Thursday, May 6, 2021

Televisit , Telehealth CPT CODES

 Telephone or Telehealth CPT codes.


E/M cpt codes - 99201-99205 & 99212- 99215 Will be consider for Televisit codes.


What is a Telehealth Visit?


A visit with a provider that uses telecommunication systems between a provider and a patient. Telemedicine visits are considered the same as in-person visits, and per CMS, require real-time communication between providers and patients using both audio and video. CMS IS WAIVING THE REQUIREMENT FOR BOTH AUDIO AND VIDEO CONNECTIVITY DURING THE COVID-19 PUBLIC HEALTH EMERGENCY


Audio & Video Telehealth Visits


FQHC’s and RHC-must use audio and video to be considered a telehealth visit!


Medicare’s Telehealth Service Spreadsheet lists which visits can be done via telehealth, including which cpt codes can be audio only

Each commercial payer determines which services are covered via telehealth and whether or not audio only qualifies.

E/M cpt codes 99201-99205 & 99212- 99215

Claim Requirements:

Most commercial payers require a 95 modifier, including Medicare (except FQHC’s and RHC’s)

Most Medicaid plans require a GT modifier


United Healthcare Medicare solutions  requires a GT modifier for UB claims


Place of service is the POS that you would have normally billed for an in person visit


Billing Guidelines


**Due to the COVID-19 public health emergency (PHE), variations of the telemedicine rules will be implemented. We will update this document as much as we can; however, for current updates, please refer to the COVID-19 coding resource on www.aap.org/coding ** For the purpose of this resource, telemedicine will be defined as: “a two-way, real- time interactive communication between a patient and a physician or practitioner at a distant site through telecommunications equipment that includes, at a minimum, audio and visual equipment.” The reporting of telemedicine services varies by payer and state regulations. In 2017, Current Procedural Terminology (CPT) published a new modifier and a new appendix related to telemedicine services. While the Centers for Medicare and Medicaid Services (CMS) have recognized telemedicine services for quite some time, the launch of the CPT infrastructure facilitates recognition by private and public payers.


Telemedicine services may make up 2 distinct services, depending on where the patient is located during the telemedicine encounter. Table 1 outlines the different coding and billing requirements whether you are the “performing physician/provider” or the “hosting facility.” In addition, since alternate terms may be used, we have included those, as well:


CPT manual) for a real time interaction between a physician or other qualified healthcare professional and a patient who is located at a distant site from the reporting provider. The totality of the communication of information exchanged between the reporting provider and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. Codes must be listed in Appendix P or have the symbol.


GT modifier: Via interactive audio and video telecommunication systems. Use only when directed by your payer in lieu of modifier 95

GQ modifier: Providers participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system.”


02 Telehealth*: The location where health services and health related services are provided or received, through a telecommunication system. (Effective January 1, 2017) *CMS refers to POS 02 as ‘telehealth’ even though it is more accurately described as ‘telemedicine’ per the definition on page one of this document


BCBS insurance Guidelines.



The purpose of the Telemedicine Medical Services and Telehealth Services policy is to provide guidance on payment and coding for services that are provided to a patient by a network healthcare provider, not at the same physical location. These services can be performed through various interactive telecommunication or information technology devices. 


Tele Medical service - A health care service delivered by a physician licensed in Texas, or a health professional acting under the delegation and supervision of a physician licensed in Texas and acting within the scope of the physician's or health professional's license to a patient at a different physical location than the physician or health professional using telecommunications or information technology. 


Telehealth service - A health service, other than a telemedicine medical service, delivered by a health professional licensed, certified, or otherwise entitled to practice in Texas and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or  information technology. All telehealth services must be provided in compliance with the standards that are established by the licensing or certifying board of the health professional providing the services.



1. The coding scenarios in this document are designed to apply best coding practices. The American Medical Association (AMA) has worked to ensure that all payors are applying the greatest flexibility to our physicians in providing care to their patients during this public health crisis.


2. The Centers for Medicare & Medicaid Services (CMS) lifted Medicare restrictions on the use of telehealth services during the COVID-19 emergency. Key changes effective March 1, and lasting throughout the national public health emergency include:

Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19

Patients can receive telehealth services in all areas of the country and in all settings, including at their home.

CMS expanded the list of services eligible to be reported via telehealth (link here)

CMS will permit reporting of telehealth E/M office or other outpatient visits based on time or Medical Decision Making (MDM).

The Qualified Healthcare Professionals that are eligible for telehealth has been expanded. Additional codes for these services were also added to  the CMS telehealth list.

CMS has clarified that telehealth services are permitted with both new and established patients.

Physicians can reduce or waive cost-sharing for telehealth visits. In addition, all cost-sharing for Medicare beneficiaries is waived for COVID19 testing and visits related to the testing. Modifier CS – Cost sharing must be appended to these claims to ensure cost-sharing.

Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply.

3. HHS Office for Civil Rights offers flexibility for telehealth via popular video chat applications, such as FaceTime or Skype, during the  pandemic.



UHC Reimbursement


UnitedHealthcare will consider for reimbursement the following Telehealth services when they are rendered via audio and video and reported with place of service POS 02 (the location where health services and health related services are provided or received, through a telecommunication system):  


•Services recognized by the Centers for Medicare and Medicaid Services (CMS), and

•Services recognized by the American Medical Association (AMA)included in Appendix P of the CPT code set, and

•Additional services identified by UnitedHealthcare that can be effectively performed via Telehealth. See the Telehealth Eligible Services Code List in the Attachments section.

The Originating Site is where the member is housed with a Telepresenter during a Telehealth encounter.  UnitedHealthcare recognizes the CMS-designated Originating Sites considered eligible for furnishing Telehealth services to a patient located in an Originating Site. The Originating Site may submit a claim for the services of the Telepresenter with code Q3014.Examples of CMS Originating Sites:

•The office of a physician or practitioner

 •A hospital (inpatient or outpatient)

 •A critical access hospital (CAH)

•A rural health clinic (RHC)

•A federally qualified health center (FQHC)

•A hospital-based or critical access hospital-based renal dialysis center (including satellites); NOTE: Independent renal dialysis facilities are not eligible Originating Sites

•A skilled nursing facility (SNF)  

As described byCMS,thetypes of care providers eligible to deliver Telehealth servicesinclude, for example:

•Physician

•Nurse practitioner

•Physician assistant

•Nurse-midwife

•Clinical nurse specialist

•Registered dietitian or nutrition professional

Telehealth/Telemedicine Telehealth services are live, interactive audio and visual transmissions of a physician-patient encounter from one site to another using telecommunications technology.  They may include transmissions of real-time telecommunications or those transmitted by store-and-forward technology.

Telehealth Eligible Services Code List added, PT/OT/ST Telehealth Eligible Services Code List added, Communication Technology Based Services and Remote Physiologic Monitoring Eligible Code List added, Communication Technology-Based and Other Related Services Non-Eligible Code List added History prior to 1/1/2019 archived



CPT TELEMEDICINE CODES


Modifier 95 indicates a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. The 2020 CPT® manual includes Appendix P, which lists a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.


Friday, April 23, 2021

CPT code 49560, 49561 - Ventral Hernia

Procedure code and Description

 49560  - Repair initial incisional or ventral hernia; reducible

49561  - Repair initial incisional or ventral hernia incarcerated or strangulated 


2016 Coding and Reimbursement Guide for Ventral/Incisional Hernia and Complex Abdominal Wall Repair


The information provided herein reflects Cook Medical's understanding of the procedure(s) and/or devices(s) from sources that may include, but are not limited to, the CPT® coding system; Medicare payment systems; commercially available coding guides; professional societies; and research conducted by independent coding and reimbursement consultants. This information should not be construed as authoritative. The entity billing Medicare and/or third party payers is solely responsible for the accuracy of the codes assigned to the services and items in the medical record. Cook Medical does not, and should not, have access to medical records, and

therefore cannot recommend codes for specific cases. We encourage you, when making coding decisions, to seek input from the AMA, relevant medical societies, CMS, your local Medicare Administrative Contractor and other health plans to which you may submit claims. Cook Medical does not promote the off-label use of its devices.


Introduction


This guide was developed to assist with Medicare reporting and reimbursement when using Biodesign® grafts during ventral/ incisional hernia and complex abdominal wall repair.


Coverage


Medicare carriers may issue local coverage decisions (LCDs) listing criteria that must be met prior to coverage. Physicians are urged to review these policies (http://www.cms.hhs.gov/mcd/search.asp) and contact their carrier’s medical director (http://www.cms.hhs.gov/apps/contacts/) or commercial insurers to determine if a procedure is covered.


Coding


Using Biodesign during ventral or incisional hernia repair typically involves coding for the repair and the appropriate C-code (when care is provided to Medicare patients in the hospital outpatient setting) to describe the device.


Ventral or incisional hernia repair is typically reported by one of the following Current Procedural Terminology (CPT®) codes. It is the physician’s responsibility to choose a CPT code that accurately describes the procedure performed.


Abdominal Procedures


1. During an open abdominal procedure, exploration of the surgical field is routinely performed to identify anatomic structures and disease. An exploratory laparotomy (CPT code 49000) is not separately reportable with an open abdominal procedure.


2. Hepatectomy procedures (e.g., CPT codes 47120-47130, 47133-47142) include removal of the gallbladder, based on anatomic considerations and standards of practice. A

cholecystectomy CPT code is not separately reportable with a hepatectomy CPT code.


3. A medically necessary appendectomy may be reported separately. However, an incidental appendectomy of a normal appendix during another abdominal procedure is not separately reportable.


4. If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 49652-49657) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair shall not be reported separately.


5. If a recurrent hernia requires repair, a recurrent hernia repair code may be reported. A code for incisional hernia repair shall not be reported in addition to the recurrent hernia repair code unless a medically necessary incisional hernia repair is performed at a different site. In the latter case, modifier 59 or XS should be used.


6. CPT code 49568 is an AOC describing implantation of mesh or other prosthesis for incisional or ventral hernia repair. This code may be reported with incisional or ventral hernia repair CPT codes 49560-49566. Although mesh or other prosthesis may be implanted with other types of hernia repairs, CPT code 49568 shall not be reported with these other hernia repair codes. If a provider performs an incisional or ventral hernia repair with mesh/prosthesis implantation as well as

another type of hernia repair at the same patient encounter, CPT code 49568 may be reported with modifier 59 or XS to bypass  edits bundling CPT code 49568 into all hernia repair codes other than the incisional or ventral hernia repair codes.



Hernia Type  Ventral Hernia


Types of Hernia Type

• Strangulated ventral hernia the intestinal tissue is firmly caught within the opening of the abdominal wall and cannot be pushed back. Blood flow is

cut off requiring surgery immediately.


Description

Bulge of tissues through a weakness within the abdominal wall muscles.


Diagnosis

Physical exam, abdominal ultrasound, abdominal CT Scan, abdominal MRI Scan.


Cause & Symptoms

Common causes: pregnancy, obesity, history of previous hernias, previous surgeries, family history, frequent lifting of heavy objects, or injuries to bowel.


Codes

49560, 49561, 49565, 49566, 49568, 49652, 49653, 49654, 49655, 49656, 49657.



Complications Infected mesh


Any downstream episode with CPT 11008 OR, in the synthetic mesh study arm, any downstream episode with ICD9 diagnosis codes 996.60 or 996.69 or a combination of diagnosis and procedure codes*; in the xenograft study arm, any downstream episode with ICD9 diagnosis codes 996.60 or 996.69 or a combination of diagnosis and procedure codes* if the episode occurred within 90 days following the index event (otherwise, the classification changes to infection); in the primary repair study arm, any downstream episode with ICD9 diagnosis codes 996.60 or 996.69 or a combination of diagnosis and procedure codes* occurring subsequent to a post-index implantation of mesh (otherwise, the classification changes to infection). 


*The qualifying combination of diagnosis and procedures is an episode that includes a hernia procedure code (CPT code 49560, 49561, 49565, 49566, 49652, 49653, 49654, 49655, 49656, 49657, 49659, S2075, S2077, 11005, 11010, 11011, 11040, 11042, 11043, 44900, 49020, 49021, 49040, 49041, 49060, or 49061; 



The Ventral Hernia Working Group (VHWG) developed a grading system to categorize patients based on risk of surgical site occurrences, with recommendations to guide

surgeons regarding the optimal type of mesh to use.3  The system uses patient and wound characteristics to define four grades with progressively increasing risk. Grade 3 includes potentially contaminated patients with a previous wound infection, stoma, or other procedure involving violation of the gastrointestinal tract performed concurrent with the ventral hernia repair, and grade 4 includes patients with infected mesh or septic dehiscence. In grade 3 and 4 patients, the VHWG concludes that synthetic mesh is generally not recommended and biologic mesh should be considered.


In this study, we retrospectively evaluated the health care resource utilization and costs associated with repair of grade 3 and 4 ventral hernias using primary hernia repair alone, repair using synthetic mesh, and repair using a xenograft. Health care resources included length of stay and return hospital visits for recurrences and complications. Hospital costs were estimated for initial repairs and postoperative complications/reoperations. 


Materials and methods


We used 2008–2009 insurance claims from US private and Medicare plans from Truven Health Analytics MarketScan® research databases to identify all patients who had an

inpatient grade 3 or 4 ventral hernia repair between January 1 and June 30, 2008, which was designated as the “index event”. Procedures were defined by Current Procedural Terminology (CPT®) codes 49560, 49561, 49565, or 49566 (repair initial or recurrent hernia, either incarcerated or strangulated), 49652–49657 (laparoscopy, repair, ventral/ incisional hernia, either incarcerated/strangulated) or 49659 (unlisted laparoscopic hernia repair). Patients were required to have a minimum of 12 months of continuous insurance coverage following the index event, except for death (as identified by inpatient discharge status).


Ventral hernias were grouped by grade using diagnosis and procedure codes to approximate the criteria specified by the VHWG (Table 1).3  For grade 3 (potentially contaminated), relevant codes occurring in services up to six months prior to the index date were used to identify previous wound infection (including previous septicemia or dehiscence); procedure codes at index date ± 2 days identified concurrent violation of the gastrointestinal tract or stoma creation. For grade 4 (infected), infected mesh was identified if mesh was removed in conjunction with the hernia repair being graded, if debridement was performed or an abscess was drained 0–2 days prior to the index date, or if confirmed by a combination of diagnosis and procedure codes during the hospital stay. Due to limitations of the data, septic dehiscence was defined as the presence of code(s) confirming either septicemia or dehiscence at index ± 2 days. To avoid confusion in attribution of complications, patients were excluded for bariatric surgery during the index event or post-transplant status at index. Codes defining each condition are listed in the online appendix.


Patients meeting the selection criteria were classified by study arm based on CPT or Healthcare Common Procedure Coding System (HCPCS) codes: synthetic mesh was defined by HCPCS C1781 or CPT 49568 (hernia repair with mesh add-on code) in a grade 3 hernia. Xenograft was defined by CPT 15430 or 15431 (acellular xenograft implant) or HCPCS J7347 (nonmetabolic active tissue, nonhuman). Further, any grade 4 hernia repair described as CPT 49568 was assigned to the xenograft arm. This is based on coding practices in 2008 before more specific HCPCS codes were introduced, and because clinical guidelines recommend against using synthetic mesh in an infected hernia.3  Index events involving none of the aforementioned codes were assumed to involve primary repair.


Each patient’s insurance claims for an 18-month postindex (study) period were reviewed to identify servicesrelated to the hernia repair. Complications and hernia recurrences were identified by diagnosis code and/or CPT or ICD9-CM procedure code (see online appendix) and grouped into categories for reporting purposes. A complication was included if it occurred during a defined post-procedure validity period (Table 2) following the index event or a subsequent hernia repair, and excluded if analysis of claims for intervening services revealed a potential alternative cause for the complication 


Sunday, March 21, 2021

CPT Ferrlecit J code - j2916, J1756, Venofer

 

HCPCS Code Description


J1756 Injection, Iron Sucrose, 1 mg (Venofer®)

J2916 Injection, Sodium Ferric Gluconate Complex in Sucrose Injection, 12.5 mg (Ferrlecit®)


Description

Sodium ferric gluconate complex in sucrose (Ferrlecit®) injection is an iron replacement product.


FDA Approved Indication(s)


Ferrlecit is indicated for the treatment of iron deficiency anemia (IDA) in adult patients and in pediatric patients with chronic kidney disease (CKD) receiving hemodialysis who are receiving supplemental epoetin therapy.


Overview


Iron is a critical structural component of hemoglobin, a key protein found in normal red blood cells (RBCs) which transport oxygen. Without this important building block, anemic patients experience difficulty in restoring adequate, healthy RBCs that improve hematocrit levels. Iron deficiency is a common condition in end stage renal disease (ESRD) patients undergoing hemodialysis. Clinical management of iron deficiency involves treating patients with iron replacement products while they undergo hemodialysis. The available evidence suggests that the mode of intravenous administration is perhaps the most effective treatment for iron deficiency in hemodialysis patients. Unlike oral iron products, which must be absorbed through the GI tract, IV iron products are infused directly into the bloodstream in a form that is readily available to the bone marrow for RBC synthesis, resulting in an earlier correction of iron deficiency and anemia.

Coverage also includes the medically necessary and reasonable use of parenteral iron preparations in non-dialysis related clinical conditions.



Guidelines


Medicare covers Sodium Ferric Gluconate Complex in Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Medicare also covers Iron Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Coverage also includes for parenteral iron in iron deficiency anemia:

• For patients with iron deficiency anemia who do not respond to oral iron supplementation due to malabsorption disorders or patients who have documented intolerance to oral iron supplementation.

• For anemia related to chronic kidney disease.

• Initial treatment of absolute iron deficiency in patients receiving myelosuppressive chemotherapy who have asymptomatic anemia and risk factors for the development of symptomatic anemia requiring transfusion. 

For the pregnant beneficiary when iron stores are depleted such that the mother and/or the fetus are at risk of adverse outcomes and oral iron replenishment is either not tolerated or the anemia is of such severity as to require more immediate replenishment. Additionally, use in the peripartum period may be indicated when intra/post-partum hemorrhage is severe and by administering parenteral iron a transfusion may be avoided. This indication does not replace the strong consideration for transfusions when the hemorrhage is potentially life threatening.


PURPOSE


The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.


The document can be used as a guide to help determine applicable:

• Medicare coding or billing requirements, and/or

• Medical necessity coverage guidelines; including documentation requirements.

UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.


Policy


*Pleasesee amendment forPennsylvaniaMedicaidattheend ofthis CPB.

I. Aetna considers intravenous iron therapy medically necessary for any of the following indications:

A. For members needing iron supplementation who are unable to tolerate compounds given orally; or

B. For members who are losing iron (blood) at a rate too rapid for oral intake to compensate for the loss; or

C. For members with a disorder of the gastrointestinal tract, such as inflammatory bowel disease (ulcerative colitis and Crohn's disease), in which symptoms may be aggravated by oral iron therapy; or

D. For members who are unable to maintain iron balance on treatment with hemodialysis (Note: Venofer, an iron sucrose injection, and Ferrlecit, a sodium ferric gluconate complex in sucrose injection, are indicated for the treatment of iron deficiency* anema in members undergoing chronic hemodialysis who are receiving supplemental erythropoietin/epoetin therapy; or

E. For members with iron deficiency* anemia associated with peritoneal dialysis and non-dialysis-dependent (NDD) chronic kidney disease (Note: Venofer [iron sucrose] and Feraheme [ferumoxytol] are indicated for such use, not Ferrlecit ([sodium ferric gluconate]); or

F. For members who are donating large amounts of blood for autologous programs; or

G. For members who repeatedly fail to heed instructions for oral iron supplementation or are incapable of accepting or following them; or

H. For members with chemotherapy-induced anemia; or

I. For members with heart failure and iron deficiency*, with or without anemia; or

J. For members with iron deficiency* anemia due to heavy uterine bleeding; or

K. For members with iron deficiency* following gastric bypass surgery and/or subtotal gastric resection and who exhibited decreased absorption of oral iron.


Dosing of Parentaral Iron Preparations:


Iron Dextran is available as Dexferrum in 50 mg and 100 mg Single-Dose Vials and Infed in 100 mg Single-Dose Vials. Iron dextran preparations contain 50 mg of elemental iron/ml, and are approved for iron deficiency anemia not amenable to oral iron therapy. High molecular weight (HMW) iron dextran preparations (Dexferrum) are now rarely used because they are associated with a considerably higher incidence of adverse events than are the low molecular weight (LMW) preparations (INFeD).

LMW preparations have a maximum daily dose 100 mg of elemental iron (2 ml). The recommended dosing in chronic kidney disease is elemental iron 50 to 100 mg once-weekly. There is no evidence that doses of LMW iron dextran larger than 1,000 mg are clinically useful. Once transferrin saturation greater than or equal to 20 % or serum ferritin greater than or equal to 100 ng/ml (224.7 pmol/L), IV iron therapy should be continued at lowest dose needed to maintain target hematocrit/hemoglobin levels and iron stores.


Sodium Ferric Gluconate Complex is available as Ferrlecit in 62.5 mg Single-Dose Ampules/Vials and Nulecit in 62.5 mg Single-Dose Vials. Ferric gluconate complex contains 12.5 mg/ml elemental iron. Ferrlecit (sodium ferric gluconate complex in sucrose injection) is approved for the treatment of iron defiency anemia in adult patients and pediatric patients age 6 years and older with chronic kidney disease receiving hemodialysis who are receiving supplemental epoetin therapy. Nulecit (sodium ferric gluconate complex in sucrose injection) is approved for treatment of iron deficiency anemia in adult patients and in pediatric patients age 6 years and older undergoing chronic hemodialysis who are receiving supplemental epoetin therapy. Ferric gluconate is approved for a maximum single dose of 125 mg, although  published evidence suggests that a dose of 250 mg is well- tolerated. The adult dose 125 mg IV at or during dialysis session, and most patients require cumulative dose greater than or equal to 1,000 mg over 8 sessions. Once transferrin saturation greater than or equal to 20 % and serum ferritin level greater than or equal to 100 ng/ml achieved, ferric gluconate should be continued at the lowest dose needed to maintain hemoglobulin/hematocrit levels (for example, 25 to 100 mg elemental iron weekly for 10 weeks). 



Anemia in Pregnancy & Parenteral Iron Therapy

Abstract

Anemia is common in pregnancy and iron deficiency is the most common cause. Oral iron is the standard therapy, but there is a problem of adherence due the gastrointestinal side effects. Intravenous iron therapy has more advantages, therefore, intravenous iron therapy is the best treatment for pregnant women during the third trimester. We reviewed the statistics of deliveries of the fiscal year 2012, the cases of anemia in pregnancy as in patients provided by Record Room from the calendar year 2012 and the patient cases that used sodium ferric gluconate complex in sucrose injection (FERRLECIT) from the Obstetrics/Gynecology Ward from the fiscal year 2012 provided by the Department of Pharmacy of the Ashford Presbyterian Community Hospital (APCH). A review of the records of pregnant women receiving iron dextran injection (INFeD) intravenously in our ambulatory infusion center was also performed. Our data confirmed that either presentations elevated the hemoglobin and they were well tolerable. Iron sucrose is the preferred and it has demonstrated a high success rate.

I recommend considering this alternative earlier at the third trimester and establishing guidelines using parenteral iron and erythropoietin in combination in refractory cases. 

Keywords: Anemia; Pregnancy; Parenteral; Iron



Sodium Ferric Gluconate Complex in Sucrose (Ferrlecit) HCPCS code J2916: Billing Guidelines

Effective with the date of service of April 30, 2018, the North Carolina Medicaid and Health Choice (NCHC) programs will be terminating Clinical Policy 1B-3, Intravenous Iron Therapy, within the Physician Drug Program (PDP). Requirements, indications, and all other information of the policy are indicated below. From the perspective of the providers, all things associated with the process of submitting claims regarding the IV Iron agents will remain unchanged.


See prescribing information for details.


Below is information regarding Ferrlecit.

Medicaid and NCHC cover sodium ferric gluconate complex in sucrose for beneficiaries aged 6 years and older for the following FDA approved indications:

a. Iron deficiency anemia in beneficiaries undergoing chronic hemodialysis (HDD-CKD) who are receiving epoetin therapy

Medicaid and NCHC covers sodium ferric gluconate complex in sucrose for beneficiaries aged 6 years and older for the following off-label indications:

a. Iron deficiency anemia in beneficiaries with chronic kidney disease who are on peritoneal dialysis (pddckd)

b. Iron deficiency anemia in beneficiaries who are non-dialysis dependent with chronic kidney disease (nddckd)

c. Iron deficiency anemia of excessive uterine blood loss or pregnancy

d. Iron deficiency anemia in beneficiaries with cancer or who have chemotherapy- associated anemia

e. Iron deficiency anemia with comorbid heart failure

f. Iron repletion for autologous blood transfusion;

g. Gastrointestinal (gi) blood loss with iron deficiency (such as gastric bypass surgery, celiac disease, inflammatory bowel disease)

h. Disorders of iron metabolism

i. Iron deficiency where oral treatment is ineffective or infeasible

j. Iron deficiency due to intravascular hemolysis (such as paroxysmal nocturnal hemoglobinuria, valvular heart disease and malfunctioning prosthetic valves), and

k. Iron deficiency due to achlorhydria (including pernicious anemia or medication induced).


 


Thursday, March 18, 2021

CPT code 49505, 49507, 49520, 49521, 49525

Procedure code and Description

49505  - Repair initial inguinal hernia, age 5 years or older; reducible

49507 - Repair initial inguinal hernia, age 5 years or older; incarcerated

49520 - Repair recurrent inguinal hernia, any age; reducible

49521 - Repair recurrent inguinal hernia, any age; incarcerated

49525 - Repair inguinal hernia, sliding, any age


For example, the CPT Manual instruction above CPT code 49491 states: “With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other

prostheses is not separately reported.” Therefore, CPT code 49568 (mesh implantation) should not be reported separately with CPT code 49505 (inguinal hernia repair).


REPAIR HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY


The hernia repair codes in this section are categorized primarily by the type of hernia (inguinal, femoral, incisional, etc.). Some types of hernias are further categorized as "initial" or "recurrent" based on whether or not the hernia has required previous repair(s). Additional variables accounted for by some of the codes include patient age and clinical presentation (reducible vs. incarcerated or strangulated).

With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prosthesis is not separately reported.

(Codes 49491-49651 are unilateral procedures. To report bilateral procedures, report modifier -50 with the appropriate procedure code)


(Do not report modifier -63 in conjunction with 49491, 49492, 49495, 49496, 49600, 49605, 49606, 49610, 49611)


49505 Repair initial inguinal hernia, age 5 years or over; reducible


49505-LT


RATIONALE: In the CPT® Index, look up Hernia Repair/Inguinal/Initial, Child 5 Years or Older. You are referred to 49491, 49495–49500, and 49505 and 49507. Review the codes to choose the appropriate service. 49505 is the correct code. The repair was through an incision (not by laparoscopy) on an initial inguinal hernia on a patient over five years of age and the hernia was not incarcerated or strangulated. According to CPT® guidelines, “With the exception of the incisional hernia repairs (49560–49566), the use of mesh or other prosthesis is not separately reported.” It would be inappropriate to code the mesh in this scenario.



Hernia Type Inguinal Hernia

Types of Hernia

• Incarcerated Hernia- hernia that is trapped in the abdominal wall.

• Strangulated Hernia- An incarcerated hernia that becomes strangulated cutting the blood flow. Symptoms of this include nausea, high fever, sharp pains and swelling


 Type Description

Occurs when tissue protrudes through a weak spot in the abdominal muscles/groin area.


 Diagnosis

Physical exam, ultrasound, CT Scan or MRI


Cause & Symptoms

Common causes: Increased pressure w/in the abdomen, pregnancy, chronic coughing or sneezing, or strenuous activity. Symptoms can include: Stomach muscle weakness,sharp pain, swelling in scrotum, or bulge in groin.


Measures of Inguinal Hernia Repair Surgeries by Setting


For each hospital and year in our sample, we construct separate counts of inguinal hernia repair surgeries performed in the outpatient setting and in the inpatient setting; both counts are done for discharges where the primary payer was fee-for-service Medicare. We identify outpatient hernia repair surgeries from CPT codes and inpatient surgeries from ICD-9-CM procedure codes. To select the relevant procedure codes, we used the Clinical Classification Software (CCS) developed by the Agency for Healthcare Quality and Research (AHRQ 2012a,b).


The CCS assigns multiple CPT and ICD-9 procedure codes to CCS 85 (inguinal and femoral hernia repair). Of the 19 CPTs codes in CCS 85, we eliminated four procedures pertaining to femoral hernia and six procedures used to treat children. As the clinical studies cited earlier showed comparable patient outcomes following open inguinal hernia repair, we excluded four CPTs used for laparoscopic hernia repair. Payment rate data for one open inguinal hernia repair procedure (CPT 49521) are not available for a large share of hospitals in our sample. Our analysis thus includes four procedures used in the open repair of inguinal hernia (CPTs 49505, 49507, 49520, and 49525). For each procedure, we count the times the CPT was recorded as the principal procedure or as one of up to nine other procedures on outpatient discharge records, by hospital and year. Of the ICD-9-CM procedures in CCS 85, we excluded codes for femoral hernia repair and laparoscopic repair of inguinal hernia, and included 14 procedures used in the open repair of inguinal hernia (5300–5305 and 5310–5317).10 We count the times any of these 14 procedures appear as the principal procedure or as one of up to nine other procedures on inpatient discharge records, by hospital and year.

1598 HSR: Health Services Research 48:5 (October 2013) Table 1 reports descriptive statistics for open inguinal hernia repair surgeries by setting in our sample hospitals in 1999. Sample sizes vary by procedure (based on the availability of payment rate data) and by setting (based on the availability of discharge records).11 Panel A reports the mean number of times the procedure was performed in the outpatient setting as the principal procedure and as either the principal or other procedure. CPT 49505 is the most commonly used of the four outpatient procedures; the average hospital performed 24.6 surgeries involving that procedure in that year. Panel B reports the mean count of hernia procedures in the inpatient setting. There were 8.2 inpatient open inguinal hernia repair surgeries performed as the principal or other procedure per hospital in 1999.


Payment Rate Measures


We next construct hospital-specific Medicare payment rates to outpatient departments for each of the open inguinal hernia repair procedures described

above (CPTs 49505, 49507, 49520, and 49525). For the post-OPPS years, we obtain quarterly CMS publications reporting payments by ambulatory payment classification (APC) along with quarterly crosswalks from CPT to APC.12 We create hospital-specific measures by adjusting APC payment rates using the hospital wage index and we create annual measures by averaging the quarterly data.


To obtain hospital- and procedure-specific payments in the pre-OPPS years, we follow the algorithm developed in He and Mellor (2012) to impute hospital- and procedure-specific charges from the total charge field on the discharge record. The algorithm identifies CPT-specific charges for 58–94 percent of the hospitals in our sample depending on the CPT.13 Once we obtain procedure- and hospital-specific charges, we apply hospital-specific outpatient surgery payment-to-charge ratios imputed from 1997 to 1999 annual Medicare cost reports. 


Figure 1 illustrates median Medicare payment rates (in 2008 dollars) over time for each of the four procedures. Median payment rates decreased by 4–10 percent between 1999 and 2004 (before and after the full phase-in of OPPS), and the majority of hospitals (51–60 percent, depending on the procedure) experienced a decrease in payment rate in this time period. About 40–45 percent of the procedure-specific within-hospital variation in payment rates over the 12 years in our sample occurs in the years around the implementation of OPPS, and a large portion (between 80–88 percent) of the 1999– 2004 payment variation represents decreases in payments from the prior year.


Indications for Use


Gentrix® Surgical Matrix Thin (3-layer) are intended for implantation to reinforce soft tissue where weakness exists in patients requiring urological, gastroenterological, or plastic & reconstructive surgery. Reinforcement of soft tissue within urological, gastroenterological, and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia and body wall repair, colon and rectal prolapse repair, tissue

repair, and esophageal repair. The Gentrix Surgical Matrix Thin minimizes tissue attachment to the device in case of direct contact with viscera.


Gentrix® Surgical Matrix (6-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia (e.g.: hiatal/diaphragmatic) and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair. The

Gentrix Surgical Matrix minimizes tissue attachment to the device in case of direct contact with viscera.


Gentrix® Surgical Matrix Plus (8-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia (e.g.: hiatal/diaphragmatic) and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair. The Gentrix Surgical Matrix Plus minimizes tissue attachment to the device in case of direct contact with viscera.


Gentrix® Surgical Matrix Thick (8-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following procedures: hernia and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair.


Procedures: CPT Codes and Medicare Payments


Physician and Outpatient Facility


The following table contains CPT codes that may be utilized when reporting surgical procedures. Please check the current CPT manual for other codes that may be applicable. The table also includes the 2020 Medicare national unadjusted payment rates. Check with your MAC for payment rates specific to your region. 


Correct Coding Initiative (CCI) Edits

Empire is increasing its compliance with industry standards by adopting the following code combinations from the Center for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (CCI) into our payment policy.

The National Correct Coding Initiative is a collection of bundling edits that are separated into two major categories: Comprehensive/Component Procedure Code edits and Mutually Exclusive Procedure Code edits.

Comprehensive/Component Procedure Code edits

Codes that are considered "Components" are incidental to the codes considered to be "Comprehensive" and will be denied as such. The table below lists the procedure that will be denied—"Deny Procedure"—as incidental to the corresponding "When Billed with Procedure."


Mutually Exclusive Procedure Code edits

Mutually Exclusive Procedures are procedures that cannot be reasonably done in the same session. To be consistent with existing payment policy, when Mutually Exclusive procedures are billed for the same date of service, only the procedure with the highest relative value ("When Billed with Procedure") will be allowed and the procedure with the lower relative value ("Deny Procedure") will be denied as Mutually Exclusive of the other procedure.

In some situations, according to CMS, certain modifiers may be allowed to bypass these edits. 


Deny Procedure When Billed with Procedure


38500 49505 

49568         49505 



Modifier 73 – Discontinued Outpatient Hospital Surgical Procedure/Service Prior to Anesthesia Administration


Used for surgical or radiological procedures in ASC.  Due to extenuating circumstances or those that threaten the well‐ being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided and being taken to the room where the procedure is to be performed), but prior to the administration of the anesthesia.



** Used for procedures that require anesthesia.


** Used for an outpatient hospital procedure discontinued before the patient has been prepared for the procedure and/or before the induction of anesthesia whether local regional block(s) or general anesthesia.


** If none of the procedures were completed, report the first planned procedure with modifier 73. Patient must be wheeled to the room where the procedure is to be performed in order to report modifier.


** Do not use this modifier for the elective cancellation of a procedure.


** Do not use this modifier if the surgeon cancels or postpones the scheduled surgery because of a patient complaint such as a cold or flu upon intake.


** The physician should not use this modifier. This is only appropriate for use by the ASC.


Example: A 65‐year old male was brought to the OR for repair of a recurrent inguinal hernia.  The patient was prepped and draped and positioning was carried out.  Before the administration of anesthesia, the patient complained of chest pain.  A cardiac monitor revealed ST segment changes.  The procedure was cancelled and the reported CPT 49520‐73:   Repair recurrent inguinal hernia, any age, reducible

Tuesday, February 9, 2021

CPT CODE 30801, 30802, 30930, 30130, 30140

Procedure code and Description


 * 30801: cautery and/or ablation, mucosa of inferior turbinates, unilat or bilat, any method; superficial (3.4 rvu)

* 30802: intramural (4.92 rvu) (this includes radiofrequency procedures)

* 30930: fracture inferior turbinates, therapeutic (3.02 rvu)

* 30130: excision inferior turbinate, partial or complete (7.15 rvu)

* 30140: submucous resection of inferior turbinate, partial or complete, any method (7.68 rvu)


INFERIOR TURBINOPLASTY

Coding for turbinoplasty procedures centers on whether bone was removed during procedure. Soft tissue reduction of turbinates, without removal of bone, is reported with code 30802. If bone is removed, it is reported with 30140

HOSPITAL OUTPATIENT CODING AND PAYMENT

Hospitals use CPT codes to report outpatient services. Payment shown is for Medicare’s APC hospital outpatient prospective payment system and is the Medicare national average without geographical adjustment. Status Indicator “T” = significant procedure, multiple reduction applies. Payment for each code is made at 100% of the rate when it is the only significant procedure billed. When billed with another status T procedure with higher weight, payment for lower weighted procedures is reduced to 50% of the rate.


CPT code 30802 is used for both unilateral or bilateral procedures and may be reported only once per operative session. Use of the phrase “any method” in the code definition indicates that the specific instruments and techniques used to accomplish the reduction do not alter the code assignment. Intramural ablation of the turbinates includes any ablation of the superficial tissues so the code for superficial ablation (30801) is not assigned separately with 30802. CPT code 30140 is considered to be unilateral and would be billed with bilateral modifier-50.


INFERIOR TURBINOPLASTY WITH OUTFRACTURE

Turbinoplasty and outfracture are sometimes performed together. According to NCCI edits or CPT descriptions, CPT code 30930 should not be billed with 30140. If CPT codes code 30802 and 30930 are reported together, only one code is paid unless procedures are performed independently on opposite sides.


b. Resection Inferior Turbinate (CPT code 30140)

CMS finalized the RUC recommended value of 3.00 RVUs for this code. One notable comment received related to this code included a request that CMS add a new supply named the “turbinate reduction wand” to the supply inputs associated with this procedure when performed in the physician office setting. The commenter stated that this device is designed to ablate, coagulate, and remove a core of tissue that provides the desired volumetric reduction of the anatomy, and supplied several invoices for use in pricing the new supply.


CMS responded stating the suggested turbinate reduction wand has a price of nearly $200, which would add substantially to the costs of CPT code 30140. Before including such significant resource costs in the code, they requested input from the physician community such as the RUC. At present, they do not have any information to suggest that the use of this new supply is typical for CPT code 30140, and the RUC did not recommend the inclusion of this supply on either of the two occasions when this code was reviewed in CY 2017. For these reasons, CMS did not believe that it would be appropriate to add the turbinate reduction wand to CPT code 30140 at this time, but welcomed the submission of additional information regarding this use of this supply from stakeholders.



Most read cpt modifiers