Tuesday, February 21, 2017

CPT A9270, E1399 - Pressure reducing support surfaces

HCPCS CODES:


Group 1 Codes:

A4640 REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD OWNED BY PATIENT

A9270 NON-COVERED ITEM OR SERVICE

E0181 POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY

E0182 PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY

E0184 DRY PRESSURE MATTRESS

E0185 GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0186 AIR PRESSURE MATTRESS

E0187 WATER PRESSURE MATTRESS

E0188 SYNTHETIC SHEEPSKIN PAD

E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE

E0196 GEL PRESSURE MATTRESS

E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0198 WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS


Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

While this Standard Documentation language makes reference to “Affordable Care Act Section 6407 (ACA 6407) requirements”, technically these requirements are found in the Social Security Act Section 1843(a)(11)(B) and its implementing regulation at 42 CFR 410.38. The CMS regulation contains the details for the face-to-face examination, written order prior to delivery and the list of items subject to these requirements.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

For some items in this policy to be covered by Medicare, a written order is required to be in the supplier’s file prior to delivery of the specified item(s). There are two differing order requirements that may apply depending upon the specific item prescribed:
The Affordable Care Act Section 6407 (ACA 6407) specifies the five elements that must be contained in this written order. For purposes of this policy, this order is termed the 5-element order (5EO).

A written order prior to delivery (WOPD) that meets all of the requirements of a standard detailed written order (DWO).


If the supplier delivers an item addressed in this policy without first receiving the completed order, the item will be denied. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and/or to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about these prescription requirements and the type of denial that will result from non-compliance.

A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:
The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or

The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or

The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

Impaired nutritional status

Fecal or urinary incontinence

Altered sensory perception

Compromised circulatory status
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.

The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out". Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the beneficiary's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the beneficiary in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Policy Article will be denied as not reasonable and necessary.

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

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

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GA – Waiver of liability statement issued as required by payer policy, individual case

GZ – Item or service expected to be denied as not reasonable and necessary

KX - Requirements specified in the medical policy have been met




Coverage Indications, Limitations, and/or Medical Necessity - Group 2

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (described by the diagnosis codes listed in the table below) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
Use of an appropriate group 1 support surface, and
Regular assessment by a nurse, physician, or other licensed healthcare practitioner, and
Appropriate turning and positioning, and
Appropriate wound care, and
Appropriate management of moisture/incontinence, and
Nutritional assessment and intervention consistent with the overall plan of care

The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (described by the diagnosis codes listed in the table below),

The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (described by the diagnosis codes listed in the table below), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days
If the beneficiary is on a group 2 surface, there should be a care plan established by the physician or home care nurse which includes the above elements. The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out" (see Appendices section).

When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.

When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces – Group 2 Policy Article will be denied as not reasonable and necessary. (See Coding Guidelines and Documentation sections concerning billing of E1399.)

Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management.

Appropriate use of the KX modifier (see Documentation section) is the responsibility of the supplier. The supplier should maintain adequate communication on an ongoing basis with the clinician providing the wound care in order to accurately determine that use of the KX modifier still reflects the clinical conditions which meet the criteria for coverage of a group 2 support surface, and that adequate documentation exists in the medical record reflecting these conditions. Such documentation should not be submitted with a claim but should be available upon request.



HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service
GA – Waiver of liability statement issued, as required by payer policy, individual case
GZ – Item or service expected to be denied as not reasonable and necessary
KX - Requirements specified in the medical policy have been met

HCPCS CODES:


Group 1 Codes:
E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)
E0277 POWERED PRESSURE-REDUCING AIR MATTRESS
E0371 NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0372 POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS
E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

L89.100 Pressure ulcer of unspecified part of back, unstageable

L89.102 Pressure ulcer of unspecified part of back, stage 2

L89.103 Pressure ulcer of unspecified part of back, stage 3

L89.104 Pressure ulcer of unspecified part of back, stage 4

L89.110 Pressure ulcer of right upper back, unstageable

L89.112 Pressure ulcer of right upper back, stage 2

L89.113 Pressure ulcer of right upper back, stage 3

L89.114 Pressure ulcer of right upper back, stage 4

L89.120 Pressure ulcer of left upper back, unstageable

L89.122 Pressure ulcer of left upper back, stage 2

L89.123 Pressure ulcer of left upper back, stage 3

L89.124 Pressure ulcer of left upper back, stage 4

L89.130 Pressure ulcer of right lower back, unstageable

L89.132 Pressure ulcer of right lower back, stage 2

L89.133 Pressure ulcer of right lower back, stage 3

L89.134 Pressure ulcer of right lower back, stage 4

L89.140 Pressure ulcer of left lower back, unstageable

L89.142 Pressure ulcer of left lower back, stage 2

L89.143 Pressure ulcer of left lower back, stage 3

L89.144 Pressure ulcer of left lower back, stage 4

L89.150 Pressure ulcer of sacral region, unstageable

L89.152 Pressure ulcer of sacral region, stage 2

L89.153 Pressure ulcer of sacral region, stage 3

L89.154 Pressure ulcer of sacral region, stage 4

L89.200 Pressure ulcer of unspecified hip, unstageable

L89.202 Pressure ulcer of unspecified hip, stage 2

L89.203 Pressure ulcer of unspecified hip, stage 3

L89.204 Pressure ulcer of unspecified hip, stage 4

L89.210 Pressure ulcer of right hip, unstageable

L89.212 Pressure ulcer of right hip, stage 2

L89.213 Pressure ulcer of right hip, stage 3

L89.214 Pressure ulcer of right hip, stage 4

L89.220 Pressure ulcer of left hip, unstageable

L89.222 Pressure ulcer of left hip, stage 2

L89.223 Pressure ulcer of left hip, stage 3

L89.224 Pressure ulcer of left hip, stage 4


L89.300 Pressure ulcer of unspecified buttock, unstageable

L89.302 Pressure ulcer of unspecified buttock, stage 2

L89.303 Pressure ulcer of unspecified buttock, stage 3

L89.304 Pressure ulcer of unspecified buttock, stage 4

L89.310 Pressure ulcer of right buttock, unstageable


L89.312 Pressure ulcer of right buttock, stage 2

L89.313 Pressure ulcer of right buttock, stage 3

L89.314 Pressure ulcer of right buttock, stage 4

L89.320 Pressure ulcer of left buttock, unstageable


L89.322 Pressure ulcer of left buttock, stage 2
L89.323 Pressure ulcer of left buttock, stage 3

L89.324 Pressure ulcer of left buttock, stage 4

L89.42 Pressure ulcer of contiguous site of back, buttock and hip, stage 2

L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3

L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4

L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable
N/A

Wednesday, February 1, 2017

Claim not on file denial


Having problems locating a claim you submitted to First Coast Service Options (First Coast)?

Claim not on file inquiry

There are steps you can take to make sure your claim was received by First Coast.

1. Before contacting customer service, check claim status.

• Reminder: The interactive voice response system (IVR) and customer service access the same claims system database. If the IVR has no record of a claim, customer service will also have no record.


2. Electronic claims

If you have not received an acknowledgement, you may have received a reject notification. If you have received a reject notification, the batch of claims you submitted contains an error that must be corrected.

3. Paper claims

If you are submitting the claims through the paper process, please allow sufficient time for us to receive, scan, and enter claims into the system. This process could take up to seven business days.

4. If the claim is not on file and still within the timely filing limits, resubmit the claim.


Enrollee not eligible on DOS Claim will deny if the client is not eligible during dates of service billed.

Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.


Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.

*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected

Monday, January 16, 2017

CPT code 81479, 81403, 81292, 81211

Procedure Codes and Description

Group 1 Codes:

81206 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MAJOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE

81207 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MINOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE

81208 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; OTHER BREAKPOINT, QUALITATIVE OR QUANTITATIVE

81219 CALR (CALRETICULIN) (EG, MYELOPROLIFERATIVE DISORDERS), GENE ANALYSIS, COMMON VARIANTS IN EXON 9

81270 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) GENE ANALYSIS, P.VAL617PHE (V617F) VARIANT

81402 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 3 (EG, >10 SNPS, 2-10 METHYLATED VARIANTS, OR 2-10 SOMATIC VARIANTS [TYPICALLY USING NON-SEQUENCING TARGET VARIANT ANALYSIS], IMMUNOGLOBULIN AND T-CELL RECEPTOR GENE REARRANGMENTS, DUPLICATION/DELETION VARIANTS OF 1 EXON, LOSS OF HETEROZYGOSITY [LOH], UNIPARENTAL DISOMY [UPD])

81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 4 (EG, ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, ANALYSIS OF >10 AMPLICONS USING MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 2-5 EXONS)

81445 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50 GENES (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED

81450 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, HEMATOLYMPHOID NEOPLASM OR DISORDER, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50 GENES (EG, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), INTERROGATION FOR SEQUENCE VARIANTS, AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED

81455 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN OR HEMATOLYMPHOID NEOPLASM, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 51 OR GREATER GENES (EG, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED

81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE

Coverage Indications, Limitations, and/or Medical Necessity


Indications and Limitations of Coverage

This policy provides coverage for multi-gene non-NGS panel testing and NGS testing for the diagnostic workup for myeloproliferative disease (MPD), and limited coverage for single-gene testing of patients with BCR-ABL negative MPD. MPD includes polycythemia vera (PV), essential thrombocytopenia (ET), and primary myelofibrosis (PMF).

For laboratories performing single gene technologies, a sequential genetic testing approach is expected. Once a positive result is obtained and the appropriate diagnosis is established, further testing should stop. Reflex testing to the next gene will be considered reasonable and necessary if the following sequence of genetic tests produce a negative result:

BCR-ABL negative test results, progress to #2

JAK 2, cv negative test results, progress to #3 or #4

JAK, exon 12 (JAK2 exon 12 is only done when PV is suspected)

CALR/MPD (CALR/MPD is only done when either ET or PMF is suspected; testing for CALR/MPD does NOT require a negative JAK2 exon 12, just a negative JAK2 V617F result)


Genetic testing of the JAK2 V617F mutation (81270) is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

Patient would meet World Health Organization’s diagnostic criteria for myeloproliferative disease (i.e. polycythemia vera, essential thrombocytopenia, primary myelofibrosis) if JAK2 V617F were identified.


Genetic testing of JAK2 exon 12 (81403), performed to identify PV, is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

Patient would meet World Health Organization’s diagnostic criteria for PV, if JAK2 exon 12 testing were positive; and

JAK2 V617F mutation analysis was previously completed and was negative.


Genetic testing of the CALR gene (81479) (only found in ET and PMF) is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

JAK2 V617F mutation analysis was previously completed and negative; and

Patient would meet World Health Organization’s diagnostic criteria for MPD (i.e. ET, PMF) if a clonal marker were identified.


Genetic testing of the MPD gene (81402) is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

JAK2 V617F mutation analysis was previously completed and negative; and

Patient would meet World Health Organization’s diagnostic criteria for MPD (i.e. ET, MPF) if a clonal marker were identified.


Note: In a single-gene sequential approach (not mandated by this policy), CALR would be a higher priority single gene test than MPD because:
CALR mutations is more prevalent than MPD mutations in ET/PMF patients; and

CALF mutations are reported to predict a more indolent disease course than patients with JAK2 mutations.


For laboratories performing next generation sequencing (NGS or “hotspot”) testing platforms: Molecular testing for BCR-ABL, JAK 2, JAK, exon 12, and CALR/MPD genes by NGS is covered as medically necessary for the identification of myeloproliferative disorders.

Background

Myeloproliferative Disorders

Myeloproliferative disorders are a group of conditions that cause abnormal growth of blood cells in the bone marrow. They include polycythemia vera (PV), essential thrombocytosis (ET), primary myelofibrosis (PMF), and chronic myelogenous leukemia (CML). The World Health Organization (WHO) further classifies PV, ET, and PMF as Philadelphia chromosome negative myeloproliferative neoplasms (MPNs). The diagnosis of an MPN is suspected based upon clinical, laboratory, and pathological findings (i.e. bone marrow morphology). MPNs are related, but distinct from, myelodysplastic syndromes (MDS). In general, MDS are characterized by ineffective or dysfunctional blood cells, while MPN are characterized by an increase in the number of blood cells.

Polycythemia Vera

Polycythemia vera is a chronic myeloproliferative disease characterized by increased hemoglobin, hematocrit, and red blood cell mass. There is an associated increased risk for thrombosis and transformation to acute myelogenous leukemia or primary myelofibrosis; however, patients are often asymptomatic. Criteria for a diagnosis of PV are based upon CBC and clinical features. The JAK2 V617F mutation is present in the vast majority of PV, accounting for approximately 90% of cases. Functionally similar mutations in JAK2 exon 12 account for most remaining cases of JAK2 V617F mutation-negative PV. Together, they are identified in 98% of PV cases and lead to high diagnostic certainty.

Among the proposed revised World Health Organization (WHO) criteria for diagnosis is presence of the somatic JAK2 V617F mutation or functionally similar exon 12 mutation. Absence of a JAK2 mutation, combined with normal or increased serum erythropoietin level, greatly decreases the likelihood of a PV diagnosis. WHO proposed revision criteria for PV do not address additional molecular markers, including CALR mutation status.

Essential Thrombocythemia

Essential thrombocythemia is a disorder of sustained increased platelet count. The majority of ET patients (60%) carry a somatic JAK2 V617F mutation, while a smaller percentage (5-10%) have activating MPD mutations. Revision to the WHO criteria for diagnosis of ET has been proposed and includes exclusion of PV, PMF, CML, myelodysplastic syndrome, or other myeloid neoplasm. Also included in the proposed major criteria for diagnosis is demonstration of somatic JAK2 V617F mutation or MPD exon 10 mutation 12. Proposed criteria additionally state that 70% of patients without a JAK2 or MPD mutation carry a somatic mutation of the calreticulin (CALR) gene. Among confirmed ET cases, mutations in CALR are more common than MPD. Positive CALR mutation status is suggested as indicating a more indolent course 5.

Primary Myelofibrosis

Primary myelofibrosis (PMF) is a rare disorder in which the bone marrow is replaced with fibrous tissue, leading to bone marrow failure. Clinical features are similar to ET. The approximate incidence is 1 in 100,000 individuals. Persons can be asymptomatic in the early stages of the disease. For such patients, treatment may not initially be necessary. Progression of the disease can include transformation to acute myeloid leukemia. Treatment is generally symptomatic and aimed at preventing complications.

Demonstration of a clonal marker is important for diagnosis. Somatic molecular markers in PMF patients are similar to those in patients with ET, and include JAK2 V617F, MPD, and CALR. Somatic mutations in JAK2 are identified in 50-60% of PMF cases, and MPD mutations in 10%. Mutations in CALR are less common than JAK2, but more common than MPD.

Molecular Genetic Testing 

One JAK2 gene mutation, V617K, is most commonly reported, occurring in over 90% of all polycythemia vera (PV) cases and about 50% of ET cases. Testing for JAK2 V617K gene mutations can be useful in diagnosis and is incorporated into the WHO’s diagnostic criteria for these conditions.

The thrombopoietin receptor MPD is one of several JAK2 cognate receptors and is considered essential for myelopoiesis. The mutation frequency of MPD mutations associated with myeloproliferative disorders is substantially less (<10 2008="" 3.="" a="" acquired="" an="" be="" british="" clonal="" committee="" criteria="" diagnostic="" disease="" e.g.="" et="" for="" gene="" genes="" group="" guideline="" health="" hematology="" identified.="" if="" in="" include="" indicated="" individuals="" jak2="" marker="" may="" meet="" modification="" mpd="" mutation="" mutations.="" myeloproliferative="" of="" or="" organization="" p="" pathogenetic="" presence="" recommended="" s="" standards="" testing="" than="" the="" therefore="" to="" were="" who="" world="" would="">
Calreticulin (CALR) mutations have been identified in patients with myeloproliferative neoplasms and recent studies have investigated the utility of CALR mutation testing for the diagnosis and classification of myeloproliferative neoplasms. The mutations themselves are variable; however, generally focused in the exon 9 region.

Studies have shown that a significant proportion of patients with myeloproliferative neoplasms and normal JAK2 617F mutation testing have a CALR gene mutation. CALR mutations account for a large proportion of JAK2/MPD-negative ET and PMF cases. Approximately 60% of JAK2/MPD-negative ET patients are CALR-positive and 30% of JAK2/MPD-negative PMF patients are CALR-positive. Overall, CALR mutations are identified in approximately 21% of ET cases and 16% of PMF cases. CALR mutations have not been reported in PV case series 2.

For this reason, CALR gene testing may be indicated for individuals who would meet World Health Organization’s diagnostic criteria for myeloproliferative disease if a clonal marker were identified. Proponents have argued for revised WHO criteria that includes CALR mutation status in the classification system for ET and PMF 12. Current NCCN guidelines do not make recommendations for CALR genetic testing; however, these guidelines are specific to MDS and do not broadly address myeloproliferative neoplasms, such as ET or PMF. Somatic mutations in non-MDS genes, such as CALR, are listed as being associated with conditions that can mimic other myelodysplastic syndromes.

Aside from diagnostic utility, some research suggests distinct clinical outcomes associated with CALR mutation status; however, the findings have not been confirmed in other studies. It is suggested that ET patients with CALR mutations have lower polycythemic transformation rates, but not lower myelofibrotic transformation rate, compared with ET patients harboring a JAK2 mutation. Others reported a higher platelet count, younger age of diagnosis, lower leukocyte count, and decreased risk for thrombosis, compared with a JAK2 positive ET population 1. CALR-mutated ET has also been associated with better thrombosis-free survival and lower leukocyte counts; overall survival has been reported as not different among CALR mutated and non-mutated ET 2,15.

Although they are useful for establishing a diagnosis, the presence of specific clonal markers does not dictate treatment. Controversy exists generally regarding the treatment of asymptomatic individuals with ET. Some argue against treatment if there are no associated complications. In general, the main goal of treatment with PV and ET is to identify persons at high risk for thrombosis and prevent complications. Persons with PV and ET are determined to be at high-risk due to age >60 years and past history of thrombotic event(s). CALR mutational status is not currently used for risk stratification 11.

In summary, multiple studies have demonstrated the diagnostic value of CALR mutation status in a population of JAK2 and MPD negative patients with suspected ET and PMF. The presence of a somatic CALR mutation can prove useful in obtaining an accurate diagnosis. Emerging evidence suggests possible differences in clinical phenotype among the associated clonal markers, including CALR-positive ET cases. However, CALR mutation status is currently not incorporated into clinical risk stratification and more research is needed in this area.


ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

C88.8 Other malignant immunoproliferative diseases
C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.20 Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission
C92.21 Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission
C92.22 Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse
C93.10 Chronic myelomonocytic leukemia not having achieved remission
C94.40 Acute panmyelosis with myelofibrosis not having achieved remission
C94.41 Acute panmyelosis with myelofibrosis, in remission
C94.42 Acute panmyelosis with myelofibrosis, in relapse
C94.6 Myelodysplastic disease, not classified
D45 Polycythemia vera
D46.0 Refractory anemia without ring sideroblasts, so stated
D46.1 Refractory anemia with ring sideroblasts
D46.20 Refractory anemia with excess of blasts, unspecified
D46.21 Refractory anemia with excess of blasts 1
D46.22 Refractory anemia with excess of blasts 2
D46.A Refractory cytopenia with multilineage dysplasia
D46.B Refractory cytopenia with multilineage dysplasia and ring sideroblasts
D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.4 Refractory anemia, unspecified
D46.Z Other myelodysplastic syndromes
D46.9 Myelodysplastic syndrome, unspecified
D47.1 Chronic myeloproliferative disease
D47.3 Essential (hemorrhagic) thrombocythemia
D47.4 Osteomyelofibrosis
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D47.9 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified
D72.821 Monocytosis (symptomatic)
D72.829 Elevated white blood cell count, unspecified
D75.1 Secondary polycythemia
D75.81 Myelofibrosis
D75.89 Other specified diseases of blood and blood-forming organs
D75.9 Disease of blood and blood-forming organs, unspecified

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Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity


Germline genetic testing of BRCA1 and BRCA2 is available to identify individuals at increased risk for breast and ovarian cancers, as individuals with an inherited cancer syndrome may benefit from screening and prevention strategies to reduce their risk. The prevalence of BRCA mutations in the population is estimated between 1 in 300 and 1 in 800; however, specific mutations known as founder mutations occur more often in populations founded by a small ancestral group, including Ashkenazi (Eastern European) Jews, French Canadians, and Icelanders. The prevalence of BRCA mutations in the Ashkenazi Jewish population is approximately 1 in 40. Three recurrent BRCA1 and BRCA2 mutations have been identified in Ashkenazi Jewish individuals (i.e., a genetically distinct population of Jewish people of eastern and central European ancestry) and make up the vast majority of BRCA mutations that occur in this population. Rearrangements, such as large genomic alterations including translocations, inversions, large deletions and insertions are believed to be responsible for 12% to 18% of BRCA1 inactivating mutations but are less common in BRCA2 and in individuals of Ashkenazi Jewish descent. The NCCN guidelines note that comprehensive genetic testing includes full sequencing of BRCA1/BRCA2 and the detection of large genomic rearrangements. The NCCN recommends that since certain large genomic rearrangements are not detectable by a primary sequencing assay, additional testing may be needed in some cases.

Evidence in the published, peer-reviewed scientific literature indicates that BRCA1 and BRCA2 genetic testing is appropriate for a specific subset of adult individuals who have been identified to be at high risk for hereditary breast and ovarian cancers. Furthermore, several specialty organizations, including NCCN, American College of Medical Genetics (ACMG), and American Society of Clinical Oncology (ASCO), have issued statements recognizing the role of pre- and post-test genetic counseling and BRCA testing in the management of at risk patients. The U.S. Preventive Services Task Force (USPSTF) has published recommendations regarding genetic risk assessment, genetic counseling and BRCA mutation testing for breast and ovarian cancer susceptibility. Based on this USPSTF recommendation, the Patient Protection and Affordable Care Act (ACA) requires that private group and individual health plans provide coverage for genetic counseling and, if appropriate, genetic testing for women at risk for hereditary breast ovarian cancer syndrome (HBOC) as a preventive service with no out of pocket expense.

Olaparib is a poly ADP-ribose polymerase (PARP) inhibitor inhibitor approved by the FDA as monotherapy in patients with ovarian cancer, with deleterious or suspected deleterious germline BRCA1 or BRCA2 mutation who have been treated with three or more prior lines of chemotherapy. Testing of ovarian cancer patients in this clinical scenario is indicated to guide treatment.

Mutations in the BRCA1 and BRCA2 genes are passed down in families through an autosomal dominant inheritance pattern meaning that the associated cancer predisposition can be inherited through either the mother’s or father’s side of the family and transmitted by a male or female. When a parent carries a BRCA mutation, there is a 50% chance of passing down the gene mutation with every pregnancy. Although the risk of inheriting the predisposition from a parent who carries a mutation is 50%, not everyone with an inherited mutation will develop cancer. The likelihood that a woman with a mutation will develop a related cancer (i.e., penetrance of a BRCA mutation) is estimated between 41% and 90% and is much lower for men. The risk of developing cancer depends on numerous variables, including the penetrance of the specific mutation, the genetic makeup of the individual, environmental risk factors, the gender of the individual and their age.

Several national evidence based and expert opinion guidelines and accrediting bodies recommend that genetic testing should be undertaken only in conjunction with independent pre-test genetic counseling services in order to assist patients in complex clinical decision-making. Post genetic testing counseling is also strongly recommended. The NCCN guidelines [2015] state that genetic counseling is a critical component of the cancer risk assessment process. In addition, the guidelines state that pretest counseling should include a discussion of why the test is being offered and how test results may impact medical management, cancer risks associated with the genes being tested, the significance of possible test results for the individual and family, the likelihood of a positive result, technical aspects and accuracy of the test, and economic considerations. Per the guidelines, posttest counseling includes disclosure of results, discussion of the significance of the results for the individual and relevant family members, a discussion of the impact of the results on psychosocial aspects and on the medical management of the individual, and how and where the patient will receive followup care and access to additional resources.

Medicare is a defined benefit program and requires that testing is only performed on patients with signs and symptoms of disease. Testing of unaffected individuals or family members is not a covered Medicare services. However, once a mutation is identified in the family, Medicare eligible relatives with signs and symptoms of breast cancer are typically tested for that specific mutation only. For patients of Ashkenazi Jewish descent, initial testing is generally done for the three specific mutations that account for most hereditary breast and ovarian cancer in that population: 185delAG and 5382insC (also called 5385insC) in the BRCA1 gene and 6174delT in the BRCA2 gene. If the test results are negative, full analysis of the BRCA1 and BRCA2 genes is only considered if testing criteria for non Jewish individuals are met. Nonetheless, Medicare does not cover testing for patients without signs and symptoms of breast or ovarian cancer.

While not required for payment, NCCN Guidelines recommend referral to a cancer genetics professional with expertise and experience in cancer genetics prior to genetic testing and after genetic testing. Examples of cancer genetics professionals with expertise and experience in cancer genetics include: an American Board of Medical Genetics or American Board of Genetic Counseling certified or board eligible Clinical Geneticist, Medical Geneticist or Genetic Counselor not employed by a commercial genetic testing laboratory (excludes individuals employed by or contracted with a laboratory that is part of an Integrated Health System which routinely delivers health care services beyond just the laboratory test itself as these individuals are also considered inter dependent); medical oncologist, obstetrician-gynecologist or other physician trained in medical cancer genetics, a genetic nurse credentialed as either a Genetic Clinical Nurse (GCN) or an Advanced Practice Nurse in Genetics (APGN) by either the Genetic Nursing Credentialing Commission (GNCC) or the American Nurses Credentialing Center (ANCC) who is not employed by a commercial genetic testing laboratory (excludes individuals employed by or contracted with a laboratory that is part of an Integrated Health System which routinely delivers health care services beyond just the laboratory test itself as these individuals are also considered inter dependent).

Indications

This is a limited coverage policy for BRCA 1 and BRCA 2 genetic testing. BRCA 1 and BRCA 2 genetic testing has been found to be reasonable and necessary in the following instances.

Personal History of Female Breast Cancer

BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered in adults [by full sequence analysis and duplication/deletion analysis of common variants (CPT codes 81211 and 81213) as medically reasonable and necessary when there is a personal history of breast cancer (invasive breast cancer or ductal carcinoma in situ) and ANY of the following indications:

Diagnosed at age 60 or younger with a triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative);
Diagnosed at age 50 or younger with a limited family history (e.g., fewer than two first- or second degree female relatives or female relatives surviving beyond 45 years in the relevant maternal and/or paternal lineage);
Diagnosed at any age and there are at least two close blood relatives* with breast cancer at any age;
Diagnosed at any age with at least one close blood relative* with breast cancer at age 50 or younger;
Diagnosed at any age and there are at least two close blood relatives* with pancreatic cancer or prostate cancer with Gleason score >7 at any age;
Diagnosed at any age with at least one close blood relative* with epithelial ovarian cancer, fallopian tube, or primary peritoneal cancer;
Close male blood relative* with breast cancer;
Individual of Ashkenazi Jewish descent begin testing with Ashkenazi Jewish founder specific mutations (a gene mutation observed with high frequency in a group that is or was geographically or culturally isolated, in which one or more of the ancestors was a carrier of the mutant gene) (CPT code 81212). If negative, complete analysis (CPT 81211 and 81213) may be considered if ancestry also includes non-Ashkenazi Jewish relatives or other criteria for BRCA1/BRCA2 genetic testing are met.

*NCCN defines blood relative as first- (parents, siblings and children), second- (grandparents, aunts, uncles, nieces and nephews, grandchildren and half-siblings), and third degree-relatives (great grandparents, great aunts, great uncles, great grandchildren and first cousins) on same side of family. Genetic testing for a known mutation in a family is a covered service for individuals with signs and/or symptoms of breast cancer. Testing of an unaffected Medicare eligible individual or family member is not a covered Medicare service.

Personal History of Other Cancer

BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered in adults [by full sequence analysis and duplication/deletion analysis of common variants (CPT codes 81211) and uncommon duplication/deletion analysis (CPT 81213)] as medically necessary when there is a personal history of ANY of the following indications:

Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer;
Personal history of male breast cancer;
Personal history of pancreatic cancer or prostate cancer with Gleason score =7 at any age, =1 close blood relatives* with breast (=50 y), invasive ovarian, pancreatic cancer, or prostate cancer with Gleason score=7 at any age;
Personal history of pancreatic cancer at any age with Ashkenazi Jewish ancestry (Begin testing with Ashkenazi Jewish founder specific mutations [CPT code 81212]. If negative, complete analysis (CPT 81211 and 81213) should be performed. Complete analysis (CPT 81211 and 81213) may be considered if ancestry also includes non-Ashkenazi Jewish relatives and other criteria for BRCA1/BRCA2 genetic testing are met.

Genetic testing for a known mutation in a family is a covered service for individuals with signs and/or symptoms of another inheritable cancer. Testing of an unaffected Medicare eligible individual or family member is not a covered Medicare service.

Multigene Panels

BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer with multi-gene next –generation sequencing (NGS) panels is covered as medically necessary when ALL of the following criteria are met:

Pre-test genetic counseling by a cancer genetics professional independent of the laboratory has been performed and post-test genetic counseling by a cancer genetics professional independent of the laboratory is planned;
All genes in the panel are relevant to the personal and family history for the individual being tested (large panels with genes that are not relevant to the individual’s personal and family history are not reasonable and necessary);

Criteria listed under Section 1, Personal history of female breast cancer and/or Section 2 Personal history of other cancer are met.

Individual also meets criteria for at least ONE other hereditary cancer syndrome for which NCCN guidelines provide clear testing criteria and management recommendations, including but not limited to Li-Fraumeni Syndrome, Cowden Syndrome, or Lynch Syndrome.


Limitations

Any test must also meet:

Availability of a clinically valid test, based on published peer reviewed medical literature; AND
Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) analytical validity and clinical utility.

BRCA1/BRCA2 genetic testing for susceptibility to breast or ovarian cancer is not covered for any other indication including any of the following because it is considered not medically reasonable and necessary for these indications:

Genetic screening in the general population. Such testing is considered screening and is excluded by Medicare statute. An ABN must be obtained for BRCA 1 and BRCA 2 testing for individuals without signs and symptoms of breast, ovarian or other hereditary cancer syndromes as indicated in this policy.
Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute.
An ABN must be obtained for BRCA 1 and BRCA 2 testing for individuals without signs and symptoms of breast, ovarian or other hereditary cancer syndromes as indicated in this policy.
Testing of individuals under 18 years of age.
Generic (not disease specific) genomic sequence panels (NGS comprehensive definitive cancer testing panel/s) of 51 or greater genes are non-covered at this time (specific testing of 51 or greater genes as expressed by disease specific coding, e.g. Prosigna breast cancer assay, can be medically necessary).


CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
81211 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND COMMON DUPLICATION/DELETION VARIANTS IN BRCA1 (IE, EXON 13 DEL 3.835KB, EXON 13 DUP 6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)
81212 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; 185DELAG, 5385INSC, 6174DELT VARIANTS
81213 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; UNCOMMON DUPLICATION/DELETION VARIANTS
81214 BRCA1 (BREAST CANCER 1) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND COMMON DUPLICATION/DELETION VARIANTS (IE, EXON 13 DEL 3.835KB, EXON 13 DUP 6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)
81215 BRCA1 (BREAST CANCER 1) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; KNOWN FAMILIAL VARIANT
81216 BRCA2 (BREAST CANCER 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81217 BRCA2 (BREAST CANCER 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; KNOWN FAMILIAL VARIANT
81445 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50 GENES (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED
81455 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN OR HEMATOLYMPHOID NEOPLASM, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 51 OR GREATER GENES (EG, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED
81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE



ICD-10 Codes that Support Medical Necessity

Group 1Codes

ICD-10 CODE DESCRIPTION

C25.4 Malignant neoplasm of endocrine pancreas

C25.7 Malignant neoplasm of other parts of pancreas

C25.8 Malignant neoplasm of overlapping sites of pancreas

C25.9 Malignant neoplasm of pancreas, unspecified

C50.011 Malignant neoplasm of nipple and areola, right female breast

C50.012 Malignant neoplasm of nipple and areola, left female breast

C50.019 Malignant neoplasm of nipple and areola, unspecified female breast

C50.021 Malignant neoplasm of nipple and areola, right male breast

C50.022 Malignant neoplasm of nipple and areola, left male breast

C50.029 Malignant neoplasm of nipple and areola, unspecified male breast

C50.111 Malignant neoplasm of central portion of right female breast

C50.112 Malignant neoplasm of central portion of left female breast

C50.119 Malignant neoplasm of central portion of unspecified female breast


C50.121 Malignant neoplasm of central portion of right male breast

C50.122 Malignant neoplasm of central portion of left male breast

C50.129 Malignant neoplasm of central portion of unspecified male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast


C50.221 Malignant neoplasm of upper-inner quadrant of right male breast

C50.222 Malignant neoplasm of upper-inner quadrant of left male breast

C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast

C50.311 Malignant neoplasm of lower-inner quadrant of right female breast

C50.312 Malignant neoplasm of lower-inner quadrant of left female breast

C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast

C50.321 Malignant neoplasm of lower-inner quadrant of right male breast

C50.322 Malignant neoplasm of lower-inner quadrant of left male breast

C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast

C50.411 Malignant neoplasm of upper-outer quadrant of right female breast

C50.412 Malignant neoplasm of upper-outer quadrant of left female breast

C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast

C50.421 Malignant neoplasm of upper-outer quadrant of right male breast

C50.422 Malignant neoplasm of upper-outer quadrant of left male breast

C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast

C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast

C50.521 Malignant neoplasm of lower-outer quadrant of right male breast

C50.522 Malignant neoplasm of lower-outer quadrant of left male breast

C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast

C50.611 Malignant neoplasm of axillary tail of right female breast

C50.612 Malignant neoplasm of axillary tail of left female breast

C50.619 Malignant neoplasm of axillary tail of unspecified female breast

C50.621 Malignant neoplasm of axillary tail of right male breast

C50.622 Malignant neoplasm of axillary tail of left male breast

C50.629 Malignant neoplasm of axillary tail of unspecified male breast

C50.811 Malignant neoplasm of overlapping sites of right female breast

C50.812 Malignant neoplasm of overlapping sites of left female breast

C50.819 Malignant neoplasm of overlapping sites of unspecified female breast

C50.821 Malignant neoplasm of overlapping sites of right male breast

C50.822 Malignant neoplasm of overlapping sites of left male breast

C50.829 Malignant neoplasm of overlapping sites of unspecified male breast

C50.911 Malignant neoplasm of unspecified site of right female breast

C50.912 Malignant neoplasm of unspecified site of left female breast

C50.919 Malignant neoplasm of unspecified site of unspecified female breast

C50.921 Malignant neoplasm of unspecified site of right male breast

C50.922 Malignant neoplasm of unspecified site of left male breast

C50.929 Malignant neoplasm of unspecified site of unspecified male breast

C56.1 Malignant neoplasm of right ovary

C56.2 Malignant neoplasm of left ovary

C56.9 Malignant neoplasm of unspecified ovary

C57.00 Malignant neoplasm of unspecified fallopian tube

C57.01 Malignant neoplasm of right fallopian tube

C57.02 Malignant neoplasm of left fallopian tube

C61 Malignant neoplasm of prostate

D05.00 Lobular carcinoma in situ of unspecified breast

D05.01 Lobular carcinoma in situ of right breast

D05.02 Lobular carcinoma in situ of left breast

D05.10 Intraductal carcinoma in situ of unspecified breast

D05.11 Intraductal carcinoma in situ of right breast

D05.12 Intraductal carcinoma in situ of left breast

D05.80 - D05.82 - Opens in a new window Other specified type of carcinoma in situ of unspecified breast - Other specified
type of carcinoma in situ of left breast

D05.90 - D05.92 - Opens in a new window Unspecified type of carcinoma in situ of unspecified breast - Unspecified type of
carcinoma in situ of left breast

Z85.07 Personal history of malignant neoplasm of pancreas

Z85.43 Personal history of malignant neoplasm of ovary

Z85.46 Personal history of malignant neoplasm of prostate
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Wednesday, January 11, 2017

CPT code 81240, 81241, 81291


Procedure Codes and Description

81240 F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT

81241 F5 (COAGULATION FACTOR V) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, LEIDEN VARIANT

81291 MTHFR (5,10-METHYLENETETRAHYDROFOLATE REDUCTASE) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, COMMON VARIANTS (EG, 677T, 1298C)

Coverage Indications, Limitations, and/or Medical Necessity

Indications

This is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients.

Testing for FVL and F2 G20210A mutations is indicated for pregnant patients who have a history of personal VTE associated with a non-recurrent (transient) risk factor who are not otherwise receiving anticoagulant prophylaxis. The results of genetic testing can inform risk stratification for venous thromboembolism (VTE) recurrence and subsequent need for antenatal prophylaxis. However, Medicare will not add coverage of thrombophilia testing for pregnant women because they likely represent a very small group of potential Medicare (disabled) patients. Claims submitted on this limited Medicare population will deny per the policy, but should be appealed for coverage with submission of medical records supporting the necessity for testing, and specify how testing changed anticoagulant prophylaxis management for the patient.

Background

Thrombophilia (or hypercoagulability) is the propensity to develop thrombosis due to either an acquired or inherited defect in the coagulation system. The major clinical manifestation of thrombophilia is VTE. Acquired thrombophilia risk factors include but are not limited to advancing age (> 50), trauma, malignancy, chemotherapy, major surgery, immobilization, pregnancy, estrogen, inflammation, antiphospholipid antibody syndrome, myeloproliferative disorders, heparin-induced thrombocytopenia, liver disease, nephrotic and prolonged air travel. Inherited thrombophilia risk factors include deficiencies in antithrombin, Protein C, Protein S, mutations in FVL and F2, and dysfibrinogenemias. Mixed or unknown risk factors include hyperhomocysteinemia, elevated levels of Factor VIII, acquired Protein C resistance in the absence of Factor V Leiden, and elevated levels of Factors IX and XI.

Testing for thrombophilia may consist of functional testing, antigenic testing, and genetic testing. Functional testing for thrombophilia may include tests such as:
Anti-phospholipid antibody (lupus anticoagulant);

Protein C;

Protein S;

Activated Protein C resistance (a surrogate for Factor V Leiden mutation);

Factor VIII

Fibrinogen

C-reactive protein

Homocysteine levels

Antigenic testing may be performed to identify specific glycoprotein antibodies associated with abnormal functional anti-phospholipid antibody studies, or to subtype deficiencies detected by decreased Protein S, Protein C and Antithrombin functional activity.

VTE is characteristically seen in deficiencies in Protein C, Protein S and antithrombin, as well as with FVL and F2 mutations. This is unlike the combination of arterial and venous thrombosis associated with hyperhomocysteinemia and lupus anticoagulant.

Genetic Testing for Thrombophilia

Genetic testing is available for a number of types of inherited thrombophilia, including mutations in the FVL, F2 and MTHFR genes. However, the clinical utility of testing is uncertain. The clinical utility of genetic testing depends on the ability of testing results to change management that results in improved clinical outcomes. The clinical utility of genetic testing for thrombophilia is based on the overall risk of thromboembolism and the risk/benefit ratio of treatment, primarily with anticoagulants.

During the previous 5 years, a number of guidelines and/or position statements on testing for thrombophilia have been published. In 2011, The Evaluation of Genomic Applications in Practice and Prevention Working Groups (EGAPP) addressed genetic testing for FVL and F2 mutations. The expert consensus recommended:
There is no evidence that knowledge of FVL/F2 mutation status in patients with VTE affects anticoagulation treatment to avoid recurrence;

There is convincing evidence that anticoagulation beyond three months reduces recurrence of VTE, regardless of mutation status;

There is no evidence that knowledge of FVL/F2 mutation status among symptomatic family members of patients with VTE leads to anticoagulation aimed at avoiding initial episodes of VTE (See note).

Note: The Medicare benefit applies only to individuals with signs and symptoms of disease. There is no Medicare benefit for assessment of thrombosis risk in asymptomatic patients (aka screening for inherited thrombophilia) or in asymptomatic individuals whose relatives have documented inherited thrombophilia.

In 2008, the American College of Chest Physician’s (ACCP) published guidelines for the treatment of thromboembolic disease stated the following concerning genetic testing for thrombophilia:
The presence of hereditary thrombophilia has not been used as a major factor to guide duration of anticoagulation for VTE in these guidelines because evidence from prospective studies suggests that these factors are not major determinates of the risk of recurrence.

In the 2012 ACCP Clinical Practice Guidelines, Guyatt et al (2012) and Bates et al (2012) make the following recommendations for treatment and management of VTE:
In persons with asymptomatic thrombophilia (i.e., without a previous history of VTE), we recommend against the long ­term daily use of mechanical or pharmacologic thromboprophylaxis to prevent VTE;

For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic­ or intermediate ­dose low­ molecular­weight heparin (LMWH) and postpartum prophylaxis for 6 weeks with prophylactic­ or intermediate­ dose LMWH or vitamin K antagonists (VKAs) targeted at INR 2.0 to 3.0 rather than no prophylaxis;

For all pregnant women with prior VTE, we suggest postpartum prophylaxis for 6 weeks with prophylactic­ or intermediate­ dose LMWH or VKAs targeted at INR 2.0 to 3.0 rather than no prophylaxis;

For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis;

For pregnant women at moderate to high risk of recurrent VTE (single unprovoked VTE, pregnancy­ or estrogen ­related VTE, or multiple prior unprovoked VTE not receiving long­ term anticoagulation), we suggest antepartum prophylaxis with
prophylactic­ or intermediate­ dose LMWH rather than clinical vigilance or routine care.

In the 2013 American Congress of Obstetricians and Gynecologists (ACOG) clinical management guidelines for inherited thrombophilia in pregnancy, ACOG experts note that the following guidelines are based on limited or inconsistent scientific evidence:
“Screening for thrombophilia is controversial. It is useful only when results will affect management decisions, and it is not useful in situations where treatment is indicated for other risk factors.

Screening may be considered in the following clinical settings:

A personal history of VTE that was associated with a non-recurrent risk factor (e.g., fractures, surgery, and prolonged immobilizations).

A first-degree relative (e.g., parent or sibling) with a history of high-risk thrombophilia.” (See note below)

ACOG also stated that testing for inherited thrombophilia in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. They indicate that there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin (LMWH) prevents recurrence in these patients, and note insufficient evidence to either screen for or treat women with inherited thrombophilia including complications such as fetal growth restriction or preeclampsia.

On behalf of the American College of Medical Genetics (ACMG) (reaffirmed in 2006), Grody, et al (2001) recommended testing for FVL for the following indications:
Age under 50, any venous thrombosis;

Venous thrombosis in unusual sites (such as hepatic, mesenteric, and cerebral veins;

Recurrent venous thrombosis;

Venous thrombosis and a strong family history of thrombotic disease;

Venous thrombosis in pregnant women or women taking oral contraceptives;

Relatives of individuals with venous thrombosis under age 50;

Myocardial infarction in female smokers under age 50.

ACMG suggested that FVL testing may also be considered in the following situations:
Venous thrombosis, age over 50, except when active malignancy is present;

Relatives of individuals known to have FVL. Knowledge that they have the FVL mutation may influence management of pregnancy and may be a factor in decision ­making regarding oral contraceptive use;

Women with recurrent pregnancy loss or unexplained severe preeclampsia, placental abruption, intrauterine fetal growth retardation, or stillbirth. Knowledge of FVL carrier status may influence management of future pregnancies.

FVL testing is not recommended for the following:
A general population screen;

A routine initial test during pregnancy or prior to the use of oral contraceptives, hormone replacement therapy (HRT) or selective estrogen receptor modulators (SERMs);

A prenatal or newborn test, or as a routine test in asymptomatic children;

A routine initial test in individuals with arterial thrombosis (testing may be considered, however, in selected young individuals [under age 50] with unexplained arterial thrombosis in the absence of other risk factors for atherosclerotic vascular disease).

In 2013, (ACMG) published a practice guideline on the lack of evidence for MTHFR polymorphism testing. Among a number of recommendations, ACMG experts concluded:
MTHFR polymorphism genotyping should not be ordered as part of the clinical evaluation for thrombophilia or recurrent pregnancy loss;

MTHFR polymorphism genotyping should not be ordered for at-risk family members.

Non-coverage Summary

Genetic testing for inherited thrombophilias is controversial. While the association between FVL and F2 mutations and increased risk for VTE is apparent, the actual impact of this increased risk on clinical management is less certain. Older professional society guidelines recommend genetic testing for thrombophilia for a wide range of indications, while more recent consensus statements and recommendations suggest much more limited clinical utility of testing.

The population for which genetic testing results have direct implications for treatment is pregnant women with a previous history of VTE associated with a transient risk factor (e.g., surgery, trauma). These women would typically not be treated with antepartum anticoagulant prophylaxis unless they were found to have a genotype associated with a high risk of VTE recurrence (FVL homozygosity, F2 G20210A homozygosity, or compound heterozygosity for FVL and F2 G20210A). Genetic testing for these patients is indicated.

There may also be benefit to screening pregnant women with a family history of known thrombophilia, as those women found to have a high risk genotype would be offered antenatal prophylactic anticoagulant therapy even in the absence of a personal history of VTE. However, the Medicare benefit applies only to patients with signs and symptoms of disease and does not include screening in asymptomatic patients.

Finally, despite many earlier publications suggesting a link between MTHFR polymorphisms and a risk for a wide spectrum of obstetric and cardiovascular complications, it is now accepted that MTHFR genotype alone is not associated with VTE. There is no clinical indication for MTHFR genotyping in any population.

There is insufficient evidence in the published peer-reviewed scientific literature to support coverage for genetic testing for inherited thrombophilias outside the pregnant women as described above. Genetic testing for FVL and F2 G20210A is considered investigational for all other indications. However, Medicare may consider coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will change clinical management of the patient. Denied claims can be appealed with supporting evidence of specific medical necessity. Only providers with evidence of formal training with board eligibility or certification in hematology/oncology, hematopathology or coagulation disorders at an accredited program satisfy reasonable and necessary criteria for these tests . There is broad consensus in the medical literature that MTHFR genotyping has no clinical utility in any clinical scenario. This testing is considered investigational and is NOT a Medicare benefit.


Bill Type Codes:

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

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

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Wednesday, December 7, 2016

Provider-level adjustments basics - FB, WO, withholding, Internal Revenue service


Locating PLBs

• Provider-level adjustments can increase or decrease the transaction payment amount.

• Adjustment codes are located in PLB03-1, PLB05-1, PLB07-1, PLB09-1, PLB11-1 and PLB13-1.

• The PLB is not always associated with a specific claim in the 835, but must be used to balance the transaction.

• Use the Reference ID to identify the claim. Exceptions are the FB, IR, J1, L6 and CS adjustment codes (when used for provider write-off only).



The most commonly used 835 adjustment codes

The following pages explain the most commonly used PLB codes (FB, WO, 72, IR, J1, L6 and CS) and provide details of the data found in corresponding Reference ID fields.


Forward Balance (FB) 

Overpayment recovery (WO) 

Authorized Return (72) 

Internal Revenue Service 

Withholding 

Non-Reimbursable (J1) 

Interest Owed (L6) 

Adjustment (CS) 

Note:

UnitedHealthcare has two claims processing systems that will be referenced throughout this document:

1. Our Commercial claim platform is used for the majority of our business, including most commercial products and select Medica claims.

2. Our Medicare Solutions claim platform is used for Medicare Advantage products (formerly called SecureHorizons and MedicareComplete from SecureHorizons) and Evercare. Additionally, select OptumHealth Behavioral Solutions (“Optum”) and select Medica claims are processed on this platform.



Adjustment Code Reference ID

Forward Balance (FB)

• Used to reflect a balance being moved forward to a future remit or a balance that is brought forward from a prior remit.

• When a balance is moving forward to a future remit, the PLB FB contains the TRN02 (check or Electronic Funds Transfer [EFT] trace number) from the current 835 transaction.

• When a balance has been brought forward from a prior remit, the PLB FB contains the TRN02 (check or EFT trace number) that was the Reference ID in the prior remit.

Commercial and Medicare Solutions platform information and posting tips

Medicare Solutions platform note: Forward Balance is only used for select government business (SecureHorizons®, MedicareComplete® from SecureHorizons, or Evercare® by UnitedHealthcare Medicare and Retirement).

• Use the dollar amount in the PLB to balance the 835 transaction.

• A negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice.

• The PLB FB is used to move a negative balance from a current 835 transaction into a future 835 transaction. Typically, this happens when we report an overpayment and there aren’t sufficient funds to recoup the entire overpayment amount.

• Forward Balance is tracked at the transaction level and is not claim-specific.




Adjustment Code Reference ID

Overpayment Recovery (WO)

• Used when a previous overpayment is recouped from the provider of service.

• Used when a reversal and corrected claim are not reported in the same transaction. WO prevents the prior claim payment from being deducted from the transaction.

• Used to offset the PLB 72.

• Used when a reversal and corrected claim are reported and the overpayment is not immediately recouped. WO prevents the prior claim payment from being deducted from the transaction.

• The Reference ID for the PLB WO contains the beginning date of service from the claim and the patient account number.

• When reporting a voided check, the Reference ID in the PLB WO is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund. We report a reversal to the original claim and a corrected claim in the 835. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the amount as a negative value in the PLB WO.

• If the reversal and corrected claim are not reported in the same 835 transaction, the 835 transaction that contains the reversal claim reports a negative value in the PLB WO. The 835 transaction that contains the corrected claim reports a positive value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• If a refund is not received within the timeframe requested in the letter, UnitedHealthcare recoups the money and reports this using the WO adjustment code. The 835 transaction that contains the overpayment recovery reduction will report a positive value in the PLB WO.



Underpayments

• Used to balance the 835 transaction when the reversal and corrected claims are not reported in the same 835 transaction and prior payment is not being recouped. The 835 transaction that contains the reversal claim will report a negative value in the PLB WO. The 835 transaction that contains the corrected claim will report a positive value in the PLB WO.

• When the reversal and corrected claim are reported in the same 835 transaction, no PLB is reported.
Provider refund check reporting

• When a refund check is received, the amount of the refund is reported as a positive value in the PLB WO and a negative value in the PLB 72.



Voided checks

When a check is voided, the amount of the voided check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

Provider refund check reporting

• When a provider’s refund check is received, the amount of the check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Voided checks

• When our check is voided, the amount of the check is reported as a positive value in the PLB WO and a negative value in the  PLB 72. The Reference ID in the PLB WO will contain the voided check number.

Overpayment Reduction (Non-Medicare Advantage products)

When we identify a claim overpayment, we report a reversal to the original claim and a corrected claim if there are sufficient funds from other claim payments to recover the amount of the overpayment. If sufficient funds are not available, we handle the overpayment with a manual recovery process after a certain amount of time.

Overpayment Reduction (specific to Medicare Advantage products and plans carrying the Medicare Solutions or Evercare®name)

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund and report a reversal to the original claim and a corrected claim. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the
overpayment amount as a negative value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• UnitedHealthcare sends a letter requesting a refund. If the refund is not received within the requested timeframe,

UnitedHealthcare recoups the money. The overpayment reduction is reported as a positive value in the PLB WO.





Adjustment Code Reference ID

Authorized Return (72)

• Used to report the dollar amount returned by the provider of service for a previous overpayment.

• Used to report a voided check.

The Reference ID in the PLB 72 contains the beginning date of service from the claim and the patient account number (Commercial and Medicare Solutions platforms).

When reporting a voided check, the Reference ID in the PLB 72 is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

For Solicited Refunds:

• The reversal and corrected claim were reported in a prior 835 and included a PLB WO so that overpayment funds weren’t recouped.

• Once the refund is received by UnitedHealthcare, the refund amount is noted as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• A PLB WO with the amount of the refund is then created to offset the PLB 72 and balance the 835 transaction. The PLB WO will contain a positive value.

For Unsolicited Refunds:

• When we post a refund, we usually enter both a reversal of payment and a corrected claim so that the reversal and PLB 72 will be in the same 835 file.

• If the refund does not cover the entire overpayment amount, the 835 will also contain a PLB WO for the amount remaining to be refunded. The PLB WO will contain a negative value.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• When we receive a refund, we note the refund amount as a negative value in the PLB segment with the 72 Adjustment
Reason Code.

• When a physician returns a UnitedHealthcare check, the voided check amount is noted as a negative value in the PLB 72.

The Reference ID in the PLB 72 will contain the voided check number.

• A PLB WO with the amount of the refund or voided check is reported as a positive value to offset the PLB 72 and balances the 835 transaction. We do not report a reversal and corrected claim in the 835 transaction.



Adjustment Code Reference ID

Internal Revenue Service Withholding (IR)

• Used for IRS tax withholding.

• The Reference ID in the PLB IR contains the beginning date of service from the applicable claim and the patient account number (Commercial platform).

• The Reference ID in the PLB IR contains the comment ‘IRS Withhold for TIN XXXXXXXXX’ (Medicare Solutions platform).

Commercial and Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• The payment amount sent to the IRS is reported in the PLB segment with an IR Adjustment Reason Code and a positive dollar amount.

• The claim will be in the same 835 as the PLB. Post the claim payment amount(s) to your patient accounts, but note that you will not physically receive funds for the payment amounts.




Adjustment Code Reference ID

Non-Reimbursable (J1)

• Used when the service provider is also the employer group and they request that monies be applied towards the Group
Medical Plan coverage premium instead of the claim.

The Reference ID in the PLB J1 contains the comment “Suppressed Payment Arrangement.”

Commercial platform information and posting tips (does not apply to Medicare Solutions platform) Use the dollar amount in the PLB to balance the 835 transaction.

• J1 will be in the same 835 as the claim.

• Post amounts to your patient accounts, but note that you will not physically receive funds for the claim payments.

• The dollar amount of the suppressed payment for the PLB J1 will be a positive value.




Adjustment Code Reference ID

Interest Owed (L6)

• Used to report interest paid on claims.

No Reference ID is included with the PLB L6. The amount reported is a sum of the AMT*I segments.

Commercial and Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• The amount of interest paid is reported in the PLB L6 as a negative amount and adds to the check total. The claim is in the same 835 transaction.

• To associate interest amounts with corresponding claims, use the AMT*1 segments at the claim level.

• The claim will contain an AMT segment in loop 2100 with an “I” (Interest) Amount Qualifier Code in the AMT01 and the interest amount in the AMT02.




Adjustment Code Reference ID

Adjustment (CS)

• Used to report the reissued payment amount for a lost check; or to

• Reduce a PLB FB balance if we write off an amount a provider owes; or to

• Reduce a PLB FB balance when the overpayment amount has been reduced.

• When reporting repayment for a lost check, the Reference ID contains the check number of the lost check (Medicare Solutions platform only).

• When reducing a prior PLB FB balance, the Reference ID is “Payer Write-Off” (Commercial platform).

• When a PLB FB balance is reduced due to claims reprocessing, the Reference ID will contain the beginning date of service and Patient Account Number of the associated claim (Commercial platform).

Commercial platform information and posting tips

Use the amount in the PLB to balance the transaction.

• A PLB FB balance was created on a prior 835 transaction. This was likely due to a recovery (PLB WO) being reported when there weren’t sufficient funds to recoup the entire overpayment amount. (See PLB FB Adjustment Code for additional information.)

• When a PLB FB remains uncollected and we decide not to recoup all or part of the remaining amount due, the amount written off will be reported in the 835 with a PLB CS.

• The 835 transaction will include the PLB FB and the balance amount from the prior 835 and a PLB CS for the amount of payer write-off. The PLB FB will report a positive amount (indicating an amount is brought forward from a prior 835) and the PLB CS will report a negative amount.

Medicare Solutions platform information and posting tips

Use the amount in the PLB to balance the transaction.

• The amount of the lost check is reported in the PLB CS as a negative value.

• The claim associated with the lost check will not be reported in an 835 transaction again. Only the payment will be reissued.



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