Tuesday, June 20, 2017

CPT 90801, 90806, 90862 - Psychotherapy codes

CPT Code Description

90801 Interview evaluation

90804 Individual therapy 20 – 30 min

90806 Psychotherapy

90807 Psychotherapy with medical evaluation and management

90862 Pharmacologic management

New and Deleted Procedure Codes

The following psychiatric services procedure codes will be discontinued and replaced as indicated:

Category 2012 Procdure Codes 2013 Procedure Codes

90801                 90791, 90792
90802 90791, 90792
90804, 90816 90832
90806, 90818 90834
90808, 90821 90837

Psychiatric Diagnostic Interview Examination (CPT code 90801):

An E/M service may be substituted for the initial interview procedure, including consultation CPT codes, (CPT codes 99241-99263), provided required elements of the E/M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice. E/M CPT codes do not include a psychotherapy service.

B. Interactive Psychiatric Diagnostic Interview Examination (CPT code 90802):

CPT codes 90802, 90810-90815, 90823-90829 and 90857 may also be covered for any psychiatric disorder as specified in the “ICD-9-CM codes that Support Medical Necessity”
section for adults who also have one of the conditions as specified in the Local Coverage Determination. Both the primary psychiatric diagnosis and secondary communication disorder must be submitted on the claim.

Understanding the Diagnosis and Treatment of Depression

In an effort to identify ways that we may help to improve Member anti-depression medication compliance, a research study was designed and conducted by TideWatch Partners, LLC to examine the diagnosis and treatment of depression. The study gathered insights from providers, primary care physicians (PCP) and behavioral health specialists, specifically psychiatrists, about
their experience treating patients who have been diagnosed with depression.

The objectives of this study were to:

• Gain an understanding of the depression diagnosing process, including diagnostic tools and methods, and treatment plan development

• Identify barriers to Member compliance with anti-depression medications

• Assess ways that Oxford might help Members overcome these barriers Analysis of the survey showed that, among other issues, clarifying and educating providers about referrals specific to depression might help eliminate some of the perceived barriers. The following list is a summary of information that will assist you when referring Oxford Members for behavioral healthcare.

• All inpatient behavioral health services require precertification

• Outpatient behavioral health services require precertification or a PCP referral when provided to all Members, excluding Members of New Jersey small group and Individual plans

• Services provided to Members of New Jersey small group gated plans and New Jersey Individual gated plans require a referral only

• Services provided to Members of New Jersey small group non-gated plans and New Jersey Individual non-gated plans do not require a referral or precertification

• Members may obtain referrals for outpatient behavioral health services through their PCP or by calling Provider Services at 800-666-1353

Please note: Members who obtain a referral from the Behavioral Health Department do not need to go to their PCP.

• Medication management may be authorized once a month or 12 times in one year for Members who are stabilized on medication; however, if more sessions are required to stabilize a patient, providers may request additional sessions by calling the Behavioral Health Department at 800- 201-6991

• A list of participating specialists (including psychiatrists, social workers and nurse practitioners) is available through the Doctor Search tool on www.oxfordhealth.com or by calling Provider Services at 800-666-1353 



Monday, June 12, 2017

CPT 19380, 19328, 19330 - Breast repair reconstruction

CPT Code Description

19328 Removal of intact mammary implant

19330 Removal of mammary implant material

19355 Correction of inverted nipples

19370 Open periprosthetic capsulotomy, breast

19371 Periprosthetic capsulectomy, breast

19380 Revision of reconstructed breast


COVERAGE RATIONALE

Indications for Coverage

If the member's condition meets the Women's Health and Cancer Rights (WHCRA) criteria, please refer to the policy titled Breast Reconstruction Post Mastectomy.

Criteria for a Coverage Determination as Reconstructive and Medically Necessary:

Removal of breast implants with capsulectomy/capsulotomy for symptomatic capsular contracture is considered reconstructive and medically necessary when the following criteria are met:

** Baker grade III or IV capsular contracture; Baker Grading System for Capsular Contracture

o Grade I - breast is soft without palpable thickening

o Grade II - breast is a little firm but no visible changes in appearance

o Grade III - breast is firm and has visible distortion in shape

o Grade IV - breast is hard and has severe distortion or malposition in shape; pain/discomfort may be associated with this level of capsule contracture (ASPS, 2005)

** Limited movement leading to an inability to perform tasks that involve reaching or abduction. Examples include retrieving something from overhead, combing one's hair, reaching out or above to grab something to stabilize oneself.

Removal of a deflated saline breast implant shell is considered cosmetic and is not medically necessary unless the implants were done post-mastectomy. Refer to the policy titled Breast Reconstruction Post Mastectomy.

Correction of inverted nipples is considered reconstructive and medically necessary when one of the following criteria are met:

** Member meets the Women's Health and Cancer Rights Act (WHCRA) criteria (refer to the policy titled Breast Reconstruction Post Mastectomy for details); or

** Documented history of chronic nipple discharge, bleeding, scabbing or ductal infection. Note: If the correction of congenital inverted nipples may be covered based on the state mandates or member specific benefit plan document. See Congenital Anomaly definition below.


Revision of a reconstructed (CPT Code 19380) breast is considered reconstructive and medically necessary when the original reconstruction was done for mastectomy or other covered health service.

Refer to the Applicable Codes section below for a list of codes that meet the criteria for a reconstructed breast. Breast reconstruction done for Poland Syndrome (see definition below) is reconstructive. Although no functional impairment may exist for the breast reconstruction for Poland Syndrome, this has been deemed reconstructive surgery.

Removal of a ruptured silicone gel breast implant is covered regardless of the indication for the initial implant placement.


Additional Information

Tissue protruding at the end of a scar ("dog ear"/standing cone), painful scars or donor site scar revisions must be reviewed to determine if the procedure meets reconstructive guidelines.


Coverage Limitations and Exclusions

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.



** Cosmetic breast procedures are excluded from coverage. Examples include but are not limited to:

o Replacement of an existing breast implant if the earlier breast implant was performed as a cosmetic procedure . (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. Refer to the Breast Reconstruction Post Mastectomy policy.)

o Breast reduction surgery that is determined to be a cosmetic procedure. This exclusion does not apply to breast reduction surgery which we determine is requested to treat a physiologic functional impairment or to coverage required by the Women's Health and Cancer Right's Act.

o Breast surgery only for the purpose of creating symmetrical breasts except when post mastectomy.

o Breast prosthetics or replacement following a cosmetic breast augmentation.

** Revision of a prior reconstructed breast due to normal aging does not meet the definition of a covered reconstructive health service.



DEFINITIONS

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Poland Syndrome: A rare, nonfamilial anomalad of unknown cause. The components of the syndrome include absence of the pectoralis major muscle, absence or hypoplasia of the pectoralis minor muscle, absence of costal cartilages, hypoplasia of breast and subcutaneous tissue (including the nipple complex), and a variety of hand anomalies. The most common chest wall reconstructive procedure in Poland’s is rotation of the latissimus dorsi muscle to reconstruct the anterior chest wall deficiency and anterior axillary fold.

Note: Poland Syndrome does not include tuberous breasts or developmental breast asymmetry.

Sickness: physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse)

Wednesday, May 24, 2017

CPT code 44970, 44960, 44950

CPT Code Description Appendectomy Code Family

44950 Appendectomy

44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure)

44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis

44970 Laparoscopy, surgical, appendectomy When any single or multiple physician or other health care professional reports a code from the Once in a Lifetime Procedures list, that code or any code from the same Code Family will be reimbursed only once during a patient’s lifetime. In the appendectomy example, a single code from the Appendectomy Code Family will be reimbursed only once during a patient’s lifetime, because each person has only one appendix and can have only one appendectomy during his or her lifetime.

REIMBURSEMENT GUIDELINES

Oxford will reimburse certain procedures only once during a patient’s lifetime. Once in a Lifetime Procedures are not limited to a single CPT code, but may be represented by Code Families, which are a group of CPT codes that describe the same or similar type of service. Under this policy, Oxford provides reimbursement for only one procedure from a designated Code Family during a patient’s lifetime.

For example, there are four separate appendectomy CPT codes that can be used, based upon the particular circumstance, to report the removal of the appendix. The four codes, listed below, make up the Code Family that describes the removal of an appendix.



Modifiers

There may be situations that require the code(s) for a Once in a Lifetime Procedure to be submitted more than once during a patient’s lifetime. In such cases, more than one Once in a Lifetime Procedure, whether the same code or a different code from the same Code Family will be considered separately for reimbursement if reported with one of the following modifiers:

Modifier Description

53 Discontinued procedure

55 Postoperative management only

56 Preoperative management only

58 Staged or related procedure or service by the same physician

For additional information related to the percentage of the allowable fee to be paid when one of these modifiers is appended to a claim for a subsequent procedure, please refer to the Discontinued Procedure policy, Split Surgical Package policy and/or Global Days policy.


DEFINITIONS

Code Family: A group of CPT codes that describe the same or similar type of service.

Once in a Lifetime Procedure: A procedure that can be performed by a physician(s) or other health care professional(s) only once in a patient’s lifetime.


QUESTIONS AND ANSWERS


Q: Would there ever be an instance where a CPT code for a Once in a Lifetime Procedure may be reported more than once?

A: Yes, there are instances where a CPT code for a Once in a Lifetime Procedure may be reported more than once. Modifiers may be used to indicate a procedure or service has been altered in some way, but not changed in its actual code description. For example, by definition, modifier 53 (Discontinued Procedure) is to be used when a procedure is terminated for unforeseeable circumstances. Per coding guidelines, the procedure code would be initially reported with modifier 53 appended to the CPT code to indicate the discontinued procedure and then at a later time, the CPT code would be submitted again when (if) the procedure took place in its entirety.



2 Q: How is a Once in a Lifetime Procedure reimbursed when reported by two different physicians on different dates of service?

A: When any physician or other health care professional reports a code from the Once in a Lifetime Procedures policy list on multiple dates of service excluding the same date of service, the code will be reimbursed only once. Oxford follows a "first in, first out" claim payment methodology in determining which claim will be considered for reimbursement when duplicate claims are received.

3 Q: What if two different physicians each report the same procedure on the same date of service for the same patient from the Once in a Lifetime Procedures list? 

A: The Once in a Lifetime procedure codes are subject to duplicate billing when reported by the same or different providers.



Wednesday, May 10, 2017

CPT 30400, 30410, 30420 & 30465 - Rhinoplasty procedures

CPT Code Description

Rhinoplasty

30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

30420 Rhinoplasty, primary; including major septal repair

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip only

30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip, septum, osteotomies Repair of Vestibular Stenosis

30465 Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)

Rhinophyma

30120 Excision or surgical planing of skin of nose for rhinophyma Lysis Intranasal Synechia

30560 Lysis intranasal synechia Septal Dermatoplasty

30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)


RHINOPLASTY AND OTHER NASAL SURGERIES


INSTRUCTIONS FOR USE

This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. 



CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.

Benefit Type General benefits package

Referral Required

(Does not apply to non-gatekeeper products)

No

Authorization Required

(Precertification always required for inpatient admission) Yes

Precertification with Medical Director Review Required Yes1 Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required)

Outpatient, Office

Special Considerations 1Precertification with review by a Medical Director or their designee may be required.

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if 
applicable.



Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

COVERAGE RATIONALE

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.

Indications for Coverage

Rhinoplasty-Primary (CPT 30410, 30420)

Rhinoplasty-primary is considered reconstructive and medically necessary when all of the following criteria are present:

** Prolonged, persistent obstructed nasal breathing due to nasal bone and septal deviation that are the primary causes of an anatomic mechanical nasal airway obstruction, and

** The nasal airway obstruction cannot be corrected by septoplasty alone as documented in the medical record, and 

** Photos clearly document the nasal bone/septal deviation as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway 
obstruction by centralizing the nasal bony pyramid (30410) and also straightening the septum (30420), and

** One of the following is present:

o Nasal fracture with nasal bone displacement severe enough to cause nasal airway obstruction, or

o Residual large cutaneous defect following resection of a malignancy or nasal trauma, and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy. 


Rhinoplasty-Tip (CPT 30400)

Rhinoplasty-tip is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:

** Prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic mechanical nasal airway obstruction (this code is usually cosmetic), and

** Photos clearly document tip drop as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam (acute columellar-labial angle), and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by lifting the nasal tip, and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and 

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.

Rhinoplasty-Secondary (CPT 30430, 30435, 30450)

Rhinoplasty-secondary is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:

** Required as treatment of a complication/residual deformity from primary surgery performed to address a functional impairment when a documented functional impairment persists due to the complication/deformity (these codes are usually cosmetic), and

** Photos clearly document the secondary deformity/complication as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by correcting the deformity or treating the complication. (These codes are usually cosmetic), and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and 

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.


DEFINITIONS

When applicable, please refer to the member specific benefit plan document for definitions. 

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth.

External Nasal Valve, NARES: Lateral Crus (wing) of the lower lateral (alar) cartilage. 

Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life function. Mechanical Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity.

Prolonged, Persistent Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) that has not responded to six weeks of medical management such as nasal steroids, antihistamines, and decongestants.

Elimination of rhinitis medicamentosa as a cause for airway obstruction.

Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, 'is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Rhinitis Medicamentosa (RM): A condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) and certain oral medications (e.g., sympathomimetic amines and various 2-imidazolines) that constrict blood vessels in the lining of the nose.

Septal Dermatoplasty: The physician removes diseased intranasal mucosa and replaces it with a separately reportable split thickness graft. The surgery is performed on one nasal side. A lateral rhinotomy is made to expose the intranasal mucosa. The diseased mucosal tissue is excised from the septum, nasal floor, and anterior aspect of the inferior turbinate. A split thickness graft is sutured to the recipient bed, covering the exposed cartilage and submucosal surfaces. Gauze packing and splints are placed in the grafted nasal cavity.

Synechia: An adhesion of parts, typically the nasal side wall to the septum. 

Tuesday, March 21, 2017

CPT g0180 - Care plan oversight services



Care Plan Oversight Services


Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients.

Separate payment is allowed for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services.

Submit HCPCS code G0179 for re-certification after a patient has received services for at least 60 days (or one certification period). HCPCS code G0179 may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be filed on the same date of service as the supervision service HCPCS codes (G0181 or G0182).
HCPCS Codes

G0179: MD re-certification HHA PT

G0180: MD certification HHA patient

G0181: Home health care supervision

G0182: Hospice care supervision

How to submit a claim

Submit CPT codes 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter

HHA / Hospice Provider Number: The requirement to include the HHA or Hospice provider number on a care plan oversight claim for HCPCS codes G0181 and G0182 is waived until further notice, and as a result, claims submitted with the number will be rejected.

Dates of service: for HCPCS codes G0181 and G0182, submit the first and last date during which documented care planning services were actually provided during the calendar month.

Do not submit the first and last calendar date of the month unless services were provided on those dates)
Submit the claim after the end of the month in which the service is performed

Report care planning only once per calendar month

Report only one month's services per line item

Dates of service: for HCPCS codes G0179 and G0180, submit the date physician signed the certification or re-certification

Documentation

Claims for care plan oversight services will be denied when review of the beneficiary claims history fails to identify a covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service
Medical records for these service must indicate:
The physician spent 30 minutes or more for countable care planning activities
The specific service furnished, including the date and length of time

Most read cpt modifiers