Friday, June 14, 2019

ACES program code list

ACES Program Codes

Some provider groups rely on the ACES program codes to help them determine if the client is on a state-only program or is on a Washington Apple Health Medicaid program to identify their funding sources. The following table lists these program codes.

SSI and SSI Related SSI and SSI related, also called Aged/Blind/Disabled (ABD); disability is determined by SSA or by NGMA referral to DDDS 

ACES DESCRIPTION  SCOPE 

S01 SSI Recipients CN
S02 ABD Categorically Needy CN
S03 QMB  Medicare Savings Program (MSP)  Medicare premium and co-pays MSP
S04 QDWI Medicare Savings Program   MSP
S05 SLMB Medicare Savings Program. Medicare Premium only  MSP
S06 QI-1 (ESLMB) Medicare Savings Program  MSP
S07 Undocumented Alien. Emergency Related Service Only ERSO 
S95 Medically Needy no Spenddown MN
S99 Medically Needy with Spenddown MN SSI Related
Living in an alternate living facility (nonmedical institution) adult family home, boarding home or DDA group home.


SSI Related Healthcare for Workers With Disability

Institutional  HCBS Waivers (HCS/DDA) and Hospice; SSI related  G03
Non Institutional Medical in ALF CN-P Income under the SIL plus under state rate x 31 days + 38.84
G95 Medically Needy Non Institutional in ALF no spenddown MN
G99 Medically Needy Non Institutional  in ALF with Spenddown MN
S08  Healthcare for Workers with Disability CN-P Premium based program.  Substantial Gainful Activity (SGA) not a factor in Disability determination.  
L21 Categorically Needy DDA/HCS Waiver or Hospice on SSI CN  L22
L24  Categorically Needy DDA/HCS Waiver or Hospice – gross income under the SIL Undocumented Alien/Non-Citizen LTC - residential placement. Must be preapproved by ADSA program manager. Emergency Related Service Only (45 slots)
L31 PACE or hospice on SSI (effective 10/1/15) CN
L32 PACE or hospice – SSI-related (effective 10/1/15) CN
L41 Roads to Community Living on SSI (effective 10/1/15) CN
L51 Community First Choice (CFC) on SSI (effective 10/1/15) CN
L52  Community First Choice (CFC) – SSI related at home or in an ALF (effective 10/1/15)
L99 Medically Needy Hospice in Medical Institution.  With Spenddown MN Institutional  SSI  L01
SSI recipient in a Medical Institution - Residing in a medical institution 30 days or more
CN Institutional
SSI Related Residing in a medical institution 30 days or more   
L02 SSI related CN-P in a Medical Institution Income under the SIL CN  L04  L95
L99  Undocumented Alien/Non-Citizen LTC must be pre-approved by ADSA program manager. Emergency Related Service Only (45 slots)
SSI related Medically Needy no Spenddown Income over the SIL. Income under the state rate.
SSI related Medically Needy with Spenddown Income over the SIL. Income over the state rate but under the private rate. Locks into state NF rate  CN  CN
ERSO – CN scope  CN
ERSO – CN scope  MN  MN


Categorically Needy Program (CNP)

This program has the largest scope of care.  A few of the services are:doctors, dentists, physical therapy, eye exams, eyeglasses (children only), mental health, prescriptions, hospitals, and family planning for men, women, and teens. There is limited coverage for maternity case management, orthodontia, private duty nursing, and psychological evaluations.Chiropractic care and nutrition therapy are limitedto the Healthy Kids program.


Alternative Benefits Plan (ABP)

This program is available to persons eligible to receive health care coverage under Washington Medicaid’s Modified Adjusted Gross Income (MAGI)-based adult coverage.  The scope of services available is equivalent to that available to CNP-covered clients with the addition of a benefit for habilitative services.  Washington Administrative Code (WAC) program policies are applicable to this new eligibility group, as are the instructions in the ProviderOne Billing & Resource Guide and program-specific provider guides.  This client population does not include those eligible for Medicare.


Emergency Related Services Only (ERSO) –PA may be required


This program has coverage for only specific medical conditions: a qualifying emergency, end stage renal disease on dialysis, cancer actively receiving treatment, or post-transplant status on anti-rejection medications. Prior authorization for some services may be required. Services not related to the medical condition are not covered. HCA determines if the client has a qualifying condition for any of these programs in accordance with the Washington Administrate Code (WAC) criteria. For specific details please see Chapter 182 - 507 WAC


.
Take Charge –Family Planning Service Only (TCFPO)

This program is for both women and men.It covers family planning services such as annual examinations, family planning education and risk reduction counseling, FDA approved contraceptive methods such as birth control pills and IUDs, emergency contraception,and sterilization procedures.

Family Planning Services Only (FPSO)


This program is  for women. Services includecoverage for all birth control methods, sterilization, OB-GYN exams, and counselingto help with family planning.

Medical Care Services (MCS) -no out of state care

This program covered many of the most basic services such as doctor's visits, prescriptions, and hospitalizations. However, some services, such as dental and mental health treatment may have restrictions that require prior authorization or may not be covered. This benefit was previously known as General Assistance (GA) and Disability Lifeline (DL).

Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) -no out of state care

This program covered many of the most basic services such as doctor's visits, prescriptions, and hospitalizations.However, some services, such as dental and mental health treatment may have restrictions that require prior authorization or may not be covered.Coverage is equivalent to Medical Care Services (MCS) below, with the addition of treatment for alcohol and drug addiction.


Limited Casualty Program – Medically Needy Program (LCP-MNP)

This program covers many medical services. A few of the services are:doctors, dentists, eye exams, eye glasses (children only), mental health , prescriptions, and hospitals, family planning for men, women, and teens.There are some services that are not covered, such as physical therapy.There are also limited services: maternity case management is one example. Chiropractic care and nutrition therapy are limited to the Healthy Kids program.


 

Monday, May 20, 2019

CPT 95940, 95941, G0453 -Intraoperative Neurophysiologic Monitoring


Medically Necessary Code Description CPT

95940 Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 

95941 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)

HCPCS

G0453
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)

Reimbursement Guidelines - UHC

Per the American Medical Association Intraoperative Neuromonitoring (IONM) is the use of electrophysiological methods to monitor the functional integrity of certain neural structures during surgery. The purpose of IONM is to reduce the risk of damage to the patient’s nervous system and to provide functional guidance to the surgeon and anesthesiologist.

IONM codes are reported based upon the time spent monitoring only, and not the number of baseline tests performed or parameters monitored. In addition, time spent monitoring excludes time to set up, record, and interpret the baseline studies, and to remove electrodes at the end of the procedure. Time spent performing or interpreting the baseline neurophysiologic study(ies) should not be counted as intraoperative monitoring, as it represents separately reportable procedures.

According to The Centers for  Medicare and Medicaid Services (CMS) , Intraoperative neurophysiology testing (HCPCS/CPT codes 95940, 95941 and G0453) should not be reported by the physician performing an operative or anesthesia procedure since it is included in the global package.
The use of either modifier 26 or TC does not apply to codes 95940, 95941 or G0453.

The American Academy of Neurology states IONM services 95940, and 95941 should be performed in Place of Service (POS) 19,21, 22 or 24. Therefore,UnitedHealthcare will only reimburse 95940, 95941 and G0453 services when reported with POS 19, 21,22 and 24.


Questions and Answers

1Q: Will IONM services be reimbursed when reported with POS 15 (mobile unit)?


A :  No. Services furnished in a mobile unit are often provided to serve an entity for which another POS code exists. When this is the case, the POS for that entity should be reported. UnitedHealthcare will only allow reimbursement for IONM services when reported with POS 19, 21
, 22and 24

2Q:Are IONM codes with a status “I” allowed when reported in a facility setting?
A: No, per CMS guidance the status “I” code is not reimbursable. For more information please review other  reimbursement policies, including but not limited to the Replacement Codes Policy.

Continuous intraoperative neurophysiology monitoring: BCBS Guideline

codes 95940, 95941 and G0453 are considered incidental to the surgeon’s or anesthesiologist’s primary service and not eligible for separate  reimbursement when performed and billed by the surgeon or anesthesiologist. HCPCS Code G0453 will not be allowed when billed during the same operative session as 95940 or 95941.

Q. How many units of G0453 may be billed per hour? 

A.  Under Medicare, total billed units for G0453 for all Medicare patients may not sum to more than the total time available. For example, when  more than one 15-minute timed code is billed during a single  hour, then the total number of timed units that can be billed for that hour across all Medicare patients is constrained by 60 minutes, or 4 units of G0453. Physicians may use the method of their choice to allocate time to patients being simultaneously monitored subject to the above restriction (only one unit of service can be billed for a 15- minute increment of time).  The physician’s attention does not have to be continuous for a 15-minute block of time; the physician may add up any non-continuous time directed at one patient to determine how many units of G0453 may be billed

.  If Medicare and non -Medicare patients are being seen, physicians must account for the exclusive, non-continuous time spent monitoring Medicare patients when billing Medicare.


General CPT instructions for time d codes indicate that a unit of time is attained when the mid -point is passed. Medicare recognizes this CPT guidance for many timed codes, including G0453. Therefore, physicians may bill for one unit of G0453 if at least 8 minutes of service is provided as long as no more than 4 units of G0453 are billed for each 60 minutes


Intraoperative Neurophysiologic Monitoring

Introduction


Tests can be done on specific nerves during complex brain, spine, and neck surgeries to help make sure the nerves are not being harmed. This is known as intraoperative neurophysiologic monitoring (IONM). There are a number of ways to perform this monitoring. It often involves the use of sophisticated medical devices to assess the muscle or electrical response when a nerve is stimulated. The goal is to provide the surgeon with immediate feedback about whether a nerve is at risk of being injured. The surgeon can make a correction right away to avoid permanent damage. This type of monitoring is well proven in specific types of surgeries. Some surgeons are using IONM during surgery for nerves located outside of the brain and spinal cord (the peripheral nerves). There is not enough medical evidence to show whether IONM leads to better health results when used for the peripheral nerves. For this reason, IONM is considered not medically necessary for peripheral nerve surgery.

Note:   The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.


Intraoperative Monitoring

* Somatosensory-evoked potentials
* Motor-evoked potentials using transcranial electrical stimulation
* Brainstem auditoryevoked potentials
* Electromyography (EMG) of cranial nerves
* Electroencephalography * Electrocorticography
* EMG

Medical Necessity

The types of Intraoperative neurophysiologic monitoring, listed on the left, may be considered medically necessary when there is significant risk of nerve or spinal cord injury during the following spinal, intracranial, vascular or recurrent laryngeal nerve surgical procedures: (this list may not be all inclusive) *  Aortic, thoracic, and abdominal aneurysm repair * Aortic cross-clamping * Arteriovenous malformation repair of the spinal cord * Brachial plexus surgery * Cerebral vascular surgery (eg, carotid endarterectomy, cerebral  aneurysm) * Clipping of intracranial aneurysms * Cortical localization * Interventional neuroradiology * Pelvic fracture surgery * Release of a tethered cord * Repair of coarctation of the aorta * Resection of fourth ventricular cyst * Resection of intracranial vascular lesions * Resection of spinal cord tumor, cyst, or vascular lesion * Scoliosis correction with instrumentation * Surgical stabilization of spine fractures * Stereotactic surgery of the brain or brain stem, thalamus, or  cerebral cortex * Thalamus tumor resection or thalamotomy * Thyroid surgery * Anterior cervical spinal fusions * Thoracic spine surgery  Intraoperative neurophysiologic monitoring for ANY other indication, including during lumbar surgery below L1/L2 is considered not medically necessary. (see Related Information)  The types of intraoperative neurophysiologic monitoring,


Intraoperative Monitoring

* Nerve conduction velocity monitoring

Intraoperative Monitoring
* Somatosensory-evoked potentials
* Motor-evoked potentials using transcranial electrical stimulation
* Brainstem auditoryevoked potentials
* Electromyography (EMG) of cranial nerves
* Electroencephalography * Electrocorticography

Motor-evoked potentials using transcranial magnetic stimulation

Coding 

Medical Necessity


listed on the left during surgery on the peripheral nerves are considered not medically necessary.

Investigational

The types of intraoperative neurophysiologic monitoring, listed on the left during the following surgical procedure is considered investigational: * Esophageal surgeries

Due to the lack of monitors approved by the U.S. Food and Drug Administration, intraoperative monitoring of motorevoked potentials using transcranial magnetic stimulation is considered investigational.



Related Information 
 

These policy statements refer only to use of these techniques as part of intraoperative monitoring. Other clinical applications of these techniques, such as visual-evoked potentials and EMG, are not considered in this policy.

Intraoperative neurophysiological monitoring is indicated in select spine surgeries when there is risk for additional spinal cord injury. Intraoperative monitoring has not been shown to be of clinical benefit for routine lumbar or cervical nerve root decompression (AANEM 2014), or during routine lumbar or cervical laminectomy or fusion (AANEM, 1999a) in the absence of myelopathy or other complicating conditions, which could increase the potential risk of damage to the nerve root or spinal cord, Resnick et al (2005) in published guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine reported that based on the medical evidence of the literature reviewed there did not appear to be support for the hypothesis that any form of intraoperative monitoring improves patient outcomes following lumbar decompression or fusion procedures for degenerative spinal disease. The authors concluded in a 2014 update there was no evidence that intraoperative monitoring can prevent injury to the nerve roots.

Intraoperative neurophysiologic monitoring including somatosensory-evoked potentials and motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography of cranial nerves, electroencephalography, and electrocorticography has broad acceptance, particularly for spine surgery and open abdominal aorta aneurysm repairs. Additionally, this policy addresses monitoring of the recurrent laryngeal nerve during neck surgeries and monitoring of peripheral nerves.

Intra-operative monitoring is considered reimbursable as a separate service only when a licensed physician, other than the operating surgeon, performs the monitoring while in attendance in the operating room or present by means of a real-time remote mechanism and is immediately available to interpret the recording and advise the surgeon throughout the procedure.
Intra-operative monitoring consists of a physician monitoring not more than three cases simultaneously.

Constant communication between surgeon, neurophysiologist, and anesthetist are required for safe and effective intraoperative neurophysiologic monitoring.

Sunday, May 19, 2019

CPT 48160, G0431, S2102, G0343 -Islet Transplantation

Code Description CPT

48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells

HCPCS

G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion
G0342 Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion
G0343 Laparotomy for islet cell transplant, includes portal vein catheterization and infusion
S2102 Islet cell tissue transplant from pancreas; allogeneic


Islet Transplantation

Introduction


The pancreas is an organ that stretches lengthwise across the abdominal area below the stomach. Within the pancreas are cell clusters commonly called “the islets.” Included in the islets are beta cells which make, store, and release insulin. Treating chronic inflammation of the pancreas may mean removing the pancreas. Removing the pancreas also removes the islets and the beta cells, which then leads to type 1 diabetes. To prevent the development of type 1 diabetes in people who have their pancreas removed, their own islet cells can be harvested and injected into a specific vein in the liver. Published medical studies show that islet cell transplantation appears to significantly decrease the development diabetes after the pancreas is removed. In this situation, islet cell transplantation may be considered medically necessary. Islet cell transplantation using donor cells is being studied as a technique to treat existing type 1 diabetes. There is not enough medical evidence to show how well this works to treat type 1 diabetes. Larger and longer studies are needed. For these reasons, islet cell transplantation to treat existing type 1 diabetes is investigational (unproven).

Note:  The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. 

Policy Coverage Criteria

Procedure Medical Necessity  Autologous pancreas islet transplantation

Autologous pancreas islet transplantation may be considered medically necessary as an adjunct to a total or near total pancreatectomy in patients with chronic pancreatitis.

Procedure Investigational
Allogeneic islet transplantation
Islet transplantation, all other

Documentation Requirements

Allogeneic islet transplantation is considered investigational for the treatment of type 1 diabetes.  Islet transplantation is considered investigational in all other situations.

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include the following: * Office visit notes that contain the relevant history and physical:
o Patient had pancreas removed because of chronic pancreatitis 


Guidelines Nationally Covered Indications

Whole organ pancreas transplantation is nationally covered by Medicare when performed simultaneous with or after a kidney transplant.  If the pancreas transplant  occurs after the kidney transplant, immunosuppressive therapy begins with the date of discharge from the inpatient  stay for the  pancreas transplant.

Pancreas transplants alone (PA) are reasonable and necessary for Medicare beneficiaries in the following limited circumstances:

• PA will be limited to those facilities that are Medicare-approved for kidney transplantation. Approved centers can be found at Approved Transplant Programs

• Patients must have a diagnosis of type I diabetes:

* Patient with diabetes must be beta cell autoantibody positive; or

* Patient must demonstrate insulinopenia defined as a fasting C-peptide level that  is less than  or equal to 110% of the lower limit of normal of the laboratory's measurement method. Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose ≤ 225 mg/dL;

• Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months with the most medically-recogni
zed advanced insulin formulations and delivery systems;

•Patients must have a history of medically -uncontrollable labile (brittle) insulin-dependent  diabetes mellitus with documented recurrent, severe, acutely life-threatening metabolic complications that require hospitalization.

Aforementioned complications include frequent hypoglycemia unawareness or recurring severe ketoacidosis, or recurring severe hypoglycemic attacks;

• Patients must have the emotional and mental capacity to understand the significant risks associated with  surgery and to effectively manage the lifelong need for immunosuppression; and,

• Patients must otherwise be a suitable candidate for transplantation.

If a kidney and pancreas transplants are performed simultaneously, the claim should contain a diabetes diagnosis code and a renal failure code or one of the hypertensive renal failure diagnosis codes. The claim should also contain two transplant procedure codes. If the claim is for a pancreas transplant only, the claim should contain a diabetes diagnosis code and a status code to indicate a previous kidney transplant. If the status code is not on the claim for the pancreas transplant, UnitedHealthcare will  search the beneficiary's claim history for a status  code indicating  a prior kidney transplant.

CPT Code Description

48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or  pancreatic islet cells (Not  covered by Medicare)

48554 Transplantation of pancreatic allograft (CMS sourced)

ICD- 10 Procedure Code Description

0FYG0Z0 Transplantation of pancreas, alloge neic, open approach  (CMS sourced)

0FYG0Z1 Transplantation of pancreas, syngeneic, open approach  (CMS sourced)




Blue Cross and Blue Shield Association Islet Cell Transplantation Billing /Coding/Physician Documentation Information


Applicable service codes:

48160, 48999, G0341, G0342, G0343, S2102

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


Coding 



Evidence Review 

Description


Performed in conjunction with pancreatectomy, autologous islet transplantation is proposed to reduce the likelihood of insulin-dependent diabetes. Allogeneic islet cell transplantation is being investigated as a treatment or cure for patients with type 1 diabetes.

Background  Chronic Pancreatitis

Primary risk factors for chronic pancreatitis may be categorized as the following: toxicmetabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, or obstructive (TIGAR-O classification system). Patients with chronic pancreatitis may experience intractable pain that can only be relieved with a total or near total pancreatectomy. However, the pain relief must be balanced against the certainty that the patient will be rendered an insulin-dependent diabetic.

Type 1 Diabetes

Glucose control is a challenge for individuals with type 1 diabetes. Failure to prevent disease progression can lead to long-term complications such as retinopathy, neuropathy, nephropathy, and cardiovascular disease.


Islet Transplantation

In autologous islet transplantation during the pancreatectomy procedure, islet cells are isolated from the resected pancreas using enzymes, and a suspension of the cells is injected into the portal vein of the patient’s liver. Once implanted, the beta cells in these islets begin to make and release insulin. 

Allogeneic islet transplantation potentially offers an alternative to whole-organ pancreas transplantation. In the case of allogeneic islet cell transplantation, cells are harvested from a deceased donor’s pancreas, processed, and injected into the recipient’s portal vein. Up to 3 donor pancreas transplants may be required to achieve insulin independence. However, a limitation of islet transplantation is that 2 or more donor organs are usually required for successful transplantation, although experimentation with single-donor transplantation is occurring. A pancreas that is rejected for whole-organ transplant is typically used for islet transplantation. Therefore, islet transplantation has generally been reserved for patients with frequent and severe metabolic complications who have consistently failed to achieve control with insulin-based management. Allogeneic transplantation may be performed in the radiology department. 

In 2000, a modified immunosuppression regimen increased the success of allogeneic islet transplantation. This regimen is known as the “Edmonton protocol.”

Monday, May 6, 2019

CPT 99453, 99454, 99447- 99448 - guidelines updates on documentation

CMS is finalizing our proposals to pay separately for two newly defined physicians’ services furnished using communication technology,


1. Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)

2. Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

3. Chronic care remote physiologic monitoring -CPT codes 99453, 99454, and 99457.

4. Interprofessional internet consultation - CPT codes 99451, 99452, 99446, 99447, 99448, and 99449.


Practitioners could be separately paid for the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.


This would increase efficiency for practitioners and convenience for beneficiaries. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.



E&M Documentation Changes for 2019


For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For CY 2019 and beyond, CMS is finalizing the following policies:

1. For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.


2. Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.




New codes for professional evaluation services:

• Testing evaluation services must always be performed and reported by professional (Physician & other qualified health care professional), using codes 96130, 96131, 96132 & 96133.

* Elements of professional work in the new evaluation service codes include:
▪ Integration of patient data.
▪ Interpretation of standardized test results and clinical data.
▪ Clinical decision making.
▪ Treatment planning and report.
▪ Interactive feedback to the patient, family member(s) or caregiver(s).
• Testing evaluation services may be billed on the same or different days.
• Testing evaluation services cannot be reported by the technician


Hint: Interactive feedback- Based on patient specific cognitive and emotional strengths and weaknesses, interactive feedback may include promoting adherence to medical and/or psychological treatment plans; educating and engaging the patient about his or her condition to maximize patient collaboration in their care; addressing safety issues; facilitating psychological coping; coordinating care; and engaging the patient in planning given the expected course of illness or condition, when performed.

Thursday, March 7, 2019

CPT 81405, 81406, 81407, 81439, s3865, s3866 -Hypertrophic Cardiomyopathy

Code Description CPT

81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis). This code includes:
* ACTC1 (actin, alpha, cardiac muscle 1) (eg, familial HCM), full gene sequence * MYL2 (myosin, light chain 2, regulatory, cardiac, slow) (eg, familial HCM), full gene
sequence * MYL3 (myosin, light chain 3, alkali, ventricular, skeletal, slow) (eg, familial HCM),
full gene sequence * TNNC1 (troponin C type 1 [slow]) (eg, hypertrophic cardiomyopathy or dilated
cardiomyopathy), full gene sequence * TNNI3 (troponin I, type 3 [cardiac]) (eg, familial HCM), full gene sequence
* TPM1 (tropomyosin 1 [alpha]) (eg, familial HCM), full gene sequence

81406
Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia). This code includes:
* TNNT2 (troponin T, type 2 [cardiac]) (eg, familial HCM), full gene sequence

81407 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform). This code includes:
* MYBPC3 (myosin binding protein C, cardiac) (eg, familial HCM), full gene sequence
* MYH7 (myosin, heavy chain 7, cardiac muscle, beta) (eg, familial HCM, Liang distal myopathy), full gene sequence


81439 Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN


S3865 Comprehensive gene sequence analysis for hypertrophic cardiomyopathy

S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family


Introduction

Hypertrophic cardiomyopathy is a condition where the muscle cells of the heart become big. This can make the walls of the heart thicker than normal, and because the walls surrounding the heart’s pumping chambers get thicker, the chambers become smaller than they should be. Hypertrophic cardiomyopathy is usually inherited, and is caused by changes to one or more of the person’s genes. The muscle problems eventually lead to enlargement of the heart and possible problems with the heart’s rhythm and valves. This policy discusses when genetic testing for this form of cardiomyopathy may be considered medically necessary.

Note:   The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. 



Testing Medical Necessity

Genetic testing for predisposition to HCM
Genetic testing for HCM gene variants
Genetic testing for predisposition to HCM

Genetic testing for predisposition to HCM may be considered medically necessary for individuals who are at risk for developing HCM.  * “At risk” is defined as having a first-degree relative who has a  confirmed diagnosis of HCM and the relative has a documented pathogenic gene variant (see below).

Genetic testing for HCM gene variants may be considered medically necessary for the index patient with confirmed clinical HCM, when used to assist unaffected first degree family members (see Benefit Application section).

Genetic testing for predisposition to HCM is considered not medically necessary for patients with a family history of HCM in which a first-degree relative has tested negative for pathologic variants.

Due to the complexity of genetic testing for hypertrophic cardiomyopathy (HCM) and the potential for misinterpretation of results, the decision to test and the interpretation of test results should be performed by, or in consultation with, an expert in the area of medical genetics and/or HCM.

To inform and direct genetic testing for at-risk individuals, genetic testing should initially be performed in at least one close relative with a confirmed diagnosis of HCM (index case), if possible. See Practice Guidelines and Position Statements and Benefit Application section for information regarding testing of the index case. 
Because there are varying degrees of penetrance for different HCM variants, consideration for testing of second- or third-degree relatives may be appropriate in certain circumstances. Some judgment should be allowed for these decisions, for example, in the case of a small family pedigree. Consultation with an expert in medical genetics and/or the genetics of HCM, in conjunction with a detailed pedigree analysis, is appropriate when testing of second- or third- degree relatives is considered.


Genetics Nomenclature Update

The Human Genome Variation Society nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics. (see Table 1). The Society’s nomenclature is recommended by the Human Variome Project, the HUman Genome Organization, and by the Human Genome Variation Society itself.

The American College of Medical Genetics and Genomics and the Association for Molecular Pathology standards and guidelines for interpretation of sequence variants represent expert opinion from both organizations, in addition to the College of American Pathologists. These recommendations primarily apply to genetic tests used in clinical laboratories, including genotyping, single genes, panels, exomes, and genomes. Table 2 shows the recommended standard terminology—“pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign”—to describe variants identified that cause Mendelian disorders.

Table 1. Nomenclature to Report on Variants Found in DNA  Previous  Updated  Definition
Mutation Disease-associated variant Disease-associated change in the DNA sequence

Variant Change in the DNA sequence 
Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives

Table 2. ACMG-AMP Standards and Guidelines for Variant Classification
Variant Classification Definition
Pathogenic Disease-causing change in the DNA sequence
Likely pathogenic Likely disease-causing change in the DNA sequence 
Variant of uncertain significance Change in DNA sequence with uncertain effects on disease
Likely benign Likely benign change in the DNA sequence
Benign Benign change in the DNA sequence
American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology.


Genetic Counseling


Genetic counseling is primarily aimed at patients who are at risk for inherited disorders, and experts recommend formal genetic counseling in most cases when genetic testing for an inherited condition is considered. The interpretation of the results of genetic tests and the understanding of risk factors can be very difficult and complex. Therefore, genetic counseling will assist individuals in understanding the possible benefits and harms of genetic testing, including the possible impact of the information on the individual’s family. Genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing. Genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Benefit Application

Some Plans may have contract or benefit exclusions for genetic testing. Recommendations indicate that, when possible, genetic testing for hypertrophic
cardiomyopathy be performed in an affected family member so that testing in unaffected, atrisk family members can focus on the variant found in the affected family member. This testing is intended to document whether a known pathologic variant is present in the family and to optimize the predictive value of predisposition testing for at-risk relatives. However, coverage for testing of the affected index case depends on contract benefit language when there is no conclusive evidence of clinical benefit to the index case from testing.

Specific contract language must be reviewed and considered when determining coverage for testing. In some cases, coverage for testing the index case may be available through the contract that covers the unaffected, at-risk individual who will benefit from knowing the results of the genetic test.

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