Sunday, May 30, 2021

CPT 80053, Comprehensive metabolic panel

 

CODE DESCRIPTION


80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide

(bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), Urea Nitrogen (BUN) (84520)



Organ or Disease-Oriented Laboratory Panel Codes


The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, and 80081. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare uses CPT coding guidelines to define the components of each panel.


UnitedHealthcare also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional. The Professional Edition of the CPT ® book, Organ or Disease-Oriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."


For reimbursement purposes, UnitedHealthcare differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare will bundle the individual Component Codes into the more comprehensive Panel Code when the combined reimbursement for the individual Panel Code(s) exceeds the reimbursement amount of the Panel Code or when the designated number of Component Codes identified within a Panel Code are submitted as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076 and 80081 identify the Component Codes that UnitedHealthcare will rebundle into the specific panel.



CPT coding guidelines indicate that Panel CPT code 80047 should not be reported in conjunction with CPT code 80053. If a submission includes CPT 80047 and CPT 80053, only CPT 80053 will be reimbursed.


CPT coding guidelines indicate that, Panel CPT code 80048 should not be reported in conjunction with Panel CPT 80053. If a submission includes Panel CPT 80048 and 80053, only Panel CPT 80053 will be reimbursed. There are 2 configurations for, Panel CPT code 80048:

1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80048.


Panel Code: 80048

Must contain 5 or more of the following Component Codes for the same patient on the same date of service

82310 82374 82435 82565 82947

84132 84295 84520


A submission that includes, Panel CPT code 80053, Panel CPT code 84443 and one of the following Component Codes, either CPT codes 85025 or 85027 + 85004 or 85027 + 85007 or 85027 + 85009 by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service, Panel CPT code 80050.


Panel Code: 80050


Includes the following Panel Code: 80053 

Plus the following Component Code: 84443 

Plus 1 of the following CBC or combination of CBC Component Codes for the same patient on the same date of service: :

85025 85027 + 85027 + 85027 +

85004 85007 85009


When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.


When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.

Panel code 80053, a component of Panel code 80050, includes all components of Panel CPT code 80076 except for code 82248.


Panel, 80053


There are 3 configurations for Panel CPT code 80053:

1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.

Panel Code: 80053

Must contain 10 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 82310 82374 82435

82565 82947 84075 84132 84155

84295 84450 84460 84520


2. A submission that includes a Panel CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.


Panel Code: 80053

Includes the following Panel Code: 80048  Plus 2 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 84075 84155 84450

84460


3. A submission that includes, Panel CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as Panel CPT code 80053.

Panel Code: 80053

Includes the following Panel Code: 80051 Plus 6 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 82310 82565 82947

84075 84155 84450 84460 84520


When the Same Individual Physician or Other Qualified Health Care Professional reports the Panel CPT codes 80053 with 80048 or 80076 for the same patient on the same date of service, neither Panel CPT codes 80048 nor 80076 will be reimbursed separately.

CPT Panel Code 80053 includes all of the components of CPT Panel Code 80048 and all the components of CPT Panel Code 80076, except for CPT 82248. Therefore, when performed with all of the components of Panel CPT code 80053, report CPT 82248 separately.


Coding Tip


This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520). Code 80048 cannot be reported in conjunction with 80053.



80053 Comprehensive metabolic panel A comprehensive metabolic panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (83435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155),

sodium (84295), alanine amino transferase (ALT) (SGPT) (84460), aspartate amino transferase (AST) (SGOT) (84450), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests



Code 80053 can not be used in addition to CPT codes 80048 and 80076.



This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA waived

test. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for

* Indicates a mutually exclusive edit


80053 80048, 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, 84520



 

Reimbursement is provided for tests that are performed in a panel if they are reasonable, medically necessary under the applicable medical policy, and otherwise reimbursable under the terms of the member's plan. The plan reserves the right to rebundle individual codes that belong to a panel. If a claim is submitted with individual codes that belong to a panel, our claim reviewers and/or correct coding software logic may rebundle the procedure codes for appropriate reimbursement. If the medical documentation submitted with a claim shows that a panel was ordered and performed but the claim submitted shows the individual components of the panel, claim reviewers may rebundle the codes into the appropriate panel for reimbursement. CPT states the following:


• Tests performed in addition to those specifically indicated for a particular panel should be reported separately from the panel code

Example, If the Electrolyte panel (80051) is billed, individual tests such as 82947 (Assay Glucose Blood Quant), 84520 (Assay of Urea Nitrogen), 82565 (Assay of

Creatinine) and 82550 (Assay of CK (CPK)) should be billed separately from the panel.


• Do not report two or more panel codes that include the same constituent tests performed from the same patient collection

Example, If the Comprehensive Metabolic Panel (80053) is billed, the Basic Metabolic Panel (80047) cannot be billed.


• If a group of tests overlaps two or more panels, you must use the panel that incorporates the greatest number of tests and report the remaining individual tests

Example, if 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium), 84295 (Assay of Serum Sodium), 84520 (Assay of

Urea Nitrogen), and 82947 (Assay Glucose Blood Quant) are billed, two panel codes overlap. The Basic Metabolic Panel (80047) and the Electrolyte Panel (80051) include

codes 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium) and 84295 (Assay of Serum Sodium). The Electrolyte Panel should be billed.


• The panel code should be billed when all individual tests in the panel have been performed and should not be billed separately

Example, If the Lipid Panel (80061) is billed, then procedures 82465 (Assay BLD/Serum Cholesterol), 83718 (Assay of Lipoprotein) and 84478 (Assay of Triglycerides) should have been performed. 


80053 Comprehensive Metabolic Panel

82040 Assay of Serum Albumin

82247 Bilirubin Total

82310 Assay of Calcium

82374 Assay Blood Carbon Dioxide

82435 Assay of Blood Chloride

82565 Assay of Creatinine

82947 Assay Glucose Blood Quant

84075 Assay Alkaline Phosphatase

84132 Assay of Serum Potassium

84155 Assay of Protein Serum

84295 Assay of Serum Sodium

84460 Alanine Amino (ALT) (SGPT)

84450 Transferase (AST) (SGOT)

84520 Assay of Urea Nitrogen



Purpose of Policy


This policy is intended to help clarify how and why the same test or service may process differently depending upon the primary diagnosis code with which it is billed. The focus of this policy is on the differences between the Preventive and the Medical benefit categories.



Scope


This policy applies to all Commercial medical plans.


Reimbursement Guidelines


A. Categories of diagnostic tests covered and not covered as routine/preventive


1. Moda Health covers the preventive services mandated in the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.


2. In addition to the mandated PPACA preventive services, Moda Health also covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code.


The codes and tests eligible for this additional screening coverage are determined by a Moda Health Medical Director and are listed below. NOTE: These tests are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit because they are not on the PPACA list of mandated preventive services.

The tests will be covered (rather than denied), but all of the following tests are subject to the member’s usual cost-sharing and deductible requirements, even

when billed with a preventive diagnosis.


Lab Panels


Organ- or disease-oriented lab panels were developed to allow for coding of a group of tests. Providers are expected to bill the lab panel when all the tests listed within each panel are performed on the same date of service. When one or more of the tests within the panel are not performed on the same date of service,

providers may bill each test individually. Providers may not bill for a panel and all the individual tests listed within that panel on the same day. However, other tests performed in addition to those listed on the panel on the same date of service may be reported separately, in addition to the panel code. Providers must

follow CPT coding guidelines when reporting multiple panels. For example, providers cannot report basic panel code 80048 with comprehensive panel code 80053 on the same date of service, because all the lab tests in 80048 are components of 80053.



On May 3, 2019 CMS issued Change Request 11248, which re-implements the Automated Multi-Channel Chemistry (AMCC) Lab Panel Claims Payment System Logic. This logic was introduced in 2017 but was suspended beginning CY 2018, due to the Protecting Access to Medicare Act of 2014 (PAMA). PAMA required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS). Under PAMA, reporting entities must report to CMS certain private payer rate information for their component applicable laboratories. The implementation of PAMA required Medicare to pay the weighted median of private payor rates for each separate HCPCS code, as one National fee schedule rate rather than individual rates per state.


Prior to PAMA, CMS paid for certain chemistry tests using Automated Test Panels (ATPs). ATPs used claims processing logic to apply a bundled rate to sets of these codes based off how many ATPs were ordered. The claims processing system would not pay more for all ATPs than the associated CPT Panel (80047-80081). Any duplicated chemistry tests across ATPs or separately billed without a 91 modifier are not counted in the ATP test total. Below will further illustrate the logic and the effect on reimbursement. The Ohio rate of the 2017 CLFS is used for this demonstration, as the 2019 CLFS has not been updated with ATP entries as of the time of this article.


Example


A lab receives an order for a Comprehensive Metabolic Panel (80053) and a Lipid Panel (80061). Both panels are processed, results sent to the referring provider and a claim is sent to Medicare for HCPCS 80053 and 80061. The 2017 CLFS indicates payment for each HCPCS code as:

80053 $14.49

80061 $17.45

Total $31.94


Under the ATP payment methodology, payment will be determined based off the total number of unique chemistry tests performed.

Medicare will first strip each panel into its component codes as follows:


80053 HCPCS 80061 HCPCS

82040 82465

82247 83718

82310 84478

82374

82435

82565

82947

84075

84132

84155

84295

84460

84450

84520


Thursday, May 20, 2021

CPT 71275 AND 74174

 CPT Code    Description

71275       Computed tomographic angiography, chest (non-coronary), with contrast material(s), including noncontrast images, if performed, and image post-processing 


CPT Code Acceptable S/S Procedure to Pre-Cert

71275 * Thoracic Aortic Dissection

* Thoracic Aortic Aneurysm

* Coarctation

* Aortic Root Dilation CTA Chest


74174 * Abdominal Aortic Dissection

* Mesenteric Ischemia

* Bowel Ischemia

* Stent Obstruction CTA Abdomen and Pelvis

* Thoracic Abdominal Aortic Dissection requires both codes 71275 and 74174


CPT Codes: 71275

Computed tomography angiography (CTA) is a non-invasive imaging modality that may be used in the evaluation of thoracic vascular problems. Chest CTA (non-coronary) may be used to evaluate vascular conditions, e.g., pulmonary embolism, thoracic aneurysm, thoracic aortic dissection, aortic coarctation, or pulmonary vascular stenosis. CTA depicts the vascular structures as well as the surrounding anatomical structures.

Initial Clinical Reviewers (ICRs) and Physician Clinical Reviewers (PCRs) must be able to apply criteria based on individual needs and based on an assessment of the local delivery system.


INDICATIONS FOR CHEST CTA:


For evaluation of suspected or known pulmonary embolism (excludes low risk*)

For evaluation of suspected or known vascular abnormalities:

* For evaluation of a thoracic/thoracoabdominal aneurysm or dissection (documentation of clinical history may include hypertension and reported “tearing or ripping type” chest pain.

* Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by GI study).

* Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound).

* Follow-up evaluation of progressive vascular disease when new signs or symptoms are present.

* Primary or secondary pulmonary hypertension.


Preoperative evaluation

* Known or suspected vascular abnormalities seen on prior imaging

* Ablation procedure for atrial fibrillation.


Postoperative or post-procedural evaluation

* Physical evidence of post-operative bleeding complication or re-stenosis.

* Post-surgical follow up when records document medical reason requiring additional imaging


Chest CTA and Abdomen CTA or Abdomen/Pelvis CTA or Pelvis CTA combo:

* For evaluation of extensive vascular disease involving the chest and abdominal cavities such as aortic dissection, vasculitic diseases such as Takayasu’s arteritis, significant post-traumatic or postprocedural vascular complications, etc.

* For preoperative or preprocedural evaluation such as transcatheter aortic valve replacement (TAVR).


ADDITIONAL INFORMATION RELATED TO CHEST CTA:

CTA and Coarctation of the Aorta – Coarctation of the aorta is a common vascular anomaly characterized by a constriction of the lumen of the aorta distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum. The clinical sign of coarctation of the aorta is a disparity in the pulsations and blood pressures in the legs and arms. Chest CTA may be used to evaluate either suspected or known aortic coarctation and patients with significant coarctation should be treated surgically or interventionally.

CTA and Pulmonary Embolism (PE) – Note: D-Dimer blood test in patients at low risk* for DVT is indicated prior to CTA imaging. Negative D-Dimer suggests alternative diagnosis in these patients. *Low risk defined as NO to ALL of the following questions:

1) Evidence of current or prior DVT;

2) HR > 100;

3) Cancer diagnosis;

4) Recent surgery or prolonged immobilization;

5) Hemoptysis;

6) History of PE; and another diagnosis is more likely.

CTA has high sensitivity and specificity and is the primary imaging modality to evaluate patients suspected of having acute pulmonary embolism. When high suspicion of pulmonary embolism on clinical assessment is combined with a positive CTA, there is a strong indication of pulmonary embolism. Likewise, a low clinical suspicion and a negative CTA can be used to rule out pulmonary embolism. CTA and Thoracic Aortic Aneurysms – Computed tomographic angiography (CTA) allows the examination of the precise 3-D anatomy of the aneurysm from all angles and shows its relationship to branch vessels. This information is very important in determining the treatment: endovascular stent grafting or open surgical repair.


CTA and Thoracic Aorta Endovascular Stent-Grafts – CTA is an effective alternative to conventional angiography for postoperative follow-up of aortic stent grafts. It is used to review complications after thoracic endovascular aortic repair. CTA can detect luminal and extraluminal changes to the thoracic aortic after stent-grafting and can be performed efficiently with fast scanning speed and high spatial and temporal resolution.


Chest CT

1. Intrathoracic abnormalities found on chest x-ray, fluoroscopy, abdominal CT scan, or other imaging modalities may be further evaluated with chest CT with contrast (CPT® 71260).

a. “Abnormalities” through these guidelines may include suspected lung or pleural nodules or masses, pleural effusion, adenopathy or other findings that are not considered benign. 

b. Lung nodule(s) identified incidentally on:

i. Chest CTA without and with contrast (CPT® 71275), or

ii. Chest MRI without contrast (CPT® 71550), or

iii. Chest MRI without and with contrast (CPT® 71552), or

iv. Chest MRA without and with contrast (CPT® 71555) can replaceChest CT with contrast (CPT® 71260) or chest CT without contrast (CPT® 71250) as the initial dedicated study

2. Chest CT without contrast (CPT® 71250) can be used for the following:

a. Patient has contraindication to contrast.

b. Follow-up of pulmonary nodule(s).

c. High Resolution CT (HRCT).

d. Low-dose chest CT (CPT® G0297)

3. Chest CT without and with contrast (CPT® 71270) does not add significant diagnostic information above and beyond that provided by chest CT with contrast, unless a question regarding calcification, most often within a lung nodule, needs to be resolved.

4. High resolution chest CT should be reported only with an appropriate code from the set CPT® 71250-CPT® 71270.

a. No additional CPT® codes should be reported for the “high resolution” portion of the scan. The “high resolution” involves additional slices which are not separately billable.

E. Chest CTA (CPT® 71275)

1. Chest CTA (CPT® 71275) can be considered for suspected Pulmonary Embolism and Thoracic Aortic disease.

a. CTA prior to minimally invasive or robotic surgery 


Non-Cardiac Chest Pain Imaging

1. Initial evaluation should include a chest x-ray.1,2

a. If x-ray is abnormal, chest CT with contrast (CPT® 71260) or CTA chest with contrast (CPT® 71275) can be performed.1,2,3,4



 Hemoptysis

A. Chest CT with contrast (CPT® 71260) OR without contrast (CPT® 71250) OR CTA chest (CPT® 71275) may be performed after:

1. Abnormal chest x-ray, or

2. No chest x-ray needed if any of the following:

a. High risk for malignancy with >40 years of age and >30 pack-year smoking history, or

b. Persistent/recurrent with >40 years of age or >30 pack year smoking history, or

c. Massive hemoptysis (=30 cc per episode or unable protect airway).1


Thursday, May 6, 2021

CPT CODE 97597, 97598 - Debridement procedure

CPT CODE AND Description 


CPT code 97598 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof) was identified by the RUC on a list of services that were originally surveyed by one specialty but are now typically performed by a different specialty.


CPT code 97597 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less) was included for review as part of the family despite being reviewed at the October 2018 RUC meeting.


Billing Guidelines


Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.

2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.

3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.

4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.

5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.

6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies

Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse

practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements.

10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.

11. Documentation must support the HCPCS being billed.

12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.


Coding Guidelines


1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.

2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.

3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).

4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.



• 97597 Removal of devitalized tissue from wounds, selective debridement, without anesthesia, wound assessment, topical applications, instructions for ongoing care, total wound surface area first 20 sq cm . May include scalpel, scissors, waterjet


• CPT 15002-15005 are NOT to be used for the removal of nonviable tissue/debris in chronic wounds left to heal by secondary intention. CPT 11042-11047 and CPT 97597- 97598 are to be used for this.


CPT codes 97597 and 97598,

• “to remove devitalized and/or necrotic tissue and promote healing”

• 97597 Selective debridement, without anesthesia – wound area <20 sq cm

• High pressure water jet

• Sharp selective debridement (scissors, scalpel and forceps)

• 97598 Wound area > 20 sq cm


Multiple Levels of Debridement Coding Example:

The patient has five wounds. There is a superficial blister on the right 1st MTPJ, an ulceration that penetrates to subcutaneous tissue beneath the left second metatarsal head, an ulceration that penetrates to subcutaneous tissue on the right anterior leg, an ulceration with necrotic Achilles tendon exposed on the

posterior right heel, and a lateral left fibular malleolus with bone exposed.

1) Debrided 2 x 3cm Right 1st MTPJ skin ulcer = 97597

2) Debrided 2 x 1cm subcutaneous ulceration plantar 2nd metatarsal head as well as the subcutaneous 5 x 4 right leg ulceration = total 22 sq cm = 11042 for the first 20 sq. cm. plus 11045 for additional 2sq. cm.

3) Debrided 7 x 4cm necrotic Achilles tendon ulceration = 11043 for the first 20 sq. cm. and 11046 for additional 8 sq. cm.

4) Debrided 0.5 x 0.5cm necrotic bone on the left lateral malleolus = 11044


CPT 97597

Debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/ or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed, and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm. or less. This code is to be used when only skin structures were debrided. It is to be used for up to and including 20 sq. cm. of tissue debrided. There is a 0 day global and the relative value unit is 2.52.


(CPT 97597/97598 coding example: If you debrided a 47 sq. cm. skin wound, you would code: 97597 x 1 for the first 20 sq. cm., plus 97598 x 2 for sq. cm. 21-40 and sq. cm. 41-47. The total RVU would be 2.52 + 0.79 + 0.79 = 4.10.)


Billing and Coding Guidelines for Wound Care

Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

2. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

3. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.


4. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their plan of care. If it is a physician or non-physician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements

Thursday, April 15, 2021

CPT code G0104, G0105, G0121 - Colorectal cancer screening

 CPT code and Description


G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy



SUMMARY OF CHANGES: The method for calculating payment for discontinued procedures is being revised. New payment rates will apply when modifier 53 (discontinued procedure) is appended to codes 44388, 45378, G0105, and G0121.


GENERAL INFORMATION


A. Background: Prior to calendar year (CY) 2015, according to Current Procedural Terminology (CPT) instruction, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is

unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.” Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specific values in the Medicare physician fee schedule database for the following codes: 44388-53, 45378-53, G0105-53, and 

G0121-53.


B. Policy: Effective for services performed on or after January 1, 2016, the Medicare physician fee schedule database will have specific values for codes 44388-53, 45378-53, G0105-53, and G0121-53. Given that the new CPT definition of an incomplete colonoscopy also includes colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.


Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)


An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.


• HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.


G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy


Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below. For claims with dates of service on or after January 1, 2002, contractors pay for screening flexible sigmoidoscopies (HCPCS G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa)(5) of the Social Security Act (the Act) and in the Code of Federal Regulations (CFR) at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted above. For claims with dates of service prior to January 1, 2002, Medicare Administrative Contractors (MACs) pay for these services

under the conditions noted only when a doctor of medicine or osteopathy performs them.

For services furnished from January 1, 1998, through June 30, 2001, inclusive:


• Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed).

For services furnished on or after July 1, 2001:


• Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §60.3 of this chapter) and he/she has had a screening colonoscopy (HCPCS G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (HCPCS G0121).


NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth; the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0104.


When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. The Medicare physician fee schedule database has specific

values for codes 44388-53, 45378-53, G0105-53 and G0121-53. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of “–53” to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, Ambulatory Surgical Centers (ASCs) are to suffix the colonoscopy code with modifier “–73” or “–74” as appropriate. Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete.

Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.


HCPCS G0121 - Colorectal Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk - Applicable On and After July 1, 2001

Effective for services furnished on or after July 1, 2001, screening colonoscopies (HCPCS G0121) performed on individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §60.3 of this chapter) may be paid under the following conditions:


• At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.)


• If the individual would otherwise qualify to have covered a HCPCS G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy (HCPCS G0104), then he or she may have covered a HCPCS G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered HCPCS G0104 flexible sigmoidoscopy was performed.


NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0121.



Colonoscopy – CPT Codes 45378-45398, G0105, G0121


The American Society for Gastrointestinal Endoscopy (ASGE) works to ensure that adequate methods are in place for gastroenterology practices to report and obtain fair and reasonable reimbursement for procedures, tests and visits. To assist practices in understanding and implementing GI-specific coding, ASGE has developed coding sheets. The purpose of the coding sheet is to provide a high-level overview to support practices in there coding and reimbursement for 2018. 


What is a Colonoscopy?


It is an examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.

The CPT© codes in this series identify services performed during Colonoscopy


HCPCS Codes for Colonoscopy

HCPCS Code Code Descriptor

G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk



Gastroenterology Coding: Screening Versus Diagnostic Colonoscopy


To define the procedure, a colonoscopy is the examination of the entire colon from the rectum to the cecum, and it may include examination of the terminal ileum (small intestine). With that being said, there are two types of colonoscopies: screening and diagnostic. Medicare has specific guidelines for screening and diagnostic colonoscopies. Other payers may have very specific criteria for both types of colonoscopies as well.


Medicare defines these two types as:


1. Screening – used for patients who have:

• No family history of colon cancer or colon polyps

• No personal history of colon cancer or polyps

• No symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)


2. Diagnostic – used for patients who have:

• Family history of colon cancer or polyps

• Personal history of colon cancer or polyps

• Symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)

• Previous colonoscopy(ies) with findings of polyps, colon cancer, diverticulitis, etc.


Medicare also defines what they consider to be high risk for colorectal cancer as an individual with:

• A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp

• A family history of familial adenomatous polyposis

• A family history of hereditary nonpolyposis colorectal cancer

• A personal history of adenomatous polyps;

• A personal history of colorectal cancer; or

• Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis


Medicare uses HCPCS codes to bill for screening colonoscopies. For a patient of typical risk, the screening procedure is reported with HCPCS code G0121; for a

patient at high risk, it is reported with HCPCS code G0105. Providers should review the policies of their insurance payers to be certain which coding system is

used, especially for Medicare Advantage plans offered by commercial insurers.

Per the 2019 AMA CPT Professional Edition guidelines:


When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colonsmall intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.


If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381, 45382, 45384, 45388, 45398) is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

For colonoscopy through stoma, see 44388-44408.


So, the first step to coding a colonoscopy is to determine if it is a screening or diagnostic colonoscopy. If the patient has had any signs or symptoms such as

abdominal pain, weight loss or rectal bleeding, then it is not a screening but rather a diagnostic (symptomatic) colonoscopy. Also, if the patient has had

previous findings such as polyps or diverticulitis, then it is not a screening colonoscopy.

Aside from the CPT coding guidelines, if you’re wondering what the current Medicare reimbursement rates are for selected GI services, GI.org has a helpful

chart.


Keeping track of gastroenterology code changes should not fall solely on you or your staff. You should have tools in place like a gastroenterology EHR system that

can help in the process.



providing the correct procedure codes to report colonoscopies continues to cause confusion for the professional coder. The American Medical Association (AMA) provides the Common Procedural Terminology (CPT) codes used to report outpatient procedures for hospitals and physicians. Medicare adds additional codes in the HCPCS  Healthcare Procedure Coding System). HCPCS includes both CPT, which is HCPCS Level I, and CMS-developed HCPCS Level II codes. The HCPCS codes are required for all Medicare outpatient hospital services, if they are available, unless specifically excepted in Medicare manual instructions. Let us take a look at some typical colonoscopy coding scenarios, and the CPT and HCPCS codes that should be reported.


Screening colonoscopy


AHA Coding Clinic provides guidance in assigning the principal or first-listed diagnosis code when the physician documents that the colonoscopy is performed for screening purposes only. Code V76.51 is used first and any findings such as polyps, diverticulosis, or hemorrhoids are listed second; see Coding Clinic, First Quarter 1999 Page: 4. CPT codes are reported based on the procedure documented, and whether the patient is Medicare. If the patient is not Medicare, the appropriate CPT, (HCPCS Level I) code is assigned. If the patient is Medicare and no other procedures, such as a polypectomy or biopsy are performed, then either code G0105 or G0121,

(HCPCSL Level II) codes are assigned. G0105 is assigned if the patient qualifies as high risk using the following criteria:


* A personal history of colorectal cancer or

* A family history of familial adenomatous polyposis or

* A family history of hereditary nonpolyposis colorectal cancer or

* A personal history of adenomatous polyps or

* Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis or

* A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyp.

HCPCS code G0121 is assigned if the patient does not qualify as high risk.

Screening colonoscopy with polypectomy

If the colonoscopy starts as a screening, but the physician finds polyps and performs a polypectomy, the principal or first-listed diagnosis code remains as V76.51. The polyp is reported as a secondary diagnosis code. The procedure reported will depend on the documentation and will include only the CPT, Level I HCPCS code(s). Medicare also requires the modifier PT to be added to the procedure code, when the screening colonoscopy becomes a diagnostic colonoscopy. Use of this modifier will allow the Medicare patient to have the deductible waved.

Colonoscopy with different polypectomy techniques

When the colonoscopy includes more than one polypectomy technique, each technique may be reported separately if performed on different polyp sites. For example the physician performs a cold forceps polypectomy on a polyp in the descending colon, a polypectomy using snare in the rectum, and a polypectomy using hot forceps in the rectum.

Each procedure is reported using modifier 59 for the second two; see Coding Clinic for HCPCS - Third Quarter 2006 Page: 4. If two techniques are used on the same polyp, such as a snare removal followed by hot cautery, only the hot cautery should be reported; see CPT Assistant January 2004, pages 5-7.

Colonoscopy with tattooing

Occasionally, the physician injects ink to identify a polypectomy or other suspicious sites in the colon when performing the colonoscopy. CPT code 45381, colonoscopy with submucosal injection, should be reported in addition to the polypectomy or other procedure; see CPT Assistant, June, 2010, page 4. A separate procedure modifier 59 is not required. 

Colonoscopy with upper endoscopy

Quite often a colonoscopy is performed either just prior to, or just following an upper endoscopy, or esophagogastroduodenoscopy, (EGD). When this situation occurs, both the code for the colonoscopy and the EGD are reported. Modifier 59 is not required as the procedures are performed in different body systems. A high percentage of modifier 59 use could prompt a focus review by an outside agency.

It is important to understand the colonoscopy coding guidelines and associated procedures for both coding compliance and to obtain the correct reimbursement due to the facility. Performing routine audits to check the coding of this procedure will help to ensure proper coding.

Tuesday, March 9, 2021

CPT code J1439, L34093, J0887, Q9976

Required Billing and Coding


J Code Product Indications

J1439 Injection, ferric carboxymaltose, 1 mg 

L34093 (Chemotherapy and Biologicals)

J0887 - Injection, Epoetin Beta (For ESRD On Dialysis), 1 microgram

Q9976 - Injection ferric pyrophosphate citrate solution; 0.1 mg of iron



INDICATIONS


Injectafer® (ferric carboxymaltose injection) is indicated for the treatment of iron deficiency anemia (IDA) in adult patients who have intolerance to oral iron or have had unsatisfactory response to oral iron, or who have non-dialysis dependent chronic kidney disease.


WARNINGS AND PRECAUTIONS


Symptomatic hypophosphatemia requiring clinical intervention has been reported in patients at risk of low serum phosphate in the postmarketing setting. These cases have occurred mostly after repeated exposure to Injectafer in patients with no reported history of renal impairment. Possible risk factors for hypophosphatemia include a history of gastrointestinal disorders associated with malabsorption of fat-soluble vitamins or phosphate, concurrent or prior use of medications that affect proximal renal tubular function, hyperparathyroidism, vitamin D deficiency and malnutrition. In most cases, hypophosphatemia resolved within three months.

Monitor serum phosphate levels in patients at risk for low serum phosphate who require a repeat course of treatment.

Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Injectafer. Patients may present with shock, clinically significant hypotension, loss of consciousness, and/or collapse. Monitor patients for signs and symptoms of hypersensitivity during and after Injectafer administration for at least 30 minutes and until clinically stable following completion of the infusion. Only administer Injectafer when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. In clinical trials, serious anaphylactic/anaphylactoid reactions were reported in 0.1% (2/1775) of subjects receiving Injectafer. Other serious or severe adverse reactions potentially associated with hypersensitivity which included, but were not limited to, pruritus, rash, urticaria, wheezing, or hypotension were reported in 1.5% (26/1775) of these subjects.


Billing and coding


Important information related to Injectafer reimbursement Proper billing and coding can help ensure eligible patients receive the proper program support. The following codes may be helpful to facilitate Injectafer reimbursement. The completion and submission of coverage-related documentation are the responsibility of the patient and healthcare provider.


Injectafer® (ferric carboxymaltose injection) is indicated for the treatment of IDA in adult patients:


• who have intolerance to or have had unsatisfactory response to oral iron or

• who have non-dialysis dependent chronic kidney disease


Product-Specific Billing Code

HCPCS J1439 Injection, ferric carboxymaltose 1 mg


Overview

Iron is a critical structural component of hemoglobin, a key protein found in normal red blood cells (RBCs) which transport oxygen. Without this important building block, anemic patients experience difficulty in restoring adequate, healthy RBCs that improve hematocrit levels. Iron deficiency is a common condition in end stage renal disease (ESRD) patients undergoing hemodialysis. Clinical management of iron deficiency involves treating patients with iron replacement products while they undergo hemodialysis. The available evidence suggests that the mode of intravenous administration is perhaps the most effective treatment for iron deficiency in hemodialysis patients. Unlike oral iron products, which must be absorbed through the GI tract, IV iron products are infused directly into the bloodstream in a

form that is readily available to the bone marrow for RBC synthesis, resulting in an earlier correction of iron deficiency and anemia.

Coverage also includes the medically necessary and reasonable use of parenteral iron preparations in non-dialysis related clinical conditions.


Guidelines


Medicare covers Sodium Ferric Gluconate Complex in Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Medicare also covers Iron Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Coverage also includes for parenteral iron in iron deficiency anemia:


• For patients with iron deficiency anemia who do not respond to oral iron supplementation due to malabsorption disorders or patients who have documented intolerance to oral iron supplementation.


• For anemia related to chronic kidney disease.


• Initial treatment of absolute iron deficiency in patients receiving myelosuppressive chemotherapy who have asymptomatic anemia and risk factors for the development of symptomatic anemia requiring transfusion.


For the pregnant beneficiary when iron stores are depleted such that the mother and/or the fetus are at risk of adverse outcomes and oral iron replenishment is either not tolerated or the anemia is of such severity as to require more immediate replenishment. Additionally, use in the peripartum period may be indicated when intra/post-partum hemorrhage is severe and by administering parenteral iron a transfusion may be avoided. This indication does not replace the strong consideration for transfusions when the hemorrhage is potentially life threatening.


APPLICABLE CODES


The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered 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 and Guidelines may apply.


PURPOSE

The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable:


• Medicare coding or billing requirements, and/or

• Medical necessity coverage guidelines; including documentation requirements.

UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.



A. Background: Section 153(b) of the Medicare Improvements for Patients and Providers Act (MIPPA) required the implementation of an ESRD PPS effective January 1, 2011. The ESRD PPS provides a single payment to ESRD facilities that covers all of the resources used in furnishing an outpatient dialysis treatment. The ESRD PPS includes consolidated billing requirements for limited Part B services included in the ESRD facility’s bundled payment. The Centers for Medicare & Medicaid Services (CMS) periodically update the lists of items and services that are subject to Part B consolidated billing (CB) and are therefore no longer separately payable when provided to ESRD beneficiaries by providers other than ESRD facilities.


The ESRD PPS provides outlier payments, if applicable, for high cost patients due to unusual variations in the type or amount of medically necessary care.

B. Policy: This change request (CR) provides instructions for new codes added to the Healthcare Common Procedure Coding System (HCPCS) file for anemia management and therefore will be added to the list of items and services subject to the ESRD PPS consolidated billing (CB) requirements.


1. J0887 - Injection, Epoetin Beta (For ESRD On Dialysis), 1 microgram

2. J1439 - Injection, ferric carboxymaltose, 1mg

3. Q9976 - Injection ferric pyrophosphate citrate solution; 0.1 mg of iron



Anemia management is a category of drugs and biologicals that are always considered to be used for the treatment of ESRD. ESRD facilities will not receive separate payment for J0887, J1439, or Q9976 with or without the AY modifier and the claims shall process the line item as covered with no separate payment under the ESRD PPS.

Q9976 is administered via dialysate. Therefore, when billing for Q9976, it should be accompanied by the JE modifier as discussed in CR 8256 issued April 26, 2013.

In accordance with 42 CFR 413.237(a)(1), HCPCS J0887, J1439, and Q9976 are considered to be eligible outlier services and will be included in the outlier calculation when CMS provides a fee amount on the Average Sales Price fee schedule.


There is a new HCPCS J0888 for epoetin beta for non-ESRD use. This code will not be permitted on the ESRD type of bill 072x.


Lastly, Q2047 was terminated effective January 1, 2013 and is therefore no longer subject to the ESRD PPS consolidated billing requirements. In addition, J0890 is a recalled drug and should not be furnished to  ESRD patients, therefore effective July 1, 2015, we are removing this code from the list of items and services that are subject to consolidated billing requirements.


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