CPT code 77052, 77057, 77063 and G0202, ICD 10 Z12.31

May 5, 2016, 11:37 pm

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Screening Mammography

Update: Medicare now requires an add-on code when you furnish a mammography using 3-D mammography in conjunction with a 2-D digital mammography, effective January 1, 2015.

HCPCS/CPT Codes

77052 – Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation; screening mammography (List separately in addition to code for primary procedure)

77057 – Screening mammography, bilateral (2-view film study of each breast)

77063 – Screening digital breast tomosynthesis; bilateral (List separately in addition to code for primary procedure) (Use this as an add-on code to G0202 when tomosynthesis is used in addition to 2-D mammography)

G0202 – Screening mammography, producing direct 2-D digital image, bilateral, all views NOTE: If billing a screening mammogram and a diagnostic mammogram on the same day,

use modifier–GG to show a screening mammogram turned into a diagnostic mammogram.


ICD-10-CM Codes
Z12.31

Who Is Covered
All female Medicare beneficiaries aged 35 and older

Frequency

• Aged 35 through 39: One baseline; or
• Aged 40 and older: Annually

Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived

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How to check Medicare appeal status online

May 10, 2016, 11:25 pm

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Appeal status lookup – Part B help guide

The appeals status lookup tool enables providers to check the status on active redeterminations to confirm if the appeal has been received by First Coast Service Options.


When using the appeals status lookup, all fields are required.

http://medicare.fcso.com/Appeals/271084.asp

1. First, select your line of business (Part A or Part B) for the Medicare Plan field. Note: If you do not select your line of business first, the remaining dropdown menus for each field will be unavailable.

2. Next select your location (Florida, Puerto Rico, or the U.S. Virgin Islands).

3. Select the third drop down to search by Case Control Number (CCN), Provider Transaction Access Number (PTAN), or PTAN and Internal Control Number (ICN). The appropriate numbers should be entered into the Value field or PTAN/ICN for that option.

Where do I find the CCN?

• CCNs may be obtained through searching the tool by PTAN
OR
• You may call the Interactive Voice Response (IVR) follow the prompts to select status information followed by claim status.

Where do I find the ICN?
• ICNs may also be obtained from your remittance advice.
OR
• You may call the Interactive Voice Response (IVR) follow the prompts to select status information followed by claim status.

4. Once all fields have been completed click the Submit button. Note: Providers with multiple appeal records may experience a slower loading time. Please allow up to 30 seconds for the results to load. We appreciate your patience.


To search using another value, click the Search Again link above the results.

Results are sorted by case received date. You may sort by any category, ascending or descending, by clicking on the column header. To change the order, simply click the column header again.

If multiple pages of results are found, use the scrolling menu bar to view the bottom results. You may also use the page number and/or arrow links found at the top or bottom of the results to view different pages. Note: You may experience a slight delay when changing pages. We appreciate your patience.
Important reminders

• Please allow 15 days after you have submitted your appeal request before checking its status in the lookup tool or contacting customer service.

• Appeals involving multiple claims may be identified by searching on the first claim listed on your request for redetermination. There will not be a separate listing for each claim on the redetermination.

• Once the request has been received, First Coast may take up to 60 days to issue a written decision on the redetermination request.

• Please keep in mind that the status tool is only as accurate as the data supplied to First Coast on the

Redetermination Request form. Status cannot be located if data was missing from your redetermination.

• Appeals which have been finalized will no longer display in the tool.

Do we need to initmate on the claim about ABN notification?

May 13, 2016, 10:58 pm

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Medicare Part B advance beneficiary notices


Medicare Part B allows coverage for services and items  deemed medically reasonable and necessary for treatment and diagnosis of the patient.

For some services, to ensure that payment is made only for medically necessary services or items, coverage may be limited based on one or more of the following factors (this list is not inclusive):


?? Coverage for a service or item may be allowed only for specific diagnoses/conditions. Always code to the highest level of specificity.

?? Coverage for a service or item may be allowed only when documentation supports the medical need for the service or item.

?? Coverage for a service or item may be allowed only when its frequency is within the accepted standards of medical practice (i.e., a specified number of services in a specified timeframe for which the service may be covered).

If the provider believes that the service or item may not be covered as medically reasonable and necessary, the patient must be given an acceptable advance notice of Medicare’s possible denial of payment if the provider does not want to accept financial responsibility for the service or item. Advance beneficiary notices (ABNs)  advise beneficiaries, before items or services actually are furnished, when Medicare is likely to deny payment.

Patient liability notice

The Centers for Medicare & Medicaid Services’ (CMS) has developed the Advance Beneficiary Notice of Noncoverage (ABN) (Form CMS-R-131), formerly the “Advance Beneficiary Notice.” Section 50 of the Medicare Claims Processing Manual provides instructions regarding the notice that these providers issue to beneficiaries in advance of initiating, reducing, or terminating what they believe to be noncovered items or services. The ABN must meet all of the standards found in Chapter 30. Beginning March 1, 2009, the ABN-G and ABN-L was no longer valid; and notifiers must use the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131). Section 50 of the Medicare Claims Processing Manual is available at http:// www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/ clm104c30. pdf#page=44.

Reproducible copies of Form CMS-R-131 ABNs (in English and Spanish) and other BNI information may be found at http://www.cms.gov/ Medicare/Medicare- General-Information/ BNI/index.html. ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item. Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item. Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

 Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

Policy Guideline for provider performed unlisted CPT code

May 15, 2016, 12:14 am

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Overview

Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.

According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record.



Supporting Documentation Requirements


Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:

• A clear description of the nature, extent, and need for the procedure or service.

• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.

• Any extenuating circumstances which may have complicated the service or procedure.

• Time, effort, and equipment necessary to provide the service.

• The number of times the service was provided.

When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.


Provider Billing Guidelines and Documentation

• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).


Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.

Where Can I Check the Fee schedule for DME, physician fee?

May 18, 2016, 2:14 am

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Q. Where can I find fee schedules for my location and line of business?
A. Select your location (Florida, Puerto Rico, or the U.S. Virgin Islands) and line of business (Part A or Part B) on the homepage of the First Coast Service Options (First Coast) Medicare provider website. This will allow you to view information that pertains specifically to your geographic location as well as your type of business. After you have selected your location, you may easily select your line of business and go directly to the ”Fee Schedules” page in one step -- just select “Fee Schedules” from the category list on the Part A or Part B homepage.


You can also access the “Fee Schedules” page for your line of business from the “Quick Find” drop-down menu located in the left-hand navigation area on each page of the website.
Once you have arrived on the “Fee Schedules” page (Part A or Part B), you’ll have access to:


• The latest news and information about fee schedules in the “News” information box
• Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
• Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
• Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive

http://medicare.fcso.com/Fee_lookup/fee_schedule.asp


Q. Where can I find fees for durable medical equipment, prosthetics/orthotics, and supplies?
A. Fees for local and joint jurisdiction durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) may be found in First Coast Service Options’ fee schedule lookup and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

Q. Where can I find fees for physician fee schedule services?
A. Fees for fee schedule services paid under the Medicare physician fee schedule database (MPFSDB), for Part A as well as Part B, may be found in First Coast Service Options’ fee schedule lookup, and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here for Part A or here for Part B, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html external link.

Q. Where can I find fees for clinical laboratory services?
A. Fees for clinical laboratory services may be found in First Coast’s fee schedule lookup and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html external link.

What is Par fee and Non par fee in Medicare

May 20, 2016, 2:17 am

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Q. I’ve been using the “First Coast Service Options fee schedule look-up” for Part B -- what do par fee, nonpar fee, and limiting charge mean?
A. Amounts listed under “par fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has signed a Medicare participation agreement (form CMS-460). (Click here for more information about the CMS-460.) Signing this agreement means the provider has agreed to accept Medicare allowances as payment in full; the benefits are therefore assigned to the provider.
Amounts listed under “nonpar fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has NOT signed a participation agreement; these allowances are generally 95 percent of the amount for a participating provider in the same area. Nonparticipating providers may choose to accept Medicare assignment or not.
The limiting charge is the maximum amount a nonparticipating provider may legally charge a beneficiary when filing an unassigned claim. The limiting charge for a service is 115 percent of the nonpar amount.


Q. Where can I obtain fee schedule policy indicators? For example, how can I find the global surgery days for a service? What about relative value units (RVUs) for a particular code?
A. Policy indicators for procedure codes in the Medicare physician fee schedule database (MPFSDB) are available in First Coast Service Options’ fee lookup tool. Select Medicare Physician and Nonphysician Practitioner Fee Schedule (MPFS) from the drop-down list enter a date of service, location, and procedure code, and select submit. Then select the “more” links in the modifier field to view MPFS policy indicators.
These Indicators include: global surgery including pre-operative, intra-operative, and post-operative days, PCTC (professional/technical component), multiple surgery, bilateral surgery, assistant surgery, cosurgery, team surgery, physician supervision requirements, and base codes for multiple endoscopy procedures. For more information regarding these indicators, click here.
Also included are work, practice expense and malpractice expense geographic practice cost indices (GPCIs) and relative value units (RVUs). Note: the allowances Medicare contractors use in their claims payment system use these factors, in combination with an annual conversion factor, but allowances are not calculated at the local level. The allowances are furnished to contractors by CMS after all calculations have been completed.


Q. In the fee schedule lookup tool -- what do the question marks in the column headers mean?
A. These are Tooltips. When the cursor is placed over the “?” on any of these items, helpful tooltips will appear, providing a description for each category.

Chiropractic three CPT CODES - 98940, 98941, 98942 with AT modifer

May 23, 2016, 11:06 pm

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Background

In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service (FFS) program reported a 54 percent error rate on claims for chiropractic services. The majority of thoseerrors were due to insufficient documentation or other documentation errors.

Medicare coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (that is, by use of the hands) of the spine to correct a subluxation. The patient must require treatment by means of manual manipulation of the spine to correct a subluxation, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. Additionally, manual devices (that is, those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

Chiropractors are limited to billing three Current Procedural Terminology (CPT®) codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions).When submitting manipulation claims, chiropractors must use an acute treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when applied appropriately, should indicate
expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.


Documentation requirements

The Social Security Act states that “no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the  mounts are being paid or for any prior period.

Documentation requirements for the initial visit - X RAY and Date of Initial treatment

May 25, 2016, 11:12 pm

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The following documentation requirements apply for initial visits whether the subluxation is demonstrated by x-ray or by physical examination:


1. History: The history recorded in the patient record should include the following:

*** Chief complaint including the symptoms causing patient to seek treatment;

*** Family history if relevant; and

*** Past medical history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).


2. Present illness: Description of the present illness including:

*** Mechanism of trauma;

*** Quality and character of symptoms/problem;

*** Onset, duration, intensity, frequency, location, and radiation of symptoms;

*** Aggravating or relieving factors;

*** Prior interventions, treatments, medications,secondary complaints; and

*** Symptoms causing patient to seek treatment.



Note: Symptoms must be related to the level of the subluxation that is cited. A statement on a claim that there is “pain” is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in that area.

3. Physical exam: Evaluation of musculoskeletal/ nervous system through physical examination. To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required and should be documented:

*** P - pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation,
provocation, etc. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.

*** A - asymmetry/misalignment: Asymmetry/ misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as,  osture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging.

*** R - range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, measurement(s).

*** T -tissue tone, texture, and temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following  procedures: observation, palpation, use of  instrumentation, test of length and strength.

Note: The P.A.R.T. (pain/tenderness; asymmetry/  misalignment; range of motion abnormality; and tissue tone, texture, and temperature abnormality) evaluation
process is recommended as the examination alternative to the previously mandated demonstration of subluxation by X-ray/MRI/CT for services beginning January 1, 2000. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).

4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation,  either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified as shown in the following table:


Area of spine     Names of vertebrae    Number of  vertebrae      Short form  or other  name   Subluxation ICD-10 code

Neck Occiput     Cervical  Atlas Axis      7         Occ,  CO  C1-C7   C1  2         M99.00  M99.01

Back         Dorsal or  Thoracic  Costovertebral    12          D1-  D12  T1-T12  R1-  R12  R1-  R12     M99.02
           
Low back      Lumbar          5             L1-L5                M99.03

Pelvis              Ilii, R and L (I, Si)        I, Si                    M99.05

Sacral            Sacrum,  coccyx            S, SC             M99.04


In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment. There are two ways in which the level of the subluxation may be specified in patient’s record.

*** The exact bones may be listed, for example: C 5, 6;

*** The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and Cl (atlas)), lumbo-sacral (L5 and Sacrum) sacro-iliac sacrum and
ilium).


Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:


*** Off-centered;

*** Misalignment;

*** Malpositioning;

*** Spacing - abnormal, altered, decreased, increased;

*** Incomplete dislocation;

*** Rotation;

*** Listhesis - antero, postero, retro, lateral, spondylo; and

*** Motion - limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant.

Other terms may be used. If they are understood clearly to  refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.
X-rays As of January 1, 2000, an X-ray is not required by  Medicare to demonstrate the subluxation. However, an x-ray may be used for this purpose if you so choose.
The x-ray must have been taken reasonably close to (within 12 months prior or three months following) the beginning of treatment. In certain cases of chronic
subluxation (for example, scoliosis), an older X-ray may be accepted if the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.

A previous CT scan and/or MRI are acceptable evidence if a subluxation of the spine is demonstrated.

5. Treatment plan: The treatment plan should always include the following:

*** Recommended level of care (duration and frequency of visits);

*** Specific treatment goals; and

*** Objective measures to evaluate treatment effectiveness.



Date of the initial treatment

The patient’s medical record.

*** Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT® code), and modifiers.

*** Verify that all Medicare benefit and medical necessity requirements were met.

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Documentation requirements for subsequent visits - Chiropractic billing

May 28, 2016, 11:17 pm

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The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination:

1. History

a. Review of chief complaint;

b. Changes since last visit; and

c. Systems review if relevant.

2. Physical examination

a. Examination of area of spine involved in diagnosis;

b. Assessment of change in patient condition since last visit;

c. Evaluation of treatment effectiveness.


3. Documentation of treatment given on day of visit.


 Necessity for treatment of acute and chronic subluxation

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must
have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

The patient must have a subluxation of the spine as demonstrated by X-ray or physical examination, as described below.

Most spinal joint problems fall into the following categories:

*** Acute subluxation – a patient’s condition is considered acute when the patient is being treated for a new injury, identified by X-ray or physical examination as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.

*** Chronic subluxation – a patient’s condition is considered chronic when it is not expected tosignificantly improve or be resolved with further treatment as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

You must place the HCPCS (healthcare common procedure coding system) modifier AT on a claim when providing active/corrective treatment to treat acute or
chronic subluxation. However, the presence of the HCPCS modifier AT may not  in all instances indicate that the service is reasonable and necessary.

CPT CODE - 93971 -Treatment of varicose veins - covered ICD code and revenue code

June 1, 2016, 10:34 pm

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Indications of Coverage and/or Medical Necessity

Varicose veins are a manifestation of chronic venous disease (CVD) caused by ambulatory venous hypertension. Varicose veins are superficially located, dilated, tortuous, veins of the lower extremities. They are usually caused by insufficiency, or valvular reflux, of the valvular apparatus (primary disease), or as a result of previous thrombosis or trauma (secondary disease). These dilated superficial veins of the lower limbs are considered pathologic when they are 5 mm or greater in diameter or sometimes 3 mm or greater in diameter (depending on the indication as outlined further in the LCD) when measured in the upright position and have greater than 500 milliseconds of reflux by duplex scan. CVD can cause clinically significant pain and result in a decrease in quality of life and even disability which may necessitate treatment which would be considered reasonable and necessary. CVD is progressive, and over time may progress to secondary skin changes (edema, lipodermatosclerosis, and ulceration), which is referred to as chronic venous insufficiency (CVI). CVD and CVI can be further complicated by superficial thrombophlebitis and variceal hemorrhage.

The superficial venous system has one-way valves that prevent backflow of blood (reflux) when normal and allow movement of blood toward the heart. The axial superficial veins communicate with the deep venous system at different locations. The point where the great saphenous vein (GSV) joins the common femoral vein, saphenofemoral junction (SFJ), is located proximally at the groin. The point where the small saphenous vein (SSV) joins the popliteal vein, saphenopopliteal junction (SPJ), is typically located behind the knee. Reflux involves the main axial superficial veins: GSV and SSV saphenous veins and their tributaries. Clinically significant reflux can also be found in accessory great saphenous veins (i.e., anterior or posterior) which parallel the GSV in the saphenous compartment, the SSV, circumflex veins which course oblique to the GSV, or perforating veins (veins that connect the superficial to the deep veins). There are numerous perforator veins found throughout the leg from the thigh to the ankle that traverse the muscular fascia of the lower extremity and, under normal circumstances, drain from the superficial veins toward the deep (intramuscular) veins. Variations in the anatomy of the deep and superficial venous systems are common.

The evaluation of a patient with lower extremity venous incompetence and its advanced consequences—edema and skin changes—should include the assessment of history and physical examination including the CEAP classification and revised Venous Clinical Severity Score (VCSS). A duplex ultrasound scan of the deep and superficial venous systems must support the examination findings.

The treatment of C1 disease (spider telangiectasia and their feeding reticular veins) is considered cosmetic, and therefore, not reasonable and necessary for the purposes of Medicare coverage.

For patients with C2 disease and VCSS score < 6, the plan of care must include at least a 90 day course of compression therapy further defined below. (C2 patients with VCSS < 6, who failed at least a 90 day course of compression therapy, would start a new 90 day episode of care, and proposed interventions should be addressed in the plan of care.)

For patients with C2 disease and VCSS score > 6, or patients with C3-C6 disease, proposed interventions for a 90 day episode of care should be addressed in the treatment plan.


Limitations of Coverage and/or Medical Necessity

CPT code 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)] is not applicable (incorrect coding) for saphenous ablation and is not covered.

CPT code 76942 has limited coverage by qualified physicians for image-guided foam sclerotherapy, as outlined in this policy.

Thermal ablation includes the necessary ultrasound imaging for any additional procedures done with the thermal ablation.

CPT add-on code 76937 (ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting) is not a covered service for outpatient varicose vein procedures.

Local anesthesia and minimal to no sedation is the standard of care. Monitored Anesthesia Care (MAC) or moderate (conscious) sedation needs clear support in the medical record based on patient clinical presentation/characteristics and may be subject to prepayment review.

Photothermal sclerosis (also referred to as an intense pulsed light source, e.g., the PhotoDerm VascuLight, VeinLase), transdermal laser treatment, and mechanicochemical ablation (MOCA) (Clarivein) do not meet the Medicare reasonable and necessary threshold for coverage. Providers are required to code to specificity. If no such procedure of service exists, then report the service using the appropriate unlisted procedure code. Unlisted procedure, vascular surgery code 37799 should be reported until the specific CPT codes are established. Claims billed for these procedures will be denied.

If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a non-covered (cosmetic) procedure. Isolated injections for the treatment of telangiectasias and reticular veins less than 3mm in diameter are considered cosmetic and do not meet the Medicare reasonable and necessary threshold for coverage. Claims billed for these procedures will be denied.

Device/sclerosant combination procedures without a unique CPT code are described by CPT code 37799. The sclerosant is included in the procedure. Coverage is limited to the ‘sclerotherapy’ indications.


Revenue Codes
CodeDescription
0360Operating Room Services - General Classification
0361Operating Room Services - Minor Surgery
0362Operating Room Services - Organ Transplant - Other than Kidney
0367Operating Room Services - Kidney Transplant
0369Operating Room Services - Other OR Services
0490Ambulatory Surgical Care - General Classification
0499Ambulatory Surgical Care - Other Ambulatory Surgical Care
0510Clinic - General Classification
0511Clinic - Chronic Pain Center
0512Clinic - Dental Clinic
0513Clinic - Psychiatric Clinic
0514Clinic - OB-GYN Clinic
0515Clinic - Pediatric Clinic
0516Clinic - Urgent Care Clinic
0517Clinic - Family Practice Clinic
0519Clinic - Other Clinic
0761Specialty Services - Treatment Room
0920Other Diagnostic Services - General Classification
0921Other Diagnostic Services - Peripheral Vascular Lab
0929Other Diagnostic Services - Other Diagnostic Service


ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph
N/A
Group 1 Codes
I80.11Phlebitis and thrombophlebitis of right femoral vein
I80.12Phlebitis and thrombophlebitis of left femoral vein
I80.13Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.221Phlebitis and thrombophlebitis of right popliteal vein
I80.222Phlebitis and thrombophlebitis of left popliteal vein
I80.223Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.231Phlebitis and thrombophlebitis of right tibial vein
I80.232Phlebitis and thrombophlebitis of left tibial vein
I80.233Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.291Phlebitis and thrombophlebitis of other deep vessels of right lower extremity
I80.292Phlebitis and thrombophlebitis of other deep vessels of left lower extremity
I80.293Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral
I80.3Phlebitis and thrombophlebitis of lower extremities, unspecified
I83.001Varicose veins of unspecified lower extremity with ulcer of thigh
I83.002Varicose veins of unspecified lower extremity with ulcer of calf
I83.003Varicose veins of unspecified lower extremity with ulcer of ankle
I83.004Varicose veins of unspecified lower extremity with ulcer of heel and midfoot
I83.005Varicose veins of unspecified lower extremity with ulcer other part of foot
I83.008Varicose veins of unspecified lower extremity with ulcer other part of lower leg
I83.009Varicose veins of unspecified lower extremity with ulcer of unspecified site
I83.011Varicose veins of right lower extremity with ulcer of thigh
I83.012Varicose veins of right lower extremity with ulcer of calf
I83.013Varicose veins of right lower extremity with ulcer of ankle
I83.014Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015Varicose veins of right lower extremity with ulcer other part of foot
I83.018Varicose veins of right lower extremity with ulcer other part of lower leg
I83.019Varicose veins of right lower extremity with ulcer of unspecified site
I83.021Varicose veins of left lower extremity with ulcer of thigh
I83.022Varicose veins of left lower extremity with ulcer of calf
I83.023Varicose veins of left lower extremity with ulcer of ankle
I83.024Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025Varicose veins of left lower extremity with ulcer other part of foot
I83.028Varicose veins of left lower extremity with ulcer other part of lower leg
I83.029Varicose veins of left lower extremity with ulcer of unspecified site
I83.10Varicose veins of unspecified lower extremity with inflammation
I83.11Varicose veins of right lower extremity with inflammation
I83.12Varicose veins of left lower extremity with inflammation
I83.201Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation
I83.202Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation
I83.203Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation
I83.204Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation
I83.205Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation
I83.208Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation
I83.209Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation
I83.211Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.219Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation
I83.221Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.229Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation
I83.811Varicose veins of right lower extremities with pain
I83.812Varicose veins of left lower extremities with pain
I83.813Varicose veins of bilateral lower extremities with pain
I83.891Varicose veins of right lower extremities with other complications
I83.892Varicose veins of left lower extremities with other complications
I83.893Varicose veins of bilateral lower extremities with other complications
I87.2Venous insufficiency (chronic) (peripheral)
R60.0Localized edema
ICD-10 Codes that DO NOT Support Medical Necessity
I78.0Hereditary hemorrhagic telangiectasia
I78.1Nevus, non-neoplastic
I78.8Other diseases of capillaries
I78.9Disease of capillaries, unspecified
I80.11Phlebitis and thrombophlebitis of right femoral vein
I80.12Phlebitis and thrombophlebitis of left femoral vein
I80.13Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.221Phlebitis and thrombophlebitis of right popliteal vein
I80.222Phlebitis and thrombophlebitis of left popliteal vein
I80.223Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.231Phlebitis and thrombophlebitis of right tibial vein
I80.232Phlebitis and thrombophlebitis of left tibial vein
I80.233Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.291Phlebitis and thrombophlebitis of other deep vessels of right lower extremity
I80.292Phlebitis and thrombophlebitis of other deep vessels of left lower extremity
I80.293Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral
I80.3Phlebitis and thrombophlebitis of lower extremities, unspecified
I83.221Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.229Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation
I83.811Varicose veins of right lower extremities with pain
I83.812Varicose veins of left lower extremities with pain
I83.813Varicose veins of bilateral lower extremities with pain
I83.891Varicose veins of right lower extremities with other complications
I83.892Varicose veins of left lower extremities with other complications
I83.893Varicose veins of bilateral lower extremities with other complications
I87.091Postthrombotic syndrome with other complications of right lower extremity
I87.092Postthrombotic syndrome with other complications of left lower extremity
I87.093Postthrombotic syndrome with other complications of bilateral lower extremity
I87.099Postthrombotic syndrome with other complications of unspecified lower extremity
I87.2Venous insufficiency (chronic) (peripheral)
R60.0Localized edema

Duplex Scan Of Lower Extremity Arteries - 93925, 93926 - Coverage info

June 3, 2016, 10:43 pm

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LCD Title
Duplex Scan Of Lower Extremity Arteries

Coverage Indications, Limitations, and/or Medical Necessity
Noninvasive peripheral arterial studies include two types of testing, noninvasive physiologic studies and duplex scans. Noninvasive physiologic studies are functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements or plethysmography. A complete extremity physiologic study includes pressure measurements and an additional physiologic technique, e.g., Doppler ultrasound study or plethysmography.

Plethysmography implies volume measurement procedures including air impedance or strain gauge methods. Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part.

Noninvasive physiologic studies are performed using equipment separate and distinct from the duplex scanner. Duplex scanning combines the information provided by two-dimensional imaging with pulsed-wave doppler techniques which allows analysis of the blood flow velocity.

Vascular studies include patient care required to perform the studies, supervision of the studies and interpretation of study results with copies for patient records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided. The display may be a two-dimensional image with spectral analysis and color flow or a plethysmographic recording that allows for quantitative analysis.]

Indications

In general, noninvasive arterial studies are indicated when endovascular or other invasive correction is contemplated, but not to follow noninvasive medical treatment regimens or to monitor unchanged symptomatology. The latter may be followed with physical findings, including Ankle/Brachial Indices (ABIs), and/or progression or relief of signs and/or symptoms.

Duplex scanning of the lower extremity arteries performed to establish the level and/or degree of arterial occlusive disease, will be considered medically necessary if a) significant signs and/or symptoms indicate a high likelihood of limb ischemia, and b) the patient is a candidate for invasive therapeutic procedures under any of the following circumstances:

• The patient has symptoms of peripheral vascular ischemia and is found on physical examination to have absence or marked diminution of pulses (suspected to be secondary to obstruction of lower extremity arteries) of one or both lower extremities.

•The patient has developed sudden pallor, numbness, and coolness of an extremity and vascular obstruction (embolism or thrombosis) is suspected.
•Claudication of less than one block or of such severity that it interferes significantly with the patient's occupation or lifestyle.
•The patient has an aneurysm or arteriovenous malformation of a lower extremity artery.
•The patient has sustained lower extremity trauma with possible vascular injury or the patient has sustained iatrogenic vascular injury.
•Rest pain of ischemic origin (typically including the forefoot), associated with absent pulses, which becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent position.
•Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of the extremity occurring in the absence of pulses.

Follow-up studies post-operative conditions:
In the immediate post-operative period if re-established pulses are lost, become equivocal, or if the patient develops related signs and/or symptoms of ischemia with impending repeat intervention.
Following bypass surgery or post-angioplasty with or without stent placement at three months, six months and one year when clinically indicated.

Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease evidenced by signs (i.e. decreased ABI from previous exam) or symptoms (i.e., recurrence of claudication symptoms that interfere significantly with the patient’s occupation or lifestyle). For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not considered necessary to do both.

Limitations


A routine history and physical examination, which includes Ankle/Brachial Indices (ABIs), can readily document the presence or absence of ischemic disease in a majority of cases. It is not medically necessary to proceed beyond the physical examination for minor signs and symptoms such as hair loss, absence of a single pulse, relative coolness of a foot, shiny thin skin, or lack of toe nail growth unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.

An ABI is not a separately reimbursable procedure when performed by itself and would be considered part of the physical examination. When the ABI is abnormal (i.e., <0 .9="" accompanied="" ankle="" another="" appropriate="" at="" be="" before="" blood="" by="" complete="" elevated="" except="" in="" indication="" it="" more="" must="" or="" p="" patients="" pressure.="" proceeding="" rest="" severely="" sophisticated="" studies="" to="" with="">
Examples of additional signs and symptoms that do not indicate medical necessity include:

•Continuous burning of the feet is considered to be a neurologic symptom.
•"Leg pain, nonspecific" or "Pain in limb" as single diagnoses are too general to warrant further investigation unless they can be related to other signs and symptoms.
•Edema rarely occurs with arterial occlusive disease unless it is in the immediate postoperative period, in association with another inflammatory process or in association with rest pain.
•Absence of relatively minor pulses (eg, dorsalis pedis or posterior tibial) in the absence of ischemic symptoms. The absence of pulses is not an indication to proceed beyond the physical examination unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.
•Screening of an asymptomatic patient is not covered.

In general, non-invasive studies of the arterial system are to be utilized when invasive correction is contemplated, but not to follow non-invasive medical treatment regimens (e.g., to evaluate pharmacologic intervention) or to monitor unchanged symptomatology. The latter may be followed with physical findings including ABIs and/or progression or relief of signs and/or symptoms.

Noninvasive vascular testing studies are medically necessary only if the outcome will potentially impact the clinical management of the patient. For example, if a patient is (or is not) proceeding on to other diagnostic and/or therapeutic procedures regardless of the outcome of non-invasive studies, and non-invasive vascular procedures will not provide any unique diagnostic information that would impact patient management, then the non-invasive procedures are not medically necessary. If it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then non-invasive vascular studies are not medically necessary. It is also expected that the studies are not redundant of other diagnostic procedures that must be performed.

When an uninterpretable study (i.e., poor quality or not in accordance with regulatory standards) results in performing another type of study, only the successful study should be billed. For example, when an uninterpretable non-invasive physiologic study (CPT code 93922, 93923 or 93924) is performed which results in performing a duplex scan (CPT codes 93925 or 93926), only the duplex scan should be billed.

Noninvasive vascular procedures will not be covered when performed based on internal protocols of the testing facility; a referral for one noninvasive study is not a blanket referral for all studies. Each procedure must be specifically ordered by the physician/nonphysician practitioner treating the patient and the medical necessity criteria specified in this LCD must be met.

Typically, it is appropriate for follow-up studies post-angioplasty, with or without stent placement to be performed at three months, six months and one year. Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease evidenced by signs (i.e. decreased ABI from previous exam) or symptoms (i.e. recurrence of claudication). For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not considered necessary to do both.

Performance of both a physiological test (93922, 93923, 93924) and duplex scanning (93925, 93926) of extremity arteries during the same encounter would not generally be expected. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available upon request. Note: Reimbursement of physiologic testing will not be allowed after a duplex scan has been performed.

Since the signs and symptoms of arterial occlusive disease and venous disease are so divergent, the performance of simultaneous arterial and venous studies during the same encounter should be rare. Consequently, documentation must clearly support the medical necessity of both procedures if performed during the same encounter.

Performance of both non-invasive extracranial arterial studies (CPT code 93880 or 93882) and non-invasive evaluation of extremity arteries (CPT code 93925 or 93926) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available upon request.

The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported (CPT 2005, page 370 and CPT 2006, page 388). The appropriate assignment of a specific ultrasound CPT code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. If an examination is performed with hand-carried equipment, the quality of the exam, printout, and report must be in keeping with accepted national standards.

Revenue Codes

CodeDescription
0920Other Diagnostic Services - General Classification
0921Other Diagnostic Services - Peripheral Vascular Lab
0929Other Diagnostic Services - Other Diagnostic Service


CPT/HCPCS Codes

Group 1 Codes
93925Lower extremity study
93926Lower extremity study

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Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission

June 4, 2016, 10:59 pm

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In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.) The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. Only the principal physician of record shall append modifier “-AI” (Principal Physician of Record) in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.



A. Initial Hospital Care From Emergency Room

Contractors pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.




B. Initial Hospital Care on Day Following Visit

Contractors pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.

Billing non-covered hospital outpatient dental services - Condition code 21

June 5, 2016, 11:48 pm

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 Medicare program’s coverage of dental services is limited. Medicare will pay for dental services if they are an integral part of a covered service or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Otherwise, items and services
in connection with the care, treatment, filling, removal or replacement of teeth or structures supporting the teeth are not covered.

First Coast understands that providers may need to bill Medicare for the non-covered dental services to receive a denial in order to then bill a secondary insurance for the patient. Please make sure you are properly billing for these non-covered dental services to ensure the claims are processed correctly and inaccurate payments are not made.

Billing Part A and B

When billing for services that are statutorily excluded or do not meet the definition of any Medicare benefit, you may use the GY modifier. The GY modifier is appended to each line item on the claim that meets the definition. Specifically for Part A only, these services should be listed on the claim itself as non-covered. The condition code 21 may also be used on the claim to obtain a denial from Medicare for submission to a subsequent insurer. These  claims are referred to as no-payment claims. If you have any additional questions about the coverage or non-coverage of dental services, please review the resources listed below.

Sources: The Centers for Medicare & Medicaid Services’ (CMS’) Medicare Dental Coverage Web page; Internetonly Manuals (IOMs) Pub. 100-02, Chapter 1, Chapter 15,
& Chapter 16; Pub. 100-04, Chapter 1

How to bill Initial Hospital Care and Discharge on Same Day

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When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.

When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.

When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.



D. Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)

The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:

• Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;

• Documentation identifying the billing physician was present and personally performed the services; and

• Documentation identifying the admission and discharge notes were written by the billing physician.

Prepayment review for CPT® codes 99232 and 99233

June 10, 2016, 11:53 pm

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The top services for First Coast Service Options Inc. (First Coast) with payment errors identified by Part  B comprehensive error rate testing (CERT) continue to be evaluation and management services. First Coast conducted a data analysis for Current Procedural Terminology® (CPT®) codes 99232 and 99233 (subsequent hospital care). The data indicates specialties internal medicine and cardiology are the primary contributors to the CERT error rate for subsequent hospital care services. Documentation requirements  the American Medical Association (AMA) CPT® manual defines code 99232 as  follows: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

*** An expanded problem focused interval history ;

*** An expanded problem focused examination;

*** 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 needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit.

The AMA CPT® manual defines code 99233 as follows: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of
these three key components:

*** A detailed interval history ;

*** A detailed examination;

*** Medical decision making of high 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 needs. Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit. First Coast and the Centers for Medicare & Medicaid Service (CMS) offer multiple resources addressing the documentation guidelines for E/M service levels at:

*** First Coast’s Evaluation and Management (E/M) services page, offering links to tools, FAQs, online learning, and additional resources.

*** CMS Internet-only manual (IOM) guidelines addressing multiple types and settings pertaining to E/M services.


First Coast actions

In response to the high percentage of error rates and the continual risks of improper payments associated with subsequent hospital care billed by internal medicine and
cardiology specialists, First Coast will be implementing a prepayment medical review audit for CPT® codes 99232 and 99233 billed by cardiology; and CPT® codes 99232
billed by internal medicine specialty. The new audit will be based on a threshold of claims submitted for payment  by cardiology and internal medicine specialties in an effort to reduce the error rates for these hospital services. The audit will be implemented for claims processed on or after March 15, 2016.

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Allergy Testing and Immunotherapy billing Guide - CPT CODE 95004 -95078 & 95120 - 95134

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A. Allergy Testing

The MPFSDB fee amounts for allergy testing services billed under codes 95004-95078 are established for single tests. Therefore, the number of tests must be shown on the claim.

EXAMPLE: If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004 and specify 25 units. To compute payment, the Medicare A/B MAC (B) multiplies the payment for one test (i.e., the payment listed in the fee schedule) by the quantity listed in the units field.



B. Allergy Immunotherapy

For services rendered on or after January 1, 1995, all antigen/allergy immunotherapy services are paid for under the Medicare physician fee schedule. Prior to that date, only the antigen injection services, i.e., only codes 95115 and 95117, were paid for under the fee schedule. Codes representing antigens and their preparation and single codes representing both the antigens and their injection were paid for under the Medicare reasonable charge system. A legislative change brought all of these services under the fee schedule at the beginning of 1995 and the following policies are effective as of January 1, 1995:

1. CPT codes 95120 through 95134 are not valid for Medicare. Codes 95120 through 95134 represent complete services, i.e., services that include both the injection service as well as the antigen and its preparation.

2. Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.

If both services are provided both codes are billed.

This includes allergists who provide both services through the use of treatment boards.


3. If a physician bills both an injection code plus either codes 95165 or 95144, A/B MACs (B) pay the appropriate injection code (i.e., code 95115 or code 95117) plus the code 95165 rate. When a provider bills for codes 95115 or 95117 plus code 95144, A/B MACs (B) change 95144 to 95165 and pay accordingly. Code 95144 (single dose vials of antigen) should be billed only if the physician providing the antigen is providing it to be injected by some other entity. Single dose vials, which should be used only as a means of insuring proper dosage amounts for injections, are more costly than multiple dose vials (i.e., code 95165) and therefore their payment rate is higher. Allergists who prepare antigens are assumed to be able to administer proper doses from the less costly multiple dose vials. Thus, regardless of whether they use or bill for single or multiple dose vials at the same time that they are billing for an injection service, they are paid at the multiple dose vial rate.


4. The fee schedule amounts for the antigen codes (95144 through 95170) are for a single dose. When billing those codes, physicians are to specify the number of doses provided. When making payment, A/B MACs (B) multiply the fee schedule amount by the number of doses specified in the units field.


5. If a patient’s doses are adjusted, e.g., because of patient reaction, and the antigen provided is actually more or fewer doses than originally anticipated, the physician is to make no change in the number of doses for which he or she bills. The number of doses anticipated at the time of the antigen preparation is the number of doses to be billed. This is consistent with the notes on page 30 of the Spring 1994 issue of the American Medical Association’s CPT Assistant. Those notes indicate that the antigen codes mean that the physician is to identify the number of doses “prospectively planned to be provided.” The physician is to “identify the number of doses scheduled when the vial is provided.” This means that in cases where the patient actually gets more doses than originally anticipated (because dose amounts were decreased during treatment) and in cases where the patient gets fewer doses (because dose amounts were increased), no change is to be made in the billing. In the first case, A/B MACs


(B) are not to pay more because the number of doses provided in the original vial(s) increased. In the second case, A/B MACs (B) are not to seek recoupment (if A/B MACs (B) have already made payment) because the number of doses is less than originally planned. This is the case for both venom and nonvenom antigen codes.



6. Venom Doses and Catch-Up Billing - Venom doses are prepared in separate vials and not mixed together - except in the case of the three vespid mix (white and yellow hornets and yellow jackets). A dose of code 95146 (the two-venom code) means getting some of two venoms. Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms. Some amount of each of the venoms must be provided. Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction. For example, a physician prepares ten doses of code 95148 (the four venom code) in two vials - one containing 10 doses of three vespid mix and another containing 10 doses of wasp venom. Because of dose adjustment, the three vespid mix doses last longer, i.e., they last for 15 doses. Consequently, questions arise regarding the amount of “replacement” wasp venom antigen that should be prepared and how it should be billed. Medicare pricing amounts have savings built into the use of the higher venom codes. Therefore, if a patient is in two venom, three venom, four venom or five venom therapy, the A/B MAC (B) objective is to pay at the highest venom level possible. This means that, to the greatest extent possible, code 95146 is to be billed for a patient in two venom therapy, code 95147 is to be billed for a patient in three venom therapy, code 95148 is to be billed for a patient in four venom therapy, and code 95149 is to be billed for a patient in five venom therapy. Thus, physicians are to be instructed that the venom antigen preparation, after dose adjustment, must be done in a manner that, as soon as possible, synchronizes the preparation back to the highest venom code possible. In the above example, the physician should prepare and bill for only 5 doses of “replacement” wasp venom - billing five doses of code 95145 (the one venom code). This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the “cheaper” four venom code. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up.”


7. Code 95165 Doses. - Code 95165 represents preparation of vials of non-venom antigens. As in the case of venoms, some non-venom antigens cannot be mixed together, i.e., they must be prepared in separate vials. An example of this is mold and pollen. Therefore, some patients will be injected at one time from one vial – containing in one mixture all of the appropriate antigens – while other patients will be injected at one time from more than one vial. In establishing the practice expense component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc. Our PE computations were based on those facts. Therefore, a physician’s removing 10 1cc aliquot doses captures the entire PE component for the service.

This does not mean that the physician must remove 1 cc aliquot doses from a multidose vial. It means that the practice expenses payable for the preparation of a 10cc vial remain the same irrespective of the size or number of aliquots removed from the vial. Therefore, a physician may not bill this vial preparation code for more than 10 doses per vial; paying more than 10 doses per multidose vial would significantly overpay the practice expense component attributable to this service. (NOTE: this code does not include the injection of antigen(s); injection of antigen(s) is separately billable.)

When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial. That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medicare for fewer than 10 doses per vial when there is less than 10cc in the vial.

If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.


EXAMPLES:

(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.

(2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.

(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.

(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.

(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.

(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.

Procedure Code Edits-Patient Billing Impact

June 15, 2016, 12:23 am

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The edits contained in the Claims Editing Tool are designed to provide appropriate coding, and to assist in processing claims accurately and consistently. The member is not responsible and should not be billed for any procedures for which payment has been denied or reduced as a result of column1/column2 and mutually exclusive edits.


Column1/Column2 and Mutually Exclusive Edits

Correct coding initiative (CCI) edits are pre-adjudication edits that prevent improper payment when incorrect code combinations are reported. Column1/ Column2 edits are code combinations that should not be reported together. Mutually exclusive procedures exist when a claim is submitted with two or more procedure codes that are not usually performed on the same patient, on the same date of service. These include combinations of procedures that may be anatomically impossible, represent overlapping and/or duplication of services, or are reported as both an initial and subsequent service.

One of the following denial reasons will be returned on the remittance advice depending on whether or not the code combination is allowed with or without a modifier:

• Mutually exclusive procedure

• Code 2 of a code pair not allowed

• Mutually exclusive procedure - Bill with appropriate mod.

• Secondary code not allowed - Bill with appropriate mod.


Medically Unlikely Edits (MUE)

A(medically unlikely edit (MUE) for a HCPCS/CPT code is an edit applied to ensure accurate coding of units reported for outpatient claims. Weuse Medical Coverage Guidelines (MCGs) to define the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. This edit is not applied to all HCPCS/CPT codes. At this time, the maximum units for outpatient HCPCS/CPT code billing do not vary from those documented and used by Medicare. We use the existing MUE units for commercial and Medicare Advantage outpatient claims.

Note: If your claim denies due to the number of units reported for a service, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation to support the number of services provided and for appropriate pricing of the claim.

One of the following denial reasons will be returned on the remittance advice


• EXCEEDS DAILY MAXIMUM LIMITATIONS

Periodic Updates
The claims editing tool is updated quarterly to accommodate coding changes. Refer to CMS website for the latest Claims Editing Tool updates. All claims submitted after the implementation date, regardless of service date, will be processed according to the updated version.

Billing Guide for Allergy Shots and Visit Services on the Same Day - CPT 95115

June 17, 2016, 12:09 am

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At the outset of the physician fee schedule, the question was posed as to whether visits should be billed on the same day as an allergy injection (CPT codes 95115-95117), since these codes have status indicators of A rather than T. Visits should not be billed with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service. This language parallels CPT editorial language that accompanies the allergen immunotherapy codes, which include codes 9515 and 95117. Prior to January 1, 1995, you appeared to be enforcing this policy through three (3) different means:


• Advising physician to use modifier 25 with the visit service;

• Denying payment for the visit unless documentation has been provided; and

• Paying for both the visit and the allergy shot if both are billed for.

For services rendered on or after January 1, 1995, you are to enforce the requirement that visits not be billed and paid for on the same day as an allergy injection through the following means. Effective for services rendered on or after that date, the global surgery policies will apply to all codes in the allergen immunotherapy series, including the allergy shot codes 95115 and 95117. To accomplish this, CMS changed the global surgery indicator for allergen immunotherapy codes from XXX, which meant that the global surgery concept did not apply to those codes, to 000, which means that the global surgery concept applies, but that there are no days in the postoperative global period.

Now that the global surgery policies apply to these services, you are to rely on the use of modifier 25 as the only means through which you can make payment for visit services provided on the same day as allergen immunotherapy services. In order for a physician to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), the physician is to bill a modifier 25 with the visit code, indicating that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.


D. Reasonable Supply of Antigens

See CMS Manual System, Internet Only Manual, Medicare Benefits Policy Manual, CMS Pub. 100-02 Chapter 15, section 50.4.4, regarding the coverage of antigens, including what constitutes a reasonable supply of antigens.

Billing tips for 98943, 97140, E0720 AND E0730

June 18, 2016, 1:41 am

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The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using modifier 25, if the member’s condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure.

Chiropractic Manipulative Treatment: CMT is a form of manual treatment to influence joint and neurophysiological function.

When similar or identical procedures are performed, but are qualified by an increased level of complexity:

Only the definitive or most comprehensive service performed should be reported

Only one CMT service of the spinal region (procedures 98940-98942) is eligible for payment on a single date of service.

Payment is limited to one clinically indicated and medically necessary physical medicine modality or procedure code per patient, per date of service.

Payment is allowed for one clinically indicated and medically necessary extra spinal manipulation code (i.e., 98943-51) in combination with a spinal manipulation code (i.e., 98940, 98941, or 98942) per date of service.

When multiple procedures are performed at the same session by the same provider, the modifier 51 may be appended to the additional CPT codes (excluding E/M codes).


Physical Medicine and Rehabilitation: The selection of appropriate physical medicine modalities and procedures should be based on the desired physiological response in correlation to the stages of healing. In most conditions or injuries, utilization of one carefully selected modality or procedure in combination with CMT is adequate to achieve a successful clinical outcome.

97140, manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, will not be separately reimbursed when billed with 98940-98943 (CMT) for the same region. Modifier 59 should be used with 97140 when billed with a CMT code, but performed on a different anatomical region.

It is not appropriate to bill 97124, massage, for myofascial release. For myofascial release, 97140 should be reported and is reimbursable if it is not billed with a CMT code pertaining to the same anatomical region. When reporting or billing for 97112 (neuromuscular reeducation) and 97124 (massage) as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical site, description of service, and time (as required by the selected procedure code).


TENS: When found to be medically necessary, the following codes are reimbursed for TENS when billed under the following codes:

• E0720

• E0730

Acupuncture CPT CODES 97810, 97813, 97814

June 20, 2016, 1:43 am

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Acupuncture: A chiropractic provider may not provide acupuncture services until certified by the Florida Board of Chiropractic Medicine. Acupuncture is reported based on 15 minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement. If no electrical stimulation is used during a 15 minute increment, use 97810 or 97811. If electrical stimulation of any needle is used during a 15 minute increment, use 97813 or 97814. Only one code may be reported for each 15 minute increment. Use either 97810 or 97813 for the initial 15 minute increment. Only one initial code is reported per day.
The FEP does not include benefits for acupuncture when performed by a chiropractor.


Covered Services for Medicare Advantage Members:

According to the Centers for Medicare & Medicaid Services (CMS) Internet-only manual, Publication 100-02 Medicare Benefit Policy Manual, chapter 15, section 30.5, chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered. Chiropractors are not limited to any specific procedures and may render services as they feel necessary, but according to CMS guidelines; the benefit will only cover manual spinal manipulation, which includes procedure codes: 98940, 98941, and 98942.


The following procedure code ranges will deny for chiropractors as non-covered services:

• 00100 through 98929

• 98943 through 99607

• A0021 through V5364