Monday, February 17, 2020

Post operative period billing guidelines - Modifier usage


POST-OPERATIVE PERIOD BILLING

Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure. These modifiers are:

Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period).

The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.

Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure. Special Reporting for Certain Practitioners for CPT code 99024 Practitioners are required to report post-operative E/M visits using CPT code 99024 if they:

• Practice in one of the following nine states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, or Rhode Island; and

• Practice in a group of ten or more practitioners;

• Practitioners who only practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible and,

• Provide global services under one of the required procedure codes. The required procedure codes are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges.

The term “practitioner” is used to refer to both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries (see 81 FR 80172). This  reporting is required for post-operative visits during the global period for procedures with dates of service on or after July 1, 2017. For more information, see Claims-Based Reporting Requirements for Post-Operative Visits. Codes for Which Reporting on Post-Operative Visits is Required As of January 1, 2018, there are some changes made to the list of codes for which reporting is required.

These changes are made necessary by changes in the coding system.

The following CPT codes no longer need to be reported: CPT codes 15732, 34802, and 34825 are deleted. Reporting is not required after December 31, 2017.


CPT codes 30140, 36470, and 36471 have a 0-day global period so reporting is not needed.

The Codes for Required Global Surgery Reporting (CY 2018) [ZIP, 20KB] shows the codes for which reporting is required on or after January 1, 2018.

Return to the OR for a Related Procedure during the Post-Operative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period).  The physician may also need to indicate that another procedure was performed during the post-operative period  of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for modifier “-78” does not limit its use to treatment for complications.

Staged or Related Procedure or Service by the Same Physician During the Post-operative Period Modifier “-58” (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the post-operative period of the first procedure. Modifier “-58” indicates that the performance of a procedure or service during the post-operative period was:
• Planned prospectively or at the time of the original procedure
• More extensive than the original procedure
• For therapy following a diagnostic surgical procedure Modifier “-58” may be reported with the staged procedure’s CPT. A new post-operative period begins when the next procedure in the series is billed.

Critical Care

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances. Pre-operative and post-operative critical care may be paid in addition to a global fee if:
• The patient is critically ill and requires the constant attendance of the physician; and
• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.


Special Reporting for Certain Practitioners for CPT code 99024

Practitioners are required to report post-operative E/M visits using CPT code 99024 if they:

• Practice in one of the following nine states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, or Rhode Island; and
• Practice in a group of ten or more practitioners;
• Practitioners who only practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible and,
• Provide global services under one of the required procedure codes. The required procedure codes are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges.

The term “practitioner” is used to refer to both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries (see 81 FR 80172). This reporting is required for post-operative visits during the global period for procedures with dates of service on or after July 1, 2017

Return to the OR for a Related Procedure during the Post-Operative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period). The physician may also need to indicate that another procedure was performed during the post-operative period of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for modifier “-78” does not limit its use to treatment for complications.

Thursday, January 30, 2020

CPT G0121, G0122, G0328, G0464

Procedure code and description

Effective for services furnished on or after July 1, 2001, the following codes are added for colorectal cancer screening services:

HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.

HCPCS G0122 - Colorectal cancer screening; barium enema (noncovered). Effective for services furnished on or after January 1, 2004, the following code is added for colorectal cancer screening services as an alternative to CPT 82270* (HCPCS G0107*):

HCPCS G0328 - Colorectal cancer screening; immunoassay, fecal-occult blood test, 1-3 simultaneous determinations.

Effective for services furnished on or after October 9, 2014, the following code is added for colorectal cancer screening services:

HCPCS G0464 – Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)


Medicare billing Guidelines

For colorectal cancer screening using multitarget sDNA test, Medicare covers the beneficiaries who fall into ALL of the following three categories:

• Aged 50 to 85 years
• Asymptomatic
• At average risk of developing colorectal cancer

For screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas, Medicare covers all the beneficiaries who are:
• 50 years and older and at normal risk of developing colorectal cancer, AND/OR
• At high risk of developing colorectal cancer
There is no age limitation for coverage of screening colonoscopies.


Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.


Screening colonoscopy

AHA Coding Clinic provides guidance in assigning the principal or first-listed diagnosis code when the physician documents that the colonoscopy is performed for screening purposes only. Code V76.51 is used first and any findings such as polyps, diverticulosis, or hemorrhoids are listed second; see Coding Clinic, First Quarter 1999 Page: 4. CPT codes are reported based on the procedure documented, and whether the patient is Medicare. If the patient is not Medicare, the appropriate CPT, (HCPCS Level I) code is assigned. If the patient is Medicare and no other procedures, such as a polypectomy or biopsy are performed, then either code G0105 or G0121,
(HCPCSL Level II) codes are assigned. G0105 is assigned if the patient qualifies as high risk using the following criteria:

* A personal history of colorectal cancer or
* A family history of familial adenomatous polyposis or
* A family history of hereditary nonpolyposis colorectal cancer or
* A personal history of adenomatous polyps or
* Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis or
* A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyp.

HCPCS code G0121 is assigned if the patient does not qualify as high risk.


Denial codes


A. If a claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a barium enema is being denied because of the age of the beneficiary, use the following MSN or EOMB message:

“This service is not covered for beneficiaries under 50 years of age.” (MSN Message 18-13, EOMB Message 18-22)

B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a barium enema is being denied because the time period between the same test or procedure has not passed, use the following MSN or EOMB message: “Service is being denied because it has not been (12, 24, 48, 120) months since your last (test/procedure) of this kind.” (MSN Message 18-14, EOMB Message 18-23)

C. If the claim is being denied for a screening colonoscopy or a barium enema because the beneficiary is not at a high risk, use the following MSN or EOMB message: “Medicare only covers this procedure for beneficiaries considered to be at a high risk for colorectal cancer.” (MSN Message 18-15, EOMB Message 18-24)

D. If the claim is being denied because payment has already been made for a screening flexible sigmoidoscopy (code G0104), screening colonoscopy (code G0105), or a screening barium enema (codes G0106 or G0120), use the following MSN or EOMB message:

“This service is denied because payment has already been made for a similar procedure within a set timeframe.” (MSN Message 18-16, EOMB Message 18-25)

NOTE: The above messages (MSN 18-16 and EOMB 18-25) should only be used when a certain screening procedure is performed as an alternative to another screening procedure. For example: If the claims history indicates a payment has been made for code G0120 and an incoming claim is submitted for code G0105 within 24 months, the incoming claim should be denied.



Thursday, December 19, 2019

CPT 99224, 99225,99226, 99234, 99235 - Subsequent observation code

CPT Code Description
99224 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically 15 minutes are spent at the bedside and on the patient's hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically 25 minutes are spent at the bedside and on the patient's hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

99234 Observation or inpatient hospital care, for the evaluation and management of a  patient including admission and discharge on the same date which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting  problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99236 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit.


Subsequent Observation Care

In the instance that a patient is held in observation status for more than two calendar dates, the supervising physician should utilize a subsequent Observation Care CPT code (99224-99226). Physicians other than the supervising physician providing care to a patient designated as "observation status" should report subsequent Observation Care.  According to the CPT codebook, “All levels of subsequent Observation Care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status (i.e., changes in history, physical conditions, and response to management) since the last assessment.”

Observation Care Discharge Services

Per CPT, Observation Care discharge day management CPT code 99217 "includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records." Observation Care discharge services include all E/M services on the date of discharge from observation services and should only be reported if the discharge from observation status is on a date other than the date of initial Observation Care.

Oxford follows CMS guidelines that physicians should not report an Observation Care discharge Service when theObservation Care is a minimum of 8 hours and less than 24 hours and the patient is discharged on the same calendar date.

Observation Care Admission and Discharge Services on Same Date Physicians who admit a patient to Observation Care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date shall report an Observation or Inpatient Care Service (Including  Admission and Discharge Services) CPT code (99234-99236).

In accordance with CMS' Claims Processing Manual, when reporting an Observation Care admission and discharge service CPT code (99234-99236) the medical record must include:

** Documentation meeting the E/M requirements for history, examination and medical decision making;



Question and answers



Q: What code should be reported for a patient who continues to be in observation status for a second date and has not been discharged?
A: A subsequent Observation Care CPT code (99224-99226) should be reported in the instance a patient is held in observation status for more than 2 calendar dates. When observation discharge services are provided to the patient, report CPT code 99217 on that calendar date. For example, report CPT 99218- 99220 for a patient designated as observation on Day 1, report CPT 99224-99226 on Day 2 and finally report CPT 99217 when the patient receives discharge services on Day 3.

Q: Why are Observation Codes G0378 and G0379 not addressed in this policy ?
A: These HCPCS codes are not to be reported for physician services. These codes are to be billed by facilities on a UB-04 claim form.


Emergency department visits will be denied when billed on the same day as an observation service (procedure codes 1-99217, 1-99218, 1-99219, and 1-99220) by the same provider.


Observation Care Admission and Discharge Services on Same DatePhysicians who admit a patient to Observation Care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date shall report an Observation or Inpatient Care Service (Including Admission and Discharge Services) CPT code (99234-99236). In accordance with CMS' Claims Processing Manual, when reporting an Observation Care admission and discharge service CPT code (99234-99236) the medical record must include:

•documentation meeting the E/M requirements for history, examination and medical decision making;
•documentation stating the stay for hospital treatment or Observation Care status involves 8 hours but less than 24 hours;
•documentation identifying the billing physician was present and personally performed the services; and
•documentationidentifying that the admission and discharge notes were written by the billing physician


Reimbursement Guidelines from Aetna Medicaid

 The order for observation must be in writing and clearly specify outpatient observation. It should also include the reason for observation and be signed, dated, and timed by the ordering physician. Verbal orders are permitted but must be documented by the individual receiving the order. The ordering practitioner must review and confirm the verbal order when they see the patient.

Applicable Codes/Conditions of Coverage

CPT Codes: 99218-99220, 99224 – 99226 Revenue Code 0762 These codes are not all inclusive. For  more reference please check LDH Fee Schedule.    On the rare occasion when a patient remains in observation  care for  3 days, the physician shall report an initial  observation  care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.


Observation: Multiple Day Codes (Admitted and Discharged on Different Calendar Days)

Day 1-The First Da
y

There are three codes for reporting the first day of observation when the discharge is on a subsequent day:
• 99218    Low complexity
• 99219    Moderate complexity
• 99220   High complexity

The Middle Days

There are three codes for reporting the middle days of observation for observation stays greater than two days:

• 99224   Low complexity
• 99225   Moderate complexity
• 99226   High complexity

The Discharge Day

There is one code for reporting the last day of observation when the discharge is on a subsequent day:
• 99217   Observation care discharge day

This code is used for the management of care on the final day, and is used in conjunction with the first day series CPT codes 99218-99220 and if applicable the middle day codes 99224-99226


Wednesday, November 13, 2019

ST Join INJECTION CPT code - 27096, G0259, G0260


CPT Description

64450 Injection, anesthetic agent; other peripheral nerve or branch

27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

G0259 Injection procedure for sacroiliac joint, arthrography.

G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). [Use when the provider does not use fluoroscopy or CT image guidance].




Billing and Coding Guidelines


L31359 LCD Title Sacroiliac Joint Injections Contractor's Determination Number MS-009 General

1. Procedure code 27096 is to be used only with imaging confirmation of intra-articular needle positioning.
2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection.
3. It is not appropriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
4. Procedure code 27096 represents a unilateral procedure. If bilateral SI joint arthrography is performed, 27096 should be reported with a –50 modifier.
5. A SI joint injection (27096) is not a stand-alone code and one of the following codes should be billed in conjunction with this code:
a. When a formal SI joint arthrography is performed with the SI joint injection, procedure code 73542 should be reported for the radiologic supervision and interpretation of sacroiliac joint arthrography.
b. Do not bill CPT code 73542 (Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation) for injection of contrast to verify needle position. The CPT code 73542 is only to be billed for a medically necessary diagnostic study and requires a full interpretation and report.
c. When fluoroscopic guidance is used to locate the specific anatomic site for needle insertion, procedure code 77003 should be reported.
d. When CT guidance is used to locate the specific anatomic site for needle insertion, procedure code 77012 should be reported.
6. CPT code G0260 should be billed by facilities paid by OPPS.
7. Use CPT code 64999 (Unlisted procedure, nervous system) for pulsed radiofrequency and the denervation procedures of the sacro-iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary. Sacro-iliac joint/nerve denervation procedures are also considered investigational and not medically necessary.


General

1. Procedure code 2709 6 is to be used o nly with imaging confirmation of intra -articular needle positioning.
2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection.
3. It is not appr opriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
4. Procedure code 27096 re presents a unilateral proce dure. If bil ateral SI joint arthrography is performed, 27096 should be reported with a –50 modifier.
5. CPT code G0260 should be billed by facilities paid by OPPS.
6. Use CPT code 64999 (Unlisted procedure, ne rvous system) for pulsed radiofrequency and the denervation procedures of the sacro- iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational a nd therefore, not m edically necessary. Sacroiliac joint/nerve denervation procedures are also considered investigational and not medically necessary.

Spinal Cord Stimulators Description


Spinal cord stimulators, also known as dorsal column stimulators (“stimulators”), are implantable devices used to treat chronic pain. Electrodes are surgically placed within the dura mater via laminectomy, or by percutaneous insertion into the epidural space. Low voltage electrical signals are delivered to the dorsal column of the spinal cord in order to override or mask sensations of pain. The patient’s pain distribution pattern determines the level at which the stimulation lead is placed. The lead may incorporate four (4) to eight (8) electrodes, with 8 electrodes typically used for complex pain patterns, such as bilateral pain or pain extending from the limbs to the trunk. Implantation is typically a 2-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed (defined as at least 50% reduction in pain), the electrodes and radio receiver/ transducer are permanently implanted.

Extensive programming of the neurostimulators is often required to achieve optimal pain control.

General Requirements
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following:
**  Prescription strength anti-inflammatory medications and analgesics
**  Adjunctive medications such as nerve membrane stabilizers or muscle relaxants
**  Physician-supervised therapeutic exercise program or physical therapy
**  Manual therapy or spinal manipulation
**  Alternative therapies such as acupuncture
**  Appropriate management of underlying or associated cognitive, behavioral, or addiction disorders

Documentation of compliance with a plan of therapy that includes elements from these areas is required. Exceptions may be considered on a case-by-case basis. Reporting of symptom severity – Severity of pain and its impact on activities of daily living (ADLs) is a key factor in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs. Imaging studies -- All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.


Indications and Limitations of Coverage and/or Medical Necessity

The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

Medicare will consider the injection procedure of the SI joint medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, Medicare will consider the injection procedure of the SI joint medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.


Subject: Sacroiliac Joint Injections


DESCRIPTION:


The sacroiliac (SI) joint connects the sacrum with the pelvis. The SI joint lies between the sacrum and the ilium, and functions more for stability than for movement. Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. The sacroiliac joint transmits all the forces of the upper body to the pelvis and legs. The joint’s stability is maintained in part by several large ligaments and muscle groups. Dysfunctions of the sacroiliac joint may be described as sacral, iliac, pubic and sacroiliac joint pain. They are typically without consistent, demonstrable radiographic, or laboratory findings, and most commonly exist in the setting of morphologically normal joints. Pain may arise in the joint itself or in the related muscles and ligaments. Pain may be felt in the lower back or may radiate to one or both hips and/or one or both legs. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the individual. Conservative treatment for sacroiliac joint dysfunction generally centers on restoring motion in the joint and may include:

**  Medications
**  Physical therapy
**  Chiropractic or osteopathic manipulation
**  Sacroiliac joint injections.

Sacroiliac joint injections are divided into two phases, the diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. A second injection may be needed in the diagnostic phase. If there is no pain relief after the diagnostic injection (s) (negative block), the therapy is not continued.

Sacroiliac joint injections are expected to be given at intervals no sooner than every week during a diagnostic phase and no sooner than every eight (8) weeks during the therapeutic phase.

POSITION STATEMENT:
Sacroiliac joint injection performed under fluoroscopy or with arthrography meets the definition of medical necessity when ALL the following criteria are met:

**  Sacroiliac joint pain for more than 3 months; AND
**  Sacroiliac joint injections are part of a comprehensive pain treatment plan; AND
**  Continued pain after 6 weeks with ALL of the following treatments:
**  NSAIDS ≥ 4 weeks (if not contraindicated); AND
**  Activity modification ≥ 6 weeks; AND
**  Physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks; OR
**  Worsening pain after 2 weeks with ALL of the following treatments:
**  NSAIDS (if not contraindicated); AND
**  Activity modification; AND
**  Physical therapy, chiropractic therapy or home exercise program.
**  In the diagnostic phase, up to two (2) injections may be administered, at intervals of no sooner than one (1) week.
**  In the therapeutic phase, each subsequent injection requires that prior injection provided ≥ 50% pain reduction for at least six (6) weeks.

Sacroiliac joint injections do not meet the definition of medical necessity if medical documentation indicates the injection procedures are not effective. Sacroiliac joint injection performed with ultrasound guidance is considered experimental or investigational. There is insufficient evidence to support conclusions regarding effects on net health outcomes.

NOTE: It is not expected that epidural blocks, multiple facet joint injections, sacroiliac joint injections, and sympathetic nerve blocks in any and all combinations would be administered to the same individual on the same day. If the first procedure used to treat the presumptive diagnosis fails to produce improvement and rules out that possibility, then it may be appropriate to proceed to the next logical treatment.


CPT Coding:
27096 Injection procedure for sacroiliac joint, anesthetic/ steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

HCPCS Coding:
G0259 Injection procedure for sacroiliac joint; arthrography
G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid AND/OR other therapeutic agent, with or without arthrography

ICD-10 Diagnosis Codes That Support Medical Necessity:
M46.1 Sacroiliitis, not elsewhere classified
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.08 Spinal stenosis, sacral and sacrococcygeal region
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M54.18 Radiculopathy, sacral and sacrococcygeal region
M54.30 – M54.32 Sciatica
M54.40 – M54.42 Lumbago with sciatica
M54.5 Lower back pain
M54.6 Pain in thoracic spine
S33.2XXA, D, S Dislocation of sacroiliac and sacrococcygeal joint
S33.6XXA, D, S Sprain of sacroiliac joint

Tuesday, October 8, 2019

Modifier UB, UC, UA - Billing Guidelines

Modifier  Description
UB Medically necessary delivery prior to 39 weeks of gestation
UC Delivery at 39 weeks of gestation or later
UA Nonmedically necessary delivery prior to 39 weeks of gestation

EED Policy Components

•  GAMMIS is being configured to link practitioners’ induction and delivery claims to the hospital’s induction and delivery claims

•  Induction and delivery claims that are submitted with medical conditions that do not warrant an exception for an induction or delivery prior to 39 weeks gestation will deny payment

•  For non-medically necessary deliveries:–  The practitioner’s claim will fully deny–  The hospital’s claim will deny for the induction and/or delivery portion

•  Practitioners and hospitals may submit an appeal for the denial (DMA 520-A form) to the DCH Medicaid peer review organization, Georgia Medical Care Foundation

•  Compliance will be monitored by DCH and the Centers for Medicare and Medicaid Services through Georgia’s reporting of the Early Elective Deliveries measure 14 found in the Initial Core Set of Health Quality Measures for Medicaid Eligible Adults

•  These specifications contain the same exclusions as the JCAHO list of exclusions•  CY 12 data will serve as the baseline for this CMS measure


Purpose of EED Policy

•  Guide providers and hospitals to sound practice recommendations made by ACOG and others
•  Reduce morbidity in neonates from birth trauma and fetal immaturity
•  Reduce non-medically necessary deliveries less than 39 weeks gestation
•  Encourage greater collaborations between hospitals and their physicians in developing quality improvement initiatives aimed at improving birth outcomes

Modifier/condition codes needed for maternity services/obstetric delivery - Unicare insurance billing


This provider bulletin is an update to information in the provider manual. For access to the latest manual, go to www.UniCare.com.West Virginia is ranked 44thby America’s Health Rankings for infant mortality; nearly eight (7.4) of every 1,000 children die before their first birthday. Infant mortality is a multi factorial health problem, and improving West Virginia’s infant mortality rate will require a multifaceted approach. One of the approaches of UniCare Health Plan of West Virginia, Inc. (UniCare)is to reduce early elective deliveries (EEDs) prior to 39 weeks of gestation. The initiative of reducing EEDs has received national attention from many organizations, including the Centers for Medicare & Medicaid Services (CMS), the March of Dimes, the American Congress of Obstetricians and Gynecologists (ACOG), and The Joint Commission.

Additionally, many West Virginia hospitals and their medical staffs have responded to this initiative by adopting policies that ensure early inductions and cesarean deliveries are medically necessary. UniCare is aligning its obstetric services policy with the goal of improving neonatal and maternal health outcomes. Deliveries that occur prior to 39 weeks, either due to spontaneous labor or as the result of a medically-indicated induction or cesarean section, will continue to remain covered; however,for claims to pay, a modifier or condition code is needed. Deliveries prior to 39 weeks, unless documented as a medical necessity or spontaneous labor, are not a covered benefit.

* Effective for dates of service on or after October 1, 2016,UniCare will require the above modifiers to be used when submitting a claim,or the claim will deny.

Effective for dates of admission on or after October 1, 2016, the following condition codes will be required on the CMS1450 (UB-04)claim form when billing for obstetric delivery services. Condition codes are to be placed in fields 18-24 of theCMS1450 (UB-04)claim form.

Condition code  Description

81 Cesarean sections or inductions performed at less than 39 weeks’ gestation for medical necessity

82 Cesarean sections or inductions performed at less than 39 weeks’ gestation electively

83 Cesarean sections or inductions performed at 39 weeks’ gestation or greater



 Coding for Maternity Care - Medicaid Guidelines

Gestational Age


Providers are required to report the gestational age of the fetus by using the appropriate ICD-10 diagnosis codes Z3A.00 through Z3A.49 on all delivery claims.

Modifier UC

Providers are required to append modifier UC on claims of deliveries 39 weeks or less that are medically necessary or on deliveries 39 weeks or more, whether spontaneous or elective.  If the modifier “UC” is not appended to the claim, it is understood that the claim was for an early elective delivery less than 39 weeks and 0 days and will be denied.  Providers are responsible for ensuring that the codes (and modifiers when applicable) submitted for reimbursement accurately
reflect the diagnosis and procedure(s) reported.

Modifier 22

All obstetrical and delivery procedure codes submitted with modifier 22 require submission of documentation (e.g., operative report) for review prior to payment.  Services for enhanced payment with the 22 modifier include multiple gestations or complications during the delivery which place the mother or fetus at risk of adverse outcome.


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