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.


Friday, December 25, 2020

Initial observation code CPT 99217, 99218, 99219, 99220

 CPT code and descriptions


99217 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])


99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; Aetailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.


99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.


99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically 70 minutes are spent at the bedside and on the patient's hospital floor or unit.



Observation care Background


Observation care is a well-defined set of specific, clinically appropriate services, which include:


• Ongoing short term treatment,

• Assessment,

• Reassessment


These are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.


Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.


In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.


In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as a inpatient can be made in less than 48 hours, usually in less than 24 hours.


Q: Can Observation Care codes 99217 and codes 99218-99220 be reported on the same date of service?


A: No. CPT codes 99234-99236 should be reported for patients who are admitted to and discharged from observation status on the same calendar date for a minimum of 8 hours but less than 24. An initial Observation Care code (99218-99220) should be reported for patients admitted and discharged from observation status for less than 8 hours on the same calendar date. CPT code 99217 can only be reported for a patient discharged on a different calendar date.




Initial Observation Care (CPT code range 99218-99220)


• Included in Initial Observation Care:

- Initiation of observation status

- Supervision of the care plan for observation

- Performance of periodic reassessments


• When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician.


• When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care,

from CPT code range 99218 – 99220, and CPT observation care discharge CPT code 99217.


• To report services provided to patient who is admitted to the hospital after receiving hospital observation care services on the same date, see initial

hospital care notes in the American Medical Association (AMA) Current Procedural Terminology (CPT) Publication.




• To report hospital admission on a date subsequent to the date of observation status, use appropriate initial hospital care codes (CPT 99221 – 99223)


• Observation status that is initiated in the course of an encounter in another site of service (eg. hospital emergency department, office, nursing facility) all E/M services provided by the supervising physician or other qualified health care professional in conjunction with initiating “observation status” are considered part of the initial observation care when performed on the same date.


- The level of service reported should include the services related to initiating “observation status” provided in the other sites of service as well as in the observation setting


• On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.


• Admitted and discharges from observation or inpatient status on the same date report CPT codes 99234-99236 as appropriate; do NOT report observation discharge in conjunction with a hospital admission.


• These codes may NOT be utilized for post-operative recovery if the procedure is considered part of the surgical “package.”



Policy Overview


Initial Observation Care CPT® codes 99218-99220 and Subsequent Observation Care CPT codes 99224-99226 are used to report evaluation and management (E/M) services provided to new or established patients designated as "observation status" in a hospital.


Observation Care Discharge Day Management CPT Code 99217 is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of “observation status”.


Observation or Inpatient Hospital Care (including admission and discharge) CPT codes 99234-99236 are used to report observation or initial hospital services for a patient that is admitted and discharged on the same date of service. Inpatient Hospital Discharge Day Management CPT Codes 99238 and 99239 are used to report all discharge day management services for the hospital inpatient when discharge is on a date other than the initial date of admission.

Saturday, August 22, 2020

CPT code 93000, 93040, 93041, 93042, 93010 - ECG and EKG codes

 CPT® Code Procedure Description  


93000 Electrocardiogram Routine ECG with at least 12 leads; with interpretation and report  

93005 Electrocardiogram Routine ECG with at least 12 leads; tracing only, without interpretation and report  

93010 Electrocardiogram Routine ECG with at least 12 leads; interpretation and report only  

93040 Rhythm ECG One to three leads; with interpretation and report  

93041 Rhythm ECG One to three leads; tracing only, without interpretation and report  

93042 Rhythm ECG One to three leads; interpretation and report only


CPT Manual Instructions for Reporting Electrocardiographic Recording


• Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.

• There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report.

• It is not appropriate to use these codes for reviewing telemetry monitor strips taken  from a monitoring system.

• The need for an electrocardiogram or rhythm strip should be supported by  documentation in the patient medical record.


Bundled Services per CPT Manual

• Do not report 93040-93042 when performing 93279-93289, 93291-93296, or  93298-93299

Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of an ECG. ICD-10-CM codes and/or ranges are provided below to help with your decision process.


Definitions

Codes 70010-79999, 93000-93010, and 0178T-0180T are used for reporting radiology procedures.


Modifiers:

-26 Professional Component

-76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care  Professional

-77 Repeat Procedure by Another Physician or Other Qualified Health Care  Professional

-ET Emergency services


Policy Statement

Medical Imaging and Electrocardiogram (ECG/EKG) Interpretation

Payment will be made for only one interpretation of any given x-ray, CT, MRI, ultrasound or ECG/EKG. Subsequent interpretations or readings by another physician (indicated by the -77 modifier) will not be covered. A re-interpretation by another physician is considered an integral part of the primary physician's medical care.


However, if the patient's condition warrants an immediate interpretation of an imaging study (emergency treatment -ET modifier), payment may be made to the attending or admitting physician even when a hospital staff physician also performs an imaging study interpretation.



OTHER CONSIDERATIONS

• Include documentation in the patient’s records to indicate medical necessity for a separate service.

• Confirm that proper ICD-10-CM diagnosis codes are reported to justify medical necessity of ECG monitoring.

• When appropriate, a modifier may be reported and support documentation should be provided with the claim.

• Some payers may have specific requirements for using certain codes, including prior authorization, restricted medical diagnoses or specialty provider types.

 


Indications and Limitations of Coverage

Nationally Covered Indications

The following indications are covered nationally unless otherwise indicated:

** Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services.

** EKG services rendered by an independent diagnostic testing facility (IDTF), including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician.

** Emergency EKGs (i.e., when the patient is or may be experiencing a life threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter.

** Home EKG services with documentation of medical necessity.

** Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described

below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to:

o Detect, characterize, and document symptomatic transient arrhythmias;

o Initiate, revise, or discontinue arrhythmic drug therapy; or,

o Carry out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 24- hour coverage is provided, see below).


Certain uses other than those specified above may be covered if, in the judgment of UnitedHealthcare, such use is medically necessary.


Additionally, the transmitting devices must meet at least the following criteria:

** They must be capable of transmitting EKG Leads, I, II, or III; and,

** The tracing must be sufficiently comparable to a conventional EKG.


24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described here: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies.


ICD-10-CM Description

ICD-10-CM Code/ Range

Abnormalities of heart beat R00.0-R00.9

Angina pectoris 120.0-120.9

Atherosclerotic heart disease I25.10-I25.119

Atrioventricular and left bundle-branch block 144.0-144.7

Cardiac arrest I46.2-I46.9

Cardiac murmurs and other cardiac sounds R01.0-R01.2

Cardiomyopathy I42.0-I42.9

Cardiomyopathy in diseases classified elsewhere I43

Essential (primary) hypertension I10

Gangrene, not elsewhere classified I96

Hypertensive heart disease I11.0-I11.9

Multiple valve diseases I08.0-I08.9

Old myocardial infarction I25.2

Other acute ischemic heart diseases I24.0-I24.9

Other cardiac arrhythmias I49.0-I49.9

Other conduction disorders I45.0-145.9

Other pulmonary heart diseases I27.0-I27.9

Pain in chest R07.1-R07.9

Rheumatic aortic valve diseases I06.0-I06.9

Rheumatic mitral valve diseases I05.0-I05.9

ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I21.0-I21.4

Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I22.0-I22.9


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