necessity


    ICD-10 CODEDESCRIPTION

    E11.649 - E11.69 - Opens in a new windowType 2 diabetes mellitus with hypoglycemia without coma - Type 2 diabetes mellitus with other specified complication

    E13.649 - E13.69 - Opens in a new windowOther specified diabetes mellitus with hypoglycemia without coma - Other
    specified diabetes mellitus with other specified complication

    E83.52Hypercalcemia

    E86.0 - E87.0 - Opens in a new windowDehydration - Hyperosmolality and hypernatremia

    I95.9Hypotension, unspecified

    K29.00 - K29.91 - Opens in a new windowAcute gastritis without bleeding - Gastroduodenitis, unspecified, with bleeding

    K52.89 - K52.9 - Opens in a new windowOther specified noninfective gastroenteritis and colitis - Noninfective
    gastroenteritis and colitis, unspecified

    K92.0Hematemesis

    N18.3Chronic kidney disease, stage 3 (moderate)

    O21.1 - O21.8 - Opens in a new windowHyperemesis gravidarum with metabolic disturbance - Other vomiting complicating
    pregnancy

    R11.10 - R11.12 - Opens in a new windowVomiting, unspecified - Projectile vomiting

    R11.2Nausea with vomiting, unspecified

    R19.7Diarrhea, unspecified

    R41.0Disorientation, unspecified

    R41.82Altered mental status, unspecified

    R42Dizziness and giddiness

    R55Syncope and collapse

    Z51.11Encounter for antineoplastic chemotherapy

    Z91.89Other specified personal risk factors, not elsewhere classified


    0 0

    CPT/HCPCS Codes

    Group 1 Paragraph: N/A

    Group 1 Codes:
    93224Ecg monit/reprt up to 48 hrs
    93225Ecg monit/reprt up to 48 hrs
    93226Ecg monit/reprt up to 48 hrs
    93227Ecg monit/reprt up to 48 hrs
    93228Remote 30 day ecg rev/report
    93229Remote 30 day ecg tech supp
    93268Ecg record/review
    93270Remote 30 day ecg rev/report
    93271Ecg/monitoring and analysis
    93272Ecg/review interpret only



    Coverage Indications, Limitations, and/or Medical Necessity

    Long-term wearable electrocardiographic monitoring (WEM) is a diagnostic procedure that provides a record of the heart rhythm during daily activities. This procedure can often identify the existence and determine the frequency of clinically significant rhythm disturbances and waveform abnormalities that are missed on a standard electrocardiogram (ECG).

    WEM are generally classified by the following:

    Non-Activated Continuous Recorders (holter monitor/external electrocardiographic recording) (CPT codes 93224 – 93227) provide a continuous record of heart rhythm during a 48 hour period. This procedure can often identify the existence of ECG rhythm derived elements that are missed on a standard ECG.

    This service is appropriate when arrhythmias are known or suspected to occur at least once in 48 hours 

    Patient/Event-Activated Intermittent Recorders (loop event monitors, remote cardiovascular monitoring) (CPT codes 93228, 93229, and 93268 - 93272) are indicated when symptoms are sporadic to establish whether or not they are caused by transient arrhythmias. 

    This service is an appropriate alternative to 48 hour monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope or syncope) or when a 48 hour service is not diagnostic.

    Indications

    The covered indications are:

    To detect, characterize and document symptomatic transient arrhythmias.

    To aid in regulating anti-arrhythmic drug dosage.

    To aid in the search for the cause of unexplained syncope, dizziness or giddiness.

    To monitor patients who have had surgical or ablative procedures for arrhythmias, since post ablation atrial fibrillation can be asymptomatic.

    To aid in the search for the cause of TIA/CVA.


    Limitations

    A WEM service is medically unnecessary if it offers little or no potential for new clinical data beyond that which has been obtained from a previous test or if other tests are better suited to obtain the clinical data relevant to the patient’s condition. 

    A test may be ordered only by a physician or other qualified health care professional treating the beneficiary.

    WEMs are not covered for outpatient monitoring of recently discharged postinfarct patients.

    When the billing of these services is split into components, it is expected that the appropriate components of the code series will be billed. 

    For 30-day WEM service: 

    WEM may be discontinued once the symptom-producing arrhythmia has been documented and diagnosed or following multiple transmissions during symptoms, without arrhythmia. It is unlikely that the arrhythmias would always be diagnosed on the first day of recording or that the service would always last only one day. The average duration of monitoring is anticipated to last 10–14 days or more.

    WEM is a 30-day packaged service. Tests may not be billed more than once within 30 days of each other, even if the earlier of the tests was discontinued when arrhythmias were documented and the patient is now reconnected for follow-up of therapy or intervention.

    Because the WEM service requires the diagnosis and evaluation of intermittent arrhythmias and patients must be continuously attached to presymptom loop recorders, each patient is required to have a recorder for his/her own exclusive use throughout the duration of the monitoring period. 

    The receiving station must be staffed on a 24-hour basis. An answering service/answering machine would not fulfill this requirement.



    Bill Type Codes:

    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    999xNot Applicable

    Revenue Codes:
    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

    99999Not Applicable




    ICD-10 Codes that Support Medical Necessity

    ICD-10 CODEDESCRIPTION

    G45.1 - G45.2 - Opens in a new windowCarotid artery syndrome (hemispheric) - Multiple and bilateral precerebral artery syndromes

    G45.8 - G46.2 - Opens in a new windowOther transient cerebral ischemic attacks and related syndromes - Posterior cerebral 
    artery syndrome

    I20.0 - I20.9 - Opens in a new windowUnstable angina - Angina pectoris, unspecified

    I24.0 - I24.9 - Opens in a new windowAcute coronary thrombosis not resulting in myocardial infarction - Acute ischemic 
    heart disease, unspecified
    I25.110 - I25.2 - Opens in a new windowAtherosclerotic heart disease of native coronary artery with unstable angina pectoris 
    - Old myocardial infarction

    I25.5 - I25.799 - Opens in a new windowIschemic cardiomyopathy - Atherosclerosis of other coronary artery bypass graft(s) 
    with unspecified angina pectoris

    I25.89 - I25.9 - Opens in a new windowOther forms of chronic ischemic heart disease - Chronic ischemic heart disease, 
    unspecified

    I34.0 - I35.9 - Opens in a new windowNonrheumatic mitral (valve) insufficiency - Nonrheumatic aortic valve disorder, 
    unspecified

    I42.0Dilated cardiomyopathy

    I42.5Other restrictive cardiomyopathy

    I42.8 - I42.9 - Opens in a new windowOther cardiomyopathies - Cardiomyopathy, unspecified

    I44.1 - I44.30 - Opens in a new windowAtrioventricular block, second degree - Unspecified atrioventricular block

    I44.4 - I45.2 - Opens in a new windowLeft anterior fascicular block - Bifascicular block

    I45.5 - I45.9 - Opens in a new windowOther specified heart block - Conduction disorder, unspecified
    I47.0 - I48.92 - Opens in a new windowRe-entry ventricular arrhythmia - Unspecified atrial flutter

    I49.02 - I50.9 - Opens in a new windowVentricular flutter - Heart failure, unspecified

    I63.40 - I63.49 - Opens in a new windowCerebral infarction due to embolism of unspecified cerebral artery - Cerebral 
    infarction due to embolism of other cerebral artery

    I66.01 - I66.3 - Opens in a new windowOcclusion and stenosis of right middle cerebral artery - Occlusion and stenosis of 
    cerebellar arteries

    I66.9Occlusion and stenosis of unspecified cerebral artery

    I67.841 - I67.848 - Opens in a new windowReversible cerebrovascular vasoconstriction syndrome - Other cerebrovascular 
    vasospasm and vasoconstriction

    R00.0 - R00.2 - Opens in a new windowTachycardia, unspecified - Palpitations

    R06.00 - R06.01 - Opens in a new windowDyspnea, unspecified - Orthopnea

    R06.09Other forms of dyspnea

    R06.89Other abnormalities of breathing

    R07.2Precordial pain

    R07.82 - R07.9 - Opens in a new windowIntercostal pain - Chest pain, unspecified

    R40.4Transient alteration of awareness

    R42Dizziness and giddiness

    R55Syncope and collapse

    T82.110A - T82.111S - Opens in a new windowBreakdown (mechanical) of cardiac electrode, initial encounter - Breakdown 
    (mechanical) of cardiac pulse generator (battery), sequela

    T82.120A - T82.121S - Opens in a new windowDisplacement of cardiac electrode, initial encounter - Displacement of 
    cardiac pulse generator (battery), sequela


    T82.190A - T82.191S - Opens in a new windowOther mechanical complication of cardiac electrode, initial encounter - Other 
    mechanical complication of cardiac pulse generator (battery), sequela

    Z09Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

    Z51.81Encounter for therapeutic drug level monitoring

    Z79.02 - Z79.1 - Opens in a new windowLong term (current) use of antithrombotics/antiplatelets - Long term (current) use of 
    non-steroidal anti-inflammatories (NSAID)

    Z79.899Other long term (current) drug therapy

    Z95.0Presence of cardiac pacemaker

    Z95.9Presence of cardiac and vascular implant and graft, unspecified


    0 0

    CPT/HCPCS Codes

    Group 1 Paragraph: N/A

    Group 1 Codes:
    92585Auditor evoke potent compre
    92586Auditor evoke potent limit

    Group 2 Paragraph: N/A

    Group 2 Codes:
    95925Somatosensory testing
    95926Somatosensory testing
    95927Somatosensory testing
    95928C motor evoked uppr limbs
    95929C motor evoked lwr limbs
    95938Somatosensory testing
    95939C motor evoked upr&lwr limbs

    Group 3 Paragraph: N/A

    Group 3 Codes:
    95930Visual evoked potential test



    Coverage Indications, Limitations, and/or Medical Necessity

    Background

    Neurophysiology Evoked Potentials (NEPs) for the purpose of this LCD include:

    Somatosensory Evoked Potentials/Responses (SEPs/SERs),
    Brainstem Auditory Evoked Potentials/Responses (BAEPs/BAERs), and
    Visual Evoked Potentials/Responses (VEPs/VERs)
    Evoked potential studies are recorded electrical responses to stimulation of a sensory system. When a sensory impulse reaches the brain, a specific Electroencephalographic (EEG) response is produced (evoked) in the cortical area appropriate to the modality and site of the stimulus. By computer averaging techniques, the evoked responses of repetitive stimuli can be separated from the spontaneous EEG activity. Evoked potentials are clinically useful in evaluating the functional integrity of the somatosensory or special sensory pathways. Different latencies and wave patterns help to localize lesions ranging from the end organ through the nervous system to the cerebral cortex. Often defects in these pathways are not otherwise evident. Evoked potentials are also used to monitor neural pathways when patients are anesthetized during surgery and to document brain death. The following are tests that evaluate potentials evoked by stimulation of the peripheral or cranial nerves:

    SEPs/SERs evaluate the pathways from nerves in the extremities through the spinal cord, to the brainstem or cerebral cortex upon stimulation of peripheral axon.

    SEPs has an advantage in that it evaluates the entire somatosensory pathway and it is possible to distinguish between lesions located in the peripheral nerve, in the dorsal column pathway, or both.

    VEPs/VERs evaluate the visual nervous system pathways from the eyes to the occipital cortex of the brain. VEP or VER involves stimulation of the retina and optic nerve with a shifting checkerboard pattern or flash method. This external visual stimulus causes measurable electrical activity in neurons within the visual pathways. This is called the Visual Evoked Response (VER) and is recorded by electroencephalography electrodes located over the occiput. Using special computer techniques, the evoked responses measured over multiple trials are amplified and averaged. A characteristic waveform is produced. With pattern-shift VER, the waveform normally appears as a straight line with a single positive peak (100 msec after stimulus presentation). Abnormalities in this characteristic waveform may be seen in a variety of pathologic processes involving the optic nerve and its radiations. Pattern-shift VER is a highly sensitive means of documenting lesions in the visual system. It is especially useful when the disease process is subclinical, e.g., ophthalmologic exam is normal and patient lacks visual symptoms.

    BAEPs/BAERs evaluate the auditory nerve pathways from the ears through the brain stem. A clicking sound is presented to one ear at a time. The electrical activity of this signal is recorded by electrodes on the scalp. The averaged response is displayed as a waveform that contains peaks and troughs, which correspond to various points along the hearing pathway. The time between these peaks is measured and compared to normal data. A delay in a component of the response might indicate an abnormality at specific anatomic sites in the acoustic nerve or brainstem.


    Indications

    Somatosensory Evoked Potentials and Responses (SEPs/SERs) (CPT codes 95925, 95926, 95927, 95928, 95929, 95938, 95939) are appropriate for the following indications:

    Spinal cord trauma
    Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy)
    Multiple sclerosis
    Spinocerebellar degeneration
    Myoclonus
    Coma
    Intraoperative monitoring
    Subacute combined degeneration
    Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, and Pelizaeus-Merzbacher disease
    Syringomyelia
    Hereditary spastic paraplegia
    Brainstem Auditory Evoked Potentials and Responses (BAEPs/BAERs) (CPT codes 92585 and 92586) are appropriate:

    For one or more of the following conditions:

    Asymmetric hearing loss
    Unilateral tinnitus
    Sudden hearing loss
    Cerebellopontine angle tumor
    Demyelinating disorder
    Functional hearing loss
    Ototoxic drug therapy monitoring including chemotherapy or antibiotics
    Auditory neuropathy
    Acoustic neuroma

    Preoperative baseline for:

    Posterior fossa surgery
    Cochlear implant

    Postoperative testing for:

    Cochlear implant
    Visual Evoked Potentials or Responses (VEPs/VERs) (CPT code 95930) are appropriate for the following indications:

    Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.

    Detect optic neuritis at an early, subclinical stage.

    Evaluate diseases of the optic nerve, such as:

    Ischemic optic neuropathy
    Pseudotumor cerebri
    Toxic amblyopias
    Nutritional amblyopias
    Neoplasms compressing the anterior visual pathways
    Optic nerve injury or atrophy
    Hysterical blindness (to rule out)

    Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies).

    Limitations

    SEP studies are appropriate only when a detailed clinical history and neurologic examination and appropriate diagnostic tests such as imaging studies, electromyogram, and nerve conduction studies make a lesion (or lesions) of the central somatosensory pathways a likely and reasonable differential diagnostic possibility.

    There is no need for SEPs in the diagnosis of most neuropathies because the conventional nerve conduction study can identify them and no added information is obtained from SEPs.



    ICD-10 Codes that Support Medical Necessity


    ICD-10 CODEDESCRIPTION

    D33.3Benign neoplasm of cranial nerves
    G10Huntington's disease
    G21.0Malignant neuroleptic syndrome
    G23.0 - G26 - Opens in a new windowHallervorden-Spatz disease - Extrapyramidal and movement disorders in diseases classified elsewhere
    G35 - G36.8 - Opens in a new windowMultiple sclerosis - Other specified acute disseminated demyelination
    G37.0 - G37.8 - Opens in a new windowDiffuse sclerosis of central nervous system - Other specified demyelinating diseases of central nervous system
    G80.3Athetoid cerebral palsy
    G90.3Multi-system degeneration of the autonomic nervous system
    H46.00 - H46.9 - Opens in a new windowOptic papillitis, unspecified eye - Unspecified optic neuritis
    H81.01 - H81.09 - Opens in a new windowMeniere's disease, right ear - Meniere's disease, unspecified ear
    H81.41 - H81.49 - Opens in a new windowVertigo of central origin, right ear - Vertigo of central origin, unspecified ear
    H83.3X1 - H83.3X9 - Opens in a new windowNoise effects on right inner ear - Noise effects on inner ear, unspecified ear
    H90.3 - H90.8 - Opens in a new windowSensorineural hearing loss, bilateral - Mixed conductive and sensorineural hearing loss, unspecified
    H91.20 - H91.23 - Opens in a new windowSudden idiopathic hearing loss, unspecified ear - Sudden idiopathic hearing loss, bilateral
    H93.11 - H93.19 - Opens in a new windowTinnitus, right ear - Tinnitus, unspecified ear
    H93.3X1 - H93.3X9 - Opens in a new windowDisorders of right acoustic nerve - Disorders of unspecified acoustic nerve
    H94.00 - H94.03 - Opens in a new windowAcoustic neuritis in infectious and parasitic diseases classified elsewhere, unspecified ear - Acoustic neuritis in infectious and parasitic diseases classified elsewhere, bilateral
    R25.0 - R25.9 - Opens in a new windowAbnormal head movements - Unspecified abnormal involuntary movements
    R42Dizziness and giddiness



    ICD-10 CODEDESCRIPTION

    A18.01Tuberculosis of spine
    A52.11Tabes dorsalis
    A52.13 - A52.15 - Opens in a new windowLate syphilitic meningitis - Late syphilitic neuropathy
    A52.17 - A52.19 - Opens in a new windowGeneral paresis - Other symptomatic neurosyphilis
    A69.20 - A69.22 - Opens in a new windowLyme disease, unspecified - Other neurologic disorders in Lyme disease
    A69.29Other conditions associated with Lyme disease
    A83.0 - A83.8 - Opens in a new windowJapanese encephalitis - Other mosquito-borne viral encephalitis
    A84.0 - A84.8 - Opens in a new windowFar Eastern tick-borne encephalitis [Russian spring-summer encephalitis] - Other tick-borne viral encephalitis
    A85.2Arthropod-borne viral encephalitis, unspecified
    B00.4Herpesviral encephalitis
    B00.82Herpes simplex myelitis
    B02.24Postherpetic myelitis
    B05.0Measles complicated by encephalitis
    B06.01Rubella encephalitis
    C41.2Malignant neoplasm of vertebral column
    C70.0 - C70.9 - Opens in a new windowMalignant neoplasm of cerebral meninges - Malignant neoplasm of meninges, unspecified
    C72.0 - C72.9 - Opens in a new windowMalignant neoplasm of spinal cord - Malignant neoplasm of central nervous system, unspecified
    C79.31 - C79.49 - Opens in a new windowSecondary malignant neoplasm of brain - Secondary malignant neoplasm of other parts of nervous system
    D32.0 - D33.7 - Opens in a new windowBenign neoplasm of cerebral meninges - Benign neoplasm of other specified parts of central nervous system
    D42.0 - D43.2 - Opens in a new windowNeoplasm of uncertain behavior of cerebral meninges - Neoplasm of uncertain behavior of brain, unspecified
    D43.4Neoplasm of uncertain behavior of spinal cord
    D44.3 - D44.5 - Opens in a new windowNeoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal gland
    D49.6Neoplasm of unspecified behavior of brain
    E03.5Myxedema coma
    E08.40Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
    E08.42Diabetes mellitus due to underlying condition with diabetic polyneuropathy
    E08.44Diabetes mellitus due to underlying condition with diabetic amyotrophy
    E09.40Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
    E09.42Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
    E09.44Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
    E10.40Type 1 diabetes mellitus with diabetic neuropathy, unspecified
    E10.42Type 1 diabetes mellitus with diabetic polyneuropathy
    E10.44Type 1 diabetes mellitus with diabetic amyotrophy
    E11.40Type 2 diabetes mellitus with diabetic neuropathy, unspecified
    E11.42Type 2 diabetes mellitus with diabetic polyneuropathy
    E11.44Type 2 diabetes mellitus with diabetic amyotrophy
    E13.40Other specified diabetes mellitus with diabetic neuropathy, unspecified
    E13.42Other specified diabetes mellitus with diabetic polyneuropathy
    E13.44Other specified diabetes mellitus with diabetic amyotrophy
    E71.50 - E71.548 - Opens in a new windowPeroxisomal disorder, unspecified - Other peroxisomal disorders
    E75.23Krabbe disease
    E75.25 - E75.29 - Opens in a new windowMetachromatic leukodystrophy - Other sphingolipidosis
    F44.4 - F44.7 - Opens in a new windowConversion disorder with motor symptom or deficit - Conversion disorder with mixed symptom presentation
    G05.4Myelitis in diseases classified elsewhere
    G06.1Intraspinal abscess and granuloma
    G11.0 - G11.8 - Opens in a new windowCongenital nonprogressive ataxia - Other hereditary ataxias
    G13.0 - G13.1 - Opens in a new windowParaneoplastic neuromyopathy and neuropathy - Other systemic atrophy primarily affecting central nervous system in neoplastic disease
    G23.0 - G23.9 - Opens in a new windowHallervorden-Spatz disease - Degenerative disease of basal ganglia, unspecified
    G32.0 - G32.81 - Opens in a new windowSubacute combined degeneration of spinal cord in diseases classified elsewhere - Cerebellar ataxia in diseases classified elsewhere
    G35 - G36.8 - Opens in a new windowMultiple sclerosis - Other specified acute disseminated demyelination
    G37.0 - G37.8 - Opens in a new windowDiffuse sclerosis of central nervous system - Other specified demyelinating diseases of central nervous system
    G45.0 - G45.2 - Opens in a new windowVertebro-basilar artery syndrome - Multiple and bilateral precerebral artery syndromes
    G45.8Other transient cerebral ischemic attacks and related syndromes
    G46.0 - G46.2 - Opens in a new windowMiddle cerebral artery syndrome - Posterior cerebral artery syndrome
    G54.0 - G54.8 - Opens in a new windowBrachial plexus disorders - Other nerve root and plexus disorders
    G55Nerve root and plexus compressions in diseases classified elsewhere
    G56.40 - G56.42 - Opens in a new windowCausalgia of unspecified upper limb - Causalgia of left upper limb
    G57.00 - G57.92 - Opens in a new windowLesion of sciatic nerve, unspecified lower limb - Unspecified mononeuropathy of left lower limb
    G58.7Mononeuritis multiplex
    G60.0 - G60.8 - Opens in a new windowHereditary motor and sensory neuropathy - Other hereditary and idiopathic neuropathies
    G61.0 - G61.89 - Opens in a new windowGuillain-Barre syndrome - Other inflammatory polyneuropathies
    G62.0 - G62.89 - Opens in a new windowDrug-induced polyneuropathy - Other specified polyneuropathies
    G63Polyneuropathy in diseases classified elsewhere
    G65.0 - G70.89 - Opens in a new windowSequelae of Guillain-Barre syndrome - Other specified myoneural disorders
    G73.1 - G73.3 - Opens in a new windowLambert-Eaton syndrome in neoplastic disease - Myasthenic syndromes in other diseases classified elsewhere
    G80.0 - G80.2 - Opens in a new windowSpastic quadriplegic cerebral palsy - Spastic hemiplegic cerebral palsy
    G80.4 - G80.8 - Opens in a new windowAtaxic cerebral palsy - Other cerebral palsy
    G81.00 - G81.94 - Opens in a new windowFlaccid hemiplegia affecting unspecified side - Hemiplegia, unspecified affecting left nondominant side
    G90.3Multi-system degeneration of the autonomic nervous system
    G93.2Benign intracranial hypertension
    G95.0 - G95.19 - Opens in a new windowSyringomyelia and syringobulbia - Other vascular myelopathies
    G95.81 - G95.89 - Opens in a new windowConus medullaris syndrome - Other specified diseases of spinal cord
    G99.2Myelopathy in diseases classified elsewhere
    I60.00 - I62.1 - Opens in a new windowNontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation - Nontraumatic extradural hemorrhage
    I63.011 - I63.09 - Opens in a new windowCerebral infarction due to thrombosis of right vertebral artery - Cerebral infarction due to thrombosis of other precerebral artery
    I63.111 - I63.19 - Opens in a new windowCerebral infarction due to embolism of right vertebral artery - Cerebral infarction due to embolism of other precerebral artery
    I63.211 - I63.239 - Opens in a new windowCerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries - Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
    I63.30 - I63.49 - Opens in a new windowCerebral infarction due to thrombosis of unspecified cerebral artery - Cerebral infarction due to embolism of other cerebral artery
    I63.59 - I63.6 - Opens in a new windowCerebral infarction due to unspecified occlusion or stenosis of other cerebral artery - Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
    I65.01 - I65.8 - Opens in a new windowOcclusion and stenosis of right vertebral artery - Occlusion and stenosis of other precerebral arteries
    I66.01 - I66.3 - Opens in a new windowOcclusion and stenosis of right middle cerebral artery - Occlusion and stenosis of cerebellar arteries
    I66.9Occlusion and stenosis of unspecified cerebral artery
    I67.1Cerebral aneurysm, nonruptured
    M05.50 - M05.59 - Opens in a new windowRheumatoid polyneuropathy with rheumatoid arthritis of unspecified site - Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
    M34.83Systemic sclerosis with polyneuropathy
    M40.00 - M41.9 - Opens in a new windowPostural kyphosis, site unspecified - Scoliosis, unspecified
    M43.8X1 - M43.9 - Opens in a new windowOther specified deforming dorsopathies, occipito-atlanto-axial region - Deforming dorsopathy, unspecified
    M47.011 - M47.029 - Opens in a new windowAnterior spinal artery compression syndromes, occipito-atlanto-axial region - Vertebral artery compression syndromes, site unspecified
    M47.11 - M47.16 - Opens in a new windowOther spondylosis with myelopathy, occipito-atlanto-axial region - Other spondylosis with myelopathy, lumbar region
    M50.00 - M50.03 - Opens in a new windowCervical disc disorder with myelopathy, unspecified cervical region - Cervical disc disorder with myelopathy, cervicothoracic region
    M51.04 - M51.06 - Opens in a new windowIntervertebral disc disorders with myelopathy, thoracic region - Intervertebral disc disorders with myelopathy, lumbar region
    M51.9 - M53.1 - Opens in a new windowUnspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder - Cervicobrachial syndrome
    M96.2 - M96.5 - Opens in a new windowPostradiation kyphosis - Postradiation scoliosis
    Q05.0 - Q05.9 - Opens in a new windowCervical spina bifida with hydrocephalus - Spina bifida, unspecified
    Q07.00 - Q07.03 - Opens in a new windowArnold-Chiari syndrome without spina bifida or hydrocephalus - Arnold-Chiari syndrome with spina bifida and hydrocephalus
    R20.0 - R20.9 - Opens in a new windowAnesthesia of skin - Unspecified disturbances of skin sensation
    R26.0 - R26.1 - Opens in a new windowAtaxic gait - Paralytic gait
    R26.81 - R27.9 - Opens in a new windowUnsteadiness on feet - Unspecified lack of coordination
    R29.5Transient paralysis

    0 0


    CPT/HCPCS Codes

    Group 1 Codes:
    72192Ct pelvis w/o dye
    72193Ct pelvis w/dye
    72194Ct pelvis w/o & w/dye
    74150Ct abdomen w/o dye
    74160Ct abdomen w/dye
    74170Ct abdomen w/o & w/dye
    74176Ct abd & pelvis w/o contrast
    74177Ct abd & pelv w/contrast
    74178Ct abd & pelv 1/> regns

    Coverage Indications, Limitations, and/or Medical Necessity

    Indications

    Evaluation of abdominal or pelvic pain.

    Evaluation of known or suspected abdominal or pelvic masses or fluid collections, primary or metastatic malignancies, abdominal or pelvic inflammatory processes, and abnormalities of abdominal or pelvic vascular structures.

    Evaluation of abdominal or pelvic trauma.

    Clarification of findings from other imaging studies or laboratory abnormalities.

    Evaluation of known or suspected congenital abnormalities of abdominal or pelvic organs.

    Treatment planning for radiation therapy.

    Limitations

    Three dimension reconstruction of CT of Abdomen and Pelvis (CPT code 76376 or 76377) is not expected to be utilized routinely. CPT code 76376 or 76377 are not an appropriate part of every CT examination.


    Bill Type Codes:

    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    999xNot Applicable

    Revenue Codes:

    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

    99999Not Applicable



    ICD-10 Codes that Support Medical Necessity


    ICD-10 CODEDESCRIPTION

    A06.2 - A06.6 - Opens in a new windowAmebic nondysenteric colitis - Amebic brain abscess
    A06.81 - A06.89 - Opens in a new windowAmebic cystitis - Other amebic infections
    A18.10 - A18.18 - Opens in a new windowTuberculosis of genitourinary system, unspecified - Tuberculosis of other female genital organs
    A18.31 - A18.39 - Opens in a new windowTuberculous peritonitis - Retroperitoneal tuberculosis
    A18.7Tuberculosis of adrenal glands
    A18.83Tuberculosis of digestive tract organs, not elsewhere classified
    A18.85Tuberculosis of spleen
    A31.0Pulmonary mycobacterial infection
    A31.2Disseminated mycobacterium avium-intracellulare complex (DMAC)
    A34Obstetrical tetanus
    A39.1Waterhouse-Friderichsen syndrome
    A40.0 - A41.9 - Opens in a new windowSepsis due to streptococcus, group A - Sepsis, unspecified organism
    A42.7Actinomycotic sepsis
    A50.04Early congenital syphilitic pneumonia
    A50.06 - A50.09 - Opens in a new windowEarly cutaneous congenital syphilis - Other early congenital syphilis, symptomatic
    A51.49Other secondary syphilitic conditions
    A52.74 - A52.75 - Opens in a new windowSyphilis of liver and other viscera - Syphilis of kidney and ureter
    A56.11Chlamydial female pelvic inflammatory disease
    B15.0 - B19.9 - Opens in a new windowHepatitis A with hepatic coma - Unspecified viral hepatitis without hepatic coma
    B25.1 - B25.2 - Opens in a new windowCytomegaloviral hepatitis - Cytomegaloviral pancreatitis
    B37.7Candidal sepsis
    B65.0 - B65.9 - Opens in a new windowSchistosomiasis due to Schistosoma haematobium [urinary schistosomiasis] - Schistosomiasis, unspecified
    B67.0Echinococcus granulosus infection of liver
    B67.5Echinococcus multilocularis infection of liver
    B67.8 - B67.99 - Opens in a new windowEchinococcosis, unspecified, of liver - Other echinococcosis
    C00.0 - C43.9 - Opens in a new windowMalignant neoplasm of external upper lip - Malignant melanoma of skin, unspecified
    C4A.0 - C4A.9 - Opens in a new windowMerkel cell carcinoma of lip - Merkel cell carcinoma, unspecified
    C44.00 - C49.9 - Opens in a new windowUnspecified malignant neoplasm of skin of lip - Malignant neoplasm of connective and soft tissue, unspecified
    C50.011 - C75.9 - Opens in a new windowMalignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of endocrine gland, unspecified
    C7A.00 - C7B.8 - Opens in a new windowMalignant carcinoid tumor of unspecified site - Other secondary neuroendocrine tumors
    C76.0 - C79.9 - Opens in a new windowMalignant neoplasm of head, face and neck - Secondary malignant neoplasm of unspecified site
    C80.0 - C84.79 - Opens in a new windowDisseminated malignant neoplasm, unspecified - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites
    C84.A0 - C84.Z9 - Opens in a new windowCutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites
    C84.90 - C84.99 - Opens in a new windowMature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
    C85.10 - C86.6 - Opens in a new windowUnspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-cell proliferations
    C88.2 - C91.62 - Opens in a new windowHeavy chain disease - Prolymphocytic leukemia of T-cell type, in relapse
    C91.A0 - C91.Z2 - Opens in a new windowMature B-cell leukemia Burkitt-type not having achieved remission - Other lymphoid leukemia, in relapse
    C91.90 - C91.92 - Opens in a new windowLymphoid leukemia, unspecified not having achieved remission - Lymphoid leukemia, unspecified, in relapse
    C92.00 - C92.62 - Opens in a new windowAcute myeloblastic leukemia, not having achieved remission - Acute myeloid leukemia with 11q23-abnormality in relapse
    C92.A0 - C92.Z2 - Opens in a new windowAcute myeloid leukemia with multilineage dysplasia, not having achieved remission - Other myeloid leukemia, in relapse
    C92.90 - C92.92 - Opens in a new windowMyeloid leukemia, unspecified, not having achieved remission - Myeloid leukemia, unspecified in relapse
    C93.00 - C93.32 - Opens in a new windowAcute monoblastic/monocytic leukemia, not having achieved remission - Juvenile myelomonocytic leukemia, in relapse
    C93.Z0 - C93.Z2 - Opens in a new windowOther monocytic leukemia, not having achieved remission - Other monocytic leukemia, in relapse
    C93.90 - C93.92 - Opens in a new windowMonocytic leukemia, unspecified, not having achieved remission - Monocytic leukemia, unspecified in relapse
    C94.00 - C94.32 - Opens in a new windowAcute erythroid leukemia, not having achieved remission - Mast cell leukemia, in relapse
    C94.80 - C96.4 - Opens in a new windowOther specified leukemias not having achieved remission - Sarcoma of dendritic cells (accessory cells)
    C96.A - C96.Z - Opens in a new windowHistiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
    C96.9Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
    D00.1 - D01.9 - Opens in a new windowCarcinoma in situ of esophagus - Carcinoma in situ of digestive organ, unspecified
    D03.0 - D03.9 - Opens in a new windowMelanoma in situ of lip - Melanoma in situ, unspecified
    D06.0 - D09.19 - Opens in a new windowCarcinoma in situ of endocervix - Carcinoma in situ of other urinary organs
    D12.0 - D12.9 - Opens in a new windowBenign neoplasm of cecum - Benign neoplasm of anus and anal canal
    D13.1 - D13.9 - Opens in a new windowBenign neoplasm of stomach - Benign neoplasm of ill-defined sites within the digestive system
    D16.8Benign neoplasm of pelvic bones, sacrum and coccyx
    D17.5Benign lipomatous neoplasm of intra-abdominal organs
    D17.71Benign lipomatous neoplasm of kidney
    D18.03Hemangioma of intra-abdominal structures
    D18.1Lymphangioma, any site
    D19.1Benign neoplasm of mesothelial tissue of peritoneum
    D20.0 - D20.1 - Opens in a new windowBenign neoplasm of soft tissue of retroperitoneum - Benign neoplasm of soft tissue of peritoneum
    D21.20 - D21.22 - Opens in a new windowBenign neoplasm of connective and other soft tissue of unspecified lower limb, including hip - Benign neoplasm of connective and other soft tissue of left lower limb, including hip
    D21.4 - D21.5 - Opens in a new windowBenign neoplasm of connective and other soft tissue of abdomen - Benign neoplasm of connective and other soft tissue of pelvis
    D25.0 - D28.9 - Opens in a new windowSubmucous leiomyoma of uterus - Benign neoplasm of female genital organ, unspecified
    D30.00 - D30.9 - Opens in a new windowBenign neoplasm of unspecified kidney - Benign neoplasm of urinary organ, unspecified
    D35.00 - D35.02 - Opens in a new windowBenign neoplasm of unspecified adrenal gland - Benign neoplasm of left adrenal gland
    D35.6Benign neoplasm of aortic body and other paraganglia
    D3A.00 - D3A.8 - Opens in a new windowBenign carcinoid tumor of unspecified site - Other benign neuroendocrine tumors
    D37.1 - D37.9 - Opens in a new windowNeoplasm of uncertain behavior of stomach - Neoplasm of uncertain behavior of digestive organ, unspecified
    D39.0 - D39.9 - Opens in a new windowNeoplasm of uncertain behavior of uterus - Neoplasm of uncertain behavior of female genital organ, unspecified
    D40.0 - D41.9 - Opens in a new windowNeoplasm of uncertain behavior of prostate - Neoplasm of uncertain behavior of unspecified urinary organ
    D44.10 - D44.12 - Opens in a new windowNeoplasm of uncertain behavior of unspecified adrenal gland - Neoplasm of uncertain behavior of left adrenal gland
    D44.6 - D44.7 - Opens in a new windowNeoplasm of uncertain behavior of carotid body - Neoplasm of uncertain behavior of aortic body and other paraganglia
    D45Polycythemia vera
    D48.3 - D48.4 - Opens in a new windowNeoplasm of uncertain behavior of retroperitoneum - Neoplasm of uncertain behavior of peritoneum
    D49.0Neoplasm of unspecified behavior of digestive system
    D57.02Hb-SS disease with splenic sequestration
    D57.212Sickle-cell/Hb-C disease with splenic sequestration
    D57.412Sickle-cell thalassemia with splenic sequestration
    D57.812Other sickle-cell disorders with splenic sequestration
    D73.1 - D73.2 - Opens in a new windowHypersplenism - Chronic congestive splenomegaly
    D73.81Neutropenic splenomegaly
    D75.0 - D75.1 - Opens in a new windowFamilial erythrocytosis - Secondary polycythemia
    D78.01 - D78.22 - Opens in a new windowIntraoperative hemorrhage and hematoma of the spleen complicating a procedure on the spleen - Postprocedural hemorrhage of the spleen following other procedure
    D86.0 - D86.2 - Opens in a new windowSarcoidosis of lung - Sarcoidosis of lung with sarcoidosis of lymph nodes
    D86.84Sarcoid pyelonephritis
    D86.89 - D86.9 - Opens in a new windowSarcoidosis of other sites - Sarcoidosis, unspecified
    E08.51 - E08.52 - Opens in a new windowDiabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene - Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
    E09.51 - E09.52 - Opens in a new windowDrug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene - Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
    E10.51 - E10.52 - Opens in a new windowType 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene - Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
    E11.51 - E11.52 - Opens in a new windowType 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene - Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
    E13.51 - E13.52 - Opens in a new windowOther specified diabetes mellitus with diabetic peripheral angiopathy without gangrene - Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
    E16.3 - E16.8 - Opens in a new windowIncreased secretion of glucagon - Other specified disorders of pancreatic internal secretion
    E24.0Pituitary-dependent Cushing's disease
    E24.2 - E27.9 - Opens in a new windowDrug-induced Cushing's syndrome - Disorder of adrenal gland, unspecified
    E28.2Polycystic ovarian syndrome
    E35 - E36.12 - Opens in a new windowDisorders of endocrine glands in diseases classified elsewhere - Accidental puncture and laceration of an endocrine system organ or structure during other procedure
    E74.00 - E74.09 - Opens in a new windowGlycogen storage disease, unspecified - Other glycogen storage disease
    E83.10 - E83.19 - Opens in a new windowDisorder of iron metabolism, unspecified - Other disorders of iron metabolism
    E84.0 - E85.9 - Opens in a new windowCystic fibrosis with pulmonary manifestations - Amyloidosis, unspecified
    E89.6Postprocedural adrenocortical (-medullary) hypofunction

    0 0
  • 03/29/17--00:32: CPT CODE 96910, 96912, 96920

  • CPT/HCPCS Codes:

    96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

    96912 Photochemotherapy; psoralens and ultraviolet A (PUVA)


    96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings)


    96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq. cm

    96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq. cm to 500 sq. cm


    96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq. cm



    DESCRIPTION 2014 Total  RVUs1 2013 Total RVUs2 Total RVUs % Difference 2014 payment in $ assuming 35.6653 CF3


    96900: Ultraviolet light therapy 0.58 0.65 -10.77% $20.69 $22.11 -6.46% 97,972

    96910: Photochemotherapy with uv-b 1.10 2.24 -50.89% $39.23 $76.21 -48.52% 383,029

    96912: Photochemotherapy with uv-a 1.10 2.87 -61.67% $39.23 $97.65 -59.82% 34,307


    Billing/Coding/Physician Documentation Information

    This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

    Applicable service codes: 96900, 96912, 96913, 96920, 96921, 96922 There is no specific CPT code for laser therapy for vitiligo. It should currently be reported using the unlisted CPT 96999, but the CPT codes for laser therapy for psoriasis (96920-96922) might be used. BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information neede  to make a medical necessity determination is included

    How Treatment Codes 96900, 96910, and 96912 are used: Phototherapy or light therapy, is a first-line treatment for psoriasis and involves exposing the skin to ultraviolet light B (UVB) or ultraviolet light A (UVA) on a regular basis under medical supervision. Phototherapy is one of the safest and most costeffective therapies for psoriasis and may be the only therapy option for certain subsets of psoriasis patients, i.e. children, pregnant women and immuno-suppressed patients. Both treatments work by penetrating the skin and slowing the growth of affected skin cells.

    Why is CMS proposing this change? Where CMS found reimbursements to be higher in a  non-facility setting than in a facility setting, non-facility practice expense relative value units (RVUs) were reduced toalign with the Medicare's Hospital Outpatient Prospective Payment System (OPPS) payment for the same service.4

    In other words, non-facility RVUs were capped at the OPPS level.5 RVUs are a calculation of physician work, practice expense, and malpractice expense. For services with no work RVUs (including phototherapy), CMS is proposing to compare the total non-facility PFS payment to the OPPS payment rates directly since no PFS payment is made for these services when furnished in the facility setting.


    CMS suggests that the unaligned payments are not the result of appropriate payment differentials between the services furnished in different settings. Rather, they believe it is due to anomalies in the data they use under the PFS and in the application of the resource-based practice expense (PE) methodology to the particular services.6


    Flaw with CMS rationale: The rationale underlying the phototherapy cuts in the CY 2014 Physician Fee Schedule is fundamentally flawed because the OPPS and ambulatory surgical center (ASC) fee setting does not evaluate the costs of the resources that are used to provide services and fails to recognize the extent to which a hospital or ASC may offset the costs of providing these services. OPPS and ASC fees are grouped into Ambulatory Payment Classifications (APCs) which are intended to cover the costs of providing services in those settings, but which may actually pay more or less than the costs incurred. Hospitals and ASCs are able to offset the underpaid services with those that pay more than costs that are incurred, something physicians are unable to do. There is no evidence that the fees OPPS or ASC fee schedule accurately reflect the cost of providing services, and they certainly do not reflect the cost of providing services in the physician’s office. Using APCs incomplete fees to value services that are performed 90.6% and 91.8% of  the time respectively (for codes 96910 and 96912) in a physician’s office is not in the best interest of Medicare beneficiaries.


    Likely Patient Impact: There is already a shortage of phototherapy units in the country, and these cuts would likely lead to additional closures of phototherapy units and decreased availability of these treatments, adversely affecting millions of patients. Should this treatment option disappear, many patients would be forced to go without treatment or transition to a systemic therapy that includes biologics, which can cost more than 10 times the expense of phototherapy treatments. (Phototherapy costs approximately $2,000- $3,000 a year.)


    Description CODE RULE CODE 

    96912 Incidental 96910

    96910

    96912 Incidental 96913 Rationale

    Anthem Central Region bundles 96912 as redundant/mutually exclusive to 96910. Based on the National Correct Coding Initiative Edits, code 96912 is listed as a component code to code 96910. Therefore, if 96912 is submitted with 96910—only 96910 reimburses. 

    Anthem Central Region bundles 96910 and 96912 as incidental with 96913. Procedure 96910 (Glockerman treatment) and 96912 (Ultraviolet A (PUVA) treatment) which are both components of 96913. Therefore if 96910 and /or 96912 is submitted with 96913—only 96913 reimburses.




    On a case-by-case basis, coverage consideration will be given for excimer laser treatment confined to areas of the face, neck or hands only. (Claims must be submitted using CPT codes 96920, 96921, 96922 or 96567)

    Prior to Medical Director consideration, substantiating documentation must first be submitted for review; these include:

    1. Progress notes indicative of the following:

    a. Baseline skin color.

    b. Treatment history; documented failure of adherent 3-month trial of both:

    i. high-potency (Class II steroids)

    ii. Protopic.

    c. Extent and distribution of vitiligo to the face, neck and or hands.

    2. Photographic evidence.




    Applicable Procedure Codes

    96567 Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin
    and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session

    96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

    96912 Photochemotherapy; psoralens and ultraviolet A (PUVA)

    96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to
    eight hours of care under direct supervision of the physician (includes application of medication and dressings)

    96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm

    96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm

    96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

    96999 Unlisted special dermatological service or procedure

    E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less

    E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 4 ft. panel

    E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 6 ft. panel

    E0694 Ultraviolet multidirectional light therapy system in 6 ft. cabinet, includes bulbs/lamps, timer, and eye protection

    A4633 Replacement bulb/lamp for ultraviolet light therapy system, each

    J7308 Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg)

    J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g



    0 0
  • 04/21/17--05:39: Denial code N290 AND N257


  • NPI: Troubleshooting Rejections

    Denial Reason, Reason/Remark Code(s)

    N257: Information missing/invalid in Item 33 - Missing/incomplete/invalid billing provider supplier primary identifier

    N290: Information missing/invalid in Item 24J - Missing/incomplete/invalid rendering provider primary identifier


    Resolution/Resources:

    Each NPI must match one Provider Transaction Access Number (PTAN) on the NPI crosswalk file.

    Step 1: If you contract with a billing service, find out if they have had communication with Palmetto GBA about NPI claim rejections. They may have important information that will help you resolve these claims.

    Step 2: Verify the information on file with the NPI Enumerator. Call the NPI Enumerator at 800-465-3203 or access their website external link  to verify your information.


    Pay special attention to the following fields in your NPPES record:

    Each 'sole proprietor' should have an Individual (Entity Type 1) NPI and not an Organization (Entity Type 2) NPI
    List your correct, current Medicare PTAN in the 'Other Provider Identifiers' section

    If your NPI matches a PTAN that you no longer use (e.g., an old practice location), obtain and complete a new CMS-855 application and mail it to Palmetto GBA. Applications are available from the CMS 855 form external link  from the Enrollment Application Finder tool. We will be happy to assist you if you have questions about how to complete the application.


    Step 3: If you are continuing to receive claim rejections after verifying information on file with the NPI Enumerator, verify the information you have on file with Palmetto GBA. Changes in this information require that you complete a new CMS-855 application.


    Pay special attention to the Taxpayer Identification Number (TIN), which is used to report your income to the IRS on Form 1099


    Consider consolidating multiple PTANs into a single number to ensure a one-to-one NPI to PTAN match. You may collapse PTANs that are assigned to additional locations only if the additional locations are all assigned the same TIN and are within the same pricing locality. More information about consolidating multiple PTANs is available in the CMS MLN Matters article MM5906
    Step 4: Be aware of NPIs submitted for ordering/referring providers and attending/operating/other/service facilities

    NPI numbers submitted in these fields must be valid. You may access the CMS NPI Registry to obtain these numbers.

    0 0


    CPT Code Description

    Non-Reimbursable

    99026 Hospital mandated on call service; in-hospital, each hour

    99027 Hospital mandated on call service; out-of-hospital, each hour

    99360 Standby service, requiring prolonged physician attendance, each 30 minutes (e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)


    QUESTIONS AND ANSWERS

    1 Q: If a pediatrician or other physician is requested by the delivering physician to attend at delivery and provide services to stabilize a newborn, are those services considered standby services?

    A: No. If a physician is requested by the delivering physician to attend at delivery and to provide stabilization of a newborn, the physician may bill for those direct face-to-face services provided to the newborn using CPT code 99464.


    APPLICABLE LINES OF BUSINESS/PRODUCTS

    This policy applies to Oxford Commercial plan membership.

    This reimbursement policy applies to services reported using the UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms. This policy applies to all network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified healthcare professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.



    OVERVIEW

    This reimbursement policy addresses reimbursement for standby services and hospital mandated on-call services.



    Current Procedural Terminology

    Per Current Procedural Terminology (CPT) definition, code 99360 is used to report physician or other qualified health care professional standby services that are requested by another individual that involves prolonged attendance without direct (face-to-face) patient contact. Care or services may not be provided to other patients during this period.

    This code is not used to report time spent proctoring another individual. It is also not used if the period of standby ends with the performance of a procedure subject to a surgical package by the individual who was on standby.




    REIMBURSEMENT GUIDELINES

    Centers for Medicare and Medicaid Services

    The Centers for Medicare and Medicaid Services (CMS) does not reimburse for physician standby services. These services are considered by CMS to be included in the payment to a facility as part of providing quality care and are not separately reimbursable.

    Standby Services

    In accordance with CMS, Oxford does not reimburse physician or other qualified health care professional standby services submitted with CPT code 99360. If a specific service is directly rendered to the patient by the standby physician or other qualified health care professional (i.e., tissue examination of frozen section biopsy), the service or procedure would be reported under the appropriate CPT code (i.e., 88331).


    Mandated Hospital On-Call Service 

    Oxford does not reimburse for hospital mandated on-call services billed under CPT codes 99026 and 99027 because they do not involve direct patient contact.

    0 0

    REIMBURSEMENT GUIDELINES

    Time Span Codes

    Oxford will reimburse a CPT or HCPCS Level II code that specifies a time period for which it should be reported (e.g., weekly, monthly), once during that time period. The time period is based on sourcing from the AMA or CMS including: the CPT or HCPCS code description, CPT book parentheticals and other coding guidance in the CPT book, other AMA publications or CMS publications.

    For example: Within the CPT book, the code description for CPT code 95250 states, “Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording”. In addition to that code description, there is also a parenthetical that provides further instructions with regard to the frequency the code can be reported. The parenthetical states, “Do not report 95250 more than once per month”. Oxford will reimburse CPT Code 95250 only once per month for the same member, for services provided by the Same Group Physician and/or Other Health Care Professional. In order to consider reimbursement for these services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

    CPT coding guidelines specify for physicians or other qualified health care professionals to select the name of the procedure or service that accurately identifies the services performed.



    End-Stage Renal Disease Services (ESRD) 90951-90962 

    CPT codes 90951-90962 are grouped by age of the patient and the number of face-to-face physician or other qualified health care professional visits provided per month (i.e., 1, 2-3, or 4 or more). Oxford will reimburse the single most comprehensive outpatient ESRD code submitted per age category (i.e., under 2 years of age, 2-11 years of age, 11- 19 years of age, and 20 years of age and older) once per month. This aligns with CPT coding guidance which states to report the age-specific ESRD codes should be reported once per month for all physician or other health care professional face-to-face outpatient services.




    Time Span Comprehensive and Component Codes

    When related Time Span Codes which share a common portion of a code description are both reported during the same time span period by the Same Group Physicians and/or Other Health Care Professional for the same patient, the code with the most comprehensive description is the reimbursable service. The other code is considered inclusive and is not a separately reimbursable service. No modifiers will override this denial. The following example illustrates how the CPT book lists code 93268 first as it is the comprehensive code. CPT codes 93270, 93271, and 93272 are indented and each share a common component of their code description with CPT code 93268.


    When CPT code 93270, 93271, or 93272 are reported with CPT 93268 during the same 30 day period by the Same Group Physician and/or Other Health Care Professional for the same patient, only CPT code 93268 is the reimbursable service.

    The Time Span Comprehensive and Component Codes list includes applicable comprehensive and related component Time Span Codes.

    DEFINITIONS Calendar Month: Oxford defines Calendar Month as the time span referring to an individually named month of the year, (e.g., January, February) and includes codes with Calendar Month in their description.



    Same Group Physician and/or Other Health Care Professional: All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

    Time Span Code: A CPT or HCPCS code that specifies a time period for which it should be reported (e.g., weekly, monthly).



    APPLICABLE CODES

    The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.


    CPT Code Description

    93268

    External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation 93270 Recording (includes connection, recording, and disconnection) 93271 Transmission and analysis

    93272 Review and interpretation by a physician or other qualified health care professional CPT® is a registered trademark of the American Medical Association QUESTIONS AND ANSWERS



    1 Q: How does Oxford determine the “time span” for codes with a description of calendar month, per month or monthly?

    A: The date of service (DOS) is the reference point for determining the frequency of code submission and subsequent reimbursement during that period. See the examples below: Calendar Month

    CPT code 94005 (home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more) is submitted March 13. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on April 5. Both codes are considered eligible for reimbursement as a Time Span Code because the service was provided in a different Calendar Month.


    Per Month/or Monthly

    HCPCS code A4595 [Electrical stimulator supplies, 2 lead, per month, (e.g. tens, nmes)] is submitted August 31. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on September 30. Both codes are considered eligible for reimbursement.

    In order to consider reimbursement for services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

    2 Q: Does Oxford recognize modifiers, (e.g., 59, 76), through the Time Span Codes Policy to allow reimbursement for additional submissions of a code within the designated time span?

    A: No. Reimbursement for codes included in the Time Span Codes Policy is based on the time span parameter specified in the code description, CPT book parentheticals and/or other coding guidance from the AMA or CMS.

    0 0

    36005 Injection procedure for extremity venography 0.95 $328 $50

    36010 Introduction of catheter, superior or inferior vena cava 2.18 $492 $114

    36011 Selective catheter placement, venous system; first order branch 3.14 $842 $164

    36012 Second order, or more selective, branch 3.51 $868 $181


    Insertion 33282 Implantation of patient-activated cardiac event recorder Removal 33284 Removal of an implantable, patient-activated cardiac event recorder


    CPT code 36005 (injection procedure for extremity venography (including introduction of needle or intracatheter)) should not be utilized to report venous catheterization unless it is for the purpose of an injection procedure for extremity venography. Some physicians have misused this code to report any type of venous catheterization.

    Reimbursement and Billing Instructions

    The procedure code for the implantation of the patient-activated event recorder – ILR is CPT code 33282.The code for the removal of this device is 33284. These procedure codes have a 90-day global postoperative care designation for which care related to the surgical procedure is not separately reimbursable unless such care is nonroutine, such as treatment of complications. Note that removal of a patient-activated event recorder – ILR on the same day as the insertion of a cardiac pacemaker is considered part of the pacemaker insertion procedure and is not reimbursed separately.

    Table 9 illustrates billing instructions for each place of service:

    * If the procedure is performed when the patient is an inpatient for a related problem, submit an institutional claim (UB-04 claim form or electronic equivalent) using a medically necessary diagnosis code.

    * If the procedure is performed on an outpatient basis, submit an institutional claim (UB-04 claim form or electronic equivalent) using revenue code 360 and CPT code 33282 for implantation. The facility should bill for the device itself on a professional claim (CMS-1500 claim form or electronic equivalent) using HCPCS code E0616 with medically necessary primary diagnosis codes. Use CPT code 33284 with revenue code 360 to bill for removal of the device. Physician’s charges for the surgery should be billed by the physician on a professional claim.

    * If the procedure is performed in a physician’s office, the physician should bill CPT code 33282 for implantation and E0616 for the device. Both codes are billed on a professional claim (CMS-1500 claim form or electronic equivalent). 

    Type of Claim Institutional Institutional (and professional, if billing for device) Professional Revenue and

    CPT Codes Revenue code 360

    CPT code not needed Revenue code 360

    CPT code 33282 for insertion

    CPT code 33284 for removal Revenue code not applicable

    CPT code 33282 for insertion

    CPT code 33284 for removal

    HCPCS Code Not needed On professional claim – E0616 On institutional claim – Not needed E0616

    Note: Institutional claim formats include the UB-04 paper claim form, the 837I electronic transaction, and the institutional claim type on the Provider Healthcare Portal. Professional claim formats include the CMS-1500 paper claim form, the 837P electronic transaction, and the professional claim type on the Provider Healthcare Portal



    Billing/Coding/Physician Documentation Information

    This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

    Applicable codes: 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 33282, 33284, E0616,0295T, 0296T, 0297T, 0298T

    BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.


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    Revenue Code Description

    Home Health Care Visits

    0642 Home iv therapy services-iv site care, central line

    0643 Home iv therapy services- IV start/change, peripheral line

    0644 Home iv therapy services-non-routine nursing, peripheral line

    0645 Home iv therapy services-training patient/caregiver, central line

    0646 Home iv therapy services-training, disabled patient, central line

    0647 Home iv therapy services-training, patient/caregiver, peripheral line

    0648 Home iv therapy services-training, disabled patient, peripheral line

    0649 Home iv therapy services-other iv therapy services

    Therapy by a Home Health Care Agency/Facility

    Coding Clarification: These codes apply to the Home Health Care Visit limit with the following Bill Type:

    • 032x : Home health - Home Health Services under a plan of treatment

    * 034x : Home health - Home Health Services not under a plan of treatment

    0420 Physical therapy-general

    0421 Physical therapy-visit charge

    0422 Physical therapy-hourly charge

    0423 Physical therapy-group rate

    0424 Physical therapy-evaluation or reevaluation

    0429 Physical therapy-other physical therapy

    0430 Occupational therapy-general

    0431 Occupational therapy-visit charge

    0432 Occupational therapy-hourly charge

    0433 Occupational therapy-group rate

    0434 Occupational therapy-evaluation or reevaluation

    0439 Occupational therapy-other occupational therapy

    0440 Speech therapy-language pathology-general

    0441 Speech therapy-language pathology-visit charge

    0442 Speech therapy-language pathology-hourly charge

    0443 Speech therapy-language pathology-group rate

    0444 Speech therapy-language pathology-evaluation or reevaluation

    0449 Speech therapy-language pathology-other speech-language pathology


    Hemophilia

    For coverage of assisted administration of clotting factors and coagulant blood products, refer to the policy titled Assisted Administration of Clotting Factors and Coagulant Blood Products. For coverage of clotting factor and coagulant blood products, refer to the policy titled Clotting Factors and Coagulant Blood Products.

    Essential Health Benefits for Individual and Small Group

    For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.



    COVERAGE RATIONALE

    Indications for Coverage

    The services being requested must meet all of the following:

    ** Be ordered and directed by a treating practitioner or specialist (M.D., D.O., P.A. or N.P); and

    ** The care must be delivered or supervised by a licensed professional in order to obtain a specified medical outcome; and

    ** Services must be skilled care in nature (refer to the policy titled Skilled Care and Custodial Care Services and the Definitions section below); and

    ** Services must be intermittent and part time (typically provided for less than 4 hours per day; refer to the member specific benefit plan document for intermittent definitions, if provided); and

    ** Services are provided in the home in lieu of skilled care in another setting (such as but not limited to a nursing facility, acute inpatient rehabilitation or a hospital); and

    ** Services must be clinically appropriate and not more costly than an alternative health services; and

    ** A written treatment plan must be submitted with the request for specific services and supplies’ periodic review of the written treatment plan may be required for continued Skilled Care needs and progress toward goals; and

    ** Services are not provided for the comfort and convenience of the member or the member’s family; and

    ** Services are not custodial care in nature. Medical Necessity Plans

    Use the criteria above where applicable.

    Additional Information

    ** Medical supplies and medications that are used in conjunction with a home health care visit are covered as part of
    that visit. Some examples are, but not limited to, surgical dressing, catheters, syringes, irrigation devices.

    Reimbursement for home health care visits and supplies are contractually determined. ** Eligible physical, occupational and speech therapy received in the home from a Home Health Agency is covered under the Home Health Care section of the member’s certificate of coverage and/or summary of benefits. The Home Health Care section only applies to services that are rendered by a Home Health Agency.





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  • 09/19/17--04:46: icd 10 code for dermatitis

  • Viral infections characterized by skin and mucous membrane lesions (B00-B09) 

    B00 Herpesviral [herpes simplex] infections

    Excludes1: congenital herpesviral infections (P35.2)

    Excludes2: anogenital herpesviral infection (A60.-) gammaherpesviral mononucleosis (B27.0-) herpangina (B08.5)

    B00.0 Eczema herpeticum Kaposi's varicelliform eruption

    B00.1 Herpesviral vesicular dermatitis

    Herpes simplex facialis
    Herpes simplex labialis
    Herpes simplex otitis externa
    Vesicular dermatitis of ear
    Vesicular dermatitis of lip

    B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis Herpesviral pharyngitis
    B00.3 Herpesviral meningitis
    B00.4 Herpesviral encephalitis Herpesviral meningoencephalitis Simian B disease Excludes1: herpesviral encephalitis due to herpesvirus 6 and 7 (B10.01,
    B10.09) non-simplex herpesviral encephalitis (B10.0-)
    B00.5 Herpesviral ocular disease
    B00.50 Herpesviral ocular disease, unspecified
    B00.51 Herpesviral iridocyclitis Herpesviral iritis  Herpesviral uveitis, anterior
    B00.52 Herpesviral keratitis Herpesviral keratoconjunctivitis
    B00.53 Herpesviral conjunctivitis
    B00.59 Other herpesviral disease of eye Herpesviral dermatitis of eyelid
    B00.7 Disseminated herpesviral disease Herpesviral sepsis
    B00.8 Other forms of herpesviral infections
    B00.81 Herpesviral hepatitis
    B00.82 Herpes simplex myelitis
    B00.89 Other herpesviral infection Herpesviral whitlow
    B00.9 Herpesviral infection, unspecified Herpes simplex infection NOS
    B08 Other viral infections characterized by skin and mucous membrane lesions, not elsewhere classified

    Excludes1: vesicular stomatitis virus disease (A93.8)

    B08.0 Other orthopoxvirus infections

    Excludes2: monkeypox (B04)

    B08.01 Cowpox and vaccinia not from vaccine
    B08.010 Cowpox
    B08.011 Vaccinia not from vaccine Excludes1: vaccinia (from vaccination) (generalized) (T88.1)
    B08.02 Orf virus disease Contagious pustular dermatitis Ecthyma contagiosum
    B08.03 Pseudocowpox [milker's node]
    B08.04 Paravaccinia, unspecified
    B08.09 Other orthopoxvirus infections Orthopoxvirus infection NOS
    B08.1 Molluscum contagiosum
    B08.2 Exanthema subitum [sixth disease] Roseola infantum
    B08.20 Exanthema subitum [sixth disease], unspecified Roseola infantum, unspecified
    B08.21 Exanthema subitum [sixth disease] due to human herpesvirus 6 Roseola infantum due to human herpesvirus 6

    B37 Candidiasis Includes: candidosis moniliasis

    Excludes1: neonatal candidiasis (P37.5)
    B37.0 Candidal stomatitis Oral thrush
    B37.1 Pulmonary candidiasis Candidal bronchitis Candidal pneumonia
    B37.2 Candidiasis of skin and nail Candidal onychia Candidal paronychia

    Excludes2: diaper dermatitis (L22)

    B37.3 Candidiasis of vulva and vagina Candidal vulvovaginitis Monilial vulvovaginitis Vaginal thrush
    B37.4 Candidiasis of other urogenital sites
    B37.41 Candidal cystitis and urethritis
    B37.42 Candidal balanitis
    B37.49 Other urogenital candidiasis Candidal pyelonephritis
    B37.5 Candidal meningitis
    B37.6 Candidal endocarditis
    B37.7 Candidal sepsis Disseminated candidiasis Systemic candidiasis
    B37.8 Candidiasis of other sites
    B37.81 Candidal esophagitis
    B37.82 Candidal enteritis Candidal proctitis
    B37.83 Candidal cheilitis
    B37.84 Candidal otitis externa
    B37.89 Other sites of candidiasis Candidal osteomyelitis
    B37.9 Candidiasis, unspecified Thrush NOS

    Helminthiases (B65-B83)

    B65 Schistosomiasis [bilharziasis]

    Includes: snail fever

    B65.0 Schistosomiasis due to Schistosoma haematobium [urinary schistosomiasis]
    B65.1 Schistosomiasis due to Schistosoma mansoni [intestinal schistosomiasis]
    B65.2 Schistosomiasis due to Schistosoma japonicum Asiatic schistosomiasis
    B65.3 Cercarial dermatitis Swimmer's itch
    B65.8 Other schistosomiasis
    Infection due to Schistosoma intercalatum
    Infection due to Schistosoma mattheei
    Infection due to Schistosoma mekongi

    B65.9 Schistosomiasis, unspecified

    B88 Other infestations
    B88.0 Other acariasis
    Acarine dermatitis
    Dermatitis due to Demodex species
    Dermatitis due to Dermanyssus gallinae
    Dermatitis due to Liponyssoides sanguineus
    Trombiculosis

    Excludes2: scabies (B86)

    B88.1 Tungiasis [sandflea infestation]

    B88.2 Other arthropod infestations Scarabiasis

    B88.3 External hirudiniasis Leech infestation NOS

    Excludes2: internal hirudiniasis (B83.4)
    B88.8 Other specified infestations Ichthyoparasitism due to Vandellia cirrhosa Linguatulosis Porocephaliasis
    B88.9 Infestation, unspecified Infestation (skin) NOS Infestation by mites NOS Skin parasites NOS

    D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified
    D89.81 Graft-versus-host disease Code first underlying cause, such as: complications of transplanted organs and tissue (T86.-) complications of blood transfusion (T80.89)

    Use additional code to identify associated manifestations, such as: desquamative dermatitis (L30.8) diarrhea (R19.7) elevated bilirubin (R17) hair loss (L65.9)

    D89.810 Acute graft-versus-host disease
    D89.811 Chronic graft-versus-host disease
    D89.812 Acute on chronic graft-versus-host disease
    D89.813 Graft-versus-host disease, unspecified
    D89.82 Autoimmune lymphoproliferative syndrome [ALPS]
    D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified
    Excludes1: human immunodeficiency virus disease (B20)
    D89.9 Disorder involving the immune mechanism, unspecified

    Immune disease NOS

    E08.6 Diabetes mellitus due to underlying condition with other specified complications
    E08.61 Diabetes mellitus due to underlying condition with diabetic arthropathy
    E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy Diabetes mellitus due to underlying condition with Charcot's joints
    E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy
    E08.62 Diabetes mellitus due to underlying condition with skin complications
    E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis Diabetes mellitus due to underlying condition with diabetic necrobiosis lipoidica
    E08.621 Diabetes mellitus due to underlying condition with foot ulcer Use additional code to identify site of ulcer (L97.4-, L97.5-)
    E08.622 Diabetes mellitus due to underlying condition with other skin ulcer Use additional code to identify site of ulcer (L97.1-
    L97.9, L98.41-L98.49)
    E08.628 Diabetes mellitus due to underlying condition with other skin complications
    E08.63 Diabetes mellitus due to underlying condition with oral complications
    E08.630 Diabetes mellitus due to underlying condition with periodontal disease
    E08.638 Diabetes mellitus due to underlying condition with other oral complications
    E08.64 Diabetes mellitus due to underlying condition with hypoglycemia
    E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
    E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma

    E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
    E08.69 Diabetes mellitus due to underlying condition with other specified complication Use additional code to identify complication
    E08.8 Diabetes mellitus due to underlying condition with unspecified complications
    E08.9 Diabetes mellitus due to underlying condition without complications

    E10.6 Type 1 diabetes mellitus with other specified complications
    E10.61 Type 1 diabetes mellitus with diabetic arthropathy
    E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy

    Type 1 diabetes mellitus with Charcot's joints

    E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
    E10.62 Type 1 diabetes mellitus with skin complications
    E10.620 Type 1 diabetes mellitus with diabetic dermatitis Type 1 diabetes mellitus with diabetic necrobiosis lipoidica
    E10.621 Type 1 diabetes mellitus with foot ulcer Use additional code to identify site of ulcer (L97.4-, L97.5-)
    E10.622 Type 1 diabetes mellitus with other skin ulcer Use additional code to identify site of ulcer (L97.1-
    L97.9, L98.41-L98.49)
    E10.628 Type 1 diabetes mellitus with other skin complications
    E10.63 Type 1 diabetes mellitus with oral complications
    E10.630 Type 1 diabetes mellitus with periodontal disease
    E10.638 Type 1 diabetes mellitus with other oral complications
    E10.64 Type 1 diabetes mellitus with hypoglycemia
    E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
    E10.649 Type 1 diabetes mellitus with hypoglycemia without coma

    E13.6 Other specified diabetes mellitus with other specified complications

    E13.61 Other specified diabetes mellitus with diabetic arthropathy

    E13.610 Other specified diabetes mellitus with
    diabetic neuropathic arthropathy
    Other specified diabetes mellitus with Charcot's joints

    E13.618 Other specified diabetes mellitus with other diabetic arthropathy

    E13.62 Other specified diabetes mellitus with skin complications

    E13.620 Other specified diabetes mellitus with diabetic dermatitis Other specified diabetes mellitus with diabetic necrobiosis lipoidica
    E13.621 Other specified diabetes mellitus with foot ulcer Use additional code to identify site of ulcer (L97.4-, L97.5-)
    E13.622 Other specified diabetes mellitus with other skin ulcer Use additional code to identify site of ulcer (L97.1- L97.9, L98.41-L98.49)
    E13.628 Other specified diabetes mellitus with other skin complications
    E13.63 Other specified diabetes mellitus with oral complications
    E13.630 Other specified diabetes mellitus with periodontal disease
    E83.1 Disorders of iron metabolism
    Excludes1: iron deficiency anemia (D50.-) sideroblastic anemia (D64.0-D64.3)
    E83.10 Disorder of iron metabolism, unspecified
    E83.11 Hemochromatosis
    E83.19 Other disorders of iron metabolism
    E83.2 Disorders of zinc metabolism Acrodermatitis enteropathica
    E83.3 Disorders of phosphorus metabolism and phosphatases

    Excludes1: adult osteomalacia (M83.-) osteoporosis (M80-)

    E83.30 Disorder of phosphorus metabolism, unspecified

    E83.31 Familial hypophosphatemia

    Vitamin D-resistant osteomalacia
    Vitamin D-resistant rickets

    Excludes1: vitamin D-deficiency rickets (E55.0)

    E83.32 Hereditary vitamin D-dependent rickets (type 1) (type 2) 25-hydroxyvitamin D 1-alpha-hydroxylase deficiency Pseudovitamin D deficiency Vitamin D receptor defect

    E83.39 Other disorders of phosphorus metabolism
    Acid phosphatase deficiency Hypophosphatasia

    E83.4 Disorders of magnesium metabolism
    E83.40 Disorders of magnesium metabolism, unspecified
    E83.41 Hypermagnesemia
    E83.42 Hypomagnesemia
    E83.49 Other disorders of magnesium metabolism
    E83.5 Disorders of calcium metabolism

    Excludes1: chondrocalcinosis (M11.1-M11.2) hungry bone syndrome (E83.81) hyperparathyroidism (E21.0-E21.3)

    E83.50 Unspecified disorder of calcium metabolism
    E83.51 Hypocalcemia
    E83.52 Hypercalcemia Familial hypocalciuric hypercalcemia
    E83.59 Other disorders of calcium metabolism Idiopathic hypercalciuria
    E83.8 Other disorders of mineral metabolism
    E83.81 Hungry bone syndrome
    E83.89 Other disorders of mineral metabolism
    E83.9 Disorder of mineral metabolism, unspecified
    F54 Psychological and behavioral factors associated with
    disorders or diseases classified elsewhere
    Psychological factors affecting physical conditions

    Code first the associated physical disorder, such as:

    asthma (J45.-)
    dermatitis (L23-L25)
    gastric ulcer (K25.-)
    mucous colitis (K58.-)
    ulcerative colitis (K51.-)
    urticaria (L50.-)

    Excludes2: tension-type headache (G44.2)

    F68 Other disorders of adult personality and behavior

    F68.1 Factitious disorder Compensation neurosis

    Elaboration of physical symptoms for psychological reasons Hospital hopper syndrome M?nchhausen's syndrome Peregrinating patient

    Excludes2: factitial dermatitis (L98.1) person feigning illness (with obvious motivation) (Z76.5)

    F68.10 Factitious disorder, unspecified

    F68.11 Factitious disorder with predominantly psychological signs and symptoms

    F68.12 Factitious disorder with predominantly physical signs and symptoms

    F68.13 Factitious disorder with combined psychological and physical signs and symptoms

    F68.8 Other specified disorders of adult personality and behavior

    H01.1 Noninfectious dermatoses of eyelid

    H01.11 Allergic dermatitis of eyelid Contact dermatitis of eyelid

    H01.111 Allergic dermatitis of right upper eyelid
    H01.112 Allergic dermatitis of right lower eyelid
    H01.113 Allergic dermatitis of right eye, unspecified eyelid
    H01.114 Allergic dermatitis of left upper eyelid
    H01.115 Allergic dermatitis of left lower eyelid
    H01.116 Allergic dermatitis of left eye, unspecified eyelid
    H01.119 Allergic dermatitis of unspecified eye, unspecified eyelid
    H01.12 Discoid lupus erythematosus of eyelid
    H01.121 Discoid lupus erythematosus of right upper eyelid
    H01.122 Discoid lupus erythematosus of right lower eyelid
    H01.123 Discoid lupus erythematosus of right eye, unspecified eyelid
    H01.124 Discoid lupus erythematosus of left upper eyelid
    H01.125 Discoid lupus erythematosus of left lower eyelid
    H01.126 Discoid lupus erythematosus of left eye, unspecified eyelid
    H01.129 Discoid lupus erythematosus of unspecified eye, unspecified eyelid
    H01.13 Eczematous dermatitis of eyelid
    H01.131 Eczematous dermatitis of right upper eyelid
    H01.132 Eczematous dermatitis of right lower eyelid
    H01.133 Eczematous dermatitis of right eye, unspecified eyelid
    H01.134 Eczematous dermatitis of left upper eyelid
    H01.135 Eczematous dermatitis of left lower eyelid
    H01.136 Eczematous dermatitis of left eye, unspecified eyelid
    H01.139 Eczematous dermatitis of unspecified eye, unspecified eyelid
    H01.14 Xeroderma of eyelid
    H01.141 Xeroderma of right upper eyelid
    H01.142 Xeroderma of right lower eyelid
    H01.143 Xeroderma of right eye, unspecified eyelid
    H01.144 Xeroderma of left upper eyelid
    H01.145 Xeroderma of left lower eyelid
    H01.146 Xeroderma of left eye, unspecified eyelid
    H01.149 Xeroderma of unspecified eye, unspecified eyelid
    H01.8 Other specified inflammations of eyelid
    H61 Other disorders of external ear
    H61.0 Chondritis and perichondritis of external ear Chondrodermatitis nodularis chronica helicis

    Perichondritis of auricle
    Perichondritis of pinna

    H61.00 Unspecified perichondritis of external ear
    H61.001 Unspecified perichondritis of right external ear
    H61.002 Unspecified perichondritis of left external ear
    H61.003 Unspecified perichondritis of external ear, bilateral
    H61.009 Unspecified perichondritis of external ear, unspecified ear
    H61.01 Acute perichondritis of external ear
    H61.011 Acute perichondritis of right external ear
    H61.012 Acute perichondritis of left external ear
    H61.013 Acute perichondritis of external ear, bilateral
    H61.019 Acute perichondritis of external ear, unspecified ear
    H61.02 Chronic perichondritis of external ear
    I83.1 Varicose veins of lower extremities with inflammation Stasis dermatitis
    I83.10 Varicose veins of unspecified lower extremity with inflammation
    I83.11 Varicose veins of right lower extremity with inflammation
    I83.12 Varicose veins of left lower extremity with inflammation
    L10-L14 Bullous disorders
    L20-L30 Dermatitis and eczema
    L40-L45 Papulosquamous disorders
    L49-L54 Urticaria and erythema
    L55-L59 Radiation-related disorders of the skin and subcutaneous tissue
    L60-L75 Disorders of skin appendages
    L76 Intraoperative and postprocedural complications of skin and subcutaneous tissue

    L80-L99 Other disorders of the skin and subcutaneous tissue

    Infections of the skin and subcutaneous tissue (L00- L08)

    Use additional code (B95-B97) to identify infectious agent.

    Excludes2: hordeolum (H00.0)

    infective dermatitis (L30.3)

    local infections of skin classified in Chapter 1

    lupus panniculitis (L93.2)

    panniculitis NOS (M79.3)

    panniculitis of neck and back (M54.0-)

    perl?che NOS (K13.0)

    perl?che due to candidiasis (B37.0)

    perl?che due to riboflavin deficiency (E53.0)

    pyogenic granuloma (L98.0)

    relapsing panniculitis [Weber-Christian] (M35.6)

    viral warts (B07.-)

    zoster (B02.-) 

    L08.0 Pyoderma Purulent dermatitis Septic dermatitis Suppurative dermatitis

    Excludes1: pyoderma gangrenosum (L88) pyoderma vegetans (L08.81)

    L12 Pemphigoid

    Excludes1: herpes gestationis (O26.4-) impetigo herpetiformis (L40.1)

    L12.0 Bullous pemphigoid

    L12.1 Cicatricial pemphigoid Benign mucous membrane pemphigoid

    L12.2 Chronic bullous disease of childhood Juvenile dermatitis herpetiformis

    L12.3 Acquired epidermolysis bullosa

    Excludes1: epidermolysis bullosa (congenital) (Q81.-)

    L12.30 Acquired epidermolysis bullosa, unspecified

    L12.31 Epidermolysis bullosa due to drug

    Code first (T36-T50) to identify drug

    L12.35 Other acquired epidermolysis bullosa

    L12.8 Other pemphigoid

    L12.9 Pemphigoid, unspecified

    L13 Other bullous disorders

    L13.0 Dermatitis herpetiformis Duhring's disease

    Hydroa herpetiformis

    Excludes1: juvenile dermatitis herpetiformis (L12.2) senile dermatitis herpetiformis (L12.0)

    L13.1 Subcorneal pustular dermatitis Sneddon-Wilkinson disease

    L13.8 Other specified bullous disorders

    L13.9 Bullous disorder, unspecified  Dermatitis and eczema (L20-L30)

    Note: In this block the terms dermatitis and eczema are used synonymously and interchangeably.

    Excludes2: chronic (childhood) granulomatous disease (D71)

    dermatitis gangrenosa (L88)

    dermatitis herpetiformis (L13.0)

    dry skin dermatitis (L85.3)

    factitial dermatitis (L98.1)

    perioral dermatitis (L71.0)

    radiation-related disorders of the skin and subcutaneous tissue (L55-L59) stasis dermatitis (I83.1-I83.2)

    L20 Atopic dermatitis

    L20.0 Besnier's prurigo

    L20.8 Other atopic dermatitis

    Excludes2: circumscribed neurodermatitis (L28.0)

    L20.81 Atopic neurodermatitis Diffuse neurodermatitis

    L20.82 Flexural eczema

    L20.83 Infantile (acute) (chronic) eczema

    L20.84 Intrinsic (allergic) eczema

    L20.89 Other atopic dermatitis

    L20.9 Atopic dermatitis, unspecified

    L21 Seborrheic dermatitis

    Excludes2: infective dermatitis (L30.3)

    seborrheic keratosis (L82.-)

    L21.0 Seborrhea capitis Cradle cap

    L21.1 Seborrheic infantile dermatitis

    L21.8 Other seborrheic dermatitis

    L21.9 Seborrheic dermatitis, unspecified

    Seborrhea NOS

    L22 Diaper dermatitis

    Includes: Diaper erythema

    Diaper rash

    Psoriasiform diaper rash

    L23 Allergic contact dermatitis

    Code first (T36-T65), to identify drug or substance

    Excludes1: allergy NOS (T78.40)

    contact dermatitis NOS (L25.9)

    dermatitis NOS (L30.9)

    Excludes2: dermatitis due to substances taken internally (L27.-)

    dermatitis of eyelid (H01.1-)

    diaper dermatitis (L22)

    eczema of external ear (H60.5-)

    irritant contact dermatitis (L24.-)

    perioral dermatitis (L71.0)

    radiation-related disorders of the skin and subcutaneous tissue (L55- L59)

    L23.0 Allergic contact dermatitis due to metals

    Allergic contact dermatitis due to chromium

    Allergic contact dermatitis due to nickel

    L23.1 Allergic contact dermatitis due to adhesives

    L23.2 Allergic contact dermatitis due to cosmetics

    L23.3 Allergic contact dermatitis due to drugs in contact with skin

    Excludes2: dermatitis due to ingested drugs and medicaments (L27.0- L27.1)

    L23.4 Allergic contact dermatitis due to dyes

    L23.5 Allergic contact dermatitis due to other chemical products

    Allergic contact dermatitis due to cement

    Allergic contact dermatitis due to insecticide

    Allergic contact dermatitis due to plastic

    Allergic contact dermatitis due to rubber

    L23.6 Allergic contact dermatitis due to food in contact with the skin

    Excludes2: dermatitis due to ingested food (L27.2)

    L23.7 Allergic contact dermatitis due to plants, except food

    Excludes2: allergy NOS due to pollen (J30.1)

    L23.8 Allergic contact dermatitis due to other agents

    L23.81 Allergic contact dermatitis due to animal (cat) (dog) dander

    Allergic contact dermatitis due to animal (cat) (dog) hair

    L23.89 Allergic contact dermatitis due to other agents

    L23.9 Allergic contact dermatitis, unspecified cause

    Allergic contact eczema NOS

    L24 Irritant contact dermatitis

    Code first (T36-T65) to identify drug or substance

    Excludes1: allergy NOS (T78.40)

    contact dermatitis NOS (L25.9)

    dermatitis NOS (L30.9)

    Excludes2: allergic contact dermatitis (L23.-)

    dermatitis due to substances taken internally (L27.-)

    dermatitis of eyelid (H01.1-)

    diaper dermatitis (L22)

    eczema of external ear (H60.5-)

    perioral dermatitis (L71.0)

    radiation-related disorders of the skin and subcutaneous tissue (L55- L59)

    L24.0 Irritant contact dermatitis due to detergents

    L24.1 Irritant contact dermatitis due to oils and greases

    L24.2 Irritant contact dermatitis due to solvents

    Irritant contact dermatitis due to chlorocompound

    Irritant contact dermatitis due to cyclohexane

    Irritant contact dermatitis due to ester

    Irritant contact dermatitis due to glycol

    Irritant contact dermatitis due to hydrocarbon

    Irritant contact dermatitis due to ketone

    L24.3 Irritant contact dermatitis due to cosmetics

    L24.4 Irritant contact dermatitis due to drugs in contact with skin

    L24.5 Irritant contact dermatitis due to other chemical products

    Irritant contact dermatitis due to cement

    Irritant contact dermatitis due to insecticide

    Irritant contact dermatitis due to plastic

    Irritant contact dermatitis due to rubber

    L24.6 Irritant contact dermatitis due to food in contact with skin

    Excludes2: dermatitis due to ingested food (L27.2)

    L24.7 Irritant contact dermatitis due to plants, except food

    Excludes2: allergy NOS to pollen (J30.1)

    L24.8 Irritant contact dermatitis due to other agents

    L24.81 Irritant contact dermatitis due to metals

    Irritant contact dermatitis due to chromium

    Irritant contact dermatitis due to nickel

    L24.89 Irritant contact dermatitis due to other agents Irritant contact dermatitis due to dyes

    L24.9 Irritant contact dermatitis, unspecified cause Irritant contact eczema NOS

    L25 Unspecified contact dermatitis

    Code first (T36-T65), to identify drug or substance

    Excludes1: allergic contact dermatitis (L23.-)

    allergy NOS (T78.40)

    dermatitis NOS (L30.9)

    irritant contact dermatitis (L24.-)

    Excludes2: dermatitis due to ingested substances (L27.-)

    dermatitis of eyelid (H01.1-)

    eczema of external ear (H60.5-)

    perioral dermatitis (L71.0)

    radiation-related disorders of the skin and subcutaneous tissue (L55- L59)

    L25.0 Unspecified contact dermatitis due to cosmetics

    L25.1 Unspecified contact dermatitis due to drugs in contact with skin

    Excludes2: dermatitis due to ingested drugs and medicaments (L27.0- L27.1)

    L25.2 Unspecified contact dermatitis due to dyes

    L25.3 Unspecified contact dermatitis due to other chemical products

    Unspecified contact dermatitis due to cement

    Unspecified contact dermatitis due to insecticide

    L25.4 Unspecified contact dermatitis due to food in contact with skin

    Excludes2: dermatitis due to ingested food (L27.2)
    L25.5 Unspecified contact dermatitis due to plants, except food

    Excludes1: nettle rash (L50.9)

    Excludes2: allergy NOS due to pollen (J30.1)

    L25.8 Unspecified contact dermatitis due to other agents
    L25.9 Unspecified contact dermatitis, unspecified cause
    Contact dermatitis (occupational) NOS
    Contact eczema (occupational) NOS



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    BILLING INSTRUCTIONS FOR HOSPICE CLAIM COMPLETION

    Use UB 04 form

    * Admission Date: Include the admission date for hospice care.

    * Inpatient Respite Care: "Occurrence Span Code" - include occurrence span code M2 and complete the "from and through" dates for an episode of inpatient respite care.

    * Core Based Statistical Area (CBSA): "Value Codes" - include value code 61 in the value code field and report the CBSA number. Hospice claims must be reported with a valid CBSA code based on the location of the beneficiary receiving services.

    * Use the Revenue Codes listed below:

    Revenue Code Description

    0651 Routine Home Care I

    0652 Continuous Home Care

    0655 Inpatient Respite Care

    0656 General Inpatient Care

    0657 Physician Services

    0658 Other Hospice I (Room & Board)

    0659 Other Hospice Service – Facility Innovative Design


    Supplemental (FIDS) Bed

    * To bill for room and board in a nursing facility, licensed hospice long-term care unit, or Ventilator Dependent Care Unit (VDCU), use Revenue Code 0658. Providers must bill their customary room and board rate and Medicaid pays the usual and customary rate or the Medicaid fee screen, whichever is less. Room and board is reimbursable on the day of discharge if the discharge is due to resident death or the resident is discharged from hospice but remains in the NF. NOTE:

    To ensure proper payment for a beneficiary in a VDCU, the VDCU provider identification number must be on the Hospice Membership Notice (DCH-1074). When a beneficiary resides in a VDCU/Dialysis Unit under which the VDCU has a special agreement with Medicaid and elects hospice, a prior authorization (PA) number for hospice is not required.

    * To bill for room and board in a nursing facility when the beneficiary resides in a Facility Innovative Design Supplemental (FIDS) bed, use Revenue Code 0659.

    * Revenue Code 0657 Physician Services requires inclusion of a HCPCS code on the claim line. Each Physician service must be billed on a separate claim line.

    * Revenue Code 0652 Continuous Home Care must be billed for each date of service on separate claim lines. To receive the Continuous Home Care rate under code 0652, a minimum of 8 hours1 of care, not necessarily consecutive, in a 24-hour period is required. Less than 8 hours is reported under code 0651. A portion of an hour counts as an hour for this determination.

    * Hospital Leave Days must be billed using Revenue Code 0185 (must not exceed 10 consecutive days). Reimbursement is at 100 percent of class-wide Nursing Facility Hospital Leave Day rate for qualifying facilities.

    * Therapeutic Leave Days must be billed using Revenue Code 0183 (must not exceed 18 total days for the year) or Revenue Code 0189, Therapeutic Leave Days, for a beneficiary in a Facility Innovative Design Supplemental (FIDS) bed. Reimbursement is at 95 percent of Nursing Facility rate for leave days.

    * Hospice services are reimbursable for day of discharge if services were rendered, regardless of the setting in which the services were provided. (See first bullet for instructions regarding room and board.)

    * When billing for a hospice/NF resident who has been approved for complex care, bill revenue code 0120 and include the assigned PA number in F.L. 84, as obtained from the NF.

    The Michigan Medicaid program, including Medicaid Health Plans (MHPs) and MIChild, as well as CSHCS, covers hospice care for children under 21 years of age concurrently with curative treatment of the child’s terminal illness when the child qualifies for hospice as described in the Hospice Chapter of this manual.


    Hospice services and curative treatment are billed and reimbursed separately under this policy. Prior to billing, it is important that providers differentiate between services that are palliative and therefore included in hospice reimbursement, and those that are curative and separately reimbursable under Medicaid. Each child’s circumstances will need to be taken into consideration when making this distinction. Caution should be taken to avoid billing both the hospice and Medicaid for the same service as this represents double billing and may constitute fraud.

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    GENERAL INFORMATION


    The following providers must use the ASC X12N 837 5010 professional format when submitting electronic claims and the CMS 1500 claim form for paper claims.


    * Ambulance

    * Ambulatory Surgical Centers

    * Anesthesiologist Assistants

    * Certified Nurse Midwives

    * Certified Nurse Practitioners

    * Certified Registered Nurse

    Anesthetists

    * Chiropractors

    * Community Mental Health Services Programs/Prepaid Inpatient Health Plans

    * Family Planning Clinics

    * Federally Qualified Health Centers

    * Hearing Aid Dealers

    * Hearing Centers

    * Independent Laboratories

    * Indian Health Centers

    * Maternal Infant Health Program

    * Medical Clinics

    * Medical Suppliers

    * Optical Companies

    * Optometrists

    * Oral-Maxillofacial Surgeons

    * Orthotists and Prosthetists

    * Physician Assistants

    * Physical Therapists

    * Physicians (MD & DO)

    * Podiatrists

    * Private Duty Nurses (Individually Enrolled)

    * Rural Health Clinics

    * School Based Services

    * Shoe Stores

    * Urgent Care Centers

    Claims for services rendered as a result of an order or referral must contain the name and individual NPI of the provider who ordered or referred the service/item. The following are the authorized health professionals who may order, prescribe or refer services to Medicaid beneficiaries:

    * Physician

    * Physician Assistant

    * Nurse Practitioner

    * Certified Nurse Midwife

    * Dentist

    * Podiatrist

    * Optometrist

    * Chiropractor (limited to spinal x-rays only)

    Examples of services that require an order, prescription or referral include, but are not limited to,:

    * Ambulance non-emergency transports

    * Ancillary services for beneficiaries residing in nursing facilities (e.g., chiropractic, dental, podiatry, vision)

    * Childbirth/parenting and diabetes self-management education

    * Consultations

    * Diagnostic radiology services, unless rendered by the ordering physician

    * Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

    * Hearing and hearing aid dealer services

    * Home health services

    * Hospice services

    * Laboratory services

    * Certain mental health and substance abuse children's waiver services

    * Certain Maternal Infant Health Program (MIHP) services

    * Pharmacy services

    * Private Duty Nursing services

    * Certain School Based Services

    * Therapy services (occupational therapy (OT), physical therapy (PT) and speech)

    * Certain vision supplies

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     MATERNITY CARE SERVICES

    Coding CPT guidelines for reporting prenatal care and delivery services apply. Bill the global obstetrical package or the antepartum, delivery, and postpartum components as  appropriate per Medicaid NCCI guidelines.



    Delivery Delivery is part of the global maternity package and should not be billed separately if the global package is billed. If the beneficiary is seen for fewer than seven antepartum visits, delivery and postpartum care should be billed separately. Use appropriate CPT guidelines.

    Global Service The global maternity package should be billed if the beneficiary is seen for seven or more antepartum visits with delivery and postpartum performed by the same physician or physician group. The provider or group may choose to bill the antepartum, delivery, and postpartum components separately as allowed by Medicaid NCCI editing.

    Multiple Gestation For twin gestation, report the service on two lines with no modifier on the first line and modifier 51 on the second line. If all maternity care was provided, report the global maternity package code for the first infant, and report the appropriate delivery-only code for the second infant using modifier 51. If multiple gestation for more than twins is encountered, report the first delivery on one line and combine all subsequent deliveries on the second line with modifiers 51 and 22. Provide information in the remarks section or submit an attachment to the claim explaining the number of babies delivered.


    Physician Change During Antepartum Care

    If the beneficiary changes physicians during the antepartum care (other than physicians within the same group), use the appropriate maternity CPT codes and guidelines for the services performed. The global package should not be billed by either physician regardless of the number of antepartum visits provided.

    Postpartum Care Postpartum care is included in the global maternity package and in the global surgical delivery period when the services are provided by the same physician or physician group. When the postpartum exam is performed by a physician not billing the global package or performing the delivery, the postpartum exam may be billed as a separate service.

    Prenatal/Antepartum Care

    If the beneficiary receives fewer than seven but greater than three antepartum visits, use the appropriate antepartum CPT code. Individual E/M codes should be used when three or fewer antepartum visits are performed.

    NEWBORN CARE

    When billing for medical services provided to the newborn, providers must use the newborn's Medicaid ID number, except if the delivering physician performs the newborn care and circumcision during the mother's inpatient stay, the delivering physician may bill for the newborn care and circumcision on the same claim as the delivery under the mother's Medicaid ID number.

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  • 11/13/17--04:50: Extended Care services
  • The term “extended care services” means the following items and services furnished to an inpatient of a skilled nursing facility (SNF) either directly or under arrangements as noted in the list below:

    • Nursing care provided by or under the supervision of a registered professional nurse;

    • Bed and board in connection with furnishing of such nursing care;

    • Physical or occupational therapy and/or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility;

    • Medical social services;

    • Such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients;

    • Medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement (see §50.7) under an approved teaching program of the hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect, and

    • Other services necessary to the health of the patients as are generally provided by skilled nursing facilities, or by others under arrangements.

    Skilled Nursing Facility Level of Care - General

    Care in a SNF is covered if all of the following four factors are met:

    • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;

    • The patient requires these skilled services on a daily basis (see §30.6); and

    • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)

    • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

    If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

    In reviewing claims for SNF services to determine whether the level of care requirements are met, the A/B MAC (A) first considers whether a patient needs skilled care. If a need for a skilled service does not exist, then the “daily” and “practical matter” requirements are not addressed. See section 30.2.2.1 for a discussion of the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care. Additional material on documentation appears in the various clinical scenarios that are presented throughout these level of care guidelines.

    Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care and/or therapy, but rather on the beneficiary’s need for skilled care. Eligibility for SNF Medicare A coverage has not changed with the inception of PPS. However, the skilled criteria and the medical review process have changed slightly. For Medicare to render payment for skilled services provided to a beneficiary during a SNF Part A stay, the facility must complete an MDS.

    EXAMPLE: Even though the irrigation of a suprapubic catheter may be a skilled nursing service, daily irrigation may not be “reasonable and necessary” for the treatment of a patient’s illness or injury.

    A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner (NP), a clinical nurse specialist (CNS) or, effective with items and services furnished on or after January 1, 2011, a physician assistant (PA)) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.

    In this context, the definition of a “direct employment relationship” is set forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under the regulations at 42 CFR 424.20(e)(2)(ii), when a physician extender has a direct employment relationship with an entity other than the facility, and the employing entity has an agreement with the facility that includes the provision of general nursing services under the regulations at 42 CFR 409.21, an “indirect employment relationship” exists between the physician extender and the facility. By contrast, such an indirect employment relationship does not exist if the agreement between the facility and the physician extender’s employer solely involves the performance of delegated physician tasks under the regulations at 42 CFR 483.40(e).

    Patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services. Payment may be based on reasonable cost or be under the SNF Prospective Payment System (see §10). The facility may charge the beneficiary for services they request that are not included in the PPS rate or otherwise covered by Medicare (i.e. extra meals for family members).

    An inpatient is a person who has been admitted to a skilled nursing facility or swing bedhospital for bed occupancy for purposes of receiving inpatient services. A person is considered an inpatient if formally admitted as an inpatient with the expectation that they will remain at least overnight and occupy a bed even though it later develops that they can be discharged and do not actually use a bed overnight.

    Physical Therapy, Speech-Language Pathology, and Occupational

    Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision

    For Speech-Language Pathology, see Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” §100. For Occupational Therapy, see Medicare Benefit Policy Manual, Chapter 1,"Inpatient Hospital Services,” §90.

    Note these services must be provided by the SNF or by others under arrangements with the SNF for beneficiaries in either a covered Part A stay or a non-covered stay in the SNF. Bundling to the SNF is not required for beneficiaries residing in a non-certified portion of a facility containing a distinct part SNF if the facility as whole is not primarily engaged in the provision of skilled care

    Drugs and Biologicals

    Drugs and biologicals for use in the facility, which are ordinarily furnished by the facility for the care and treatment of inpatients, are covered. Such drugs and biologicals are not limited to those routinely stocked by the skilled nursing facility but include those obtained for the patient from an outside source, such as a pharmacy in the community. Drugs and biologicals are included in the SNF PPS except for those Part B drugs specifically excluded. Since the provision of drugs and biologicals is considered an essential part of skilled nursing care, a facility must assure their availability to inpatients

    in order to be found capable of furnishing the level of care required for participation in the program. When a facility secures drugs and biologicals from an outside source, their availability is assured only if the facility assumes financial responsibility for the necessary drugs and biologicals, i.e., the supplier looks to the facility, not the patient, for payment.

    The use of an operating room and any special equipment, supplies, or services would not constitute covered extended care services except when furnished to the facility by a hospital with which the facility has a transfer agreement, since operating rooms are not generally maintained by skilled nursing facilities. However, supplies and nursing services connected with minor surgery performed in a skilled nursing facility that does not require the use of an operating room or any special equipment or supplies associated with such a room would be covered extended care services and paid as part of inpatient SNF PPS.