Saturday, August 10, 2019

Condition code G0 - Billing Guideliens

Condition code G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.

Proper Reporting of Condition Code G0

Hospitals should report condition code G0 in Form Locators 24-30 on the UB-04 claim form, the electronic equivalent, when multiple medical visits occur on the same day in the same revenue center, but the visits were distinct and independent visits.


Beneficiary presents to the emergency room in the morning for a broken arm, then later that same day presents for chest pain.

On the first claim, report the first ER visit (revenue code 045X plus E/M code) with all ancillary services rendered on that day.

On the second claim, report only the unrelated ER visit (revenue code 045X plus E/M code) with condition code G0 and modifier 27. All other charges are reported on the first claim.

Proper reporting of condition code G0 allows for proper payment under the Outpatient Prospective Payment System. The Outpatient Code Editor contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of condition code G0.

Multiple Medical Visits billing Guideline

• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.

Multiple Unrelated Visits on the Same Date of Service

Forward Health defines a related visit as one whose primary diagnosis matches the primary diagnosis of a subsequent visit. When billing one or more separate, unrelated visits that occur on the same DOS as an outpatient continuous visit, Forward Health recommends providers do the following: ? Submit separate claims for each visit. Include condition code G0 (the letter G and the digit zero) on the second claim submitted and send it to Written Correspondence for special handling. To do this, attach the Written Correspondence Inquiry form, F-01170 (07/12), to the paper claim or adjustment form and indicate “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the Other Information field of the form.

* If a claim that indicates the G0 condition code also requires consideration for an exception to the submission deadline, submit a completed Timely Filing Appeals Request form, F-13047 (07/12), for each claim, entering “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the free format field near the bottom of the form.

For example, a member comes in to the emergency room (ER) on the morning of January 8, 2012, with a concussion and returns home once treated. He returns to the ER later that same night with a high fever and vomiting and is kept over midnight for observation. In this situation, the provider is encouraged to bill the two visits on two separate claims and to differentiate the visits using condition code G0 on the second claim submitted, following the special handling instructions stated previously. This allows Forward Health to reimburse both visits and pay two access payments to the provider, if applicable.

Note: The special handling instructions listed above apply to claims or adjustments with DOS between January 1, 2010, and March 31, 2013. Claims and adjustments with DOS on and after April 1, 2013, will not require special handling for the G0 condition code; these claims will be processed using the new Enhanced Ambulatory Patient Groups (EAPG) reimbursement methodology for outpatient hospital services.

Friday, July 12, 2019

Medicare part B basics - covered service and premium

Four categories of Medicare insurance: Parts A, B, C, and D.

1. Part A. Provides hospital facilities, nursing facilities, hospices and home health facilities.

2. Part B. covers physician services, ambulatory care and non-hospital services.

3. Part C. Medicare advantage plan, both includes Parts A and B.

4. Part D. Prescription plan.

Medicare Part B

All persons entitled to Part A are also entitled to Part B. Usually, the monthly premium has to be collected from person. An annual Part B deduction also applies, and coins will be processed in each claim, which means that Medicare pays a share of the allowed amount for all covered services and the patient has to pay the remaining 20 % or co-insurance.

The most important thing to remember about Part B is that it covers doctoral bills, wherever they may be, at home, in the doctor's office, in a clinic and hospital.

Part B also covers:

• Outpatient hospital services
• X-rays and diagnostic tests
• Ambulance services
• Durable medical equipment (e.g. wheelchairs )
• Certain non-physician services
• Physical therapy

Medicare Part B covers numerous preventive companies to assist seniors and adults with disabilities to stay healthy. These embrace an Annual Wellness Visit, most cancers screenings, vaccines, and testing and management of chronic situations.

Medicare Part B Premium

In a number of ways, Part B premiums can be collected. In case an enrollee receives social security and railway pension , Part B premiums shall, by legislation, be deducted  automatically. In addition, Part B premiums are deducted from the benefits of retired persons of the Federal Civil Service. The purpose of auto collection of premiums is to maintain a minimum of premium collection costs.

The normal monthly premium for Part B was $135.50 in 2019.

Medicare Part B Eligibility and Enrollment

A person who has worked in covered employment and who has paid Medicare payroll tax for 40 quarters is eligible to receive Medicare Part A premium-free benefits at the age of sixty-five. All persons eligible for part A (whether eligible for Part A premium-free), also have the right to register in Part B. An old person who is not eligible in part A can register in part B when he or she is 65 or older, and either an American citizen or foreign national is legally permitted in the name of a permanent resident.

Common Medicare Questions

Q: Do I have to apply to Medicare or do I receive it automatically?

A: When you've received Medicare, you've been registered automatically for both Parts A and Part B when you get some type of Social Security (pension advantages or disability benefits).

Do both parts A and B have to be taken?

A: The need for the part A and B of Medicare depends on whether Medicare will be your primary or secondary insurer. Part A is hospital and Part B is health insurance. You do not need either Part A or Part B if your present employer insurance is primary. Most individuals choose to take Part A because it is free for them. For example, if you have a retirement or a COBRA insurance, you need both Part A and Part B since Medicare is the primary one.

How do I pay for Medicare if my Social Security Check does not automatically take it away?

A: If you do not automatically take your Part B premium from your social security check, you can send your check to your local social security office. It is however a good idea to automatically taken from your social security check.

Is there additional insurance for which I can buy that to pay for the deductibles and coinsurance?

A: Yes. A: Yes. Medigap policy can help pay your Medicare copays and allowable deductible amount.   See if you have the right to purchase a Medigap plan by the State Insurance Department

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 


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)


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


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

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


Medical Necessity

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


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


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


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. 


Evidence Review 


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.”

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