tag:blogger.com,1999:blog-37412819587323792032024-02-06T21:44:54.225-08:00Medicare denial codes, reason, action and Medical billing appealMedicare denial codes, reason, remark and adjustment codes.Medicare, UHC, BCBS, Medicaid denial codes and insurance appeal. Sample appeal letter for denial claim. CO, PR and OA denial reason codes codes.Unknownnoreply@blogger.comBlogger423125tag:blogger.com,1999:blog-3741281958732379203.post-6517538906756684472022-03-17T04:22:00.009-07:002022-03-17T04:22:39.425-07:00Medicaid Guidelines - OCCUPATIONAL THERAPY SERVICES<div><b>OCCUPATIONAL THERAPY SERVICES</b></div><div><br /></div><div>Occupational Therapy is provided by an appropriately licensed occupational therapist who evaluates the student's level of functioning and develops a KPOC. Licensed occupational therapist assistants functioning under the general supervision of the licensed occupational therapist may assist in the delivery of the POC.</div><div><br /></div><div>Occupational Therapy evaluation and treatment includes: assessing, improving, developing, or restoring functions impaired or lost through illness, injury or deprivation; improving ability to perform tasks for independent functioning when functions are lost or impaired, preventing through early intervention, initial or further impairment or loss of function; obtaining and interpreting information; coordinating care and integrating services the student is receiving.</div><div><br /></div><div><b><br /></b></div><div><b>How to bill for therapy services</b></div><div><br /></div><div>Enter one date of service per claim line (From and To dates must be the same). Include the appropriate modifier(i.e., GO) on all claims. After prior authorization is issued, billed services must match the approved authorization. Be sure to include the authorization number on all claims. Submit claims using Direct Data Entry through the Electronic Verification System (EVS) secure Provider WebPortal or use an approved Trading Partner to submit your claims. See EVS User Manual Chapter 3 Claims and the Professional Fee-for-Service 837PCompanion Guide for claim submission instructions. When a licensed therapy assistant provides a service under the supervision of a licensed therapist, the licensed therapist must bill with the appropriate modifier CO(Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant) or CQ (Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant).</div><div><br /></div><div><br /></div><div><b>Referral for Services</b></div><div><br /></div><div>•Occupational therapy services must be ordered by a licensed physician or other licensed health care provider within their scope of practice per:Federal regulations (42 CFR 440.110) </div><div><br /></div><div>•For SBHS, licensed occupational therapists can evaluate, diagnose, and provide services per an IEP or IFSP without a script from a physician within their scope of practice per:</div><div><br /></div><div>** Department of Health (DOH) regulations (Chapter 246-847 WAC).</div><div>** OTs should review DOH regulations to ensure they refer and provide services per their scope of practice.18</div><div><br /></div><div><b><br /></b></div><div><b>COVERED SERVICES</b></div><div><br /></div><div>1. Evaluation and diagnosis to determine the extent of a student's disabilities in areas such as sensorimotor skills, self-care, daily living skills, play and leisure skills, and use of adaptive or corrective equipment;</div><div><br /></div><div>2. Individual Therapy provided to a student to remediate and/or adapt skills necessary to promote the student's ability to function independently;</div><div><br /></div><div>3. Group Therapy provided to more than one student but less than seven simultaneously to correct or ameliorate and/or adapt skills necessary to promote the students' ability to function independently;</div><div><br /></div><div>4. Task-oriented activities to prevent or correct physical or emotional deficits to minimize the disabling effect of these deficits;</div><div><br /></div><div>5. Exercise to enhance functional performance;</div><div><br /></div><div>6. Medical Team Conference participation time for the development of medical relatedmservices in the POC. Payment is excluded for participation time of POC development for educational pr.</div><div><br /></div><div><b>Billing for Evaluations and Reevaluations</b></div><div><br /></div><div>•The SBHS program utilizes three occupational therapy evaluation codes and one reevaluation code:</div><div><br /></div><div>Evaluations codes: 97165, 97166, 97167</div><div><br /></div><div>Re-evaluation code: 97168•Even though time is associated with each evaluation code, evaluation codes are untimed. </div><div><br /></div><div>•Times associated with the evaluation codes are provided as “guidance” for providers in order to determine which code is most appropriate to use.</div><div><br /></div><div>•Providers should use their professional judgement to determine the most appropriate code to use</div><div><br /></div><div><b>SPEECH THERAPY AND AUDIOLOGY SERVICE</b>S </div><div><br /></div><div>Speech, hearing, and language pathology services are those services necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and for the diagnosis and treatment of swallowing disorders with or without the presence of a communication disability. The services must be of such a level of complexity and sophistication or the condition of the student must be such that the services required can be safely and effectively performed only by a qualified therapist.</div><div><br /></div><div>The practice of audiology consists of rendering services for the measurement, testing, appraisal prediction, consultation, counseling, research, or treatment of hearing impairment for the purpose of modifying disorders in communication involving speech, language, and hearing. Audiology services must be performed by a certified and licensed audiologist.</div><div><br /></div><div><b>Covered Services</b></div><div><br /></div><div>1. Speech and Language evaluation and diagnosis of delays and/or disabilities including, but not limited to, voice, communication, fluency, articulation or language development. Audiological evaluation and diagnosis to determine the presence and extent of hearing impairments that affect the student's educational performance. Audiological evaluations include complete hearing and/or hearing aid evaluation, hearing aid fittings or reevaluations, and audiograms.</div><div><br /></div><div>2. Individual Therapy provided to a student in order to correct or ameliorate delays and/or disabilities associated with speech, language, hearing, or communication.</div><div><br /></div><div>3. Group Therapy provided to one student, but less than seven, simultaneously in order to correct or ameliorate delays and/or disabilities associated with speech, language, hearing, or communication.</div><div><br /></div><div>4. Medical Team Conference participation time for the development of medical related services in the POC. Payment is excluded for participation time of POC development for educational processes and goals. ocesses and goals.</div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-14398331951697149612021-07-10T03:23:00.008-07:002021-07-10T03:23:39.561-07:00Venipuncture CPT codes - 36415, 36416, G0471<p> </p><p><b>CPT Code and Definitions</b></p><p><br /></p><p><b>36415</b> Collection of venous blood by venipuncture</p><p><br /></p><p><b>36416 </b>Collection of capillary blood specimen (e.g., finger, heel, ear stick)</p><p><br /></p><p><b>G0471</b> Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a SNF or by a laboratory on behalf of a HHA </p><p><br /></p><p><b>S9529</b> Routine venipuncture for collection of specimen (s), single home bound, nursing home, or skilled nursing facility patient.</p><p><br /></p><p><br /></p><p><b>Venipuncture Definition</b><span style="white-space: pre;"><b> </b> </span></p><p>Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the Cubital vein of the anterior forearm at the elbow fold.</p><p><br /></p><p><br /></p><p><b>Reimbursement Guidelines</b></p><p><br /></p><p>A. For Professional and Clinical Laboratory Services (including Dialysis Centers and Home Health): </p><p>Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures. The work of obtaining the specimen sample is an essential part of performing the test.</p><p><br /></p><p>Reimbursement for the venipuncture is included in the reimbursement for the lab test procedure code.</p><p>1. CPT Code 36415</p><p>a. For Moda Health Advantage:</p><p>36415 is eligible for separate reimbursement, consistent with Original Medicare payment policy.</p><p>b. For all other lines of business, the following policies apply:</p><p><br /></p><p>i. CPT 36415 is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed to obtain an adequate specimen size for the</p><p>desired test(s). (CMS4)</p><p><br /></p><p>ii. Moda Health does not allow separate reimbursement for CPT 36415 (venipuncture) when billed in conjunction with a blood or serum lab procedure performed on the</p><p>same day and billed by the same provider (procedure codes in the 80048 - 89399 range). 36415 will be denied as a subset to the lab test procedure. </p><p><br /></p><p>iii. If some of the blood and/or serum lab procedures are performed by the provider and others are sent to an outside lab, CPT 36415 is not eligible for separate reimbursement. </p><p><br /></p><p>iv. Modifier 90 (reference laboratory) will not bypass the subset edit. The outside laboratory that is actually performing the test will need to bill Moda Health directly for the lab tests in order for 36415 to be separately reimbursable to the provider performing the venipuncture to obtain the specimen for the outside laboratory.</p><p><br /></p><p>v. The use of modifiers XS, XP, XE, XU, or 59 with 36415 when blood/serum lab tests are also billed is not a valid use of the modifier. The venipuncture is not a separate procedure in this situation.</p><p><br /></p><p>vi. Moda Health does allow separate reimbursement for CPT 36415 when the only other lab services billed for that date by that provider are for specimens not obtained by venipuncture (e.g. urinalysis). </p><p><br /></p><p>* For Ambulatory Surgery Centers (ASC):</p><p>Per CMS policy, routine venipuncture or other routine collection of specimens, if needed, is not separately reimbursable to ASCs. These services are included in the packaged reimbursement for the primary procedure or service.</p><p><br /></p><p>*For Outpatient Hospital (OPPS) Services:</p><p>The CMS OPPS Medically Unlikely Edit (MUE) limits apply for routine venipuncture procedure codes or other routine collection of specimens.</p><p><br /></p><p><b>Coding Guidelines for CPT 36415</b></p><p><br /></p><p>• When existing vascular access lines or selectively placed catheters are utilized to procure arterial or venous samples, reporting the sample collection separately is inappropriate. (CMS3)</p><p><br /></p><p>• CPT codes 36500 or 75893 may occasionally be appropriate if more extensive work beyond routine venipuncture is required. For instance, if a physician needs to place a catheter to obtain a blood specimen from a specific organ or location. CPT codes 36500 (venous catheterization for selective organ blood sampling) or 75893 (venous sampling through catheter with or without angiography...) may be reported for venous blood sampling through a catheter placed for the sole purpose of venous blood sampling. CPT code 75893 includes concomitant venography if performed.(CMS3) </p><p><br /></p><p><b>Background Information</b></p><p><br /></p><p>Venipuncture or phlebotomy is the puncture of a vein with a needle or an IV catheter to withdraw blood. Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures, and is sometimes referred to as a “blood draw.” Collection of a capillary blood specimen (36416) or of venous blood from an existing access line or by venipuncture that does not require a physician’s skill or a cutdown is considered “routine venipuncture.”</p><p><br /></p><p><br /></p><p><b>Overview</b></p><p><br /></p><p>This policy addresses the ConnectiCare, Inc. reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for provider claims submitted on a CMS-1500, whether performed in a physician’s office, a hospital laboratory, or an independent laboratory. Note this policy does not address reimbursement for all laboratory codes. Coding relationships for laboratory topics not included within this policy are administered through ConnectiCare administrative and reimbursement policies. All services described in this policy may be subject to additional reimbursement policies.</p><p><br /></p><p><br /></p><p>If you are a physician, practitioner, or medical group, you may only bill for services that you or your staff perform. Pass-through billing is not permitted and may not be billed to our members. We only reimburse for laboratory services that you are certified to perform through the Federal Clinical Laboratory Improvement Amendments (CLIA). You must not bill our members for any laboratory services for which you lack the applicable CLIA certification. To validate whether a test requires CLIA visit CMS/FDA websites.</p><p><br /></p><p><b>Policy statement:</b></p><p><b><br /></b></p><p><b>Duplicate Laboratory Charges – Multiple Providers</b></p><p><br /></p><p>Only one provider will be reimbursed when multiple providers bill identical services. ConnectiCare will reimburse the provider or entity that actually performed the test. Duplicate laboratory services are defined as identical or equivalent bundled laboratory codes. Note: For the purpose of this policy, CPT codes 82947 and 82948 are not considered to be equivalent codes:</p><p>• 82947 - Glucose; quantitative, blood (except reagent strip)</p><p>• 82948 - Glucose; blood, reagent strip</p><p><b>Pathologist and Physician Laboratory Providers</b></p><p>If a pathologist and another physician or other qualified health care professional’s offices submit identical laboratory codes for the same patient on the same date of service, only the pathologist’s service is reimbursable.</p><p><br /></p><p><b>Place of Service</b></p><p><br /></p><p>The Place of Service (POS) identifies where the laboratory service was performed. ConnectiCare uses the codes indicated in the Centers for Medicare and Medicaid Services (CMS) Place of Service Codes for Professional Claims Database to determine if laboratory services are reimbursable.</p><p><br /></p><p><b>Examples:</b></p><p>• If the physician bills for lab services performed in his/her office, the POS code 11 for "Office" is reported.</p><p>• If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, the POS code 81 for "Independent Laboratory" is reported. Laboratory Panels</p><p><br /></p><p>Individual laboratory codes, which together make up a laboratory panel code, will be combined into and reimbursed as the more comprehensive laboratory panel code as described under the specific laboratory panel headings below.</p><p><br /></p><p>ConnectiCare also considers an individual component code included in the more comprehensive panel code when reported on the same date of service by the same individual physician or other qualified health care professional. The Professional Edition of the CPT book, Organ or DiseaseOriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."</p><p><br /></p><p>In addition, it is not appropriate for a laboratory panel to be split amongst multiple laboratories or office/laboratory settings. This is also considered unbundling of a laboratory panel. Laboratory panels that have been split billed, or unbundled are not reimbursable. Venipuncture and Specimen Collection Specimen collection fees are not reimbursed when billed by the same provider who is rendering blood or related laboratory services Consistent with CMS, only one collection fee for each type of specimen per patient encounter, regardless of the number of specimens drawn, will be allowed. A collection fee will not be reimbursed to anyone who did not extract the specimen.</p><p><br /></p><p>Venous blood collection by venipuncture and capillary blood specimen collection (CPT codes 36415 and 36416) will be reimbursed once per patient per date of service when reported by the Same Individual Physician or Other Qualified Health Care Professional. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.</p><p><br /></p><p>Consistent with CMS, ConnectiCare considers collection of a specimen from a completely implantable venous access device and from an established catheter (CPT codes 36591 and 36592) to be bundled into services assigned a CMS NPFS Status Indicator of A, R or T provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional, for which payment is made. When CPT code 36591 is submitted with CPT code 36592, CPT code 36592 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36591 from bundling into CPT code 36592.</p><p><br /></p><p>ConnectiCare considers venipuncture code S9529 (Routine venipuncture for collection of Specimen(s), single homebound, nursing home, or skilled nursing facility patient) a nonreimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.</p><p><br /></p><p>Consistent with CMS, specimen collection HCPCS code G0471 is reimbursable only when a Specimen is collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency.</p><p><br /></p><p>Laboratory Handling Laboratory handling and conveyance CPT codes 99000 and 99001 and HCPCS code H0048 are included in the overall management of a patient and are not separately reimbursed when submitted with another code, or when submitted as the only code on a claim for the same date of service.</p><p><br /></p><p><b>Code Q0091</b></p><p><br /></p><p>HCPCS code Q0091 (screening Papanicolaou smear, obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory) is eligible for reimbursement for Medicare beneficiaries only. For all other products it is considered to be part of the E/M and Pap smear codes and is not eligible for separate reimbursement.</p><p>Guidelines for Billing Units When submitting multiple units of one code, the guidelines are based on code descriptions:</p><p><br /></p><p>• If the CPT or HCPCS code description contains "per" or "each" or another unit of measurement and multiple services are provided, providers should bill the code on one line with the appropriate number of units.</p><p><br /></p><p>• If the code does not contain a measurement such as "per" or "each" in the description of the code, providers should report one unit for all services.</p><p><br /></p><p><b>Venipuncture and Specimen Collection</b></p><p><br /></p><p>Consistent with CMS, only one collection fee for each type of Specimen per patient encounter, regardless of the number of Specimens drawn, will be allowed. A collection fee will not be reimbursed to anyone who did not extract the Specimen. Venous blood collection by venipuncture and capillary blood Specimen collection (CPT codes 36415 and 36416) will be reimbursed once per patient per date of service when reported by the Same Individual Physician or Other Qualified Health Care Professional. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.</p><p><br /></p><p>Consistent with CMS, UnitedHealthcare considers collection of a Specimen from a completely implantable venous access device and from an established catheter (CPT codes 36591 and 36592) to be bundled into services assigned a CMS NPFS Status Indicator of A, R or T provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional, for which payment is made. When CPT code 36591 is submitted with CPT code 36592, CPT code 36592 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36591 from bundling into CPT code 36592.</p><p><br /></p><p>UnitedHealthcare considers venipuncture code S9529 a non-reimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.</p><p>Consistent with CMS, specimen collection HCPCS code G0471 is reimbursable only when a Specimen is collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency.</p><p><br /></p><p>Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the cubital vein of the anterior forearm at the elbow fold. Please</p><p>refer to the coding section of this policy for the CPT code most applicable to the method of blood withdrawal.</p><p><br /></p><p>This policy addresses the Health Plan’s reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for provider claims submitted on a CMS-1500, whether performed in a physician’s office, a hospital laboratory,</p><p>or an independent laboratory. </p><p><br /></p><p><b>. Routine Venipuncture and the Collection of Blood Specimen </b></p><p><b><br /></b></p><p><b>A. Routine Venipuncture/Capillary Blood Collection</b></p><p><br /></p><p> Healthcare Common Procedure Coding System (HCPCS Level II) code S9529 and capillary blood collection code 36416, are eligible for separate reimbursement when reported with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, the frequency limit for any of these services is once per member, per provider, per date of service. The frequency limit will also apply to any combination of these codes reported on the same date of service for the same member by the same provider. (See also our Frequency Editing Reimbursement Policy.)</p><p><br /></p><p>When routine venipuncture CPT code 36415 is reported with Evaluation and Management (E/M) office visit codes (99201-99205 and 99211-99215) then the routine venipuncture code is included in the reimbursement for office visit E/M services and not reimbursed separately.</p><p><br /></p><p>Modifiers will not override the edit.</p><p><br /></p><p>Routine venipuncture CPT 36415 is eligible for separate reimbursement when reported with a laboratory service.</p><p><br /></p><p>In addition, HCPCS code G0471 for the collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA) collected by a laboratory technician that is employed by the laboratory that is performing the test will be eligible for separate reimbursement when reported with a laboratory service.</p><p><b><br /></b></p><p><b>B. Collection of Blood Specimen from Access Device or Catheter</b></p><p> The Health Plan follows CPT coding guidelines which state that CPT codes 36591and 36592 should not be reported “…in conjunction with other services except a laboratory service.2 ” Therefore, CPT codes 36591 and 36592 are only eligible for separate reimbursement when reported with a laboratory service. See also our Bundled Services and Supplies Reimbursement Policy. </p><p><br /></p><p><br /></p><p><b>Coding</b></p><p>The following tables are provided as an informational tools only to help identify some of the procedures described above. The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement under all circumstances.</p><p>According to Health Plan policy, the following codes are eligible for separate reimbursement when reported with a laboratory service:</p><p><br /></p><p><b>Code Description</b></p><p><br /></p><p><br /></p><p>36415 Collection of venous blood by venipuncture</p><p>36420 Venipuncture, cutdown; younger than age 1 year</p><p><br /></p><p><b>Coding Tips</b></p><p>Local anesthesia is included in these services. For handling or conveyance of a specimen transported to an outside laboratory, see 99000. For venipuncture on a patient younger than 3 years of age, see 36400–36406. For venipuncture requiring physician skill on a patient 3 years of age or older, see code 36410. Do not report code 36420 if providedwith critical care; see codes 99468–99480. Code 36425 should not be reportedwith endovenous ablation(36475–36479)</p><p><br /></p><p><b>Terms To Know</b></p><p>critical care. Treatment of critically ill patients in a variety of medical emergencies that requires the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, respiratory failure, postoperative complications, critically ill neonate). cutdown. Small, incised opening in the skin to expose a blood vessel, especially over a vein (venous cutdown) to allow venipuncture and permit a needle or cannula to be inserted for the withdrawal of blood or administration of fluids.</p><p><br /></p><p>venipuncture. Piercing a vein through the skin by a needle and syringe or sharp-ended cannula or catheter to draw blood, start an intravenous infusion, instill medication, or inject another substance such as radiopaque dye</p><p><br /></p><p>Venipuncture is the process of collecting or “drawing” blood from a vein and the most common way to collect blood specimens for laboratory testing. It is the most frequent procedure performed by a phlebotomist and the most important step in this procedure is patient identification. This chapter addresses how to correctly identify all types of patients and how to safely obtain high-quality blood specimens from them. Venipuncture techniques covered in this chapter include ETS, butterfly, and syringe procedures on arm and hand veins. This chapter also addresses challenges and unique issues associated with pediatric, geriatric, dialysis, long-term care, home care, and hospice patients. Venipuncture procedures in this chapter conform to CLSI standards.</p><p><br /></p><p><br /></p><p>Cognitively Impaired or Combative Patients Some patients may display unpredictable or sudden movements and behaviors that could pose a danger to themselves, the phlebotomist or others nearby. If a patient exhibits such behaviors it is essential for an additional person or employee to be enlisted to assist if necessary. In addition, make certain you have an obstructed exit route in case it is needed. Also be mindful of where you place equipment, being certain to keep it out of the reach of the patient. As with venipuncture on every patient, always have a gauze pad ready and be prepared to release the tourniquet quickly in case the patient pulls the needle out, or suddenly jerks causing the needle to either come out or go deep into the arm. Should the needle penetrate deep into the arm the patient’s nurse or healthcare provider must be informed and the incident documented according to facility policy.</p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-62272236283000355962021-05-30T03:00:00.002-07:002021-05-30T03:00:00.229-07:00CPT 80053, Comprehensive metabolic panel<p> <br /></p><p><b>CODE<span style="white-space: pre;"> </span> DESCRIPTION</b></p><p><br /></p><p>80053<span style="white-space: pre;"> </span> Comprehensive metabolic panel This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide</p><p><span style="white-space: pre;"> </span>(bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), <span style="white-space: pre;"> </span>Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), Urea Nitrogen (BUN) (84520)</p><p><br /></p><p><br /></p><p><b>Organ or Disease-Oriented Laboratory Panel Codes</b></p><p><br /></p><p>The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, and 80081. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare uses CPT coding guidelines to define the components of each panel.</p><p><br /></p><p>UnitedHealthcare also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional. The Professional Edition of the CPT ® book, Organ or Disease-Oriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."</p><p><br /></p><p>For reimbursement purposes, UnitedHealthcare differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare will bundle the individual Component Codes into the more comprehensive Panel Code when the combined reimbursement for the individual Panel Code(s) exceeds the reimbursement amount of the Panel Code or when the designated number of Component Codes identified within a Panel Code are submitted as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076 and 80081 identify the Component Codes that UnitedHealthcare will rebundle into the specific panel.</p><p><br /></p><p><br /></p><p>CPT coding guidelines indicate that Panel CPT code 80047 should not be reported in conjunction with CPT code 80053. If a submission includes CPT 80047 and CPT 80053, only CPT 80053 will be reimbursed.</p><p><br /></p><p>CPT coding guidelines indicate that, Panel CPT code 80048 should not be reported in conjunction with Panel CPT 80053. If a submission includes Panel CPT 80048 and 80053, only Panel CPT 80053 will be reimbursed. There are 2 configurations for, Panel CPT code 80048:</p><p>1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80048.</p><p><br /></p><p>Panel Code: 80048</p><p>Must contain 5 or more of the following Component Codes for the same patient on the same date of service</p><p>82310 82374 82435 82565 82947</p><p>84132 84295 84520</p><p><br /></p><p>A submission that includes, Panel CPT code 80053, Panel CPT code 84443 and one of the following Component Codes, either CPT codes 85025 or 85027 + 85004 or 85027 + 85007 or 85027 + 85009 by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service, Panel CPT code 80050.</p><p><br /></p><p>Panel Code: 80050</p><p><br /></p><p>Includes the following Panel Code: 80053 </p><p>Plus the following Component Code: 84443 </p><p>Plus 1 of the following CBC or combination of CBC Component Codes for the same patient on the same date of service: :</p><p>85025 <span style="white-space: pre;"> </span>85027 +<span style="white-space: pre;"> </span> 85027 +<span style="white-space: pre;"> </span>85027 +</p><p><span style="white-space: pre;"> </span>85004<span style="white-space: pre;"> </span> 85007<span style="white-space: pre;"> </span>85009</p><p><br /></p><p>When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.</p><p><br /></p><p>When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.</p><p>Panel code 80053, a component of Panel code 80050, includes all components of Panel CPT code 80076 except for code 82248.</p><p><br /></p><p>Panel, 80053</p><p><br /></p><p>There are 3 configurations for Panel CPT code 80053:</p><p>1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.</p><p>Panel Code: 80053</p><p>Must contain 10 or more of the following Component Codes for the same patient on the same date of service:</p><p>82040 82247 82310 82374 82435</p><p>82565 82947 84075 84132 84155</p><p>84295 84450 84460 84520</p><p><br /></p><p>2. A submission that includes a Panel CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.</p><p><br /></p><p>Panel Code: 80053</p><p>Includes the following Panel Code: 80048 Plus 2 or more of the following Component Codes for the same patient on the same date of service:</p><p>82040 82247 84075 84155 84450</p><p>84460</p><p><br /></p><p>3. A submission that includes, Panel CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as Panel CPT code 80053.</p><p>Panel Code: 80053</p><p>Includes the following Panel Code: 80051 Plus 6 or more of the following Component Codes for the same patient on the same date of service:</p><p>82040 82247 82310 82565 82947</p><p>84075 84155 84450 84460 84520</p><p><br /></p><p>When the Same Individual Physician or Other Qualified Health Care Professional reports the Panel CPT codes 80053 with 80048 or 80076 for the same patient on the same date of service, neither Panel CPT codes 80048 nor 80076 will be reimbursed separately.</p><p>CPT Panel Code 80053 includes all of the components of CPT Panel Code 80048 and all the components of CPT Panel Code 80076, except for CPT 82248. Therefore, when performed with all of the components of Panel CPT code 80053, report CPT 82248 separately.</p><p><br /></p><p><b>Coding Tip</b></p><p><br /></p><p>This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520). Code 80048 cannot be reported in conjunction with 80053.</p><p><br /></p><p><br /></p><p>80053 Comprehensive metabolic panel A comprehensive metabolic panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (83435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155),</p><p>sodium (84295), alanine amino transferase (ALT) (SGPT) (84460), aspartate amino transferase (AST) (SGOT) (84450), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests</p><p><br /></p><p><br /></p><p>Code 80053 can not be used in addition to CPT codes 80048 and 80076.</p><p><br /></p><p><br /></p><p>This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA waived</p><p>test. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for</p><p>* Indicates a mutually exclusive edit</p><p><br /></p><p>80053 <span style="white-space: pre;"> </span>80048, 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, 84520</p><p><br /></p><p><br /></p><p> </p><p>Reimbursement is provided for tests that are performed in a panel if they are reasonable, medically necessary under the applicable medical policy, and otherwise reimbursable under the terms of the member's plan. The plan reserves the right to rebundle individual codes that belong to a panel. If a claim is submitted with individual codes that belong to a panel, our claim reviewers and/or correct coding software logic may rebundle the procedure codes for appropriate reimbursement. If the medical documentation submitted with a claim shows that a panel was ordered and performed but the claim submitted shows the individual components of the panel, claim reviewers may rebundle the codes into the appropriate panel for reimbursement. CPT states the following:</p><p><br /></p><p>• Tests performed in addition to those specifically indicated for a particular panel should be reported separately from the panel code</p><p>Example, If the Electrolyte panel (80051) is billed, individual tests such as 82947 (Assay Glucose Blood Quant), 84520 (Assay of Urea Nitrogen), 82565 (Assay of</p><p>Creatinine) and 82550 (Assay of CK (CPK)) should be billed separately from the panel.</p><p><br /></p><p>• Do not report two or more panel codes that include the same constituent tests performed from the same patient collection</p><p>Example, If the Comprehensive Metabolic Panel (80053) is billed, the Basic Metabolic Panel (80047) cannot be billed.</p><p><br /></p><p>• If a group of tests overlaps two or more panels, you must use the panel that incorporates the greatest number of tests and report the remaining individual tests</p><p>Example, if 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium), 84295 (Assay of Serum Sodium), 84520 (Assay of</p><p>Urea Nitrogen), and 82947 (Assay Glucose Blood Quant) are billed, two panel codes overlap. The Basic Metabolic Panel (80047) and the Electrolyte Panel (80051) include</p><p>codes 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium) and 84295 (Assay of Serum Sodium). The Electrolyte Panel should be billed.</p><p><br /></p><p>• The panel code should be billed when all individual tests in the panel have been performed and should not be billed separately</p><p>Example, If the Lipid Panel (80061) is billed, then procedures 82465 (Assay BLD/Serum Cholesterol), 83718 (Assay of Lipoprotein) and 84478 (Assay of Triglycerides) should have been performed. </p><p><br /></p><p>80053 <span style="white-space: pre;"> </span>Comprehensive Metabolic Panel</p><p>82040 <span style="white-space: pre;"> </span>Assay of Serum Albumin</p><p>82247 <span style="white-space: pre;"> </span>Bilirubin Total</p><p>82310 <span style="white-space: pre;"> </span>Assay of Calcium</p><p>82374<span style="white-space: pre;"> </span>Assay Blood Carbon Dioxide</p><p>82435<span style="white-space: pre;"> </span>Assay of Blood Chloride</p><p>82565 <span style="white-space: pre;"> </span>Assay of Creatinine</p><p>82947<span style="white-space: pre;"> </span>Assay Glucose Blood Quant</p><p>84075<span style="white-space: pre;"> </span>Assay Alkaline Phosphatase</p><p>84132 <span style="white-space: pre;"> </span>Assay of Serum Potassium</p><p>84155 <span style="white-space: pre;"> </span>Assay of Protein Serum</p><p>84295<span style="white-space: pre;"> </span>Assay of Serum Sodium</p><p>84460 <span style="white-space: pre;"> </span>Alanine Amino (ALT) (SGPT)</p><p>84450 <span style="white-space: pre;"> </span>Transferase (AST) (SGOT)</p><p>84520 <span style="white-space: pre;"> </span>Assay of Urea Nitrogen</p><p><br /></p><p><br /></p><p><b>Purpose of Policy</b></p><p><br /></p><p>This policy is intended to help clarify how and why the same test or service may process differently depending upon the primary diagnosis code with which it is billed. The focus of this policy is on the differences between the Preventive and the Medical benefit categories.</p><p><br /></p><p><br /></p><p><b>Scope</b></p><p><br /></p><p>This policy applies to all Commercial medical plans.</p><p><br /></p><p><b>Reimbursement Guidelines</b></p><p><br /></p><p>A. Categories of diagnostic tests covered and not covered as routine/preventive</p><p><br /></p><p>1. Moda Health covers the preventive services mandated in the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.</p><p><br /></p><p>2. In addition to the mandated PPACA preventive services, Moda Health also covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code.</p><p><br /></p><p>The codes and tests eligible for this additional screening coverage are determined by a Moda Health Medical Director and are listed below. NOTE: These tests are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit because they are not on the PPACA list of mandated preventive services.</p><p>The tests will be covered (rather than denied), but all of the following tests are subject to the member’s usual cost-sharing and deductible requirements, even</p><p>when billed with a preventive diagnosis.</p><p><br /></p><p><b>Lab Panels</b></p><p><br /></p><p>Organ- or disease-oriented lab panels were developed to allow for coding of a group of tests. Providers are expected to bill the lab panel when all the tests listed within each panel are performed on the same date of service. When one or more of the tests within the panel are not performed on the same date of service,</p><p>providers may bill each test individually. Providers may not bill for a panel and all the individual tests listed within that panel on the same day. However, other tests performed in addition to those listed on the panel on the same date of service may be reported separately, in addition to the panel code. Providers must</p><p>follow CPT coding guidelines when reporting multiple panels. For example, providers cannot report basic panel code 80048 with comprehensive panel code 80053 on the same date of service, because all the lab tests in 80048 are components of 80053.</p><p><br /></p><p><br /></p><p>On May 3, 2019 CMS issued Change Request 11248, which re-implements the Automated Multi-Channel Chemistry (AMCC) Lab Panel Claims Payment System Logic. This logic was introduced in 2017 but was suspended beginning CY 2018, due to the Protecting Access to Medicare Act of 2014 (PAMA). PAMA required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS). Under PAMA, reporting entities must report to CMS certain private payer rate information for their component applicable laboratories. The implementation of PAMA required Medicare to pay the weighted median of private payor rates for each separate HCPCS code, as one National fee schedule rate rather than individual rates per state.</p><p><br /></p><p>Prior to PAMA, CMS paid for certain chemistry tests using Automated Test Panels (ATPs). ATPs used claims processing logic to apply a bundled rate to sets of these codes based off how many ATPs were ordered. The claims processing system would not pay more for all ATPs than the associated CPT Panel (80047-80081). Any duplicated chemistry tests across ATPs or separately billed without a 91 modifier are not counted in the ATP test total. Below will further illustrate the logic and the effect on reimbursement. The Ohio rate of the 2017 CLFS is used for this demonstration, as the 2019 CLFS has not been updated with ATP entries as of the time of this article.</p><p><br /></p><p><b>Example</b></p><p><br /></p><p>A lab receives an order for a Comprehensive Metabolic Panel (80053) and a Lipid Panel (80061). Both panels are processed, results sent to the referring provider and a claim is sent to Medicare for HCPCS 80053 and 80061. The 2017 CLFS indicates payment for each HCPCS code as:</p><p>80053 $14.49</p><p>80061 $17.45</p><p>Total $31.94</p><p><br /></p><p>Under the ATP payment methodology, payment will be determined based off the total number of unique chemistry tests performed.</p><p>Medicare will first strip each panel into its component codes as follows:</p><p><br /></p><p><b>80053 <span style="white-space: pre;"> </span>HCPCS<span style="white-space: pre;"> </span> 80061 <span style="white-space: pre;"> </span>HCPCS</b></p><p><span style="white-space: pre;"> </span>82040 <span style="white-space: pre;"> </span>82465</p><p><span style="white-space: pre;"> </span>82247 <span style="white-space: pre;"> </span>83718</p><p><span style="white-space: pre;"> </span>82310 <span style="white-space: pre;"> </span>84478</p><p><span style="white-space: pre;"> </span>82374</p><p><span style="white-space: pre;"> </span>82435</p><p><span style="white-space: pre;"> </span>82565</p><p><span style="white-space: pre;"> </span>82947</p><p><span style="white-space: pre;"> </span>84075</p><p><span style="white-space: pre;"> </span>84132</p><p><span style="white-space: pre;"> </span>84155</p><p><span style="white-space: pre;"> </span>84295</p><p><span style="white-space: pre;"> </span>84460</p><p><span style="white-space: pre;"> </span>84450</p><p><span style="white-space: pre;"> </span>84520</p><p></p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-90770522012445762572021-05-20T04:01:00.001-07:002021-05-20T04:01:00.228-07:00CPT 71275 AND 74174<p><b> CPT Code Description</b></p><p><b>71275 </b> Computed tomographic angiography, chest (non-coronary), with contrast material(s), including noncontrast images, if performed, and image post-processing </p><p><br /></p><p><b>CPT Code <span style="white-space: pre;"> </span>Acceptable S/S <span style="white-space: pre;"> </span>Procedure to Pre-Cert</b></p><p>71275<span style="white-space: pre;"> </span>* Thoracic Aortic Dissection</p><p><span style="white-space: pre;"> </span>* Thoracic Aortic Aneurysm</p><p><span style="white-space: pre;"> </span>* Coarctation</p><p><span style="white-space: pre;"> </span>* Aortic Root Dilation<span style="white-space: pre;"> </span>CTA Chest</p><p><br /></p><p>74174 <span style="white-space: pre;"> </span>* Abdominal Aortic Dissection</p><p><span style="white-space: pre;"> </span>* Mesenteric Ischemia</p><p><span style="white-space: pre;"> </span>* Bowel Ischemia</p><p><span style="white-space: pre;"> </span>* Stent Obstruction<span style="white-space: pre;"> </span>CTA Abdomen and Pelvis</p><p><span style="white-space: pre;"> </span>* Thoracic Abdominal Aortic Dissection requires both codes 71275 and 74174</p><p><br /></p><p><b>CPT Codes: 71275</b></p><p>Computed tomography angiography (CTA) is a non-invasive imaging modality that may be used in the evaluation of thoracic vascular problems. Chest CTA (non-coronary) may be used to evaluate vascular conditions, e.g., pulmonary embolism, thoracic aneurysm, thoracic aortic dissection, aortic coarctation, or pulmonary vascular stenosis. CTA depicts the vascular structures as well as the surrounding anatomical structures.</p><p>Initial Clinical Reviewers (ICRs) and Physician Clinical Reviewers (PCRs) must be able to apply criteria based on individual needs and based on an assessment of the local delivery system.</p><p><br /></p><p><b>INDICATIONS FOR CHEST CTA:</b></p><p><br /></p><p>For evaluation of suspected or known pulmonary embolism (excludes low risk*)</p><p>For evaluation of suspected or known vascular abnormalities:</p><p>* For evaluation of a thoracic/thoracoabdominal aneurysm or dissection (documentation of clinical history may include hypertension and reported “tearing or ripping type” chest pain.</p><p>* Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by GI study).</p><p>* Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound).</p><p>* Follow-up evaluation of progressive vascular disease when new signs or symptoms are present.</p><p>* Primary or secondary pulmonary hypertension.</p><p><br /></p><p><b>Preoperative evaluation</b></p><p>* Known or suspected vascular abnormalities seen on prior imaging</p><p>* Ablation procedure for atrial fibrillation.</p><p><br /></p><p>Postoperative or post-procedural evaluation</p><p>* Physical evidence of post-operative bleeding complication or re-stenosis.</p><p>* Post-surgical follow up when records document medical reason requiring additional imaging</p><p><br /></p><p><b>Chest CTA and Abdomen CTA or Abdomen/Pelvis CTA or Pelvis CTA combo:</b></p><p>* For evaluation of extensive vascular disease involving the chest and abdominal cavities such as aortic dissection, vasculitic diseases such as Takayasu’s arteritis, significant post-traumatic or postprocedural vascular complications, etc.</p><p>* For preoperative or preprocedural evaluation such as transcatheter aortic valve replacement (TAVR).</p><p><br /></p><p><b>ADDITIONAL INFORMATION RELATED TO CHEST CTA:</b></p><p>CTA and Coarctation of the Aorta – Coarctation of the aorta is a common vascular anomaly characterized by a constriction of the lumen of the aorta distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum. The clinical sign of coarctation of the aorta is a disparity in the pulsations and blood pressures in the legs and arms. Chest CTA may be used to evaluate either suspected or known aortic coarctation and patients with significant coarctation should be treated surgically or interventionally.</p><p>CTA and Pulmonary Embolism (PE) – Note: D-Dimer blood test in patients at low risk* for DVT is indicated prior to CTA imaging. Negative D-Dimer suggests alternative diagnosis in these patients. *Low risk defined as NO to ALL of the following questions:</p><p>1) Evidence of current or prior DVT;</p><p>2) HR > 100;</p><p>3) Cancer diagnosis;</p><p>4) Recent surgery or prolonged immobilization;</p><p>5) Hemoptysis;</p><p>6) History of PE; and another diagnosis is more likely.</p><p>CTA has high sensitivity and specificity and is the primary imaging modality to evaluate patients suspected of having acute pulmonary embolism. When high suspicion of pulmonary embolism on clinical assessment is combined with a positive CTA, there is a strong indication of pulmonary embolism. Likewise, a low clinical suspicion and a negative CTA can be used to rule out pulmonary embolism. CTA and Thoracic Aortic Aneurysms – Computed tomographic angiography (CTA) allows the examination of the precise 3-D anatomy of the aneurysm from all angles and shows its relationship to branch vessels. This information is very important in determining the treatment: endovascular stent grafting or open surgical repair.</p><p><br /></p><p>CTA and Thoracic Aorta Endovascular Stent-Grafts – CTA is an effective alternative to conventional angiography for postoperative follow-up of aortic stent grafts. It is used to review complications after thoracic endovascular aortic repair. CTA can detect luminal and extraluminal changes to the thoracic aortic after stent-grafting and can be performed efficiently with fast scanning speed and high spatial and temporal resolution.</p><p><br /></p><p><b>Chest CT</b></p><p>1. Intrathoracic abnormalities found on chest x-ray, fluoroscopy, abdominal CT scan, or other imaging modalities may be further evaluated with chest CT with contrast (CPT® 71260).</p><p>a. “Abnormalities” through these guidelines may include suspected lung or pleural nodules or masses, pleural effusion, adenopathy or other findings that are not considered benign. </p><p>b. Lung nodule(s) identified incidentally on:</p><p>i. Chest CTA without and with contrast (CPT® 71275), or</p><p>ii. Chest MRI without contrast (CPT® 71550), or</p><p>iii. Chest MRI without and with contrast (CPT® 71552), or</p><p>iv. Chest MRA without and with contrast (CPT® 71555) can replaceChest CT with contrast (CPT® 71260) or chest CT without contrast (CPT® 71250) as the initial dedicated study</p><p>2. Chest CT without contrast (CPT® 71250) can be used for the following:</p><p>a. Patient has contraindication to contrast.</p><p>b. Follow-up of pulmonary nodule(s).</p><p>c. High Resolution CT (HRCT).</p><p>d. Low-dose chest CT (CPT® G0297)</p><p>3. Chest CT without and with contrast (CPT® 71270) does not add significant diagnostic information above and beyond that provided by chest CT with contrast, unless a question regarding calcification, most often within a lung nodule, needs to be resolved.</p><p>4. High resolution chest CT should be reported only with an appropriate code from the set CPT® 71250-CPT® 71270.</p><p>a. No additional CPT® codes should be reported for the “high resolution” portion of the scan. The “high resolution” involves additional slices which are not separately billable.</p><p>E. Chest CTA (CPT® 71275)</p><p>1. Chest CTA (CPT® 71275) can be considered for suspected Pulmonary Embolism and Thoracic Aortic disease.</p><p>a. CTA prior to minimally invasive or robotic surgery </p><p><br /></p><p><b>Non-Cardiac Chest Pain Imaging</b></p><p>1. Initial evaluation should include a chest x-ray.1,2</p><p>a. If x-ray is abnormal, chest CT with contrast (CPT® 71260) or CTA chest with contrast (CPT® 71275) can be performed.1,2,3,4</p><p><br /></p><p><br /></p><p><b> Hemoptysis</b></p><p>A. Chest CT with contrast (CPT® 71260) OR without contrast (CPT® 71250) OR CTA chest (CPT® 71275) may be performed after:</p><p>1. Abnormal chest x-ray, or</p><p>2. No chest x-ray needed if any of the following:</p><p>a. High risk for malignancy with >40 years of age and >30 pack-year smoking history, or</p><p>b. Persistent/recurrent with >40 years of age or >30 pack year smoking history, or</p><p>c. Massive hemoptysis (=30 cc per episode or unable protect airway).1</p><div><br /></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-75518426543607272502021-05-06T04:00:00.006-07:002021-05-06T04:00:59.063-07:00CPT CODE 97597, 97598 - Debridement procedure<p><b>CPT CODE AND Description </b></p><p><b><br /></b></p><p><b>CPT code 97598 (Debridement</b> [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof) was identified by the RUC on a list of services that were originally surveyed by one specialty but are now typically performed by a different specialty.</p><p><br /></p><p><b>CPT code 97597 (Debridement</b> [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less) was included for review as part of the family despite being reviewed at the October 2018 RUC meeting.</p><p><br /></p><p><b>Billing Guidelines</b></p><p><b><br /></b></p><p><b>Wound Care (CPT Codes 97597, 97598 and 11042-11047)</b></p><p>1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.</p><p>2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.</p><p>3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.</p><p>4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.</p><p>5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.</p><p>6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.</p><p>7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.</p><p>8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.</p><p>9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies</p><p>Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse</p><p>practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements.</p><p>10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.</p><p>11. Documentation must support the HCPCS being billed.</p><p>12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.</p><p>13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.</p><p><br /></p><p><b>Coding Guidelines</b></p><p><br /></p><p>1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.</p><p>2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.</p><p>3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).</p><p>4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.</p><p><br /></p><p><br /></p><p>• 97597 Removal of devitalized tissue from wounds, selective debridement, without anesthesia, wound assessment, topical applications, instructions for ongoing care, total wound surface area first 20 sq cm . May include scalpel, scissors, waterjet</p><p><br /></p><p>• CPT 15002-15005 are NOT to be used for the removal of nonviable tissue/debris in chronic wounds left to heal by secondary intention. CPT 11042-11047 and CPT 97597- 97598 are to be used for this.</p><p><br /></p><p><b>CPT codes 97597 and 97598,</b></p><p>• “to remove devitalized and/or necrotic tissue and promote healing”</p><p>• 97597 Selective debridement, without anesthesia – wound area <20 sq cm</p><p>• High pressure water jet</p><p>• Sharp selective debridement (scissors, scalpel and forceps)</p><p>• 97598 Wound area > 20 sq cm</p><p><br /></p><p><b>Multiple Levels of Debridement Coding Example:</b></p><p>The patient has five wounds. There is a superficial blister on the right 1st MTPJ, an ulceration that penetrates to subcutaneous tissue beneath the left second metatarsal head, an ulceration that penetrates to subcutaneous tissue on the right anterior leg, an ulceration with necrotic Achilles tendon exposed on the</p><p>posterior right heel, and a lateral left fibular malleolus with bone exposed.</p><p>1) Debrided 2 x 3cm Right 1st MTPJ skin ulcer = 97597</p><p>2) Debrided 2 x 1cm subcutaneous ulceration plantar 2nd metatarsal head as well as the subcutaneous 5 x 4 right leg ulceration = total 22 sq cm = 11042 for the first 20 sq. cm. plus 11045 for additional 2sq. cm.</p><p>3) Debrided 7 x 4cm necrotic Achilles tendon ulceration = 11043 for the first 20 sq. cm. and 11046 for additional 8 sq. cm.</p><p>4) Debrided 0.5 x 0.5cm necrotic bone on the left lateral malleolus = 11044</p><p><br /></p><p><b>CPT 97597</b></p><p>Debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/ or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed, and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm. or less. This code is to be used when only skin structures were debrided. It is to be used for up to and including 20 sq. cm. of tissue debrided. There is a 0 day global and the relative value unit is 2.52.</p><p><br /></p><p>(CPT 97597/97598 coding example: If you debrided a 47 sq. cm. skin wound, you would code: 97597 x 1 for the first 20 sq. cm., plus 97598 x 2 for sq. cm. 21-40 and sq. cm. 41-47. The total RVU would be 2.52 + 0.79 + 0.79 = 4.10.)</p><p><br /></p><p><b>Billing and Coding Guidelines for Wound Care</b></p><p><b>Wound Care (CPT Codes 97597, 97598 and 11042-11047)</b></p><p>1. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.</p><p>2. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.</p><p>3. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.</p><p><br /></p><p>4. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their plan of care. If it is a physician or non-physician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements</p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-16801012854638257532021-04-15T03:30:00.001-07:002021-04-15T03:30:05.984-07:00CPT code G0104, G0105, G0121 - Colorectal cancer screening<p><b> CPT code and Description</b></p><p><br /></p><p><b>G0105</b><span style="white-space: pre;"> </span> Colorectal cancer screening; colonoscopy on individual at high risk</p><p><b>G0121</b><span style="white-space: pre;"> </span> Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk</p><p><b>G0104</b> - Colorectal Cancer Screening; Flexible Sigmoidoscopy</p><p><br /></p><p><br /></p><p><b>SUMMARY OF CHANGES</b>: The method for calculating payment for discontinued procedures is being revised. New payment rates will apply when modifier 53 (discontinued procedure) is appended to codes 44388, 45378, G0105, and G0121.</p><p><br /></p><p><b>GENERAL INFORMATION</b></p><p><br /></p><p>A. Background: Prior to calendar year (CY) 2015, according to Current Procedural Terminology (CPT) instruction, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.</p><p>In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is</p><p>unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.” Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specific values in the Medicare physician fee schedule database for the following codes: 44388-53, 45378-53, G0105-53, and </p><p><b>G0121-53.</b></p><p><br /></p><p>B. Policy: Effective for services performed on or after January 1, 2016, the Medicare physician fee schedule database will have specific values for codes 44388-53, 45378-53, G0105-53, and G0121-53. Given that the new CPT definition of an incomplete colonoscopy also includes colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.</p><p><br /></p><p><b>Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)</b></p><p><br /></p><p>An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.</p><p><br /></p><p>• HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.</p><p><br /></p><p>G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy</p><p><br /></p><p>Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below. For claims with dates of service on or after January 1, 2002, contractors pay for screening flexible sigmoidoscopies (HCPCS G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa)(5) of the Social Security Act (the Act) and in the Code of Federal Regulations (CFR) at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted above. For claims with dates of service prior to January 1, 2002, Medicare Administrative Contractors (MACs) pay for these services</p><p>under the conditions noted only when a doctor of medicine or osteopathy performs them.</p><p>For services furnished from January 1, 1998, through June 30, 2001, inclusive:</p><p><br /></p><p>• Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed).</p><p>For services furnished on or after July 1, 2001:</p><p><br /></p><p>• Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §60.3 of this chapter) and he/she has had a screening colonoscopy (HCPCS G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (HCPCS G0121).</p><p><br /></p><p>NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth; the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0104.</p><p><br /></p><p>When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. The Medicare physician fee schedule database has specific</p><p>values for codes 44388-53, 45378-53, G0105-53 and G0121-53. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of “–53” to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, Ambulatory Surgical Centers (ASCs) are to suffix the colonoscopy code with modifier “–73” or “–74” as appropriate. Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete.</p><p>Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.</p><p><br /></p><p>HCPCS G0121 - Colorectal Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk - Applicable On and After July 1, 2001</p><p>Effective for services furnished on or after July 1, 2001, screening colonoscopies (HCPCS G0121) performed on individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §60.3 of this chapter) may be paid under the following conditions:</p><p><br /></p><p>• At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.)</p><p><br /></p><p>• If the individual would otherwise qualify to have covered a HCPCS G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy (HCPCS G0104), then he or she may have covered a HCPCS G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered HCPCS G0104 flexible sigmoidoscopy was performed.</p><p><br /></p><p>NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0121.</p><p><br /></p><p><br /></p><p>Colonoscopy – CPT Codes 45378-45398, G0105, G0121</p><p><br /></p><p>The American Society for Gastrointestinal Endoscopy (ASGE) works to ensure that adequate methods are in place for gastroenterology practices to report and obtain fair and reasonable reimbursement for procedures, tests and visits. To assist practices in understanding and implementing GI-specific coding, ASGE has developed coding sheets. The purpose of the coding sheet is to provide a high-level overview to support practices in there coding and reimbursement for 2018. </p><p><br /></p><p><b>What is a Colonoscopy?</b></p><p><br /></p><p>It is an examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.</p><p>The CPT© codes in this series identify services performed during Colonoscopy</p><p><br /></p><p><b>HCPCS Codes for Colonoscopy</b></p><p><b>HCPCS Code <span style="white-space: pre;"> </span>Code Descriptor</b></p><p>G0105<span style="white-space: pre;"> </span> Colorectal cancer screening; colonoscopy on individual at high risk</p><p>G0121<span style="white-space: pre;"> </span> Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk</p><p><br /></p><p><br /></p><p><b>Gastroenterology Coding: Screening Versus Diagnostic Colonoscopy</b></p><p><br /></p><p>To define the procedure, a colonoscopy is the examination of the entire colon from the rectum to the cecum, and it may include examination of the terminal ileum (small intestine). With that being said, there are two types of colonoscopies: screening and diagnostic. Medicare has specific guidelines for screening and diagnostic colonoscopies. Other payers may have very specific criteria for both types of colonoscopies as well.</p><p><br /></p><p>Medicare defines these two types as:</p><p><br /></p><p>1. Screening – used for patients who have:</p><p>• No family history of colon cancer or colon polyps</p><p>• No personal history of colon cancer or polyps</p><p>• No symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)</p><p><br /></p><p>2. Diagnostic – used for patients who have:</p><p>• Family history of colon cancer or polyps</p><p>• Personal history of colon cancer or polyps</p><p>• Symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)</p><p>• Previous colonoscopy(ies) with findings of polyps, colon cancer, diverticulitis, etc.</p><p><br /></p><p>Medicare also defines what they consider to be high risk for colorectal cancer as an individual with:</p><p>• A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp</p><p>• A family history of familial adenomatous polyposis</p><p>• A family history of hereditary nonpolyposis colorectal cancer</p><p>• A personal history of adenomatous polyps;</p><p>• A personal history of colorectal cancer; or</p><p>• Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis</p><p><br /></p><p>Medicare uses HCPCS codes to bill for screening colonoscopies. For a patient of typical risk, the screening procedure is reported with HCPCS code G0121; for a</p><p>patient at high risk, it is reported with HCPCS code G0105. Providers should review the policies of their insurance payers to be certain which coding system is</p><p>used, especially for Medicare Advantage plans offered by commercial insurers.</p><p>Per the 2019 AMA CPT Professional Edition guidelines:</p><p><br /></p><p>When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colonsmall intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.</p><p><br /></p><p>If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381, 45382, 45384, 45388, 45398) is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.</p><p>For colonoscopy through stoma, see 44388-44408.</p><p><br /></p><p>So, the first step to coding a colonoscopy is to determine if it is a screening or diagnostic colonoscopy. If the patient has had any signs or symptoms such as</p><p>abdominal pain, weight loss or rectal bleeding, then it is not a screening but rather a diagnostic (symptomatic) colonoscopy. Also, if the patient has had</p><p>previous findings such as polyps or diverticulitis, then it is not a screening colonoscopy.</p><p>Aside from the CPT coding guidelines, if you’re wondering what the current Medicare reimbursement rates are for selected GI services, GI.org has a helpful</p><p>chart.</p><p><br /></p><p>Keeping track of gastroenterology code changes should not fall solely on you or your staff. You should have tools in place like a gastroenterology EHR system that</p><p>can help in the process.</p><p><br /></p><p><br /></p><p>providing the correct procedure codes to report colonoscopies continues to cause confusion for the professional coder. The American Medical Association (AMA) provides the Common Procedural Terminology (CPT) codes used to report outpatient procedures for hospitals and physicians. Medicare adds additional codes in the HCPCS Healthcare Procedure Coding System). HCPCS includes both CPT, which is HCPCS Level I, and CMS-developed HCPCS Level II codes. The HCPCS codes are required for all Medicare outpatient hospital services, if they are available, unless specifically excepted in Medicare manual instructions. Let us take a look at some typical colonoscopy coding scenarios, and the CPT and HCPCS codes that should be reported.</p><p><br /></p><p><b>Screening colonoscopy</b></p><p><br /></p><p>AHA Coding Clinic provides guidance in assigning the principal or first-listed diagnosis code when the physician documents that the colonoscopy is performed for screening purposes only. Code V76.51 is used first and any findings such as polyps, diverticulosis, or hemorrhoids are listed second; see Coding Clinic, First Quarter 1999 Page: 4. CPT codes are reported based on the procedure documented, and whether the patient is Medicare. If the patient is not Medicare, the appropriate CPT, (HCPCS Level I) code is assigned. If the patient is Medicare and no other procedures, such as a polypectomy or biopsy are performed, then either code G0105 or G0121,</p><p>(HCPCSL Level II) codes are assigned. G0105 is assigned if the patient qualifies as high risk using the following criteria:</p><p><br /></p><p>* A personal history of colorectal cancer or</p><p>* A family history of familial adenomatous polyposis or</p><p>* A family history of hereditary nonpolyposis colorectal cancer or</p><p>* A personal history of adenomatous polyps or</p><p>* Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis or</p><p>* A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyp.</p><p>HCPCS code G0121 is assigned if the patient does not qualify as high risk.</p><p><b>Screening colonoscopy with polypectomy</b></p><p>If the colonoscopy starts as a screening, but the physician finds polyps and performs a polypectomy, the principal or first-listed diagnosis code remains as V76.51. The polyp is reported as a secondary diagnosis code. The procedure reported will depend on the documentation and will include only the CPT, Level I HCPCS code(s). Medicare also requires the modifier PT to be added to the procedure code, when the screening colonoscopy becomes a diagnostic colonoscopy. Use of this modifier will allow the Medicare patient to have the deductible waved.</p><p><b>Colonoscopy with different polypectomy techniques</b></p><p>When the colonoscopy includes more than one polypectomy technique, each technique may be reported separately if performed on different polyp sites. For example the physician performs a cold forceps polypectomy on a polyp in the descending colon, a polypectomy using snare in the rectum, and a polypectomy using hot forceps in the rectum.</p><p>Each procedure is reported using modifier 59 for the second two; see Coding Clinic for HCPCS - Third Quarter 2006 Page: 4. If two techniques are used on the same polyp, such as a snare removal followed by hot cautery, only the hot cautery should be reported; see CPT Assistant January 2004, pages 5-7.</p><p><b>Colonoscopy with tattooing</b></p><p>Occasionally, the physician injects ink to identify a polypectomy or other suspicious sites in the colon when performing the colonoscopy. CPT code 45381, colonoscopy with submucosal injection, should be reported in addition to the polypectomy or other procedure; see CPT Assistant, June, 2010, page 4. A separate procedure modifier 59 is not required. </p><p><b>Colonoscopy with upper endoscopy</b></p><p>Quite often a colonoscopy is performed either just prior to, or just following an upper endoscopy, or esophagogastroduodenoscopy, (EGD). When this situation occurs, both the code for the colonoscopy and the EGD are reported. Modifier 59 is not required as the procedures are performed in different body systems. A high percentage of modifier 59 use could prompt a focus review by an outside agency.</p><p>It is important to understand the colonoscopy coding guidelines and associated procedures for both coding compliance and to obtain the correct reimbursement due to the facility. Performing routine audits to check the coding of this procedure will help to ensure proper coding.</p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-31018015648551457102021-03-09T02:27:00.002-08:002021-03-09T02:27:47.492-08:00CPT code J1439, L34093, J0887, Q9976<p><b>Required Billing and Coding</b></p><p><br /></p><p><b>J Code<span style="white-space: pre;"> </span> Product<span style="white-space: pre;"> </span> Indications</b></p><p>J1439<span style="white-space: pre;"> </span> Injection, ferric carboxymaltose, 1 mg </p><p>L34093 (Chemotherapy and Biologicals)</p><p>J0887 - Injection, Epoetin Beta (For ESRD On Dialysis), 1 microgram</p><p>Q9976 - Injection ferric pyrophosphate citrate solution; 0.1 mg of iron</p><p><br /></p><p><br /></p><p><b>INDICATIONS</b></p><p><br /></p><p>Injectafer® (ferric carboxymaltose injection) is indicated for the treatment of iron deficiency anemia (IDA) in adult patients who have intolerance to oral iron or have had unsatisfactory response to oral iron, or who have non-dialysis dependent chronic kidney disease.</p><p><br /></p><p><b>WARNINGS AND PRECAUTIONS</b></p><p><br /></p><p>Symptomatic hypophosphatemia requiring clinical intervention has been reported in patients at risk of low serum phosphate in the postmarketing setting. These cases have occurred mostly after repeated exposure to Injectafer in patients with no reported history of renal impairment. Possible risk factors for hypophosphatemia include a history of gastrointestinal disorders associated with malabsorption of fat-soluble vitamins or phosphate, concurrent or prior use of medications that affect proximal renal tubular function, hyperparathyroidism, vitamin D deficiency and malnutrition. In most cases, hypophosphatemia resolved within three months.</p><p>Monitor serum phosphate levels in patients at risk for low serum phosphate who require a repeat course of treatment.</p><p>Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Injectafer. Patients may present with shock, clinically significant hypotension, loss of consciousness, and/or collapse. Monitor patients for signs and symptoms of hypersensitivity during and after Injectafer administration for at least 30 minutes and until clinically stable following completion of the infusion. Only administer Injectafer when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. In clinical trials, serious anaphylactic/anaphylactoid reactions were reported in 0.1% (2/1775) of subjects receiving Injectafer. Other serious or severe adverse reactions potentially associated with hypersensitivity which included, but were not limited to, pruritus, rash, urticaria, wheezing, or hypotension were reported in 1.5% (26/1775) of these subjects.</p><p><br /></p><p><b>Billing and coding</b></p><p><br /></p><p>Important information related to Injectafer reimbursement Proper billing and coding can help ensure eligible patients receive the proper program support. The following codes may be helpful to facilitate Injectafer reimbursement. The completion and submission of coverage-related documentation are the responsibility of the patient and healthcare provider.</p><p><br /></p><p>Injectafer® (ferric carboxymaltose injection) is indicated for the treatment of IDA in adult patients:</p><p><br /></p><p>• who have intolerance to or have had unsatisfactory response to oral iron or</p><p>• who have non-dialysis dependent chronic kidney disease</p><p><br /></p><p><b>Product-Specific Billing Code</b></p><p>HCPCS J1439 Injection, ferric carboxymaltose 1 mg</p><p><br /></p><p><b>Overview</b></p><p>Iron is a critical structural component of hemoglobin, a key protein found in normal red blood cells (RBCs) which transport oxygen. Without this important building block, anemic patients experience difficulty in restoring adequate, healthy RBCs that improve hematocrit levels. Iron deficiency is a common condition in end stage renal disease (ESRD) patients undergoing hemodialysis. Clinical management of iron deficiency involves treating patients with iron replacement products while they undergo hemodialysis. The available evidence suggests that the mode of intravenous administration is perhaps the most effective treatment for iron deficiency in hemodialysis patients. Unlike oral iron products, which must be absorbed through the GI tract, IV iron products are infused directly into the bloodstream in a</p><p>form that is readily available to the bone marrow for RBC synthesis, resulting in an earlier correction of iron deficiency and anemia.</p><p>Coverage also includes the medically necessary and reasonable use of parenteral iron preparations in non-dialysis related clinical conditions.</p><p><br /></p><p><b>Guidelines</b></p><p><br /></p><p>Medicare covers Sodium Ferric Gluconate Complex in Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.</p><p><br /></p><p>Medicare also covers Iron Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.</p><p><br /></p><p>Coverage also includes for parenteral iron in iron deficiency anemia:</p><p><br /></p><p>• For patients with iron deficiency anemia who do not respond to oral iron supplementation due to malabsorption disorders or patients who have documented intolerance to oral iron supplementation.</p><p><br /></p><p>• For anemia related to chronic kidney disease.</p><p><br /></p><p>• Initial treatment of absolute iron deficiency in patients receiving myelosuppressive chemotherapy who have asymptomatic anemia and risk factors for the development of symptomatic anemia requiring transfusion.</p><p><br /></p><p>For the pregnant beneficiary when iron stores are depleted such that the mother and/or the fetus are at risk of adverse outcomes and oral iron replenishment is either not tolerated or the anemia is of such severity as to require more immediate replenishment. Additionally, use in the peripartum period may be indicated when intra/post-partum hemorrhage is severe and by administering parenteral iron a transfusion may be avoided. This indication does not replace the strong consideration for transfusions when the hemorrhage is potentially life threatening.</p><p><br /></p><p><b>APPLICABLE CODES</b></p><p><br /></p><p>The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or</p><p>guarantee claim payment. Other Policies and Guidelines may apply.</p><p><br /></p><p><b>PURPOSE</b></p><p>The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable:</p><p><br /></p><p>• Medicare coding or billing requirements, and/or</p><p>• Medical necessity coverage guidelines; including documentation requirements.</p><p>UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.</p><p><br /></p><p><br /></p><p><b>A. Background: </b>Section 153(b) of the Medicare Improvements for Patients and Providers Act (MIPPA) required the implementation of an ESRD PPS effective January 1, 2011. The ESRD PPS provides a single payment to ESRD facilities that covers all of the resources used in furnishing an outpatient dialysis treatment. The ESRD PPS includes consolidated billing requirements for limited Part B services included in the ESRD facility’s bundled payment. The Centers for Medicare & Medicaid Services (CMS) periodically update the lists of items and services that are subject to Part B consolidated billing (CB) and are therefore no longer separately payable when provided to ESRD beneficiaries by providers other than ESRD facilities.</p><p><br /></p><p>The ESRD PPS provides outlier payments, if applicable, for high cost patients due to unusual variations in the type or amount of medically necessary care.</p><p>B. Policy: This change request (CR) provides instructions for new codes added to the Healthcare Common Procedure Coding System (HCPCS) file for anemia management and therefore will be added to the list of items and services subject to the ESRD PPS consolidated billing (CB) requirements.</p><p><br /></p><p>1. J0887 - Injection, Epoetin Beta (For ESRD On Dialysis), 1 microgram</p><p>2. J1439 - Injection, ferric carboxymaltose, 1mg</p><p>3. Q9976 - Injection ferric pyrophosphate citrate solution; 0.1 mg of iron</p><p><br /></p><p><br /></p><p>Anemia management is a category of drugs and biologicals that are always considered to be used for the treatment of ESRD. ESRD facilities will not receive separate payment for J0887, J1439, or Q9976 with or without the AY modifier and the claims shall process the line item as covered with no separate payment under the ESRD PPS.</p><p>Q9976 is administered via dialysate. Therefore, when billing for Q9976, it should be accompanied by the JE modifier as discussed in CR 8256 issued April 26, 2013.</p><p>In accordance with 42 CFR 413.237(a)(1), HCPCS J0887, J1439, and Q9976 are considered to be eligible outlier services and will be included in the outlier calculation when CMS provides a fee amount on the Average Sales Price fee schedule.</p><p><br /></p><p>There is a new HCPCS J0888 for epoetin beta for non-ESRD use. This code will not be permitted on the ESRD type of bill 072x.</p><p><br /></p><p>Lastly, Q2047 was terminated effective January 1, 2013 and is therefore no longer subject to the ESRD PPS consolidated billing requirements. In addition, J0890 is a recalled drug and should not be furnished to ESRD patients, therefore effective July 1, 2015, we are removing this code from the list of items and services that are subject to consolidated billing requirements.</p><div><br /></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-73471465100321928872020-12-25T22:07:00.008-08:002020-12-25T22:07:35.315-08:00Initial observation code CPT 99217, 99218, 99219, 99220<p><b> CPT code and descriptions</b></p><p><br /></p><p><b>99217 </b>Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])</p><p><br /></p><p><b>99218</b> Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; Aetailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.</p><p>Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.</p><p><br /></p><p><b>99219</b> Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.</p><p><br /></p><p><b>99220</b> Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically 70 minutes are spent at the bedside and on the patient's hospital floor or unit.</p><p><br /></p><p><br /></p><p><b>Observation care Background</b></p><p><br /></p><p>Observation care is a well-defined set of specific, clinically appropriate services, which include:</p><p><br /></p><p>• Ongoing short term treatment,</p><p>• Assessment,</p><p>• Reassessment</p><p><br /></p><p>These are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.</p><p><br /></p><p>Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.</p><p><br /></p><p>In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.</p><p><br /></p><p>In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as a inpatient can be made in less than 48 hours, usually in less than 24 hours.</p><p><br /></p><p><b>Q: Can Observation Care codes 99217 and codes 99218-99220 be reported on the same date of service?</b></p><p><br /></p><p>A: No. CPT codes 99234-99236 should be reported for patients who are admitted to and discharged from observation status on the same calendar date for a minimum of 8 hours but less than 24. An initial Observation Care code (99218-99220) should be reported for patients admitted and discharged from observation status for less than 8 hours on the same calendar date. CPT code 99217 can only be reported for a patient discharged on a different calendar date.</p><p><br /></p><p><br /></p><p><br /></p><p><b>Initial Observation Care (CPT code range 99218-99220)</b></p><p><br /></p><p>• Included in Initial Observation Care:</p><p>- Initiation of observation status</p><p>- Supervision of the care plan for observation</p><p>- Performance of periodic reassessments</p><p><br /></p><p>• When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician.</p><p><br /></p><p>• When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care,</p><p>from CPT code range 99218 – 99220, and CPT observation care discharge CPT code 99217.</p><p><br /></p><p>• To report services provided to patient who is admitted to the hospital after receiving hospital observation care services on the same date, see initial</p><p>hospital care notes in the American Medical Association (AMA) Current Procedural Terminology (CPT) Publication.</p><p><br /></p><p><br /></p><p><br /></p><p>• To report hospital admission on a date subsequent to the date of observation status, use appropriate initial hospital care codes (CPT 99221 – 99223)</p><p><br /></p><p>• Observation status that is initiated in the course of an encounter in another site of service (eg. hospital emergency department, office, nursing facility) all E/M services provided by the supervising physician or other qualified health care professional in conjunction with initiating “observation status” are considered part of the initial observation care when performed on the same date.</p><p><br /></p><p>- The level of service reported should include the services related to initiating “observation status” provided in the other sites of service as well as in the observation setting</p><p><br /></p><p>• On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.</p><p><br /></p><p>• Admitted and discharges from observation or inpatient status on the same date report CPT codes 99234-99236 as appropriate; do NOT report observation discharge in conjunction with a hospital admission.</p><p><br /></p><p>• These codes may NOT be utilized for post-operative recovery if the procedure is considered part of the surgical “package.”</p><p><br /></p><p><br /></p><p><b>Policy Overview</b></p><p><br /></p><p>Initial Observation Care CPT® codes 99218-99220 and Subsequent Observation Care CPT codes 99224-99226 are used to report evaluation and management (E/M) services provided to new or established patients designated as "observation status" in a hospital.</p><p><br /></p><p>Observation Care Discharge Day Management CPT Code 99217 is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of “observation status”.</p><p><br /></p><p>Observation or Inpatient Hospital Care (including admission and discharge) CPT codes 99234-99236 are used to report observation or initial hospital services for a patient that is admitted and discharged on the same date of service. Inpatient Hospital Discharge Day Management CPT Codes 99238 and 99239 are used to report all discharge day management services for the hospital inpatient when discharge is on a date other than the initial date of admission.</p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-54703759721814573622020-08-22T01:09:00.004-07:002020-08-22T01:09:34.289-07:00CPT code 93000, 93040, 93041, 93042, 93010 - ECG and EKG codes<p><b> CPT® Code<span style="white-space: pre;"> </span> Procedure<span style="white-space: pre;"> </span> Description<span style="white-space: pre;"> </span> <span style="white-space: pre;"> </span> </b></p><p><br /></p><p>93000<span style="white-space: pre;"> </span> Electrocardiogram <span style="white-space: pre;"> </span>Routine ECG with at least 12 leads; with interpretation and report<span style="white-space: pre;"> </span> </p><p>93005<span style="white-space: pre;"> </span> Electrocardiogram <span style="white-space: pre;"> </span>Routine ECG with at least 12 leads; tracing only, without interpretation and report <span style="white-space: pre;"> </span> </p><p>93010<span style="white-space: pre;"> </span> Electrocardiogram <span style="white-space: pre;"> </span>Routine ECG with at least 12 leads; interpretation and report only<span style="white-space: pre;"> </span> </p><p>93040 <span style="white-space: pre;"> </span> Rhythm ECG <span style="white-space: pre;"> </span>One to three leads; with interpretation and report <span style="white-space: pre;"> </span> </p><p>93041 <span style="white-space: pre;"> </span> Rhythm ECG <span style="white-space: pre;"> </span>One to three leads; tracing only, without interpretation and report <span style="white-space: pre;"> </span> </p><p>93042 <span style="white-space: pre;"> </span> Rhythm ECG <span style="white-space: pre;"> </span>One to three leads; interpretation and report only</p><p><br /></p><p><b>CPT Manual Instructions for Reporting Electrocardiographic Recording</b></p><p><br /></p><p>• Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.</p><p>• There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report.</p><p>• It is not appropriate to use these codes for reviewing telemetry monitor strips taken from a monitoring system.</p><p>• The need for an electrocardiogram or rhythm strip should be supported by documentation in the patient medical record.</p><p><br /></p><p><b>Bundled Services per CPT Manual</b></p><p>• Do not report 93040-93042 when performing 93279-93289, 93291-93296, or 93298-93299</p><p>Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of an ECG. ICD-10-CM codes and/or ranges are provided below to help with your decision process.</p><p><br /></p><p><b>Definitions</b></p><p>Codes 70010-79999, 93000-93010, and 0178T-0180T are used for reporting radiology procedures.</p><p><br /></p><p><b>Modifiers:</b></p><p>-26 Professional Component</p><p>-76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional</p><p>-77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional</p><p>-ET Emergency services</p><p><br /></p><p><b>Policy Statement</b></p><p><b>Medical Imaging and Electrocardiogram (ECG/EKG) Interpretation</b></p><p>Payment will be made for only one interpretation of any given x-ray, CT, MRI, ultrasound or ECG/EKG. Subsequent interpretations or readings by another physician (indicated by the -77 modifier) will not be covered. A re-interpretation by another physician is considered an integral part of the primary physician's medical care.</p><p><br /></p><p>However, if the patient's condition warrants an immediate interpretation of an imaging study (emergency treatment -ET modifier), payment may be made to the attending or admitting physician even when a hospital staff physician also performs an imaging study interpretation.</p><p><br /></p><p><br /></p><p><b>OTHER CONSIDERATIONS</b></p><p>• Include documentation in the patient’s records to indicate medical necessity for a separate service.</p><p>• Confirm that proper ICD-10-CM diagnosis codes are reported to justify medical necessity of ECG monitoring.</p><p>• When appropriate, a modifier may be reported and support documentation should be provided with the claim.</p><p>• Some payers may have specific requirements for using certain codes, including prior authorization, restricted medical diagnoses or specialty provider types.</p><p> </p><p><br /></p><p><b>Indications and Limitations of Coverage</b></p><p><b>Nationally Covered Indications</b></p><p>The following indications are covered nationally unless otherwise indicated:</p><p>** Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services.</p><p>** EKG services rendered by an independent diagnostic testing facility (IDTF), including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician.</p><p>** Emergency EKGs (i.e., when the patient is or may be experiencing a life threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter.</p><p>** Home EKG services with documentation of medical necessity.</p><p>** Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described</p><p>below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to:</p><p>o Detect, characterize, and document symptomatic transient arrhythmias;</p><p>o Initiate, revise, or discontinue arrhythmic drug therapy; or,</p><p>o Carry out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 24- hour coverage is provided, see below).</p><p><br /></p><p>Certain uses other than those specified above may be covered if, in the judgment of UnitedHealthcare, such use is medically necessary.</p><p><br /></p><p>Additionally, the transmitting devices must meet at least the following criteria:</p><p>** They must be capable of transmitting EKG Leads, I, II, or III; and,</p><p>** The tracing must be sufficiently comparable to a conventional EKG.</p><p><br /></p><p>24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described here: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies.</p><p><br /></p><p><b>ICD-10-CM Description <span style="white-space: pre;"> </span></b></p><p><b><span style="white-space: pre;"> </span>ICD-10-CM Code/ Range</b></p><p>Abnormalities of heart beat <span style="white-space: pre;"> </span>R00.0-R00.9</p><p>Angina pectoris <span style="white-space: pre;"> </span>120.0-120.9</p><p>Atherosclerotic heart disease<span style="white-space: pre;"> </span>I25.10-I25.119</p><p>Atrioventricular and left bundle-branch block <span style="white-space: pre;"> </span>144.0-144.7</p><p>Cardiac arrest<span style="white-space: pre;"> </span>I46.2-I46.9</p><p>Cardiac murmurs and other cardiac sounds <span style="white-space: pre;"> </span>R01.0-R01.2</p><p>Cardiomyopathy <span style="white-space: pre;"> </span>I42.0-I42.9</p><p>Cardiomyopathy in diseases classified elsewhere <span style="white-space: pre;"> </span>I43</p><p>Essential (primary) hypertension <span style="white-space: pre;"> </span>I10</p><p>Gangrene, not elsewhere classified<span style="white-space: pre;"> </span>I96</p><p>Hypertensive heart disease<span style="white-space: pre;"> </span>I11.0-I11.9</p><p>Multiple valve diseases <span style="white-space: pre;"> </span>I08.0-I08.9</p><p>Old myocardial infarction<span style="white-space: pre;"> </span>I25.2</p><p>Other acute ischemic heart diseases <span style="white-space: pre;"> </span>I24.0-I24.9</p><p>Other cardiac arrhythmias <span style="white-space: pre;"> </span>I49.0-I49.9</p><p>Other conduction disorders<span style="white-space: pre;"> </span> I45.0-145.9</p><p>Other pulmonary heart diseases<span style="white-space: pre;"> </span> I27.0-I27.9</p><p>Pain in chest<span style="white-space: pre;"> </span> <span style="white-space: pre;"> </span>R07.1-R07.9</p><p>Rheumatic aortic valve diseases<span style="white-space: pre;"> </span>I06.0-I06.9</p><p>Rheumatic mitral valve diseases <span style="white-space: pre;"> </span>I05.0-I05.9</p><p>ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction<span style="white-space: pre;"> </span>I21.0-I21.4</p><p>Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction <span style="white-space: pre;"> </span>I22.0-I22.9</p><div><br /></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-23227493778012402372020-07-24T01:43:00.001-07:002020-07-24T01:43:23.989-07:00CPT G0108, G0109 and MODIFIER GQ<br />
<b>HCPCS Code Description</b><br />
<br />
<b>G0108 </b>Diabetes outpatient self-management training services, individual, per 30 minutes<br />
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<b>G0109</b> Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes<br />
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<b>Modifier Description</b><br />
<br />
<b>GQ </b>Via asynchronous telecommunications system<br />
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<b>Place of Service Description</b><br />
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<b>02 Telehealth:</b> The location where health services and health related services are provided or received, through a telecommunication system.<br />
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<b>PURPOSE</b><br />
<br />
The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.<br />
<br />
<br />
<b>Certified Providers</b><br />
<br />
A designated certified provider bills for DSMT provided by an accredited DSMT program. C ertified providers must submit a copy of their accreditation certificate to the contractor. The statute states that a “certified provider” is a physician or other individual or entity designated by the Secretary that, in addition to providing outpatient selfmanagement training services, provides other items and services for which payment may be made under title XVIII,<br />
<br />
and meets certain quality standards. The CMS is designating all providers and suppliers that bill Medicare for other individual services such as hospital outpatient departments, renal dialysis facilities, physicians and durable medical equipment suppliers as certified. All suppliers/providers who may bill for other Medicare services or items and who represent a DSMT program that is accredited as meeting quality standards can bill and receive payment for the entire DSMT program. Registered dietitians are eligible to bill on behalf of an entire DSMT program, as long as the provider has obtained a Medicare provider number. A dietitian may not be the sole provider of the DSMT service. There is an exception for rural areas. In a rural area, an individual who is qualified as a registered dietitian and as a certified diabetic educator who is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement. C ertified providers may be asked to submit updated accreditation documents at any time or to submit outcome data to an organization designated by CMS.<br />
<br />
<b>Frequency of Training</b><br />
<br />
The initial year for DSMT is the 12 month period following the initial date. Medicare will cover initial training that meets the following conditions:<br />
• Is furnished to a beneficiary who has not previously received initial or follow-up training under HCPCS codes G0108 or G0109;<br />
• Is furnished within a continuous 12-month period;<br />
• Does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of 1/2 hour increments);<br />
• With the exception of 1 hour of individual training, training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries, and;<br />
• One hour of individual training may be used for any part of the training including insulin training.<br />
<br />
<b>Follow-Up Training</b><br />
<br />
Medicare covers follow-up training under the following conditions:<br />
• No more than 2 hours individual or group training per beneficiary per year;<br />
• Group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;<br />
• Follow-up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;<br />
• Follow-up training is furnished in increments of no less than one-half hour; and<br />
• The physician (or qualified non-physician practitioner) treating the beneficiary must document in the beneficiary's medical record that the beneficiary is a diabetic.<br />
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<b>Coverage Requirements for Individual Training</b><br />
<br />
Medicare covers training on an individual basis for a Medicare beneficiary under any of the following conditions:<br />
<br />
• No group session is available within 2 months of the date the training is ordered;<br />
• The beneficiary’s physician (or qualified non-physician practitioner) documents in the beneficiary’s medical record that the beneficiary has special needs resulting from conditions, such as severe vision, hearing or language limitations or other such special conditions as identified by the treating physician or non-physician practitioner, that will hinder effective participation in a group training session; or<br />
• The physician orders additional insulin training.<br />
• The need for individual training must be identified by the physician or non-physician practitioner in the referral.<br />
<br />
<br />
<b>Telehealth</b><br />
<br />
Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the –GT or –GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.<br />
<br />
As specified in the Medicare Benefit Policy Manual, chapter 15, section 300.2, individual DSMT services may be furnished by a physician, individual, and group DMST services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by, a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 C FR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a licensed PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.<br />
<br />
For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.<br />
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<b>DMEPOS Suppliers</b><br />
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The DMEPOS suppliers are reimbursed for diabetes training through local carriers. In order to file claims for DSMT, a DMEPOS supplier must be enrolled in the Medicare program with the National Supplier Clearinghouse (NSC ). The supplier must also meet the quality standards of a CMS-approved national accreditation organization as stated above. DMEPOS suppliers must obtain a provider number from the local carrier in order to bill for DSMT.<br />
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The carrier requires the appropriate completed form, along with an accreditation certificate as part of the provider application process. After it has been determined that the quality standards are met, a billing number is assigned to the supplier. Once a supplier has received a National Provider Identification (NPI) number, the supplier can begin receiving reimbursement for this service.<br />
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<br />
<b>Diabetes Education</b><br />
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Yes. In order for a client to participate in the diabetes education program, a licensed primary health care provider must refer the client to a program for diabetes education. Hospitals must be approved by the Washington State Department of Health (DOH) as a diabetes education provider.<br />
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For diabetes education services provided in a hospital outpatient setting, the provider must:<br />
• Bill using revenue code 0942.<br />
• Provide a minimum of 30 minutes of education/management per session.<br />
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Note: Services provided in an outpatient hospital department or hospital-based clinic must be billed on a UB-04 claim form. Services provided in a non-hospital based clinic or a physician’s office must be billed on a CMS-1500 claim form.<br />
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Note: The agency requires authorized hospital outpatient diabetes education programs to bill with revenue code 0942. Claims submitted using HCPCS codes G0108 and G0109 will be denied.<br />
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<b>Denial reasons</b><br />
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Providers should be aware that MACs will return claims if you append demo code 85, and:<br />
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• You are not on the CEC participant provider list with a telehealth record type; or<br />
• DOS “from date” is prior to your telehealth effective date, or<br />
• DOS “from date” is after your telehealth termination date, or<br />
• The DOS “from date” is prior to the beneficiary’s effective date; or<br />
• The DOS “from date” is after the beneficiary’s termination date, or<br />
• The DOS “from date” is more than 90 days after the beneficiary’s termination date; or<br />
• The beneficiary was not aligned to the same ESCO with which you are participating, as identifi ed by ESCO ID; or<br />
• The claim is for Part A and the TOB is other than 12X, 13X, 22X, 23X, 71X, 72X, 76X, 77X, and 85X,<br />
• Other, non-telehealth services are billed on the same claim. In these cases, none of the services on the claim are processed.<br />
<br />
In returning Part B claims, your MAC will use the following messaging:<br />
• Claims Adjustment Reason Code (CARC) 16: (Claim/service lacks information or has submission/billing error(s) which is needed for adjudication) and<br />
• Remittance Advice Remark Code (RARC) N763 (The demonstration code is not appropriate for this claim; resubmit without a demonstration code.)<br />
• Group Code: CO (Contractual Obligation)<br />
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-40766323751360087272020-03-28T02:54:00.000-07:002020-03-28T02:54:09.302-07:00Hospital Acquired conditions (HAC) CATAGORIES AND billing guidelines<b>Overview</b><br />Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. UnitedHealthcare Medicare Advantage doesn't pay for any of these conditions, and patients can't be billed for them, if acquired while in the hospital. UnitedHealthcare Medicare Advantage will only pay for these conditions if they were present on admission to the hospital. <br /><br />Effective October 1, 2015, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Version 33 Hospital Acquired Condition (HAC) list replaced the ICD-9-CM Version 32 HAC list.<br /><br /><b>HAC Categories:</b><br /><br />01- Foreign Object Retained Following Surgery<br />02- Air Embolism<br />03- Blood Incompatibility<br />04- Stage III and IV Pressure Ulcers<br />05- Falls and Trauma<br />06- Catheter-Associated Urinary Tract Infection (UTI)<br />07- Vascular Catheter-Associated Infection<br />08- Surgical Site Infection (SSI) –Mediastinitis Following Coronary Artery Bypass Graft (CABG)<br />09- Manifestations of Poor Glycemic Control<br />10- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) With Total Knee or Hip Replacement<br />11- Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity<br />12- Surgical Site Infection (SSI) Following Certain Orthopedic Procedures of Spine, Neck, Shoulder or Elbow<br />13- Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures<br />14- Iatrogenic Pneumothorax w/ Venous Catheterization<br /><br /><b>Present on Admission Guidelines</b><br /><br />To group diagnoses into the proper Diagnosis-related group (DRG), CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Collection of POA indicator data is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision as well as for broader public health uses of Medicare data. Use the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" diagnoses codes reported on claim forms UB-04 and 837 Institutional.<br /><br /><br />The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been coded.<br /><br />A joint effort between the health care provider and the coder is essential to achieve accurate and complete documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.<br /><br />The provider, a provider's billing office, third party billing agents and anyone else involved in the transmission of this data shall insure that any re-sequencing of diagnosis codes prior to transmission to CMS also includes a re-sequencing of the POA Indicators<br /><br /><br /><b>General POA Reporting Requirements</b><br /><br />** POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.<br /><br />** POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.<br /><br />** A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an "other diagnosis."<br /><br />** Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.<br /><br />** If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.<br /><br /><b> CMS POA Indicator Reporting Options, Description, and Payment Indicator Description Medicare Payment</b><br />Y Diagnosis was present at time of inpatient admission. Payment is made for condition when an HAC is present<br />N Diagnosis was not present at time of inpatient admission. No payment is made for condition when an HAC is present<br />U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment is made for condition when an HAC is present<br />W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment is made for condition when an HAC is present<br />1 Unreported/Not used. Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, it was determined that blanks were undesirable when submitting this data via the 4010A.<br /><br /><b>NOTE:</b> The number “1” POA Indicator should not be applied to any codes on the HAC list. Exempt from POA reporting<br /><br /><br /><b>Paper Claims</b><br /><br />On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting.<br /><br /><b>Electronic Claims</b><br /><br />Submit the POA indicator on the 837I in the appropriate Health Care Information Codes segment as directed by the “UB04 Data Specifications Manual.<br /><br /><br /><b>Reimbursement Guidelines</b><br /><br />For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.<br /><br />The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. CMS also required hospitals to report POA information for both primary and secondary diagnoses when submitting claims for discharges on or after October 1, 2007.<br /><br /><br /><b>Q: Do the POA and HAC programs apply to outpatient or ambulatory surgery services?</b><br />A: No, this program is only for inpatient acute care admissions.<br /><br /><b>Q: If the POA indicator is not on the claim, will the claim be returned?</b><br />A: Beginning with claims with discharges on or after October 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will be returned to the hospital for correct submission of POA informationUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-15513283987092771302020-02-18T02:47:00.000-08:002020-02-18T02:47:18.633-08:00Occurrence code, special program indicator list<b>OCCURRENCE CODE/DATE ( Form Field 31a - 34B) </b>– Enter the applicable code and associated date to identify significant events relating to this bill that may affect processing. Dates are entered in an MMDDYY format. A maximum of eight codes and associated dates can be entered.<br /><br />Required, if applicable.<br />
<br />The IHCP uses the following occurrence codes:<br /><br /><b>Occurrence Codes Code Description</b><br /><br />01 Auto accident<br />02 No-fault insurance involved – Including auto accident or other<br />03 Accident or tort liability<br />04 Accident or employment related<br />05 Other accident<br />06 Crime victim<br />25 Date benefits terminated by primary payer<br />27 Date home health plan established or last reviewed<br />42 Date of discharge – This code is used to show the date of live discharge from the<br />hospital confinement being billed, from a long-term care facility, or from home health<br />care or hospice, as appropriate.<br />52 Certification/recertification date – This code is used to show that an initial examination<br />or initial evaluation is being billed in a hospital setting. This code bypasses certain PA<br />editing. Details can be found in the applicable sections of the IAC.<br />55 Date of death – This code is used to show the date of death.<br />73 Benefit eligibility – This code is used to bill for home health overhead – One per day.<br /><br /><b>Special Program Indicators</b><br /><br />A0 Special Zip Code Reporting-Ambulance<br />A3 Special Federal Funding<br />A5 Disability<br />A6 PPV/Medicare Pneumococcal Pneumococcal/Influenza<br />A7 Induced Abortion - Danger to Life<br />A9 Second Opinion Surgery<br />AA Abortion performed due to Rape<br />AB Abortion performed due to Incest<br />AC Abortion performed due to serious fetal genetic defect, deformity, abnormality<br />AD Abortion performed due to life endangering condition<br />AE Abortion performed due to physical health of mother that is not life endangering<br />AF Abortion performed due to emotional/psychological health of mother<br />AG Abortion performed due to social economic reasons<br />AH Elective abortion<br />AI Sterilization<br />AJ Payer responsible for Co-payment<br />AK Air ambulance required<br />AL Specialized treatment/bed unavailable<br />AM Non-emergency Medically Necessary Stretcher Transport Required<br />AN Preadmission Screening Not Required<br />AO-AZ Reserved for National Assignment<br />B0 Medicare coordinated care demonstration program<br />B1 Beneficiary is ineligible for demonstration program<br />B2 Ambulance-CAH exempt from fee schedule if not exempt CAH don’t use B2<br />B3 Pregnancy indicator<br />B4 Admission Unrelated to Discharge - Admission unrelated to discharge on same day. This code is<br />for discharges starting on January 1, 2004. Effective January 1, 2005<br />BP Gulf Oil Spill Related, all services on claim<br />DR Disaster Related<br /><a href="http://www.insuranceclaimdenialappeal.com/2019/08/condition-code-g0-billing-guideliens.html">G0 Distinct Medical visit</a> - multiple medical visits occurred same day in same revenue center - 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 (zero) 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 (zero).<br /><br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-5414725523025032382019-08-10T03:41:00.000-07:002020-02-17T02:14:52.658-08:00Condition code G0 - Billing Guideliens<br />
<b>Condition code G0</b> 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. <br />
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<b>Proper Reporting of Condition Code G0 </b><br />
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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.<br />
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<br />
<b>Example</b><br />
<br />
Beneficiary presents to the emergency room in the morning for a broken arm, then later that same day presents for chest pain.<br />
<br />
On the first claim, report the first ER visit (revenue code 045X plus E/M code) with all ancillary services rendered on that day.<br />
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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.<br />
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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.<br />
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<br />
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<b><br />Multiple Medical Visits billing Guideline</b><br />
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• 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).<br />
• Without this code subsequent claims will deny.<br />
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.<br />
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<br />
<br />
<b>Multiple Unrelated Visits on the Same Date of Service</b><br />
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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.<br />
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* 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.<br />
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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.<br />
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<b>Note:</b> 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.<br />
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<br />
<br />Multiple Medical Visits<br /><br />• 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).<br />• Without this code subsequent claims will deny.<br />• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.<br />
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<br /><br />Use of Modifier –25 and Modifier 27 in the Hospital Outpatient Prospective Payment System (OPPS)<br /><br />This Program Memorandum (PM) provides clarification on reporting modifier –25 and modifier –27 under the hospital OPPS.<br /><br />The Current Procedural Terminology (CPT) defines modifier 25 as “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Modifier –25 was approved for hospital outpatient use effective June 5, 2000.<br /><br />The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001. Although HCFA will accept modifier –27 for OPPS claims, this modifier will not replace condition code G0. The reporting requirements for condition code G0 have not changed. Continue to report condition code G0 for multiple medical visits that occur on the same day in the same revenue centers. For further clarification on both modifiers, refer to the CPT 2001 Edition. Below are general guidelines in reporting modifiers –25 and –27 under the hospital OPPS.<br /><br />A. Modifier –27 should be appended only to E/M service codes within the range of 92002- 92014, 99201-99499, and with HCPCS codes G0101 and G0175.<br /><br />B. Hospitals may append modifier –27 to the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital outpatient setting.<br /><br />C. When reporting modifier 27, report with condition code G0 when multiple medical visits occur on the same day in the same revenue centers.<br /><br />As is true for any modifier, the use of modifiers –25 and –27 must be substantiated in the patient’s medical record.<br /><br />Fiscal Intermediaries should forward this PM electronically to providers and place on their web site. This PM should also be distributed with your next regularly scheduled bulletin. Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-25144981340062545562019-07-12T03:32:00.004-07:002019-07-12T03:32:46.026-07:00Medicare part B basics - covered service and premium<br />Four categories of Medicare insurance: Parts A, B, C, and D.<br /><br />1. Part A. Provides hospital facilities, nursing facilities, hospices and home health facilities.<br /><br />2. Part B. covers physician services, ambulatory care and non-hospital services.<br /><br />3. Part C. Medicare advantage plan, both includes Parts A and B.<br /><br />4. Part D. Prescription plan.<br />
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<br /><b>Medicare Part B</b><br />
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<br />
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<br />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.<br /><br /><br /><br />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. <br /><br />Part B also covers:<br /><br />• Outpatient hospital services<br />• X-rays and diagnostic tests <br />• Ambulance services <br />• Durable medical equipment (e.g. wheelchairs ) <br />• Certain non-physician services <br />• Physical therapy<br /><br />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.<br /><br /><br /><b>Medicare Part B Premium</b><br /><br />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.<br /><br />The normal monthly premium for Part B was $135.50 in 2019.<br /><br /><b>Medicare Part B Eligibility and Enrollment</b><br /><br />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.<br /><br /><br /><b>Common Medicare Questions</b><br /><b><br />Q: Do I have to apply to Medicare or do I receive it automatically?</b><br /><br />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).<br /><br /><b>Do both parts A and B have to be taken?</b><br /><br />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.<br /><br /><br /><b>How do I pay for Medicare if my Social Security Check does not automatically take it away?</b><br /><br />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.<br /><br /><br /><b>Is there additional insurance for which I can buy that to pay for the deductibles and coinsurance?</b><br /><br />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<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-60831918177551948022019-06-14T03:17:00.000-07:002019-06-14T03:17:00.410-07:00ACES program code list<b>ACES Program Codes </b><br />
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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.<br />
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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 <br />
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<b>ACES DESCRIPTION SCOPE </b><br />
<br />
S01 SSI Recipients CN <br />
S02 ABD Categorically Needy CN <br />
S03 QMB Medicare Savings Program (MSP) Medicare premium and co-pays MSP <br />
S04 QDWI Medicare Savings Program MSP <br />
S05 SLMB Medicare Savings Program. Medicare Premium only MSP <br />
S06 QI-1 (ESLMB) Medicare Savings Program MSP <br />
S07 Undocumented Alien. Emergency Related Service Only ERSO <br />
S95 Medically Needy no Spenddown MN <br />
S99 Medically Needy with Spenddown MN SSI Related <br />
Living in an alternate living facility (nonmedical institution) adult family home, boarding home or DDA group home. <br />
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<b>SSI Related Healthcare for Workers With Disability </b><br />
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Institutional HCBS Waivers (HCS/DDA) and Hospice; SSI related G03 <br />
Non Institutional Medical in ALF CN-P Income under the SIL plus under state rate x 31 days + 38.84 <br />
G95 Medically Needy Non Institutional in ALF no spenddown MN <br />
G99 Medically Needy Non Institutional in ALF with Spenddown MN <br />
S08 Healthcare for Workers with Disability CN-P Premium based program. Substantial Gainful Activity (SGA) not a factor in Disability determination. <br />
L21 Categorically Needy DDA/HCS Waiver or Hospice on SSI CN L22 <br />
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) <br />
L31 PACE or hospice on SSI (effective 10/1/15) CN <br />
L32 PACE or hospice – SSI-related (effective 10/1/15) CN <br />
L41 Roads to Community Living on SSI (effective 10/1/15) CN <br />
L51 Community First Choice (CFC) on SSI (effective 10/1/15) CN <br />
L52 Community First Choice (CFC) – SSI related at home or in an ALF (effective 10/1/15) <br />
L99 Medically Needy Hospice in Medical Institution. With Spenddown MN Institutional SSI L01 <br />
SSI recipient in a Medical Institution - Residing in a medical institution 30 days or more <br />
CN Institutional <br />
SSI Related Residing in a medical institution 30 days or more <br />
L02 SSI related CN-P in a Medical Institution Income under the SIL CN L04 L95 <br />
L99 Undocumented Alien/Non-Citizen LTC must be pre-approved by ADSA program manager. Emergency Related Service Only (45 slots) <br />
SSI related Medically Needy no Spenddown Income over the SIL. Income under the state rate. <br />
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 <br />
ERSO – CN scope CN <br />
ERSO – CN scope MN MN<br />
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<b>Categorically Needy Program (CNP)</b><br />
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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.<br />
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<b>Alternative Benefits Plan (ABP)</b><br />
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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.<br />
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<b>Emergency Related Services Only (ERSO) –PA may be required </b><br />
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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<br />
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<br />
.<br />
<b>Take Charge –Family Planning Service Only (TCFPO)</b><br />
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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.<br />
<b><br />Family Planning Services Only (FPSO) </b><br />
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This program is for women. Services includecoverage for all birth control methods, sterilization, OB-GYN exams, and counselingto help with family planning.<br />
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<b>Medical Care Services (MCS) -no out of state care</b><br />
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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). <br />
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<b>Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) -no out of state care </b><br />
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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.<br />
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<b>Limited Casualty Program – Medically Needy Program (LCP-MNP)</b><br />
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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.<br />
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-30742531078198276042019-05-20T02:31:00.000-07:002019-05-20T02:31:01.089-07:00CPT 95940, 95941, G0453 -Intraoperative Neurophysiologic Monitoring<br />
<b>Medically Necessary Code Description CPT </b><br />
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<b>95940</b> 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) <br />
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<b>95941</b> 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) <br />
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<b>HCPCS <br /><br />G0453</b> 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)<br />
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<b>Reimbursement Guidelines - UHC</b><br /><br />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.<br /><br />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.<br /><br />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.<br />The use of either modifier 26 or TC does not apply to codes 95940, 95941 or G0453. <br /><br />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.<br /><br /><b><br />Questions and Answers <br /><br />1Q: Will IONM services be reimbursed when reported with POS 15 (mobile unit)?</b><br /><br />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<br />, 22and 24<br /><br /><b>2Q:Are IONM codes with a status “I” allowed when reported in a facility setting?</b><br />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.<br /><br /><b>Continuous intraoperative neurophysiology monitoring: BCBS Guideline</b><br /><br />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.<br /><br /><b>Q. How many units of G0453 may be billed per hour? </b><br /><br />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<br /><br />. 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.<br /><br /><br />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 <br />
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<b>Intraoperative Neurophysiologic Monitoring<br /><br />Introduction </b><br />
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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. <br />
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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. <br />
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<b>Intraoperative Monitoring </b><br />
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* Somatosensory-evoked potentials <br />
* Motor-evoked potentials using transcranial electrical stimulation <br />
* Brainstem auditoryevoked potentials <br />
* Electromyography (EMG) of cranial nerves <br />
* Electroencephalography * Electrocorticography <br />
* EMG <br />
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<b>Medical Necessity </b><br />
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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, <br />
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<b>Intraoperative Monitoring </b><br />
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* Nerve conduction velocity monitoring <br />
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Intraoperative Monitoring <br />
* Somatosensory-evoked potentials <br />
* Motor-evoked potentials using transcranial electrical stimulation <br />
* Brainstem auditoryevoked potentials <br />
* Electromyography (EMG) of cranial nerves <br />
* Electroencephalography * Electrocorticography <br />
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Motor-evoked potentials using transcranial magnetic stimulation <br />
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<b>Coding <br /><br />Medical Necessity </b><br />
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listed on the left during surgery on the peripheral nerves are considered not medically necessary. <br />
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<b>Investigational </b><br />
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The types of intraoperative neurophysiologic monitoring, listed on the left during the following surgical procedure is considered investigational: * Esophageal surgeries <br />
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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.<br />
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<b>Related Information <br /> </b><br />
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. <br />
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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. <br />
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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. <br />
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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. <br />
Intra-operative monitoring consists of a physician monitoring not more than three cases simultaneously. <br />
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Constant communication between surgeon, neurophysiologist, and anesthetist are required for safe and effective intraoperative neurophysiologic monitoring. Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-89370044109490456892019-05-19T02:25:00.000-07:002019-05-19T02:25:01.056-07:00CPT 48160, G0431, S2102, G0343 -Islet Transplantation <b>Code Description CPT </b><br />
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<b>48160</b> Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells <br />
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<b>HCPCS </b><br />
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<b>G0341</b> Percutaneous islet cell transplant, includes portal vein catheterization and infusion <br />
<b>G0342</b> Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion <br />
<b>G0343</b> Laparotomy for islet cell transplant, includes portal vein catheterization and infusion <br />
<b>S2102</b> Islet cell tissue transplant from pancreas; allogeneic <br />
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<b>Islet Transplantation <br /><br />Introduction </b><br />
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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). <br />
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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. <br />
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<b>Policy Coverage Criteria </b><br />
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Procedure Medical Necessity Autologous pancreas islet transplantation <br />
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Autologous pancreas islet transplantation may be considered medically necessary as an adjunct to a total or near total pancreatectomy in patients with chronic pancreatitis. <br />
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Procedure Investigational <br />
Allogeneic islet transplantation <br />
Islet transplantation, all other <br />
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<b>Documentation Requirements </b><br />
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Allogeneic islet transplantation is considered investigational for the treatment of type 1 diabetes. Islet transplantation is considered investigational in all other situations. <br />
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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: <br />
o Patient had pancreas removed because of chronic pancreatitis <br />
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<b>Guidelines Nationally Covered Indications</b><br /><br />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.<br /><br />Pancreas transplants alone (PA) are reasonable and necessary for Medicare beneficiaries in the following limited circumstances:<br /><br />• PA will be limited to those facilities that are Medicare-approved for kidney transplantation. Approved centers can be found at Approved Transplant Programs<br /><br />• Patients must have a diagnosis of type I diabetes:<br /><br />* Patient with diabetes must be beta cell autoantibody positive; or<br /><br />* 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;<br /><br />• Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months with the most medically-recogni<br />zed advanced insulin formulations and delivery systems;<br /><br />•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. <br /><br />Aforementioned complications include frequent hypoglycemia unawareness or recurring severe ketoacidosis, or recurring severe hypoglycemic attacks;<br /><br />• 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,<br /><br />• Patients must otherwise be a suitable candidate for transplantation.<br /><br />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.<br /><br /><b>CPT Code Description</b><br /><br />48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells (Not covered by Medicare)<br /><br />48554 Transplantation of pancreatic allograft (CMS sourced)<br /><br /><b>ICD- 10 Procedure Code Description</b><br /><br />0FYG0Z0 Transplantation of pancreas, alloge neic, open approach (CMS sourced)<br /><br />0FYG0Z1 Transplantation of pancreas, syngeneic, open approach (CMS sourced)<br />
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<br /><br /><b>Blue Cross and Blue Shield Association Islet Cell Transplantation Billing /Coding/Physician Documentation Information</b><br /><br /><br /><b>Applicable service codes: </b><br /><br />48160, 48999, G0341, G0342, G0343, S2102<br /><br />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. <br />
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<b>Coding <br /><br /><br /><br />Evidence Review <br /><br />Description </b><br />
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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. <br />
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<b>Background Chronic Pancreatitis </b><br />
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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. <br />
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<b>Type 1 Diabetes </b><br />
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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.<br />
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<b>Islet Transplantation </b><br />
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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. <br />
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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. <br />
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In 2000, a modified immunosuppression regimen increased the success of allogeneic islet transplantation. This regimen is known as the “Edmonton protocol.” Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-34089840973807639412019-05-06T01:25:00.004-07:002019-05-06T01:25:44.747-07:00CPT 99453, 99454, 99447- 99448 - guidelines updates on documentationCMS is finalizing our proposals to pay separately for two newly defined physicians’ services furnished using communication technology,<br /><br /><br />1. Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)<br /><br />2. Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)<br /><br />3. Chronic care remote physiologic monitoring -CPT codes 99453, 99454, and 99457.<br /><br />4. Interprofessional internet consultation - CPT codes 99451, 99452, 99446, 99447, 99448, and 99449. <br /><br /><br />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.<br /><br /><br />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.<br /><br /><br /><br /><b>E&M Documentation Changes for 2019</b><br /><br /><br />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:<br /><br />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.<br /><br /><br />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.<br /><br /><br /><br /><br /><b>New codes for professional evaluation services:</b><br /><br />• Testing evaluation services must always be performed and reported by professional (Physician & other qualified health care professional), using codes 96130, 96131, 96132 & 96133.<br /><br />* Elements of professional work in the new evaluation service codes include:<br />▪ Integration of patient data.<br />▪ Interpretation of standardized test results and clinical data.<br />▪ Clinical decision making.<br />▪ Treatment planning and report.<br />▪ Interactive feedback to the patient, family member(s) or caregiver(s).<br />• Testing evaluation services may be billed on the same or different days.<br />• Testing evaluation services cannot be reported by the technician<br /><br /><br />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.<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-70873382593327223072019-03-07T00:17:00.000-08:002019-03-07T00:17:04.474-08:00CPT 81405, 81406, 81407, 81439, s3865, s3866 -Hypertrophic Cardiomyopathy <b>Code Description CPT </b><br /><br /><b>81405</b> 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: <br />* 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 <br />sequence * MYL3 (myosin, light chain 3, alkali, ventricular, skeletal, slow) (eg, familial HCM), <br />full gene sequence * TNNC1 (troponin C type 1 [slow]) (eg, hypertrophic cardiomyopathy or dilated <br />cardiomyopathy), full gene sequence * TNNI3 (troponin I, type 3 [cardiac]) (eg, familial HCM), full gene sequence <br />* TPM1 (tropomyosin 1 [alpha]) (eg, familial HCM), full gene sequence <br /><b><br />81406</b> 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: <br />* TNNT2 (troponin T, type 2 [cardiac]) (eg, familial HCM), full gene sequence <br /><br /><b>81407</b> 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: <br />* MYBPC3 (myosin binding protein C, cardiac) (eg, familial HCM), full gene sequence <br />* MYH7 (myosin, heavy chain 7, cardiac muscle, beta) (eg, familial HCM, Liang distal myopathy), full gene sequence <br /><br /><br /><b>81439</b> 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 <br /><br /><br /><b>S3865</b> Comprehensive gene sequence analysis for hypertrophic cardiomyopathy <br /><br /><b>S3866 </b>Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family<br />
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<b>Introduction </b><br /><br />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. <br /><br />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. <br /><br /><br /><br /><b>Testing Medical Necessity </b><br /><br />Genetic testing for predisposition to HCM <br />Genetic testing for HCM gene variants <br />Genetic testing for predisposition to HCM <br /><br />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). <br /><br />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). <br /><br />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. <br /><br />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. <br /><br />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. <br />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. <br /><br /><br /><b>Genetics Nomenclature Update </b><br /><br />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.<br />
<br />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. <br /><br /><b>Table 1. Nomenclature to Report on Variants Found in DNA Previous Updated Definition </b><br />Mutation Disease-associated variant Disease-associated change in the DNA sequence <br /><br />Variant Change in the DNA sequence <br />Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives <br /><br /><b>Table 2. ACMG-AMP Standards and Guidelines for Variant Classification </b><br />Variant Classification Definition <br />Pathogenic Disease-causing change in the DNA sequence <br />Likely pathogenic Likely disease-causing change in the DNA sequence <br />Variant of uncertain significance Change in DNA sequence with uncertain effects on disease <br />Likely benign Likely benign change in the DNA sequence <br />Benign Benign change in the DNA sequence <br />American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology. <br /><br /><b><br />Genetic Counseling </b><br /><br />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. <br /><br /><b>Benefit Application </b><br /><br />Some Plans may have contract or benefit exclusions for genetic testing. Recommendations indicate that, when possible, genetic testing for hypertrophic <br />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. <br /><br />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. <br /><br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-7502395389017519302019-02-22T00:14:00.000-08:002019-02-22T00:14:04.012-08:00CPT 11055, 11056, 11057, 11719, 11720, 11721 - Routine Foot Care Services <b>Coding Code Description CPT </b><br /><br /><b>11055</b> Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion <br /><br /><b>11056</b> Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions <br /><br /><b>11057</b> Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions <br /><br /><b>11719</b> Trimming of nondystrophic nails, any number <br /><br /><b>11720</b> Debridement of nail(s) by any method(s); 1 to 5 <br /><br /><b>11721</b> Debridement of nail(s) by any method(s); 6 or more <br /><br /><br /><b>HCPCS </b><br /><br /><b>G0127</b> Trimming of dystrophic nails, any number <br /><br />
<b>S0390</b> Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (eg, diabetes), per visit<br />
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<br /><b>Introduction </b><br /><br />Most adults are able to provide their own routine foot care, such as trimming nails or filing calluses. Therefore, this type of foot care is not covered under the medical benefits. However, for some individuals with certain medical conditions, it may be important to have professional help with routine foot care in order to prevent serious problems. Routine foot care includes services such as cutting corns and calluses or trimming, cutting, clipping, or removing part of the nail (debridement). This benefit coverage guideline discusses when routine foot care may be covered. <br /><br />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. <br />Coverage Guideline <br /><br /><b>Indication Medical Necessity </b><br />Conditions associated with poor blood flow to the legs and feet <br />Routine foot care may be considered medically necessary for patients with conditions associated with poor blood flow to the legs and feet such as peripheral vascular disease and/or numbness (desensitization). <br /><br /><br /><br />Routine foot care Routine foot care, such as trimming nails or removing corns and calluses, does not typically require the skills of a qualified provider of foot care services and is therefore considered not medically necessary. <br /><br /><br /><br /><b>ICD-10 Diagnosis Codes - Covered </b><br /><br />A52.16 Charcot's arthropathy (tabetic) <br />B35.1 Dermatophitosis (Tinea unquium) <br />B37.2 Candidiasis of skin and nail <br />B52.0 Plasmodium malariae with neuropathy <br />E08.00 – E13.9 Diabetes Mellitus <br />O24.011 – O24.93 Diabetes mellitus in pregnancy <br />G13.0 – G13.1 Systemic atrophy and neuropathy <br />G6281 – G65.2 Polyneuropathies <br /><br /><br /><b>Code Description </b><br />G73.3 Myasthenic syndromes in other diseases classified elsewhere <br />G90.09 Peripheral neuropathy <br />G99.0 Autonomic neuropathy <br />I70.201 – I70.799 Atherosclerosis of arteries, lower extremities <br />I73.00 – I79.8 Peripheral vascular disease <br />I80.00 – I80.3 Phlebitis and thrombophlebitis, lower extremities <br />I82.501 – I87.9 Chronic embolism and thrombosis, lower extremities <br />I89.0 Lymphedema <br />I99.8 Circulatory system disorder <br />L02.415 – L03.129 Infections of skin and subcutaneous tissue, lower limb <br />L11.0 Acquired keratosis follicularis <br />L60.0 – L60.9 Nail disorders <br />L84 – L85.2, L86, L87.0, L87.2, L97.501 – L97.529 <br />Disorders of skin and subcutaneous tissue <br />M05.571 – M05.59 Polyarthropathies <br />M14.671 – M14.69 Arthropathies, Charcot's joint, ankle and foot <br />M20.10 – M02.12 Hallus valgus <br />M34.83 Systemic sclerosis with polyneuropathy <br />M90.561 – M90.59 Osteonecrosis, lower ley, ankle and foot <br />M90.861 – M90.89 Osteopathy, lower leg, ankle and foot <br />Q82.0 Hereditary lymphedema <br />R20.0 – R20.9 Disorders of skin and subcutaneous tissue <br />R60.0 – R60.9 Edema <br />Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS). <br /><br /><br />This coverage guideline describes the clinical indications for routine foot care services. <br /><br /><b>Routine foot care includes: </b><br /><br />* Cutting or removal of corns and calluses <br />* Trimming, cutting/clipping and debridement of nails <br /><br />Generally, routine foot care services are performed by the member or the caregiver. However, if certain medical conditions are present they may pose a hazard when foot care is performed by a non-professional. <br /><br />The following conditions may pose a risk to life or limb loss, so a qualified provider of foot care services should perform the routine foot care. Conditions that may require a qualified provider to perform routine foot care include but are not limited to any of the following: <br /><br />* Arteriosclerosis of the extremities <br />* Buerger’s disease (ie, thromboangiitis obliterans) <br />* Chronic thrombophlebitis of lower extremities <br />* Diabetes <br />* Peripheral neuropathies <br />* Peripheral vascular disease <br /><br />This policy only addresses routine foot care. It does not address the treatment of symptomatic diseases and medical conditions of the feet, which may include: <br />* Bunion <br />* Bursitis <br />* Hammer toe <br />* Heel spur <br />* Ingrown toenail <br />* Neuroma <br />* Plantar fasciitis <br />* Sprain/strain of the foot <br />* Warts, includingUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-31234869171637396102019-02-05T00:09:00.000-08:002019-02-05T00:09:00.486-08:00CPT 37243, 75894, 79445, S2095 - Radioembolization for Primary and Metastatic Tumors of the Liver <b>Code Description CPT </b><br /><br /><b>37243</b> Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction. <br /><br /><b>75894</b> Transcatheter therapy, embolization, any method, radiological supervision and interpretation <br /><br /><b>79445</b> Radiopharmaceutical therapy, by intra-arterial particulate administration <br /><br /><b>Code Description HCPCS </b><br /><br /><b>S2095 </b>Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using ytrrium-90 microspheres<br />
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<br /><b>Introduction </b><br /><br />Embolization is procedure to block blood flow. Combined with radiation, it is a way to treat cancer in the liver in some situations. In this procedure a catheter (a long, thin, hollow tube) is inserted in an artery near the groin. It’s threaded to the tumor’s blood supply. Tiny radioactive particles are released into the artery that feeds the tumor. The particles travel into the tumor and block off — embolize — the blood supply feeding the tumor, causing it to shrink. The radiation works to kill the cancer cells. The radiation dissipates in a few weeks and the particles stay in the liver permanently. The radiation usually doesn’t affect the healthy liver tissue around the tumor very much. This policy describes when radioembolization may be considered medically necessary. <br /><br /><b>Policy Coverage Criteria <br /><br />Service Medical Necessity</b> <br /><br />Radioembolization Radioembolization may be considered medically necessary in the following situations: * Treatment of primary hepatocellular carcinoma that is unresectable and limited to the liver (size of 3cm or larger, and patient with good performance status) OR * Treatment of primary hepatocellular carcinoma as a bridge to liver transplantation OR * Treatment of primary intrahepatic cholangiocarcinoma in patients with unresectable tumors OR * Treatment of hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms. (symptoms related to excess hormone production) OR * Treatment of unresectable hepatic metastases <br /><br />o From breast, colorectal or melanoma (ocular or cutaneous) AND o That are progressive and unresectable in patients with liver dominant disease <br />AND o That are refractory to chemotherapy or are not candidates for chemotherapy Service Investigational Radioembolization Radioembolization is considered investigational for all other hepatic metastases except as noted in the Medical Necessity section above. <br /><br /><b><br />Service Investigational <br /><br />Documentation Requirements </b><br />Radioembolization is considered investigational for all other indications not described in the Medical Necessity section above. <br />The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include office visit notes that contain the relevant history and physical supporting ANY of the following situations: * Patient with primary liver cancer that cannot be removed by surgery and limited to the liver (size of 3 cm or larger, and patient with good performance status) * Treatment for hepatocellular carcinoma before a liver transplant * <br />Treatment of primary intrahepatic cholangiocarcinoma that cannot be removed by surgery * Treatment of hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms (symptoms related to excess hormone production) <br /><br />* Treatment of hepatic metastases that cannot be removed by surgery: o From breast, colorectal, or melanoma (ocular or cutaneous) <br />AND o That are progressive and unresectable in patients with liver dominant disease ND * Has failed chemotherapy or are not candidates for chemotherapy <br /><br /><b>Coding </b><br /><br /><br />The coding for radioembolization may depend on the medical specialty providing the therapy. <br /><br /><br /><br /><b>Related Information </b><br /><br /><br />In general, radioembolization is used for unresectable hepatocellular carcinoma that is greater than 3 cm. <br /><br />There is little information on the safety or efficacy of repeated radioembolization treatments or about the number of treatments that should be administered. <br />Radioembolization should be reserved for patients with adequate functional status (Eastern Cooperative Oncology Group Performance Status 0-2), adequate liver function and reserve, Child-Pugh class A or B, and liver-dominant metastases. <br />Symptomatic disease from metastatic neuroendocrine tumors refers to symptoms related to excess hormone production. <br /><br /><b>Definition of Terms </b><br /><br />Child-Pugh Score: This score is used to assess the prognosis of chronic liver disease, usually cirrhosis. <br />Eastern Cooperative Oncology Group (ECOG): The ECOG performance status is used to assess the patient’s disease progression and how the disease impacts the patient’s activities of daily living (ADLs). http://www.ecog.org/ (Accessed September 2018) <br /><br /><br /><b>Description</b> <br /><br />Radioembolization (RE), also referred to as selective internal radiotherapy, delivers small beads (microspheres) impregnated with yttrium 90 intra-arterially via the hepatic artery. The microspheres, which become permanently embedded, are delivered to tumors preferentially, because the hepatic circulation is uniquely organized, whereby tumors greater than 0.5 cm rely on the hepatic artery for blood supply while the normal liver is primarily perfused via the portal vein. Radioembolization has been proposed as a therapy for multiple types of primary and metastatic liver tumors. <br /><br /><b>Background <br /><br />Treatments for Hepatic and NeuroEndocrine Tumors </b><br /><br />The use of external-beam radiotherapy and the application of more advanced radiotherapy approaches (eg, intensity-modulated radiotherapy) may be of limited use in patients with multiple diffuse lesions due to the low tolerance of normal liver to radiation compared with thehigher doses of radiation needed to kill the tumor.<br />
<br />Various nonsurgical ablative techniques have been investigated that seek to cure or palliate unresectable hepatic tumors by improving locoregional control. These techniques rely on extreme temperature changes (cryosurgery or radiofrequency ablation), particle and wave physics (microwave or laser ablation), or arterial embolization therapy including chemoembolization, bland embolization, or radioembolization. <br /><br /><b>Radioembolization </b><br /><br />Radioembolization, (radiotherapy in older literature) delivers small beads (microspheres) impregnated with yttrium 90 intra-arterially via the hepatic artery. The microspheres, which become permanently embedded, are delivered to tumors preferentially because thehepatic circulation is uniquely organized, whereby tumors greater than 0.5 cm rely on the hepatic arteryfor blood supply while normal liver is primarily perfused via the portal vein. Yttrium-90 is a pure beta-emitter with a relatively limited effective range and short half-life that helps focus the radiation and minimize its spread. Candidates for radioembolizationare initially examined by hepatic angiogram to identify and map the hepatic arterial system. At that time, a mixture of technetium 99-labeled albumin particles is delivered via the hepatic artery to simulate microspheres. Single-photon emission computed tomography is used to detect possible shunting of the albumin particles into gastrointestinal or pulmonary vasculature. <br /><br />Currently 2 commercial forms of yttrium-90 microspheres are available: a glass sphere, (TheraSphere) and a resin sphere (SIR-Spheres). Noncommercial forms are mostly used outside the United States. While the commercial products use the same radioisotope (yttrium-90) and have the same target dose (100 Gy), they differ in microsphere size profile, base material (ie, resin vs glass), and size of commercially available doses. The physical characteristics of the active and inactive ingredients affect the flow of microspheres during injection, their retention at the tumor site, spread outside the therapeutic target region, and dosimetry calculations. The Food and Drug Administration (FDA) granted premarket approval of SIR-Spheres for use in combination with 5-floxuridine chemotherapy by hepatic arterial infusion to treat unresectable hepatic metastases from colorectal cancer. In contrast, TheraSphere’s glass sphere was approved under a humanitarian device exemption for use as monotherapy to treat unresectable hepatocellular carcinoma. In 2007, this humanitarian device exemption was expanded to include patients with hepatocellular carcinoma who have partial or branch portal vein thrombosis. For these reasons, results obtained with 1 product do not necessarily apply to other commercial (or non-commercial) products (see Regulatory Status section). <br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-39992847652460895902019-01-27T00:03:00.000-08:002019-01-27T00:03:04.138-08:00CPT 81504, 81540, 81599 - Assays for Cancers of Unknown Primary <b>Policy Coverage Criteria <br /><br />Type of Test Investigational </b><br />
Gene expression profiling Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown primary, or to distinguish a primary from a metastatic tumor. <br /><br /><b>Coding code Description CPT </b><br /><br />81479 Unlisted molecular pathology procedure <br /><br /><b>81504 </b>Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores <br /><br /><b>81540</b> Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype <br /><br /><b>81599</b> Unlisted multianalyte assay with algorithmic analysis<br />
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<br /><b>Introduction </b><br /><br />A primary site is the part of the body where cancer started. Cancers are named on this primary site, even when they spread to other parts of the body. For example, if cancer starts in the breast but spreads to the bones, lungs, or liver, it is still classified as breast cancer. Cancer treatment is often based on the primary cancer. In rare cases, a cancer may have already spread before the original cancer is found. This is known as cancer of unknown primary. Cancers of unknown primary happen in three to four percent of all cancers in the United States. Certain genetic tests are being studied as one way to try to find the original site of the cancer. There is not yet enough scientific evidence about how these genetic tests might affect overall health outcomes. These tests are considered unproven (investigational). <br /><br /><br /><br /><b><br />Related Information <br /><br />Genetics Nomenclature Update </b><br />
<br />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. <br /><br /><br />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. <br /><br /><b>Table 1. Nomenclature to Report on Variants Found in DNA </b><br />Previous Updated Definition <br />Mutation Disease-associated variant Disease-associated change in the DNA sequence <br /> Variant Change in the DNA sequence <br /><br />Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives <br />Table 2. ACMG-AMP Standards and Guidelines for Variant Classification <br />Variant Classification Definition <br />Pathogenic Disease-causing change in the DNA sequence <br />Likely pathogenic Likely disease-causing change in the DNA sequence <br />Variant of uncertain significance Change in DNA sequence with uncertain effects on disease <br />Likely benign Likely benign change in the DNA sequence <br />Benign Benign change in the DNA sequence <br />American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology <br /><br /><b>Genetic Counseling </b><br />Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of genetic tests and understanding risk factors can be difficult for some patients; genetic counseling helps individuals understand the impact of genetic testing, including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing; further, genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods. <br /><br /><b>Evidence Review <br /><br />Description </b><br /><br />Cancers of unknown primary represent 3% to 4% of cancers diagnosed in the United States. These cancers are heterogeneous and many accompanied by poor prognoses. A detailed history and physical combined with imaging and tissue pathology can identify some, but not all, primary sources of secondary tumors. It is suggested that identifying the likely primary source with gene expression profiling to direct treatment may improve health outcomes. <br /><br /><b>Background <br /><br />Cancers of Unknown Primary </b><br /><br />Cancers of unknown primary (CUPs), or occult primary malignancies, are tumors that have metastasized from an unknown primary source; they make up about 3% to 4% of all cancers in the United States. Identifying the primary origin of a tumor can dictate cancer-specific treatment, expected outcome, and prognosis.<br /><br />Most CUPs are adenocarcinomas or undifferentiated tumors; less commonly, they may be squamous carcinomas, melanoma, soft tissue sarcoma, or neuroendocrine tumors. Osteo- and chondrosarcomas rarely produce CUPs. The most common primary sites of CUPs are the lung and pancreas, followed by colon and stomach, then breast, ovary, prostate, and solid-organ carcinomas of the kidney, thyroid, and liver. Conventional methods used to aid in the identification of the origin of a CUP include a thorough history and physical examination; computed tomography scans of the chest, abdomen, and pelvis; routine laboratory studies; and targeted evaluation of specific signs and symptoms.<br /><br /><b>Diagnosis and Classification </b><br /><br />Biopsy of a CUP with detailed pathology evaluation may include immunohistochemical (IHC) analysis of the tumor. IHC analysis identifies different antigens present in different types of tumors and can usually distinguish an epithelial tumor (ie, carcinoma) from melanoma or sarcoma. Detailed cytokeratin panels often allow further classification of carcinoma; however, tumors of different origins may show overlapping cytokeratin expression. Results of IHC may provide a narrow differential of possible sources of a tumor’s origin, but not necessarily a definitive answer. <br />Recent advances in the understanding of gene expression in normal and malignant cells have led researchers to explore molecular classification to improve the identification of the site of origin of a CUP. The molecular classification of cancers is based on the premise that, despite different degrees of differentiation, tumors retain sufficient gene expression “signatures” as to their cell of origin, even after metastasis. Theoretically, it is possible to build a gene expression database spanning many different tumor types to compare to the expression profile of very poorly differentiated tumors, or a CUP, to aid in the identification of the tumor type and organ of origin. The feasibility of using molecular classification schemes with gene expression profiling (GEP) to classify these tumors of uncertain origin has been demonstrated in several studies.<br /><br /><b>Tissue of Origin Testing, Treatment Selection, and Health Outcomes </b><br /><br />Patients with CUP have generally poor prognoses. For example, patients with disease limited to lymph nodes have a median survival of 6 to 9 months, and those with a disease that is extranodal 2 to 4 months.<br /><br />The premise of tissue of origin testing in CUPs is that identifying a likely primary tumor site will inform treatment selection leading to improved survival and other outcomes or as a predictive test. To evaluate whether treatment selection can be improved, the ability of a test to suggest a likely site of origin (clinical validity) must be first be shown. But demonstrating clinical validity may be problematic because patients with CUPs have no identified primary tumor for a reference standard. <br />Imperfect reference standards must be relied on such as the available presumptive or a reference pathologic diagnosis, known tumor types, or comparisons IHC. A primary tumor diagnosed during follow-up might also be used as a reference standard, but its use would be subject to potential selection bias. Therefore, even substantial evidence supporting the ability of a test to suggest a likely site of origin will be insufficient to infer benefit. Convincing evidence for benefit requires demonstrating that using a test to select treatment will improve outcomes. <br /><br />
<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-7283751436653038582019-01-08T23:59:00.000-08:002019-01-08T23:59:09.470-08:00CPT 81225, 81226, 81227, 81599 - Genotype-Guided Tamoxifen Treatment <b>Policy Coverage Criteria Test Investigational Cytochrome P450 2D6 (CYP2D6) testing <br /><br />Coding <br /> </b><br />Genotyping to determine cytochrome P450 2D6 (CYP2D6) variants is considered investigational for the purpose of managing treatment with tamoxifen for women at high risk for or with breast cancer. <br /><br /><b>Code Description CPT </b><br /><br /><br /><b>81225</b> CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) <br /><br /><b>81226</b> CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) <br /><br /><b>81227</b> CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) <br /><br /><b>81479</b> Unlisted molecular pathology procedure <br /><b><br />81599 </b>Unlisted multianalyte assay with algorithmic analysis <br />
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<br /><br /><b>Introduction </b><br />Certain types of breast cancer are affected by hormones. Cancer cells that are said to be estrogen receptor positive (ER-positive) have receptors that attach to estrogen. Once attached, estrogen then acts like a fertilizer to help the cancer grow. Hormone therapy is used to prevent estrogen from connecting to the receptors. Tamoxifen is a type of hormone therapy that can be used for ER-positive breast cancer to prevent it from coming back and to treat breast cancer that’s already spread to other parts of the body. It’s also used for ER-positive ductal carcinoma in situ (DCIS). To process tamoxifen into its more active form, the body uses a specific, important enzyme (CYP2D6) that’s made by a particular gene. A small percentage of people (about 10%) have a form of the gene that doesn’t make as much of this important enzyme as most other people make. A genetic test has been developed to try to see if a person has the gene form that makes a smaller amount of the needed enzyme. This genetic test is investigational (unproven). Large, well-designed medical studies don’t show a strong link between this gene and tamoxifen’s effectiveness. More studies are needed. <br /><br /><br /><br /><br /><b>Related Information <br /><br />Genetics Nomenclature Update </b><br /><br />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. It is being implemented for genetic testing medical evidence review updates starting in 2017 (see Table 1). <br /><br /><br />The Society’s nomenclature is recommended by the Human Variome Project, the HUman Genome Organization, and by the Human Genome Variation Society itself. <br /><br />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. <br /><br /><b>Table 1. Nomenclature to Report on Variants Found in DNA </b> <br /><br />Previous Updated Definition <br />Mutation Disease-associated variant <br />Disease-associated change in the DNA sequence <br />Variant Change in the DNA sequence <br />Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives <br /><br /><b>Table 2. ACMG-AMP Standards and Guidelines for Variant Classification </b><br />Variant Classification Definition <br />Pathogenic Disease-causing change in the DNA sequence <br />Likely pathogenic Likely disease-causing change in the DNA sequence <br />Variant of uncertain significance Change in DNA sequence with uncertain effects on disease <br />Likely benign Likely benign change in the DNA sequence <br />Benign Benign change in the DNA sequence <br />ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology. <br /><br /><br /><b>Description </b><br /><br />Tamoxifen is prescribed as a component of adjuvant endocrine therapy to prevent endocrine receptor-positive breast cancer recurrence, to treat metastatic breast cancer, and to prevent disease in high-risk populations and in women with ductal carcinoma in situ. Tamoxifen is a prodrug that undergoes extensive metabolism to yield its active form: 4-hydroxy tamoxifen and endoxifen (primary active form) via the CYP2D6 enzyme. Variants in the CYP2D6 gene are associated with significant alterations in endoxifen concentrations leading to the hypothesis that CYP2D6 variation may affect the clinical outcomes of women treated with tamoxifen but not with drugs not metabolized by CYP2D6, such as anastrozole. <br /><br /><b>Background Tamoxifen Metabolism </b><br /><br />Tamoxifen is a pro-drug that undergoes extensive metabolism to yield its active form: 4hydroxytamoxifen (4-OH tamoxifen) and 4-hydroxy-N-desmethyltamoxifen (endoxifen).<br /><br />Among these 2 metabolites, endoxifen is thought to be the major metabolite that exerts the pharmacodynamic effect of tamoxifen. The metabolism of tamoxifen into 4-OH tamoxifen is catalyzed by multiple enzymes, while endoxifen is formed predominantly by the CYP2D6 enzyme. Plasma concentrations of endoxifen exhibit high interindividual variability, as described in breast cancer patients.<br />
<br />Because CYP2D6 enzyme activity is known to vary across individuals, variants in the CYP2D6 gene are of great interest for understanding tamoxifen metabolism variability and variation in levels of circulating active metabolites. Moreover, known variability in endoxifen levels has been hypothesized to result in variable response to tamoxifen treatment. <br /><br /><b>Metabolic Enzyme Genotypes </b><br /><br />The CYP2D6 gene exhibits a high degree of polymorphism, with more than 100 allelic variants identified. The relations among genotype, phenotype, and clinical implications are summarized in Table 3. <br /><br />The prevalence of CYP2D6 poor metabolizers is approximately 7% to 10% in whites of Northern European descent, 1.9% to 7.3% in blacks, and 1% or less in most Asian populations studied. The poor metabolizer phenotype in whites is largely accounted for by CYP2D6*3 and *4 nonfunctional variants, and in black and Asian populations, by the *5 nonfunctional variant. Some poor metabolizers may have 1 nonfunctional allele and 1 reduced-function allele. Among reduced function variants, CYP2D6*17, *10, and *8 are the most important in blacks, Asians, and whites, respectively. Few studies have investigated the frequency of CYP2D6-variant alleles or of poor metabolizers in the Hispanic population.<br /><br /><b>Endocrine Therapy Regimens <br /><br />Tamoxifen has several labelled indications</b><br /><br />* Chemoprevention of invasive breast cancer in high-risk women without current disease or with ductal carcinoma in situ <br />* Adjuvant treatment of primary breast cancer <br />* Treatment of metastatic disease <br /><br /><br />In women with breast cancer, endocrine receptor-positive disease predicts a likely benefit from tamoxifen treatment. Tamoxifen is currently the most commonly prescribed adjuvant treatment to prevent recurrence of endocrine receptor-positive breast cancer in premenopausal or perimenopausal women. <br />
<br />For post-menopausal women with osteoporosis or at high risk for invasive breast cancer, raloxifene is an alternative treatment for invasive cancer risk reduction. Currently, raloxifene is indicated for treatment of reduction in the “risk of invasive breast cancer in postmenopausal women with osteoporosis” or those at “high risk for invasive breast cancer.”<br /><br /><b>Pharmacologic Inhibitors of Metabolic Enzymes </b> <br /><br />CYP2D6 activity may be affected not only by genotype but also by co-administered drugs that block or induce CYP2D6 function. Studies of selective serotonin reuptake inhibitors, in particular, have shown that fluoxetine and paroxetine, but not sertraline, fluvoxamine, or venlafaxine, are potent CYP2D6 inhibitors.<br /><br />Some individuals treated with fluoxetine or paroxetine have changed from extensive metabolizer phenotype to poor metabolizer.<br /><br />The degree of inhibition may depend on selective serotonin reuptake inhibitors dose. <br />Thus, CYP2D6 inhibitor use must be considered in assigning CYP2D6 functional status, and potent CYP2D6 inhibitors may need to be avoided when tamoxifen is administered. <br /><br /><b>Summary of Evidence </b><br /><br />For individuals who are treated with tamoxifen for breast cancer or are high risk for breast cancer who receive CYP2D6 genotype-guided tamoxifen treatment, the evidence includes multiple retrospective cohort studies and nonconcurrent prospective studies. Relevant outcomes include overall survival, disease-specific survival, medication use, and treatment-related morbidity. Data in most of these studies derived from a convenient sample, which was further limited by relatively small numbers of patients and lack of comprehensive genotype data, patient data (eg, concomitant medications), and detailed clinical outcomes data. Three influential nonconcurrent prospective studies nested within large prospective, randomized double-blind clinical trials in postmenopausal women with hormone receptor–positive earlystage breast cancer also reported contradictory results. Two larger studies failed to show statistically significant associations between phenotype (patients classified as poor, intermediate, or extensive metabolizer) and recurrence of breast cancer. No trials of genotype-directed dosing or drug choice that compared health outcomes for patients managed with and without the test were identified. It is not known whether CYP2D6 genotype-guided tamoxifen treatment results in the selection of a treatment strategy that would reduce the rate of breast cancer recurrence, improve disease-free survival or overall survival, or reduce adverse events. The evidence is insufficient to determine the effects of the technology on health outcomes.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-58014665985350464362018-12-27T23:55:00.000-08:002018-12-27T23:55:03.279-08:00CPT G9143, 0030U - Genotype-Guided Warfarin Dosing <br /><b>Code Description CPT </b><br /><br /><b>0030U </b>Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) (new code effective 1/1/18) <br /><br /><b>HCPCS </b><br /><b>G9143</b> Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)<br />
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<br /><br /><br /><b>Introduction </b><br /><br />Warfarin (Coumadin) is a blood thinner that works by reducing the blood’s ability to clot. It’s often prescribed to prevent blood clot formation in people who have conditions like atrial fibrillation. Finding the correct dose can be complicated. Too high a dose can cause bleeding. Too low a dose can result in blood clots being formed. Factors such as age, weight, use of other medications, and smoking go into the calculation of how much is prescribed. Once the drug is prescribed, the doctor then adjusts the dose based on blood tests. Two genes have been associated with how well the body processes warfarin. Genetic tests have been developed to look at these genes to try to determine warfarin dosing. These genetic tests are investigational (unproven). Medical studies do not show whether genetic testing to try to adjust warfarin doses leads to better health results. More studies are needed. <br /><br /><br /><br /><b>Test Investigational </b><br />
<br />Testing of cytochrome p450 2C9 (CYP2C9), P450 4F2 (CYP4F2), and vitamin K epoxide reductase subunit C1 (VKORC1) <br /><br />Coding Genotyping for CYP2C9, CYP4F2, and VKORC1 variants is considered investigational to manage the administration and dosing of warfarin, including: * Guiding the initial warfarin dose * Decreasing the time needed to achieve a stable international normalized ratio (INR) * Reducing the risk of serious bleeding <br /><br /><br /><br /><br /><b>Related Information <br /><br />Genetics Nomenclature Update </b><br /><br />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. <br /><br /><b>Table 1. Nomenclature to Report on Variants Found in DNA <br />Previous Updated Definition <br /><br />Mutation Disease-associated variant <br /> </b><br />Disease-associated change in the DNA sequence <br />Variant Change in the DNA sequence <br />Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives <br />Table 2. ACMG-AMP Standards and Guidelines for Variant Classification <br />Variant Classification Definition <br />Pathogenic Disease-causing change in the DNA sequence <br />Likely pathogenic Likely disease-causing change in the DNA sequence <br />Variant of uncertain significance Change in DNA sequence with uncertain effects on disease <br />Likely benign Likely benign change in the DNA sequence <br />Benign Benign change in the DNA sequence <br />ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology. <br /><br /><b>Genetic Counseling </b><br /><br />Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of genetic tests and understanding risk factors can be difficult for some patients; genetic counseling helps individuals understand the impact of genetic testing, including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing; further, genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods. <br /><br /><br /><br /><b>Evidence Review </b><br /><br /><b>Description </b><br /><br />Using information about an individual’s genotypes may help in guiding warfarin dosing and could reduce the time to dose stabilization and selection of an appropriate maintenance dose that might avoid the consequences of too much or too little anticoagulation. <br /><br /><b>Background </b><br /><br />Warfarin is administered to prevent and treat thromboembolic events in high-risk patients; warfarin dosing is a challenging process due to the narrow therapeutic window, variable response to dosing, and serious bleeding events in 5% or more of patients (depending on definition). Patients are typically given a starting dose of 2 to 5 mg and are frequently monitored with dose adjustments until a stable international normalized ratio value (a standardized indicator of clotting time) between 2 and 3 is achieved. During this adjustment period, a patient is at high risk of bleeding. <br />Stable or maintenance warfarin dose varies among patients by more than an order of magnitude. Factors influencing stable dose include body mass index, age, interacting drugs, and indication for therapy. <br /><br />Warfarin, which is primarily metabolized in the liver by the CYP2C9 enzyme, exerts an anticoagulant effect by inhibiting the protein vitamin K epoxide reductase complex, subunit 1 (VKORC1). Three single nucleotide variants, two in the CYP2C9 gene and one in the VKORC1 gene play key roles in determining the effect of warfarin therapy on coagulation.<br /><br /> CYP2C9*1 metabolizes warfarin normally, CYP2C9*2 reduces warfarin metabolism by 30%, and CYP2C9*3 reduces warfarin metabolism by 90%. Because warfarin given to patients with *2 or *3 variants will be metabolized less efficiently, the drug will remain in circulation longer, so lower warfarin doses will be needed to achieve anticoagulation. CYP2C9 and VKORC1 genetic variants account for approximately 55% of the variability in warfarin maintenance dose.<br />1,11<br /><br /> Recent genome-wide association studies have also identified that a single nucleotide variant in the CYP4F2 gene has been reported to account for a small proportion of the variability in stable dose (the CYP4F2 gene encodes a protein involved in vitamin K oxidation).<br /><br /><b>Medicare National Coverage </b><br /><br />In 2009, the Centers for Medicare and Medicaid Services published a national coverage determination on pharmacogenomic testing for warfarin response.<br /><br />The Centers for Medicare & Medicaid Services stated that “the available evidence does not demonstrate that pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness improves health outcomes in Medicare beneficiaries outside the context of CED, and is therefore not reasonable and necessary….” <br />However, the Centers also “believes that the available evidence supports that coverage with evidence development (CED) …. is appropriate for pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness by any method, and is therefore covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin who: <br />* Have not been previously tested for CYP2C9 or VKORC1 alleles; and <br /><br />* Have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and <br />* Are enrolled in a prospective, randomized, controlled clinical study when that study meets described standards.” <br /><br /><br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3741281958732379203.post-3974470830991221792018-12-05T23:52:00.003-08:002018-12-05T23:52:59.159-08:00What is CPC+ - General Guide<br />
<b>GENERAL</b><br />
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<b>Q: Why is CMS testing CPC+?</b><br />
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CMS believes that through multi-payer payment reform and practice transformation, primary care practices will be able to build capabilities and care processes to deliver patient-centered, high quality care and lower the use of unnecessary services that drive total costs of care. Payment redesign by payers, both public and private, will offer the ability for greater cash flow and flexibility for primary care practices.<br />
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<b>Q: When will CPC+ Round 2 start and how long will it last? Can my practice join later?</b> CPC+ Round 2 is expected to begin on January 1, 2018. Eligible practices located in the CPC+ Round 2 regions can apply from May 18-July 13, 2017.<br />
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CPC+ Round 2 consists of five performance years, as identified in the table below. CMS expects practices to participate for the full five years of their respective round of the model and will not allow practices to join the model after CMS selects practices to participate in each round of the Model.<br />
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<b>PERFORMANCE YEARS FOR CPC+ Round 2 Calendar Year Round 2 Performance Year</b><br />
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2018 1<br />
2019 2<br />
2020 3<br />
2021 4<br />
2022 5<br />
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<b>Q: Are practices required to participate in CPC+ for the full five years?</b><br />
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CMS expects practices to participate in CPC+ for the full five years. However, participation in CPC+ is voluntary and practices may withdraw from the model without penalty during the fiveyear performance period. Practices are required to notify CMS at least 90 calendar days before the planned day of withdrawal. Departing the model before completion of a performance year (PY) puts a practice at risk for recoupment of unearned CPC+ payments.<br />
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<b>Q: Where will CPC+ Round 2 be implemented?</b><br />
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CPC+ Round 2 will be implemented in four regions throughout the U.S.:<br />
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1. Louisiana: Statewide<br />
2. Nebraska: Statewide<br />
3. North Dakota: Statewide<br />
4. New York: Greater Buffalo Region<br />
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The CPC+ Round 2 regions were selected based on payer alignment and market density to ensure that CPC+ practices have sufficient payer support to make fundamental changes in their primary care delivery.<br />
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<b>Q: How is CMS defining the “Greater Buffalo Region (NY)”? </b><br />
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Based on payer alignment and market density, CMS is defining the Greater Buffalo region with the following counties:<br />
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• New York: Greater Buffalo Region: Erie County, NY; Niagara County, NY Only practices located in these counties are eligible to apply and participate in CPC+ Round 2.<br />
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<b>Q: Which payers have been selected to partner in CPC+ Round 2?</b><br />
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CPC+ Round 2 payer partners in the four new CPC+ Round 2 regions:<br />
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1. Louisiana: Amerigroup Louisiana, Inc., AmeriHealth Caritas Louisiana, Inc., Blue Cross Blue Shield of Louisiana<br />
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2. Nebraska: Blue Cross Blue Shield of Nebraska<br />
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3. New York: Greater Buffalo Region: HealthNow New York Inc., Independent Health Association, Inc.<br />
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4. North Dakota: Blue Cross Blue Shield of North Dakota<br />
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<b>Q: When and how can a practice apply to participate in CPC+ Round 2? </b><br />
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Based on payer interest and proposed alignment, CMS announced four regions for CPC+ Round<br />
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2. Practices located in these regions are eligible to apply via an online portal (https://app1.innovation.cms.gov/cpcplus/) from May 18-July 13, 2017. For questions about the Model or the solicitation process, please email CPCPlusapply@telligen.com or call 1-877-309- 6114.<br />
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<b>Q: How many practices will be accepted in CPC+ Round 2? </b><br />
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CMS expects to accept up to 1,000 practices in CPC+ Round 2.<br />
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Q: Why will new practice applications only be accepted in CPC+ Round 2 regions? CPC+ is a voluntary test of primary care payment and delivery system changes at the practice level, and will be independently evaluated throughout the five years of each Round of the model. The evaluation compares practices in each region to similar practices in the same region. CMS is unable to add new practices in the existing regions without potentially compromising the evaluation. Therefore, new practices will only be able to apply for participation in CPC+ in new regions selected for CPC+ Round 2, not in the 14 Round 1 regions.<br />
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<b>Q: What is expected of the control group practices in CPC+ Round 2?</b><br />
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CMS will randomly assign eligible practices to an intervention group and a control group. The control group practices will not be required to implement the CPC+ care delivery practice changes, will not receive CPC+ Payments, and will not participate in the CPC+ learning communities, and will sign a different CPC+ Participation Agreement with CMS than the intervention group. Additionally, they will not be considered participants in an Advanced APM through participation in the CPC+ control group, but may otherwise be Advanced APM participants through their participation in other CMS models or programs. Control group practices may be compensated for their participation in CPC+ evaluation-related activities. CMS also expects to promulgate a rule that could allow for control group practices to potentially receive favorable scoring under the Improvement Activities category of the Merit-based Incentive Payment System (MIPS), subject to notice and comment rulemaking. More details for control group practices will be announced in late 2017.<br />
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<b>Q: Are practices outside of the CPC+ Round 2 regions eligible to apply and participate in CPC+?</b><br />
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Practices will only be eligible to apply to Round 2 if they are located in one of the selected Round 2 regions. The purpose of the CPC+ multi-payer design is to ensure that primary care practices receive the adequate support from multiple payers to change care delivery for a practice’s entire panel of patients. The CPC+ regions were carefully selected to ensure adequate payer support for participating practices.<br />
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a Greater Kansas City Region is defined as Johnson County, KS; Wyandotte County, KS; Clay County, MO; Jackson County, MO; Platte County, MO<br />
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b North Hudson-Capital Region of New York is defined as Albany County, NY; Columbia County, NY; Dutchess County, NY; Greene County, NY; Montgomery County, NY; Orange County, NY; Rensselaer County, NY; Saratoga County, NY; Schenectady County, NY; Schoharie County, NY; Sullivan County, NY; Ulster County, NY; Warren County, NY Washington County, NY<br />
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c Ohio-Northern Kentucky Region is defined as all counties in Ohio; Boone County, KY; Campbell County, KY; Grant County, KY; Kenton County, KY<br />
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d Greater Philadelphia Region is defined as Bucks County, PA; Chester County, PA; Delaware County, PA; Montgomery County, PA; Philadelphia County, PA<br />
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e Greater Buffalo Region is defined as Erie County, NY and Niagara County, NY<br />
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<b>Q: Is CPC+ an Advanced APM under the Quality Payment Program?</b><br />
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CPC+ is included on the list of Advanced APMs. This determination was based on medicalhome model-specific requirements. For payment years 2019 through 2024, clinicians who meet the threshold for sufficient participation in Advanced APMs and who meet requirements, as applicable for 2018 onward, regarding parent organization size are excluded from the Meritbased Incentive Payment System (MIPS) reporting requirements and payment adjustments and qualify for a five percent APM incentive payment.<br />
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<b>Q: Where can practices find more information about the QPP and Advanced APMs? </b><br />
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More information about the QPP and Advanced APMs can be found on the new website from CMS: https://qpp.cms.gov.<br />
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<b>Q. What role do other payers play in CPC+?</b><br />
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Multi-payer engagement is an essential goal of CPC+, as it enables both public and private payers to sponsor comprehensive primary care reform. CMS will partner with payers that share Medicare’s interest in strengthening primary care in each of the CPC+ regions. Payer partners, both public and private, will provide their own financial support to practices, separate from that of Medicare Fee-for-Services (FFS). Any questions regarding non-Medicare payer support should be directed to the payer partner.Unknownnoreply@blogger.com0