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

Monday, March 20, 2017

cpt 66821 - YAG capusulotomy surgery

CPT/HCPCS Codes

Group 1 Codes:

66821 After cataract laser surgery

Coverage Indications, Limitations, and/or Medical Necessity

Indications

YAG laser capsulotomies (YAG) are performed in cases of opacification of the posterior capsule, generally no less than 90 days following cataract extraction. YAG performed less than 90 days following cataract extraction should meet both the indications and limitations of this LCD. The percentage of patients having this procedure varies greatly among ophthalmologists. Diagnosis of functional visual impairment due to capsular opacification is based on clinical judgment regarding one or more of the following:

Visual loss and/or symptom of glare (visual acuity 20/30 or worse under Snellen conditions, using contrast sensitivity, or simulated glare testing);
Symptoms of decreased contrast;
Amount of posterior capsular opacification; or
Other possible causes of decreased vision following cataract surgery.

Limitations 

This procedure will not be covered within three months post cataract surgery unless justified by one of the following indications:

Posterior capsular plaque/opacity which cannot be safely removed during primary phacoemulsification cataract procedure
Capsular block during which cataract remnants and fluid become trapped within the lens capsule and addressed with YAG laser posterior capsulotomy
Contraction of the posterior capsule with displacement of the intraocular lens



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.
N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A


ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

H26.491 - H26.493 - Opens in a new window Other secondary cataract, right eye - Other secondary cataract, bilateral
T85.21XA Breakdown (mechanical) of intraocular lens, initial encounter
T85.29XA Other mechanical complication of intraocular lens, initial encounter

Friday, March 10, 2017

CPT 19318 - Surgery reduction mammplasty

CPT/HCPCS Codes

19318 Reduction of large breast

Coverage Indications, Limitations, and/or Medical Necessity

Background:

Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained.

Reduction mammaplasty is performed to reduce the size of the breast/breasts and:

help ameliorate symptoms caused by hypertrophy or

to reduce the size of a contralateral breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Indications:

Reduction mammaplasty is considered medically necessary:

When the patient has significant symptoms that have interfered with normal daily activities despite conservative management for at least 6 months, including at least one of the following criteria:

History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.: conservative analgesia (e.g., such as NSAID, compresses, massage, etc.), supportive measures (e.g., such as garments, back brace, etc.), physical therapy, correction of obesity.

History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with medication and/or significant restriction of activity (e.g.: signs and symptoms of ulnar paresthesias evidenced by nerve conduction studies, cervicalgia, torticollis, or acquired kyphosis).

Signs and symptoms of: intertrigonous maceration and/or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown refractory to dermatologic measures), or shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment.

AND:

The amount of breast tissue removed (by pathology report) is at least 400 grams per breast.


When the patient’s normal breast is reduced to achieve symmetry with a breast reconstructed after cancer surgery.

Limitations

Cosmetic surgery to reshape the breasts and surrounding tissue to improve appearance is not a Medicare benefit. The use of such CPT codes as 12034 and 12035, 14001, 15830, 15836, 15839, 15876 through 15879, and 19350 associated with reshaping will be considered part of (bundled into) the primary reduction mammaplasty procedure.

Indications of coverage must be met.




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.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

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