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CPT for shoulder Arthroscopy - 29806 , 29820 - 29828

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cpt code and description

29806  ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY
29807  ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION
29819  ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB
29820  ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL
29821  ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE
29822  ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED
29823  ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE
29824  ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY
29825  ARTHROSCOPY SHOULDER AHESIOLYSIS W/WO MANIPJ
29826  ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE
29827  ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIRaverage fee amount - $1000 - $1100
29828  ARTHROSCOPY SHOULDER BICEPS TENODESIS


29826 - Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromialligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)    average fee amount - $150 - $200

CCI Edits and Bundling CMS Guidelines 

•Effective Apr. 1, 2012 the edit bundling CPT code 29822 into 29826 will be removed

•After Apr. 1, 2012, the provider may resubmit the claim if the local A/B MAC permits, or appeal previously denied claims involving the NCCI edit code pair (Opportunity to increase revenue on previously denied claims when the ASC remains updated to changes)


Co-surgery diagnosis

If there is a co-surgery, the diagnosis has to match for both OP notes.

Osteoarthritis

When coding for Osteoarthritis we will need the following to be documented within the OP note in order to code and process for billing within a timely manner. I know this is a repeat from last month, but we are starting to receive denials for the use of a more specific diagnosis code.

• Nature of Osteoarthritis (Primary, Secondary, post-traumatic)

• Laterality (Left, Right, Bilateral)

• Anatomical Location (Hip, Knee, CMC, etc.)

What to code when only an Acromioplasty is performed alone(29826) 29826 is defined as an Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).

• This code can only be reported with other scope procedures

• It is not a stand alone code

• If this is the only procedure performed, you should report 29822/29823 per CPT and AAOS

• What to do if performed with an open procedure… o CPT 29826 should not be reported with any procedure other than those identified as appropriate parent codes. It is not an add-on code to CPT 23410 or 23412, and an unlisted code cannot be reported to reflect this work. Instead, you should report 29822 or 29823 as appropriate.


Column 1 Code / Column 2 Code - 29827/29820

* CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

* CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not modifier 59.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ



Rotator cuff repair and reconstruction 

Use CPT code series 23410 to 23412 to report mini open rotator cuff tear repairs, with code selection determined by acute versus chronic conditions. While CPT provides a parenthetical statement under CPT 29827 (Arthroscopy, shoulder, surgical;
with rotator cuff repair) directing the CPT user to report 23412 for mini open rotator cuff repair, you still need to determine the final code selection based on the acute versus chronic condition. Recall that CPT code verbiage in 23410 to 23420 is specific to an acute versus chronic condition.

Mini open rotator cuff tear repairs typically don’t involve entry into the shoulder joint while the tear can still be visualized and repaired. When a surgeon performs an arthroscopic rotator cuff repair, report  CPT 29827 regardless of whether the condition is acute versus chronic.

The operative report should specify an acute versus chronic condition. The technique (open versus arthroscopic) will need to be apparent to include a detailed description of a repair versus reconstruction of the specific tendon(s) or cuff.




Rotator Cuff Codes

CPT Code          Procedure             MCR 


29827 Arthroscopic surgical  shoulder; repair of rotator cuff    $1,342.79


Background:

The Medicare beneficiary underwent a surgical procedure at the Appellant’s ASC facility on March 25, 2011. Medical documentation in the record consists of an Operative Report dated March 25, 2011 that the surgeon, Thomas B. Viehe, M.D., authored. Exh 1 at P 099. In addition to identifying the preoperative and postoperative diagnoses, the Operative Report includes a description of the procedure. The section for “Operation(s) Performed” includes the following entries:

1. Right shoulder arthroscopic rotator cuff repair.

2. Right shoulder arthroscopic subacromial decompression with partial acromioplasty.

3. Right shoulder arthroscopic distal clavicle resection.

4. Right shoulder arthroscopic glenohumeral joint debridement, extensive.

Id. The report also included a detailed description of the procedure. Id.
 The ASC facility billed Medicare for CPT codes 29823 (arthroscopy, shoulder, surgical;  debridement, extensive), 29824 (arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (mumford procedure)), 29826 (arthroscopy, shoulder, surgical, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed, 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair) and 29999 (unlisted procedure, arthroscopy).

Wisconsin Physicians Services (WPS), the Medicare Part B contractor in the Appellant’s jurisdiction, reimbursed the facility for 29823, 29824, 29826 and 29827 but denied payment for 29999. Id. at P 097. According to the Remittance Advice, 29999 denied on the basis that “this procedure code/bill type is inconsistent with the place of service.”  1 Id.

The ASC’s basis for appeal was essentially the same at all levels: “code 29999 is used for arthroscopic biceps tenotomy, as there is no more specific code.” Exh 1 at P 093 and Exh 6 at P 022. In its redetermination notice, WPS explained:


Surgeons bill separately for physician’s services. The physician’s bill is not at issue in this case. We note, however, that review of the Health Insurance Master Record (HIMR) shows the physician billed and was paid for 29823, 29824, 29826 and 29827. We were unable to locate any record indicating the physician either billed for or was paid for CPT code 29999.3 Nothing in the Operative Report indicates that the physician performed a  separate procedure, considered the biceps tenotomy to be a separately indentifiable procedure, or intended to bill Medicare for a separate procedure.

As discussed above, both the Part B contractor and the QIC allowed payment for 29823, 29824, 29826 and 29827 but denied payment for 29999 because 29999 is noncovered when provided in an ASC facility. Thus, the WPS and QIC decisions appear
to be wholly consistent with the surgeon’s report and claim information, which indicate that four separate and distinct procedures—not five—were performed and billed.

As part of its agreement with CMS, an ASC agrees to charge the beneficiary only the applicable deductible and coinsurance amounts for facility services for which the beneficiary is entitled to have payment made on his or her behalf. 42 CFR § 416.30. The Appellant billed, and was paid, for 29823, 29824, 29826 and 29827. This constitutes payment in full for services performed. Pursuant to 42 CFR § 416.30, the appellant may not charge the beneficiary for more than the applicable deductible and coinsurance for 29823, 29824, 29826 and 29827.


Conclusion:

The beneficiary underwent arthroscopic shoulder surgery at the Appellant’s ASC facility.

The Appellant billed Medicare, and was paid, for CPT codes 29823, 29824, 29826 and 29827. The Appellant also billed Medicare for unlisted procedure code 29999 because there was no specific billing code assigned to arthroscopic biceps tenotomy. Exh 6 at P 032.

CMS regulations are binding on Office of Medicare Hearings and Appeals ALJs. 42 CFR § 405.1063(a). Pursuant to 42 CFR § 416.166(b), Medicare only pays ASCs for services that appear on a list of approved services published in the Federal Register and for which separate payment is made under OPPS. CPT code 29999 is not an approved service when furnished in an ASC. 75 FR 72279-72331, November 24, 2010,

Addendum AA. Under 42 CFR § 416.166(c)(7), services that can only be reported using an unlisted surgical CPT code are excluded from coverage in an ASC. CMS has also expressly excluded CPT code 29999 from coverage when furnished in an ASC.


Medicare Fee schedule - important dates to watch

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Key Implementation Dates

A detailed schedule of key implementation dates will be provided in an annual temporary instruction in advance of receiving the MPFS Database file. The following outlines significant disclosure activities and anticipated implementation dates. A detailed schedule is provided under separate cover by CMS.

Carriers must:

October:

• Download fee schedules
• Download HCPCS


November:
• Release participation materials and disclosure reports;
• Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;

December:

• Furnish DMEPOS fee schedule and physician fee schedules to State Medicaid Agencies;
• Furnish conversion factors and inflation indexed charge data to the carrier State Medicaid Agencies;
• Process participation elections and withdrawals; and,
• Send a complete fee schedule to the State medical societies and State beneficiary associations.

January:

• Implement annual fee schedule amounts;
• Implement annual HCPCS update;
• Send an updated provider file to the Railroad Retirement Board; and
• Load MEDPARD equivalent information on the carrier Web site.


February:
• Submit participation counts to CMS Central Office via CROWD.

CPT Arthroscopy, knee codes, 29881 , 29876 -29884

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CPT code and description

29881 - Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed  average fee amount - $540 - $600

29871 - ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE

29873 - ARTHROSCOPY KNEE LATERAL RELEASE

29874 - ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY

29875 - ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX

29876 - ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS

29882 - ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL

29883 - ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL

29884 - ARTHROSCOPY KNEE W/LYSIS ADHESIONS W/WO MANJ SPX


Issues

Is the value of CPT code 29875 included in the value of code 29881 billed on the disputed date* Does the documentation support a separate service* Is the requestor entitled to reimbursement?

Findings

28 Texas Administrative Code §134.203(b)(1) “For coding, billing, reporting, and reimbursement of professional medical services, Texas workers' compensation system participants shall apply the following: Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus payments for health professional shortage areas (HPSAs) and physician scarcity areas (PSAs); and other payment policies in effect on the date a service is provided with any additions or exceptions in the rules.”

According to the explanation of benefits, the respondent denied reimbursement for code 29875-LT-59 based upon reason code “X901.”

On the disputed date of service, the requestor billed CPT codes 29881-LT and 29875-LT-59.

Per CCI edits, CPT code 29875 is a component of CPT code 29881; however, a modifier is allowed to ifferentiate the service. A review of the requestor’s billing finds that the requestor appended modifier “59-Distinct Procedural Service” to CPT code 29875.


Modifier 59 is defined as “Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

However, when another already established modifier is appropriate it should be used rather than modifier 59.

Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”The respondent maintains the denial of payment for code 29875 based upon “Per NCCI, 29875 is incidental to 29881…Modifier not supported as same knee.”

The National Correct Coding Initiative Manual defines “separate procedure” as “The narrative for many HCPCS/CPT codes includes a parenthetical statement that the procedure represents a "separate procedure". The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed. A “separate procedure” should not be reported when performed along with another procedure in an anatomically related region through the same skin incision or orifice, or surgical  approach.”

The Division finds that because code 29875 has the parenthetical statement “separate procedure” the CCI policyapplies. Both procedures code 29881 and 29875 were performed on the same anatomically related region (knee); therefore, 29875 cannot be reported with 29881 and the use of modifier 59 is not supported. As a result, reimbursement is not recommended.



Conclusion

For the reasons stated above, the Division finds that the requestor has established that additional reimbursement  is not due. As a result, the amount ordered is $0.00.


Is knee arthroscopy typically covered by health insurance plans*

Yes, knee arthroscopy is usually covered by health insurance. Always check with your insurer to make sure a procedure is covered before seeking treatment. Your insurer may require pre-certification prior to agreeing to cover your knee arthroscopy.

You should always ask and then confirm that your provider is going to obtain precertification for your knee arthroscopy before you receive treatment.

If your provider does not obtain pre-certification prior to your knee arthroscopy, you will need to call the health plan and request pre-certification yourself. Insurers may deny payment of the claim if you have not obtained pre-certification.



Is knee arthroscopy typically covered by Medicare or Medicaid plans*

Yes, knee arthroscopy is covered under Medicare and Medicaid. Your provider may need to establish medical necessity or pre-certification before you receive treatment.



What kind of out-of-pocket costs should I expect to pay*

Your out of pocket costs will depend on the type of insurance that you have. You maybe responsible for copays, deductibles or coinsurance amounts. In order to determine your out of pocket costs, always review your co-pay amounts, current deductible balance and current co-insurance obligation before seeking treatment. If you have questions about your benefit plan or out of pocket costs, talk to your insurance company.

Remember, if you have a Health Savings Account (HSA) or Health Reimbursement Account (HRA) you can apply those funds to any deductible, co-insurance or other out of pocket costs.

Rationale EDIT

Anthem Central Region bundles 29870, 29871, 29875 and 29884 as incidental with 29881; bundles 29870-50, 29871-50, 29875-50 and 29884-50 as incidental with 29881-50; bundles 29870-LT, 29871- LT, 29875-LT and 29884-LT as incidental with 29881-LT and bundles 29870-RT, 29871-RT, 29875- RT and 29884-RT as incidental with 29881-RT. Based on the Complete Global Service Data for
Orthopaedic Surgery, codes 29870, 29871, 29875 and 29884 are listed as procedures that included in CPT 29881. Based on the National Correct Coding Initiative Edits, codes 29870, 29871, 29875 and 29884 are listed as component codes to code 29881. Therefore, if 29870, 29871, 29875 and/or 29884 is submitted with 29881—only 29881 reimburses; if 29870-50, 29871-50, 29875-50 and/or 29884-50 is submitted with 29881-50—only 29881-50 reimburses; if 29870-LT, 29871-LT, 29875-LT and/or 29884-LT is submitted with 29881-LT—only 29881-LT reimburses and if 29870-RT, 29871-RT, 29875-RT and/or 29884-RT is submitted with 29881-RT—only 29881-RT reimburses.

Anthem Central Region does not bundle 29870-59, 29871-59, 29875-59 and 29884-59 with 29881; does  not bundle and does not bundle 29870-LT, 29871-LT, 29875-LT and 29884-LT with 29881-RT. If 29870, 29871, 29875 or 29884 is performed on one knee and 29881 is performed on the opposite knee, either append modifier 59 to 29870, 29871, 29875 or 29884; or append the appropriate LT or RT modifier on 29870, 29871, 29875 or 29884 and the opposite LT/RT side modifier on 29881. Therefore, if 29870-59, 29871-59, 29875-59 and/or 29884-59 is submitted with 29881—both services reimburse separately or if 29870-LT, 29871-LT, 29875-LT and/or 29884-LT is submitted with 29881-RT—both services reimburse separately.

Anthem Central Region bundles 29874 as incidental with 29881. Based on National Correct Coding Initiative Edits, code 29874 is listed as a component code to code 29881. If a loose body is less than 5 mm and is removed from the same incision, it is included in 29881. If the loose body is greater than 5mm or a separate incision is required to remove this loose body, append modifier 59 on 29874 and both services reimburse separately. If 29874 is performed on one knee and 29881 is performed on the
opposite knee, append the appropriate LT/RT modifier to 29874 and the opposite LT/RT modifier to 29881 and both reimburse. Therefore, if 29874 is submitted with 29881—only 29881 reimburses. If 29874-59 is submitted with 29881—both services reimburse separately or if 29874-LT is submitted with 29881-RT—both services reimburse separately.

Anthem Central Region does not bundle 29879 or 29882 with 29881. Based on the Complete Global Service Data for Orthopaedic Surgery, codes 29879 or 29882 are not listed as being included in the performance of 29881. Based on the National Correct Coding Initiative Edits, codes 29879 and 29882 are not listed as being component to code 29881. Therefore, if 29879 or 29882 is submitted with 29881—both services reimburse separately

CPT CODE 63047, 63045 - 63048 - Billing Guide

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CPT code and description

63047 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar -  average fee amount - $1100 - $1200

63045 - LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT CERVICAL

63046 - LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT THORACIC

63048 - LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR



Note: Codes 63030 and 63047 are bundled per the NCCI edits with code 22630. CPT® Assistant (January 2001, page 12) states that these codes can be reported in addition to the fusion code if performed for decompression (apply modifier-59 to the decompression code in this instance.)


PLIF and TLIF Procedures

For 2012, the AMA made changes to the Lumbar and Thoracic codes for Posterior Fusion procedures by combining commonly performed procedures into one code.

The 22610 code for an Arthrodesis (Fusion) using the Posterior or Posterolateral Technique, single level; Thoracic now states this code is done WITH the Lateral Transverse Technique (the code previously stated with or without).

Code 22612 for an Arthrodesis, posterior or posterolateral technique, single level; Lumbar now states this code is done WITH the Lateral Transverse Technique (the code previously stated with or without). This code has an instructional note to NOT report the 22612 code with code 22630 for an Arthrodesis, Posterior Interbody Technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar. The codes can only be billed together when the procedures are performed at different spinal levels or alone.

The new CPT code for use instead for the PLIF Posterior Lumbar Interbody Fusion procedure for 2012 would now be 22633 for an Arthrodesis, combined Posterior or Posterolateral Technique with Posterior Interbody Technique, including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment;

Lumbar. Use new Add-on Code 22634 for additional Lumbar levels performed.

In these procedures, the surgeon removes the entire facet joint so that more disc material can be excised during the procedure and producing less nerve retraction. These procedures are only performed on one side of the spine – not bilaterally, which would result in spinal instability.

An Example of coding for the PLIF procedure performed at 2 levels L3-4 and L4-5 using cages and a morcellized autograft harvested from the iliac crest would be:

22633

63047-59

22842

22851

22851-59

22634




63048

20937

38220-59

L8699

Rationale EDIT

Anthem Central Region does not bundle 63042 with 22630, does not bundle 63042-50 with 22630, does not bundle 63042-LT with 22630 and does not bundle 63047-RT with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT Code 22630, code 63042 is not listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63042 is not listed as a component code to code 22630. Therefore, if 63042 is submitted with 22630—both services reimburse separately, if 63042-50 is submitted with 22630—both services reimburse separately, if 63042-LT is submitted with 22630—both reimburse separately and if 63042-RT is submitted with 22630—both services reimburse separately.

Anthem Central Region bundles 63047 and 63048+ as incidental with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT code 22630, code 63047 is listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63047 is listed as a component code to code 22630. Since 63048 is an add on code that only may be reported along with 63047, 63048 follows the same rationale that is used with 63047. Therefore, if 63047 and 63048+ are submitted with 22630—only 22630 reimburses

CPT CODE 84153, g0103 - Prostate Specific Antigen

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CPT CODE and description

84152 – Prostate Specific Antigen (PSA); Complexed (Direct Measurement)

84153 – Prostate Specific Antigen (PSA); Total - average fee amount - $30 - $40

84154 – Prostate Specific Antigen (PSA); Free

G0102 Prostate cancer screening; digital rectal examination

G0103 – Prostate Cancer Screening; Prostate Specific Antigen Test (PSA)

Prostate Specific Antigen (PSA) 

Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA  is reported to provide a sensitive indicator of persistent disease. Six months following introduction of antiandrogen therapy, PSA is reported of distinguishing patients with favorable response from those in whom limited response is anticipated.

PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment. UnitedHealthcare Community Plan reimburses for Prostate Specific Antigen (PSA) (CPT code 84153), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-9-CM and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.


Why doesn’t Medicare cover a Prostate Specific Antigen (PSA) test for my patients with benign prostatic hypertrophy (BPH)?

The code for BPH, 600.00, is not on the ICD-9-CM Codes Covered by Medicare listing for a diagnostic PSA. Medicare does, however, cover an annual screening PSA test for men over 50. Men with BPH receiving an annual PSA screening should have their claims coded with procedure code G0103 in lieu of CPT code 84153. This screening procedure code requires a diagnosis code of V76.44 that must appear on the claim form. If the patient has symptoms of prostate carcinoma along with the BPH, such as hematuria, nocturia, urinary frequency, and slow stream, a diagnostic PSA can be covered.



Prostate Cancer Screening Tests and Procedures, states that the revenue code 770 is to be used with HCPCS code G0102, digital rectal examination; and revenue code 30X is to be used with HCPCS code G0103, prostate specific antigen blood test

Payment Requirements Intermediaries.--

o G0102 - digital rectal examination - Deductible and coinsurance apply. Payment varies depending on the facility providing the service as follows:

12X = Outpatient Prospective Payment System
13X = Outpatient Prospective Payment System
14X = Outpatient Prospective Payment System
22X = Reasonable Cost
23X = Reasonable Cost
71X = All Inclusive Rate
73X = All Inclusive Rate
75X = Medicare Physician Fee Schedule
85X = Cost (Payment should be consistent with amounts you pay for code 84153 or code 86316.)

o G0103 - antigen test - pay under the clinical diagnostic lab fee schedule. Use CPT code 99211 as a guide. Deductible and coinsurance apply.

D. Calculating Frequency.--To determine the 11 month period, start the count beginning with the month after the month in which a previous test/procedure was performed.


Diagnosis Code Description V76.44 Prostate cancer screening digital rectal examinations (DRE) and screening prostate specific antigen (PSA) blood tests must be billed using screening (“V”) code V76.44 (Special Screening for Malignant Neoplasms, Prostate)


Medicare National Coverage Determination Policy

ICD10       DESCRIPTION

Abn findings on dx imaging of abd regions, inc retroperiton R93.5

Abnormal findings on diagnostic imaging of limbs R93.6

Abnormal findings on diagnostic imaging of prt ms sys R93.7

Abnormal results of function studies of organs and systems R94.8

Benign essential microscopic hematuria R31.1

Bladder-neck obstruction N32.0

Carcinoma in situ of prostate D07.5

Disorder of prostate, unspecified N42.9

Elevated prostate specific antigen [PSA] R97.2

Enlarged prostate with lower urinary tract symptoms N40.1

Enlarged prostate without lower urinary tract symptoms N40.0

Feeling of incomplete bladder emptying R39.14

Frequency of micturition R35.0

Gross hematuria R31.0

Hematuria, unspecified R31.9

Hesitancy of micturition R39.11

Inflammatory disease of prostate, unspecified N41.9

Malignant neoplasm of bladder neck C67.5

Malignant neoplasm of prostate C61

Neoplasm of uncertain behavior of prostate D40.0

Neoplasm of unsp behavior of other genitourinary organs D49.5

Nocturia R35.1

Nodular prostate with lower urinary tract symptoms N40.3

Nodular prostate without lower urinary tract symptoms N40.2

Obstructive and reflux uropathy, unspecified N13.9

Other microscopic hematuria R31.2

Personal history of malignant neoplasm of prostate Z85.46

R39.12 Poor urinary stream

Retention of urine, unspecified R33.9

Sec and unsp malig neoplasm of inguinal and lower limb nodes C77.4

Sec and unsp malig neoplasm of nodes of multiple regions C77.8

Secondary and unsp malignant neoplasm of intrapelv nodes C77.5

Secondary malignant neoplasm of bone C79.51
Secondary malignant neoplasm of bone marrow C79.52

Secondary malignant neoplasm of genital organs C79.82

Straining to void R39.16

Unspecified urinary incontinence R32

Urgency of urination R39.15

Encounter for screening for malignant neoplasm of prostate Z12.5

CPT CODE 87086, 87186, 87184 - Medicare Guidelines

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CPT CODE and description

87086 - Culture, bacterial; quantitative colony count, urine - average fee amount - $10 - $20

87088 - Culture, bacterial; with isolation and presumptive identification of each isolate, urine

87186 - Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate

87184 - Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents


Urine Culture, Bacterial

1. Specific coding guidelines:

a. Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine culture colony count is performed to determine the approximate number of bacteria present per milliliter of urine. The number of units of service is determined by the number of specimens.

b. Use CPT 87088 where a commercial kit uses manufacturer defined media for isolation, presumptive identification, and quantitation of morphotypes present. The number of units of service is determined by the number of specimens.


c. Use CPT 87088 where identification of morphotypes recovered by quantitative culture or commercial kits and deemed to represent significant bacteriuria requires the use of additional testing, for example, biochemical test procedures on colonies. Identification based solely on visual observation of the primary media is usually not adequate to justify use of this code. The number of units of service is determined by the number of isolates.

d. Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be significant is performed concurrently with identification. The number of units of service is determined by the number of isolates. These codes are not exclusively
used for urine cultures but are appropriate for isolates from other sources as well.

 e. Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088, 1 per isolate and 87184 or 87186 where appropriate.

f. Culture for other specific organism groups not ordinarily recovered by media used for aerobic urine culture may require use of additional CPT codes (for example, anaerobes from suprapubic samples).

g. Identification of isolates by non-routine, nonbiochemical methods may be coded appropriately (for example, immunologic identification of streptococci, nucleic acid techniques for identification of N. gonorrhoeae).

h. While infrequently used, sensitivity studies by methods other than CPT 87184 or 87186 are appropriate. CPT 87181, agar dilution method, each antibiotic or CPT 87188, macrotube dilution method, each antibiotic may be used. The number of units of service is the number of antibiotics multiplied by the number of unique isolates.



Limitations

1. CPT 87086 may be used one time per encounter.

2. Colony count restrictions on coverage of CPT 87088 do not apply as they may be highly variable according to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, and degree of hydration).

3. CPT 87088, 87184, and 87186 may be used multiple times in association with or independent of 87086, as urinary tract infections may be polymicrobial.

4. Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate but is considered screening and therefore not covered by Medicare. The U.S. Preventive Services Task Force has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant women is generally not indicated. There are insufficient data to recommend screening in ambulatory elderly patients including those with diabetes. Testing may be clinically indicated on other grounds including likelihood of recurrence or potential adverse effects of antibiotics, but is considered screening in the absence of clinical or laboratory evidence of infection


Commonly Used ICD-10 Codes Medical Necessity

Effective October 1, 2015, appropriate ICD-10 code(s) are required with each requisition.

Note: This is a partial listing of ICD-10 Codes and is no way indicative of all available codes. For complete list of codes, refer to www.cms.gov/medicare-coverage-database Medical Necessity guideline

URINE CULTURE (CPT 87086, 87088)

ICD-10 Description ICD-10 ICD-9

Abdominal Tenderness, Unspecified Site R10.819 789.6

Abdominal tenderness, Unspecified Site R10.819 789.69

Acute Cystitis without Hematuria N30.0 595.0

Acute Cystitis with Hematuria N30.01 595.0

Cystitis, Unspecified without Hematuria N30.90 595.9

Cystitis, Unspecified with Hematuria N30.91 595.9

Acute Prostatitis N41.0 601.0

Altered Mental Status, Unspecified R41.82 80.97

Bacteremia R78.81 790.7

Calculus in Bladder N21.0 594.0

Calculus of Lower Urinary Tract, Unspecified N21.9 594.9

Calculus of Prostate N42.0 602.0

Enlarged Prostate w/o Lower Urinary Tract Symptoms N40.0 600.0

Inflammatory Disease of the Prostate, Unspecified N41.9 601.9

Fever, Unspecified R50.9 780.6

Functional Urinary Incontinence R39.81 788.81

Hematuria, Unspecified R31.9 599.7

Hesitancy of Micturition R39.11 788.64

Other Amnesia R41.3 780.93

Other Difficulties with Micturition R39.19 788.69

Other Long-Term (Current) Drug Therapy Z79.899 V58.69

Other Symptoms & Signs Involving Genitourinary

System R39.89 788.99

Pain, Unspecified R52 780.96

Rebound Abdominal Tenderness, Unspecified Site R10.829 789.6

Rebound Abdominal Tenderness, Unspecified Site R10.829 789.69

Sepsis, Unspecified Organism A41.9 38.9

Streptococcal Sepsis, Unspecified A40.9 38.0

Tachycardia, Unspecified R00.0 785

Unspecified Abdominal Pain R10.9 789.00/ 789.09

Unspecified Renal Colic N23 788

Urethral Discharge without Blood R36.0 788.7

Urethral Discharge, Unspecified R36.9 788.7

Urgency of Urination R39.15 788.63

Urinary Tract Infection, Site Not Specified N39.0 599


CPT CODE 87880, 87561

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CPT CODE and description

87880 - Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A  - average fee amount - $20 - $30

87561 - Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique


Coding for Reflex Testing

Some clinicians may desire to use both rapid immunoassay and molecular Strep A testing methods in a reflex testing scheme. This scheme is analogous to reflexing a rapid immunoassay to culture in which the molecular test is used in place of culture. For example, the initial test might be performed with a rapid immunoassay and then reflexed to molecular if the immunoassay results are negative but clinical signs suggest Strep A infection.

While the codes described above apply separately to these different testing technologies, both are Strep A tests. There is a Correct Coding Initiative (CCI) edit for CPT® 87880 and 87651. This CCI edit CANNOT be overcome by a modifier. Therefore, for Medicare and any other payer that utilizes CCI edits, billing for both tests of this reflex testing scheme is not permitted.

Coding for CPT® 87880 and 87651 may be permitted by some non-Medicare payers if they do not utilize CCI edits. Providers should contact non-Medicare payers to determine whether billing for both CPT® 87880 and 87651 is permitted.

Note that ordering clinicians must be aware of any reflex testing policy by a laboratory and should only order reflex testing if medically reasonable and necessary


Coding Summary

Test             CLIA         Payer           CPT® Coding

Rapid Immunoassay

Acceava®, BinaxNOW®, or Clearview® brands or other Strep A tests manufactured by Alere

Waived Medicare 87880QW

Waived Non-Medicare 87880


Amerigroup Reminder: We Cover Rapid Strep Tests

Reminder: Rapid strep tests billed with CPT code 87880 are covered. This test should be completed for any child prescribed an antibiotic for pharyngitis

What this means to you: For your information only. No immediate action is  necessary



Background

As part of our annual Healthcare Effectiveness Data and Information Set (HEDIS) audit, we assess appropriate testing for children with pharyngitis. The Centers for Disease Control and Prevention and the National Committee for Quality Assurance guidelines constitute the basis for this HEDIS measure.

As part of our audit, we review members’ medical records, claims and laboratory data.

 During our last audit, many of you said Amerigroup Community Care does not reimburse for rapid strep tests; therefore, you don’t file claims for this service. 

We want you to know Amerigroup does cover the rapid strep test when you file a claim using CPT code 87880. Pharyngitis can be validated through lab results; therefore, it serves as an indicator of appropriate antibiotic use. Attached is a summary sheet for this measure and the appropriate codes to use for diagnosis and payment.

We know many parents and guardians request or insist on antibiotics when they aren’t necessary for treatment. We count on your excellent training and cooperation to comply with this standard for appropriate antibiotic use.


Billing example

Mrs. x’ Visit

• Physician Visit – CPT 99202

• Nursing Work – CPT – (Office)

• Rapid Strep – CPT 87880

• All Linked to ICD-9 Code 462 (Pharyngitis)


Payments

• Medicare Pays $36.8729 per RVU

– 1.73 RVUs X 36.8729 = $63.790117

– Rapid Step (CPT 87880) = $16.01

• Total Payment From Medicare = $79.80

Determining Start Date of Timely Filing Period -- Date of Service

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In general, the start date for determining the 12 month timely filing period is the date of service or “From” date on the claim. For institutional claims (Form CMS-1450, the UB-04 and now the 837 I or its paper equivalent) that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim is used for determining the date of service for claims filing timeliness.


Certain claims for services require the reporting of a line item date of service. For professional claims (Form CMS-1500 and 837-P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date is used for determining the date of service for claims filing timeliness. (This includes DME supplies and rental items.) If a line item “From” date is not timely but the “To” date is timely, contractors must split the line item and deny the untimely services as not timely filed. Claims having a date of service on February 29 must be filed by February 28 of the following year to be considered timely filed. What constitutes a claim is defined below.


Time Limitations for Filing Part A and Part B Claims

Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee for service claims. In general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. (See section §70.7 below for details of the exceptions to the 12 month timely filing limit.)

CPT code 90460, 90471 - Immunization administration

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CPT CODE and description

90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administere -average fee amount - $20 - $30

90461 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)


90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

Policy Guidelines

If a significantly separately identifiable evaluation and management service is provided at the time of vaccine administration, the evaluation and management service should be reported in addition to the vaccine and toxoid procedure.

Separate reimbursement will be allowed for preventive medicine services 99381-99397.

Separate reimbursement will be allowed for the administration of the vaccines codes (90460-90474).


Immunization Guidelines

Applicable Codes: 90460-90749, G0008, G0009, G0010, Q2034-Q2039

Codes 90460 and 90461 must be reported in addition to the vaccine and toxoid codes 90476-90749.

Report codes 90460-90461 only when the physician or qualified health care professional provides faceto-face counseling of the patient and family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

Codes 90476-90748 identify the vaccine product only. To report the administration of a vaccine/toxoid, the vaccine product code must be used in addition to the administration code 90460-90474. Modifier 51 should not be reported for the vaccines/toxoids when performed with these administration procedures.

Each immunization given must be filed on a single line of the CMS 1500 claim form, with its specific CPT code.

The -25 modifier must be used with all evaluation and management services except preventive services CPT 99381-99397, when reporting a significant, separately identifiable service in addition to the immunization services.

It is inappropriate to use the unlisted vaccine code CPT 90749 to report immunization administration services.

The invoice from the laboratory or pharmacy the vaccine has been purchased from may be requested for claim review.

ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older.


Vaccines For Childern (VFC) Billing Instructions through 18 years of age: Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code. Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age). For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

* Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the  VFC program. For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

* Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age. Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85. By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

Immunization CPT along with E & M codes


Previously announced as a revision to the Rebundling Policy and effective in the first quarter of 2014, UnitedHealthcare will deny Preventive Medicine Evaluation and Management (E/M) services (CPT codes 99381-99397) when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474) through the CCI Editing Policy. This change aligns with the CMS National Correct Coding Initiative (NCCI) and the American Medical Association Current Procedural Terminology (CPT®)

If modifier 25 is reported with the Preventive Medicine E/M service and the documentation supports that a significant and separately identifiable E/M service was provided on the same date as the administration service, both would be reimbursed. It would not be appropriate to additionally report the Preventive Medicine E/M code for the counseling provided when a vaccine is administered.


Medicaid billing Guide for Immunization Administration

Billing Instructions for 19 years of age and older: 

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure code 90656 (Influenza Virus Vaccine), and another claim line for Procedure code 90471 (Immunization Administration through 19 years of age and older).  For administration (ages 19 and older) of multiple vaccines on the same date, code 90471 should be used for the  first vaccine and 90472 for ANY other vaccines administered on that day. One line will be billed for 90472 indicating the additional number of vaccines administered (insert 1 or 2).

Vaccines For Childern (VFC) Billing Instructions through 18 years of age:  

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age).  For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

** Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the VFC program.  For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

 ** Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age.   Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85.  By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

If a clinical staff member performs vaccine administration with or without counseling under the supervision of the provider and, reports the service under the supervising provider, CPT codes 90471 , 90474 must be reported

Vaccine Administration Codes and Reimbursement Rates

The following codes should be used for all vaccine administration, including VFC vaccine administration for members 18 years old and younger. Report these codes in addition to the vaccine and toxoid code(s).

CPT Code          Description                Rate

Use the following codes for vaccine administration to patients of any age when the administration is not accompanied by any face-to-face counseling, or for administration to patients over 18 with or without counseling:

90471 (Including percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccines/toxoid) (do not report in conjunction with 90473) $21.68


+ 90472 Each additional vaccine/toxoid (List separately in addition to 90471, 90473) $12.59


90473 By intranasal or oral route; one vaccine (single or combination vaccine/toxoid) (do not report in conjunction with 90471)  $21.68


+ 90474 Each additional vaccine/toxoid administered by intranasal or oral route (List separately in addition to 90471, 90473) $12.59

Using Vaccine Administration Codes 90471-90474

The immunization administration codes 90471-90474 need to be billed as one (1) line item, and the vaccine product should be billed as a separate line item. In order for an immunization claim to be reimbursed both an administration code and the vaccine product must be billed. If an immunization is the only service rendered, providers may not submit charges for an E&M service.

Adult immunizations are reimbursed at the lower of: billed charges, or the Medicaid fee schedule amount  for each immunization.

Note: Providers are not to bill CPT codes 90471-90474 for children ages 0-18 for whom counseling was given (see section “Using Pediatric Immunization Codes 90460 and 90461” in this manual). CPT Codes 90471-90474 must only be billed for members (ages 19 and older) or members ages 18 and under for whom no counseling was given.

1. Patient/Parent are not counseled on 2 multi-component vaccines. Both are injectables. Patient is 5 years old.

90471 and 90472

Teaching point: Even though the patient meets the age requirement, counseling is not done.


2. Patient/Parent are counseled by the nurse on 2 multiple component vaccines. Both are injectables. Patient is 5 years old.


90471 and 90472

Teaching point: Even though the patient meets the age requirement, vaccine is done by clinical staff (nurse) and therefore
does not meet the OQHCP requirement.

Determining End Date of Timely Filing Period—Receipt Date

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A submission, as defined above, is considered to be a filed claim for purposes of determining timely filing on the date that the submission is received by the appropriate Medicare claims processing contractor. At this point, the submission receives a permanent receipt date that remains part of the claim record. Once a submission (or claim) passes edits for completeness and validity described in §70.2 above, it is accepted into the Medicare claims processing system.

The receipt date has two functions. It is used for determining whether the claim was timely filed . The same date is also used as the receipt date for purposes of determining claims processing timeliness on the part of the intermediary.

Determination of Untimely Filing and Resulting Actions


Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal.

Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. In appropriate cases, such claims should be processed because of the spell-of-illness implications and/or in order to record the days, visits, cash and blood deductibles. The beneficiary is charged utilization days, if applicable for the type of services received.

CPT CODE 62310, 62311 - Epidural injection

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CPT CODE and description

62310 - Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic - Average fee amount $230 - 260

62311 - Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Average fee amount $230 - 260

62318 - Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

62319 - Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) - average fee payment - $150 - $180

Coverage Indications, Limitations, and/or Medical Necessity

    Epidural injections are used for the treatment of multiple different conditions in chronic and acute pain. Epidural injections may be used for therapeutic and/or diagnostic purposes. There are multiple approaches to epidural injections including caudal, translaminar, and transforaminal. These different approaches are used for different but specific indications. (In general it is felt that the closer the injection can be placed to the pathology the more likely to achieve a beneficial response). Correct placement is best confirmed by using fluoroscopic guidance and injection of contrast.

    Epidural injections and/or infusions will be considered medically reasonable and necessary for the following conditions:

    1. Management of pain caused by intervertebral disc disease with or without myelopathy.

    2. Management of pain caused by spinal stenosis.

    3. Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome.

    4. Management of intractable pain due to complex regional pain syndrome.

    5. Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.

    6. Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.

    7. Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic).

    8. Management of severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less.

    9. Management of pain caused by radiculitis (inflammation of the nerve roots).

    Low back pain may also be produced by “Myofascial Pain Syndrome” in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.

    Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.

CPT/HCPCS Codes
  
    For Single Injection

    62310Inject spine cerv/thoracic
    62311Inject spine lumbar/sacral
 
    For Transforaminal Epidural Injections
 
    64479Inj foramen epidural c/t
    64480Inj foramen epidural add-on
    64483Inj foramen epidural l/s
    64484Inj foramen epidural add-on

Coding Guidelines

1. The HCPCS/CPT code(s) may be subject to Correct Coding initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the current version CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

2. All procedures related to pain management procedures performed by the physician/provider performed on the same day must be billed on the same claim.

3. An imaging guidance code is billed only once per session for CPT code 77003, fluoroscopy or CPT code 77012 for CT guidance. Physicians may only bill for the professional component when imaging is performed in a hospital or non-office facility. No claim should be submitted for the hard or digital film(s) maintained to document needle placement.

4. The CPT code 72275 (Epidurography, radiological supervision and interpretation) differs from CPT code 77003 in that it represents a formal recorded and reported contrast study that includes fluoroscopy. Epidurography should only be reported when it is reasonable and medicallynecessary to perform a diagnostic study. Epidurography should not be billed when the contrast injection is part of the fluoroscopic guidance and contrast injection to confirm correct needle placement that is integral to the epidural, transforaminal and intrathecal injections addressed in the policy.

5. All the CPT codes applicable to this policy include allowance for the insertion of the needle into the epidural space, as well as the injection of the drug.

6. Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region.


7. The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

8. The CPT codes 64479-64484 (transforaminal epidurals) have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.

9. Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.

10.Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

11. CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

12. These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier -59 should be used when billing these services to indicate that the catheter or injection was a separate procedure from the surgical anesthesia care.

13. The epidural catheter insertion (CPT codes 62318 or 62319) includes the setup and start of theinfusion. Therefore, the daily management of epidural or subarachnoid drug administration (CPT code 01996) should not be billed for the same day as the catheter insertion.

14. The daily management of epidural or subarachnoid drug administration (CPT code 01996), is a daily service and should only be coded with a number of services (NOS) of one (1) for each day billed. Post-operative pain management services should be reported in the inpatient hospital setting (21) only.

15. When performed primarily for postoperative pain management the time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one (1).

Bundling Issues with ESI Procedures

The 64479 code is Unbundled in the CCI Edits from code 62310 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Code 64483 is Unbundled from code 62311 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Therefore, for Medicare and other payors who observe the CCI edits, these codes are not billable together when they are performed at the SAME spinal area. If the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L4-5, the procedures are Unbundled and not both billable – only code 62311 would be billable in that case. However, if the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L3-4, then it is allowable to put a -59 Modifier on the 64483 code and bill it as the 2nd code following the 62311 ESI code on the claim form.


Documentation Requirements

Medical necessity for providing the service must be clearly documented in the patient’s medical record and submitted upon request for review.
Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

    Whether the block was a diagnostic or therapeutic injection
    Pre and post procedure evaluation of patient
    Patient education
    Subjective and objective response from the patient regarding pain provocative maneuvers documented by pre and post procedure measurement


According to the American Society of Interventional Pain Physicians (ASIPP) guidelines, a positive response to a series of three (3) epidural injections, is noted when > 50 % relief is obtained for 6 to 8 weeks.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It is expected that providing an epidural block in conjunction with multiple facet joint blocks, bilateral sacroiliac joint injections, trigger point injections, and/or lumbar sympathetic blocks in any combination to a patient on the same day is not considered medically necessary, unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management. It is expected that interlaminar, transforaminal or caudal epidural injections are not performed on the same date of service at the same level.

Procedures performed during the diagnostic phase should be limited to two (2) injections.

Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.

In the treatment or therapeutic phase, a series of three (3) injections may be given at a minimum interval of two (2) weeks to the suspect level. If a positive response (per ASIPP guidelines) is not obtained, then a repeat series of injections at that level is considered not medically necessary.

It is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or bilateral) on any given date of service. (A level is defined as the articulation between two vertebrae i.e., C4-5; or L2-3).

A series of three (3) epidural injections may be repeated at six (6) month intervals (assuming there was a positive response as defined by the ASIPP guidelines) to the first series of three (3) injections. Caution should be used to monitor the side effects of frequent steroid use.

Under unusual circumstances with a recurrent injury, carcinoma, or reflex sympathetic dystrophy, blocks may be repeated more frequently in the treatment phase after stabilization. Documentation must be present in the medical record to support the more frequent use of such therapy in this setting.


Filing Claim Where General Time Limit Has Expired

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As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.
Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in §70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action.

• Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. (See Chapter 3 for no-payment bill processing instructions.)

Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no-payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiary’s view on these circumstances.

• Where the beneficiary does not agree with the determination that the claim was not filed timely or the determination that he/she is responsible for the late filing, the usual appeal rights are available to the beneficiary. Where the provider or supplier is protesting the denial of payment or the assignment of responsibility, no formal channels of appeal are available. However, the contractor may, at the request of the provider or supplier, informally review its initial determination.


Exceptions Allowing Extension of Time Limit

 the following exceptions to the 1 calendar year time limit for filing fee for service claims:

(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).

(2) Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).

(3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the the timely filing limit has expired

(4) Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups it payment from a provider or supplier 6 months or more after the date the service was furnished



Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the provider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database. As explained in sections 70.7.1 – 70.7.4, the contractor will determine if the requirements for a particular exception are met. However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision-making of the specific exception request. In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination

How to handle Retroactive Medicare entitlement

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 Retroactive Medicare Entitlement

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

Thus, a provider or supplier may have furnished services to an individual who was not entitled to Medicare. More than a year later, the individual receives notification from SSA that he or she is entitled to Medicare benefits retroactive to or before the date he or she received services from the provider or supplier. In this situation, the provider or supplier may submit a request for a filing extension to the appropriate Medicare claims processing contractor, as long as the provider or supplier submits supporting documentation that verifies that the conditions above are met.

If the beneficiary and the provider or supplier is notified on different days about the beneficiary’s retroactive Medicare entitlement, there will be two extensions of time triggers. One extension of time trigger is when the beneficiary is first notified about the beneficiary’s retroactive Medicare entitlement and the other extension of time trigger is when the provider or supplier is the first party notified of the beneficiary’s retroactive Medicare entitlement. If the beneficiary is submitting the claim, the time to file the claim is based on the day the beneficiary is first notified of the retroactive Medicare entitlement. If the provider or supplier is submitting the claim, the time to file the claim is based on the day the provider or supplier is first notified of the retroactive Medicare entitlement.

Where retroactive Medicare entitlement is alleged, the provider, supplier, or beneficiary will need to provide the contractor with the following information:

• an official Social Security Administration (SSA) letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement; and,

• documentation describing the service/s furnished to the beneficiary and the date of the furnished service/s.

If the provider, supplier, or beneficiary is unable to provide the contractor with an official SSA letter, the Medicare contractor shall check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement. For example, if the CWF indicates a Medicare entitlement date of March 1, 2008 and a date of accretion of December 14, 2010, then the contractor may interpret the CWF data to mean that the beneficiary was retroactively entitled to Medicare as of March 1, 2008 and that this data was added to the CWF database on December 14, 2010. If the contractor has any problems or concerns with respect to interpreting the CWF data, then the contractor should consult with the appropriate CMS regional office.

If the contractor determines that both of the conditions for meeting this exception described above are met, the time to file a claim will be extended through the last day of the 6th calendar month following the month in which either the beneficiary or the provider or supplier received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.



Enrollment Medicare EDI

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How to Enroll in Medicare Electronic Data Interchange

  The Centers for Medicare & Medicaid Services (CMS) Standard Electronic Data Interchange (EDI) Enrollment Form must be completed prior to submitting electronic media claims (EMC) or other EDI transactions to Medicare. The agreement must be executed by each provider of health care services, physician, or supplier that intends to submit EMC or use EDI, either directly with Medicare or through a billing service or clearinghouse.

Each new EMC biller must sign the form and submit it to their local Medicare carrier, durable medical equipment regional carrier (DMERC), or fiscal intermediary. For more information regarding the CMS Standard EDI Enrollment Form, please contact your local Carrier, DMERC or Intermediary.

An organization comprising of multiple components that have been assigned Medicare provider numbers, supplier numbers, or UPINs may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these numbers have been assigned. The organization as a whole is held responsible for the performance of its components.

Electronic Data Interchange System Access and Privacy

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Medicare systems contain extensive personally identifiable information on beneficiaries. As established by the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA), beneficiaries have a right to expect that their data will not be seen by individuals or entities that do not have a need to know that information for billing or payment purposes. Acceptable uses of beneficiary data, such as for claims processing, are periodically published in the Federal Register.

Electronic Data Interchange (EDI) cannot occur unless providers and their agents such as billing services and clearinghouses are given some level of access to Medicare Systems, but the information which they submit to or obtain from Medicare systems, and the purposes for which they may use that data are limited to protect beneficiaries. Each provider must complete an EDI Enrollment form prior to starting to exchange any EDI transactions either directly with Medicare or through a billing service or clearinghouse. In that agreement, the provider agrees to accept responsibility for safeguarding of beneficiary data and to assure that billing services or clearinghouses whom they may engage to assist with transmission of beneficiary data in turn sign an agreement to also meet the same security and privacy requirements that are binding on the provider as required by CMS and HIPAA.

As part of their EDI Enrollment, each provider must also submit a written notice to their carrier, durable medical equipment regional carrier (DMERC) or fiscal intermediary (FI) specifying which transactions a billing service or clearinghouse is authorized to submit or receive on behalf of the provider, and must notify that same Medicare contractor whenever there is a change in that authorization or representation.

Electronic Data Interchange (EDI) Support

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Medicare Carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (MACs), and Durable Medical Equipment (DME) MACs as well as the DME MAC Common Electronic Data Interchange (CEDI) contractor furnish first line Electronic Data Interchange (EDI) support to physicians, suppliers and other providers that submit claims and conduct other Health Insurance Portability and Accountability Act (HIPPA) of 1996 named electronic business with the Medicare Part A and Part B program.Providers, billing services, clearinghouses, or other entities that furnish services to providers, shall contact the following:

Carrier or A/B MAC– For professional claims, by geographic area in which the provider operates.
FI or A/B MAC– For institutional claims, by FI that a provider chooses to process their claims. This only applies for Title XVIII FIs, as the A/B MACs will be handling institutional claims by geographic area in which the institution operates.

DME MACor CEDI– For durable medical equipment, claims are submitted by zip code of a beneficiary that receives services or supplies billed to.

Use of EDI transactions allows a provider to submit transactions faster and be paid for claims faster, and to accomplish this at a lower cost than is generally the case for paper or manual transactions.

Medicare contractors can assist you to begin exchanging EDI transactions by furnishing you with enrollment and connectivity information, system access numbers and passwords, information on those transactions supported by Medicare Part A and Part B, and testing with you to assure correct transmission of the EDI formats. Although these contractors can supply limited EDI training, it is the responsibility of physicians, suppliers and other providers and other entities that will be using EDI to train their staff members on use of the hardware, software, and the security and privacy requirements that apply to HIPAA EDI transactions.

You can use the link(s) below to identify the contractor responsible for your EDI connectivity and for further information on the level of support available by the contractor to entities that exchange Medicare HIPAA EDI transactions.

Handling Medicaid and HMO retroactive eligibility?

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Retroactive Medicare Entitlement Involving State Medicaid Agencies

The time for filing a claim will be extended if CMS or one of its contractors determines that failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

(c) A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier 6 months or more after the date of the furnished service.

In these situations, at the time services were furnished the beneficiary was entitled to Medicaid but not to Medicare. After the date of the furnished services, the beneficiary is then notified that he or she is entitled to Medicare. Finally, sometime after the date of the furnished service, the State Medicaid Agency recoups the money it paid the provider or supplier. If the State Medicaid Agency recoups the money it paid the provider or supplier 6 months or more after the date the service was furnished, the provider or supplier may be given an extension to have those claims filed to Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:

• documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;

• documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (e.g., an official SSA letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check the CWF database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement; see the example in section 70.7.2 above concerning the CWF for additional details regarding this contractor verification process); and,

• documentation verifying the service/s furnished to the beneficiary and the date of the furnished service/s.

If the contractor determines that all of the conditions described above for meeting this exception are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the State Medicaid Agency recovered its money.

 Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.

(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.

(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:

• prior enrollment of the beneficiary in an MA plan or PACE provider organization;

• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;

• the effective date of the disenrollment; and,

• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.

Why Medicare splitting claims for processing ?

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Splitting Claims for Processing

There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims. The splitting of such a claim is necessary for various reasons such as proper recording of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes. Split a claim for processing in the following situations:

• Expenses incurred in different calendar years cannot be processed as a single claim. A separate claim is required for the expenses incurred in each calendar year;

EXCEPTION FOR DURABLE MEDICAL EQUIPMENT REGIONAL CARRIERS (DMERCs):

Expendable items (disposable items such as blood glucose test strips and PEN nutrients) that will be used in a time frame that spans two calendar years and are required to be billed with appropriately spanned “from” and “to” dates of service may be processed on a single claim line. For these types of items, DMERCs must base pricing and deductible calculations on the “from” date, since that is the date when the item was furnished.

• A claim other than a DMERC claim that spans two calendar years where the “from” date of service is untimely but the “to” date of service is timely should be split and processed as follows:

1. Where the number of services on the claim is evenly divisible by the number of days spanned, assume that the number of services for each day is equal. Determine the number of services per day by dividing the number of services by the number of days spanned. Then split the claim into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.

2. Where the number of services on the claim is not evenly divisible by the number of days spanned and it is not otherwise possible to determine from the claim the dates of services, suspend and develop the claim in order to determine the dates of services. After determining the dates of services, split the claim accordingly into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.

• A claim containing both assigned and unassigned charges. Split assigned and unassigned services from non-participating physicians/suppliers into separate assigned and unassigned claims for workload counts and processing;
• Assigned claims from different physicians/suppliers (excluding group practices and persons or organizations to whom benefits may be reassigned). Process a separate claim for the services from each physician/supplier. Where the assigned claim is from a person or organization to which the physicians performing the services have reassigned their benefits, process all of the services as a single claim;

• A claim where there is more than one beneficiary on a single claim. There can only be one beneficiary per claim; and

NOTE: Roster bills for covered immunization services furnished by mass immunizers may be submitted for multiple beneficiaries. You must create individual claims for each Medicare beneficiary based on the roster bill information.

• Outpatient physical therapy services furnished on a cost basis by a physician-directed clinic cannot be processed when combined on the same claim with other charge-related services by the clinic. Process the cost related services as a separate claim.

• If an unassigned claim includes services by an independent physical therapist together with other physician services, process the physical therapy services as a separate claim. Process an assigned claim from an independent physical therapist as a single claim.

• A claim that is a duplicate of a claim previously denied is treated as a new claim if there is no indication that the claim is a resubmittal of a previous claim with additional information, or there is no indication on the second claim that the beneficiary is protesting the previous determination.

• In a claim containing services from physicians/suppliers covering more than one carrier jurisdiction, the carrier receiving the claim must split off the services to be forwarded to another contractor and count the material within the local jurisdiction as a claim. The carrier receiving the transferred material must also count it as a separate claim.

• When services in a claim by the same physician/supplier can be identified as being both second/third opinion services and services not related to second/third opinion, the "opinion" services must be split off from the "non-opinion" services and counted as a separate claim. When one physician/supplier in an unassigned claim has provided the "opinion" service and another physician(s)/supplier(s) has provided the "non-opinion" services, the claim may not be split.

• Claims containing any combination of the following types of services must be split to process each type of service as a separate claim. These services are:

-- Physical therapy by an independent practitioner, or

-- any services paid at l00 percent of reasonable charges.

(Any of these types of services may be combined on the same claim with any other type of service.)

Do not deviate from defining claims as described above. Split claims in accordance with the appropriate definition. Throughout the claims process count each of the separate claims, resulting from the split, as an individual claim.

Procedure codes 11042, 11043, 11044 , 97597 - Debridement tissue

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procedure code and description

11042-Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm or less.  - average fee payment- $120 - $130

11045 (add-on code for 11042) each additional 20 square cm, or part thereof.

 11043 Debridement, muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue, if performed); first 20 square cm or less.

11046 (add-on code for 11043) each additional 20 square cm, or part thereof.

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 square cm or less. procedure  +11047 (add-on code for 11044) each additional 20 square cm, or part thereof.



Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

    Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing.

    Debridement services will be considered medically reasonable and necessary when they are provided for the management of wounds and ulcers of the skin and underlying tissue to promote optimal wound healing or to prepare sites for appropriate surgical intervention. The requirements for reasonable and necessary service(s) include safe and effective debridement methods most appropriate to the type of wound, furnished in the appropriate setting, and ordered and/or performed by qualified personnel.

    Skin Debridement (procedure  codes 11000-11001)

    procedure  codes 11000 and 11001 describe removal of extensive eczematous or infected skin. Conditions that may require debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus).

    procedure  code 11001 is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, furnucles, and localized skin infections.

    Debridement of Necrotizing Soft Tissue Infections (procedure  codes 11004-11008)

    procedure  codes 11004-11006 describe extensive debridement of skin, subcutaneous tissue, muscle, and fascia to treat necrotizing soft tissue infections. Generally, these debridement procedures are performed on high-risk patients. The code descriptor indicates the specific area that receives treatment.

    procedure  code 11008 describes the concurrent removal of a mesh or prosthetic device.

    Surgical Debridement (procedure  codes 11042-11047)

    Surgical debridement occurs only if material has been excised and is typically reported for the treatment of a wound to clear and maintain the site free of devitalized tissue including necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., to the margins of viable tissue. Surgical excision includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in some cases. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement. Unless the medical record shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).

    Surgical debridement codes (11042-11047), as performed by physicians and qualified non-physician practitioners licensed by the state to perform those services,are reported by depth of tissue removed and by surface area of the wound. These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia. Surgical debridement will be considered as “not medically necessary” when documentation indicates the wound is without infection, necrosis, or nonviable tissues and has pink to red granulated tissue.

    Documentation for surgical debridement procedures should include the indications for the procedure, the type of anesthesia if and when used, and the narrative of the procedure that describes the wounds, as well as the details of the debridement procedure itself. The procedure  code selected should reflect the level of debrided tissue (e.g.,skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound. For example, procedure  code 11042 defined as “Debridement, subcutaneous tissue” should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.

    It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues do not regrow very quickly.

    Active Wound Care Management

    Debridement is indicated whenever necrotic tissue is present on an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care. It should be billed no more than once per day, regardless of the number of wounds.

    Selective Debridement (97597 and 97598)

    procedure  codes 97597 and 97598 are used for the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Selective debridement includes:

        Selective removal of necrotic tissue by sharp dissection including scissors, scalpel, and forceps

        Selective removal of necrotic tissue by high pressure water jet

    Coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient’s medical record that the wound is improving in response to the wound care being provided. It is neither reasonable nor medically necessary to continue a given type of would care if evidence of wound improvement cannot be shown.

    Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

        Drainage (color, amount, consistency)

        Inflammation

        Swelling

        Pain

        Wound dimensions (diameter, depth, tunneling)

        Granulation tissue

        Necrotic tissue/slough

    Such evidence must be documented with each visit. A wound that shows no improvement after 30 days requires a new approach, which may include a reassessment, by a qualified professional, of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new plan of care or treatment method.

    In rare instances, the goal of wound care provided in the outpatient setting may only be to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve.

    LIMITATIONS

    The following services are not considered to be wound debridement:

        Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.
        Washing bacterial or fungal debris from lesions.
        Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
        Dressing of small or superficial lesions.
        Removal of fibrinous material from the margin of an ulcer.
        Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.
        Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate procedure  or HCPCS codes.




Bill Type Codes

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

    12Hospital Inpatient (Medicare Part B only)
    13Hospital Outpatient
    22Skilled Nursing - Inpatient (Medicare Part B only)
    23Skilled Nursing - Outpatient
    71Clinic - Rural Health
    74Clinic - Outpatient Rehabilitation Facility (ORF)
    75Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
    85Critical Access Hospital


procedure /HCPCS Codes
 
    11001Debride infected skin add-on
    11000Debride infected skin
    11042Deb subq tissue 20 sq cm/<
    11043Deb musc/fascia 20 sq cm/<
    11044Deb bone 20 sq cm/<
    11045Deb subq tissue add-on
    11046Deb musc/fascia add-on
    11047Deb bone add-on
    97597Rmvl devital tis 20 cm/<
    97598Rmvl devital tis addl 20cm/<


Billing Guidelines

*A. Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care is performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed over or onto a wound that is attached with dressings.

2. 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.

3. CPT 97597 and/or CPT 97598 are typically used for recurrent wound debridements.

4. CPT 97597 and/or CPT 97598 are not limited to any specialty.

Coding Guidelines

1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or 97598.

2. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047.


3. CPT code 11044 or CPT code 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC).

ICD-10 Codes that Support Medical Necessity


    The diagnoses listed below are applicable to the procedure /HCPCS codes listed above in both Group 1 (Part A) and Group 2 (Part B).
 

    A48.0Gas gangrene
    B35.0Tinea barbae and tinea capitis
    B35.1Tinea unguium
    B35.2Tinea manuum
    B35.3Tinea pedis
    B35.4Tinea corporis
    B35.5Tinea imbricata
    B35.6Tinea cruris
    B35.8Other dermatophytoses
    B35.9Dermatophytosis, unspecified
    I70.231Atherosclerosis of native arteries of right leg with ulceration of thigh
    I70.232Atherosclerosis of native arteries of right leg with ulceration of calf
    I70.233Atherosclerosis of native arteries of right leg with ulceration of ankle
    I70.234Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
    I70.235Atherosclerosis of native arteries of right leg with ulceration of other part of foot
    I70.238Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
    I70.239Atherosclerosis of native arteries of right leg with ulceration of unspecified site
    I70.241Atherosclerosis of native arteries of left leg with ulceration of thigh
    I70.242Atherosclerosis of native arteries of left leg with ulceration of calf
    I70.243Atherosclerosis of native arteries of left leg with ulceration of ankle
    I70.244Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
    I70.245Atherosclerosis of native arteries of left leg with ulceration of other part of foot
    I70.248Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
    I70.249Atherosclerosis of native arteries of left leg with ulceration of unspecified site
    I70.261Atherosclerosis of native arteries of extremities with gangrene, right leg
    I70.262Atherosclerosis of native arteries of extremities with gangrene, left leg
    I70.263Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
    I70.268Atherosclerosis of native arteries of extremities with gangrene, other extremity
    I70.269Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
    I70.331Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh
    I70.332Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf
    I70.333Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle
    I70.334Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.335Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot
    I70.338Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.339Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site
    I70.341Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh
    I70.342Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf
    I70.343Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle
    I70.344Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.345Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot
    I70.348Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.349Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site
    I70.35Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration
    I70.431Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh
    I70.432Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf
    I70.433Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle
    I70.434Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.435Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
    I70.438Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.439Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site
    I70.441Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh
    I70.442Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf
    I70.443Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle
    I70.444Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.445Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot
    I70.448Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.449Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site
    I70.45Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
    I70.531Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh
    I70.532Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf
    I70.533Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle
    I70.534Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.535Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot
    I70.538Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.539Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site
    I70.541Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh
    I70.542Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf
    I70.543Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle
    I70.544Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.545Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot
    I70.548Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.549Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site
    I70.55Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
    I70.631Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh
    I70.632Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf
    I70.633Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle
    I70.634Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.635Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot
    I70.638Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.639Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site
    I70.641Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh
    I70.642Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf

Documentation Requirements

1. The medical record must clearly show that the criteria listed in LCD GSURG-051 under “Indications and Limitation of Coverage and/or Medical Necessity” have been met.

2. There must be a documented plan of care with documented goals and documented provider follow-up present in the patient's medical record. Wound healing must be a medically reasonable expectation based on the clinical circumstances documented.

3. Documentation of the progress of the wound’s response to treatment must be made for each service billed. At a minimum this must include current wound size, wound depth, presence and extent of or absence of obvious signs of infection, presence and extent of or absence of necrotic, devitalized or non-viable tissue, or other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.

4. When debridements are performed, the debridement procedure notes must document tissue removal (i.e. skin, full or partial thickness; subcutaneous tissue; muscle; and/or bone), the method used to debride (i.e., hydrostatic versus sharp versus abrasion methods), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.

5. When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.


Procedure code 11400, 11401, 11402 and 11406 - Excision benign lesion

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Procedure code and description

11400- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less   - average fee payment - $130 - $140

11401 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm

11402- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm

11403 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm

11404 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm

11406 xcision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm


Coding Information

procedure codes 11400-11446 should be used when the excision is a full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.


Claims for removal of benign skin lesions performed merely for cosmetic reasons may not necessarily need to be submitted to Medicare unless the patient requests that a formal Medicare denial is issued. If a claim is filed, ICD-9 CM code V50.1 (Other plastic surgery for unacceptable cosmetic appearance) should be used in conjunction with the appropriate procedure code



If a dermatologist performs an excision (11400) with benign lesion destruction (17110), both codes are reportable and a modifier will be necessary to “bypass” the edit. 11400 is mutually exclusive to the 17110 which documentation of both procedures will support reporting both codes with the appropriate modifier. According to CMS, there must be a NCCI procedure to procedure (PTP) edits, which in this case there is, to require a modifier. Otherwise it is not needed.

Col 1 Col 2 Effect Date Allowance

17000 11900 19980401 1

17000 11901 19980401 1

17110 11400 19990101 1


Documentations Requirements

The medical record must be made available to Medicare upon request.

The HCPCS/procedure code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.

When requesting a written redetermination (formerly appeal), please send all relevant documentation with the request.

Benign skin lesion removals for reasons other than those given under the Indications andLimitations of Coverage and or Medical Necessity Section above are considered to be cosmetic and will not be covered. These noncovered reasons include, but are not limited to, emotional distress, “makeup trapping” and non-problematic lesions in any anatomic location.


Medical documentation must clearly and unequivocally document the medical necessity for lesion removal(s) if Medicare is billed for the service.

A medical record statement of “irritated skin lesion” is insufficient justification for lesion removal when solely used to reference a patient’s complaint or a physician’s physical findings. Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient to justify lesional removal without medical documentation of the patient’s symptoms and physical findings.

Medicare will not pay for a separate E/M service on the same day dermatologic surgery is performed unless significant and separately identifiable medical services were rendered and clearly documented in the patient’s medical record. Append modifier 25 to the appropriate visit code to indicate the patient’s condition required a significant, separately identifiable visit service unrelated to the procedure that was performed.

Office visits will be covered when the diagnosis of a benign skin lesion(s) is made even if the removal of a particular lesion or lesion(s) is not medically indicated and is therefore not done.

Lesions in sensitive anatomic locations that are non-problematic do not qualify for        removal coverage on the basis of location alone.

The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision (procedure 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. This means the medical record for a benign lesion excision (procedure 11400-11446) must show why an excisional removal was the procedure of choice.

The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.

How should CPT or HCPCS codes such as 11400 (excision of benign lesion) be billed when they are performed on both sides of the body and are not CMS bilateral eligible?

A: An excision of a lesion is not truly bilateral. It should be billed with units, rather than the bilateral modifier.

Indications and Limitations of Coverage and/or Medical Necessity 

Abstract:

Benign skin lesions are common in the elderly and are frequently removed at the patient's request to improve appearance. Removals of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic, and as such, are not covered by the Medicare program. These cosmetic reasons include, but are not limited to, emotional distress, "makeup trapping," and non-problematic lesions in any anatomic location. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone.

Benign skin lesions to which the accompanying lesion removal policy applies are the following: seborrheic keratoses, sebaceous (epidermoid) cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts.

Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient characteristics.

Indications:

There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts is medically appropriate. Medicare will, therefore, consider their removal as medically necessary, and not cosmetic, if one or more of the following conditions are presented and clearly documented in the medical record:

Bleeding;
Intense itching;
Pain;
Change in physical appearance (reddening or pigmentary change);
Recent enlargement;
Increase in the number of lesions;
Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.;
Lesion obstructs an orifice;
Lesion clinically restricts eye function. For example:
Lesion restricts eyelid function;
lesion causes misdirection of eyelashes or eyelid;
lesion restricts lacrimal puncta and interferes with tear flow;
lesion touches globe;
Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance;
A prior biopsy suggests or is indicative of lesion malignancy;
The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has, in fact, occurred;
Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of rupture of epidermal inclusion (sebaceous) cyst.
Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are present:
Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding;
Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patients;
Lesions are condyloma acuminata or molluscum contagiosum;
Cervical dysplasia or pregnancy is associated with genital warts.
Limitations:

Medicare will not pay for a separate E & M service on the same day as a minor surgical procedure unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient’s medical record and a modifier 25 should be used.

Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient’s medical record.

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.

The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesion excision (CPT 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Each benign lesion excised should be reported separately. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.
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