Thursday, June 11, 2020

Medicare Credit balance report - General overview


MEDICARE CREDIT BALANCE REPORT 

CERTIFICATION PAGE

The Medicare Credit Balance Report is required under the authority of sections 1815(a), 1833(e), 1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program.

ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY ESSENTIAL INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL MONEY PENALTIES UNDER APPLICABLE FEDERAL LAWS.

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER

I HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying credit balance report prepared by



Medicare Credit Balance Report – Provider Instructions

General

The Paperwork Burden Reduction Act of 1995 was enacted to inform you about why the Government collects information and how it uses the information. In accordance with sections 1815(a) and 1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program. In addition, section 1866(a)(1)(C) of the Act requires participating providers to furnish information about payments made to them, and to refund any monies incorrectly paid. In accordance with these provisions, all providers participating in the Medicare program are to complete a Medicare Credit Balance Report (CMS-838) to help ensure that monies owed to Medicare are repaid in a timely manner.

The CMS-838 is specifically used to monitor identification and recovery of “credit balances” owed to Medicare. A credit balance is an improper or excess payment made to a provider as the result of patient billing or claims processing errors. Examples of Medicare credit balances include instances where a provider is:

• Paid twice for the same service either by Medicare or by Medicare and another insurer;

• Paid for services planned but not performed or for non-covered services;

• Overpaid because of errors made in calculating beneficiary deductible and/or coinsurance amounts; or

• A hospital that bills and is paid for outpatient services included in a beneficiary’s inpatient claim. Credit balances would not include proper payments made by Medicare in excess of a provider’s charges such as DRG payments made to hospitals under the Medicare prospective payment system.

For purposes of completing the CMS-838, a Medicare credit balance is an amount determined to be refundable to Medicare. Generally, when a provider receives an improper or excess payment for a claim, it is reflected in their accounting records (patient accounts receivable) as a “credit.” However, Medicare credit balances include monies due the program regardless of its classification in a provider’s accounting records. For example, if a provider maintains credit balance accounts for a stipulated period; e.g., 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider must identify and repay all monies due the Medicare program.

Only Medicare credit balances are reported on the CMS-838.

To help determine whether a refund is due to Medicare, another insurer, the patient, or beneficiary, refer to the sections of the manual [each provider manual will have the appropriate cite for that manual] that pertain to eligibility and Medicare Secondary Payer (MSP) admissions procedures.

Submitting the CMS-838

Submit a completed CMS-838 to your fiscal intermediary (FI) within 30 days after the close of each calendar quarter. Include in the report all Medicare credit balances shown in your accounting records (including transfer, holding or other general accounts used to accumulate credit balance funds) as of the last day of the reporting quarter.

Report all Medicare credit balances shown in your records regardless of when they occurred. You are responsible for reporting and repaying all improper or excess payments you have received from the time you began participating in the Medicare program. Once you identify and report a credit balance on the CMS-838 report, do not report the same credit balance on subsequent CMS-838 reports.



Completing the CMS-838

The CMS-838 consists of a certification page and a detail page. An officer (the Chief Financial Officer or Chief Executive Officer) or the Administrator of your facility must sign and date the certification page. Even if no Medicare credit balances are shown in your records for the reporting quarter, you must still have the form signed and submitted to your FI in attestation of this fact. Only a signed certification page needs to be submitted if your facility has no Medicare credit balances as of the last day of the reporting quarter. An electronic file (or hard copy) of the certification page is available from your FI.

The detail page requires specific information on each credit balance on a claim-by-claim basis. This page provides space to address 17 claims, but you may add additional lines or reproduce the form as many times as necessary to accommodate all of the credit balances that you have reported. An electronic file (or hard copy) of the detail page is available from your FI.

You may submit the detail page(s) on a diskette furnished by your contractor or by a secure electronic transmission as long as the transmission method and format are acceptable to your FI. Segregate Part A credit balances from Part B credit balances by reporting them on separate detail pages. NOTE: Part B pertains only to services you provide which are billed to your FI. It does not pertain to physician and supplier services billed to carriers.

Begin completing the CMS-838 by providing the information required in the heading area of the detail page(s) as follows:

• The full name of the facility;

• The facility’s provider number. If there are multiple provider numbers for dedicated units within the facility (e.g., psychiatric, physical medicine and rehabilitation), complete a separate Medicare Credit Balance Report for each provider number;

• The month, day and year of the reporting quarter; e.g., 12/31/02;

• An “A” if the report page(s) reflects Medicare Part A credit balances, or a “B” if it reflects Part B credit balances;

• The number of the current detail page and the total number of pages forwarded, excluding the certification page (e.g., Page 1 of 3); and

• The name and telephone number of the individual who may be contacted regarding any questions that may arise with respect to the credit balance data. Complete the data fields for each Medicare credit balance by providing the following information (when a credit balance is the result of a duplicate Medicare primary payment, report the data pertaining to the most recently paid claim):

Column 1 - The last name and first initial of the Medicare Beneficiary, (e.g., Doe, J.).

Column 2 - The Medicare Health Insurance Claim Number (HICN) of the Medicare Beneficiary.

Column 3 - The multiple-digit Internal Control Number (ICN) assigned by Medicare when the claim is processed.



Column 4 - The 3-digit number explaining the type of bill; e.g., 111 - inpatient, 131 - outpatient, 831 - same day surgery. (See the Uniform Billing instructions, [each provider manual has the appropriate cite for the manual].)

Columns 5/6 - The month, day and year the beneficiary was admitted and discharged, if an inpatient claim; or “From” and “Through” dates (date service(s) were rendered), if an outpatient service. Numerically indicate the admission (From) and discharge (Through) date (e.g., 01/01/02).

Column 7 - The month, day and year (e.g., 01/01/02) the claim was paid. If a credit balance is caused by a duplicate Medicare payment, ensure the paid date and ICN number correspond to the most recent payment.

Column 8 - An “O” if the claim is for an open Medicare cost reporting period, or a “C” if the claim pertains to a closed cost reporting period. (An open cost report is one where an NPR has not yet been issued. Do not consider a cost report open if it was reopened for a specific issue such as graduate medical education or malpractice insurance.)

Column 9 - The amount of the Medicare credit balance that was determined from your patient/ accounting records.

Column 10 - The amount of the Medicare credit balance identified in column 9 being repaid with the submission of the report. (As discussed below, repay Medicare credit balances at the time you submit the CMS-838 to your FI.)

Column 11 - A “C” when you submit a check with the CMS-838 to repay the credit balance amount shown in column 9, an “A” if a claim adjustment is being submitted in hard copy (e.g., adjustment bill in UB-92 format) with the CMS-838, and a “Z” if payment is being made by a combination of check and adjustment bill with the CMS-838. Use an “X” if an adjustment bill has already been submitted electronically or by hard copy.

Column 12 - The amount of the Medicare credit balance that remains outstanding (column 9 minus column 10). Show a zero (“0”) if you made full payment with the CMS-838 or a claim adjustment had been submitted previously, including electronically.

Column 13 - The reason for the Medicare credit balance by entering a “1” if it is the result of duplicateMedicare payments, a “2” for a primary payment by another insurer, or a “3” for “other reasons.” Provide an explanation on the detail page for each credit balance with a “3.”

Column 14 - The Value Code to which the primary payment relates, using the appropriate two digit code as follows: (This column is completed only if the credit balance was caused by a payment when Medicare was not the primary payer. If more than one code applies, enter the code applicable to the payer with the largest liability. For code description, see [each provider manual has the appropriate cite for that manual].)

12 – Working Aged

13 – End Stage Renal Disease

14 – Auto/No Fault


15 – Workers’ Compensation

16 – Other Government Program

41 – Black Lung

42 – Department of Veterans Affairs (VA)

43 – Disability

44 – Conditional Payment

47 – Liability

Column 15 - The name and billing address of the primary insurer identified in column 14.

NOTE: Once a credit balance is reported on the CMS-838, it is not to be reported on a subsequent  period report.

Payment of Amounts Owed Medicare

Providers must pay all amounts owed (column 9 of the report) at the time the credit balance report is submitted. Providers must submit payment, by check or adjustment bill.

• Payments by check must also be accompanied by a separate adjustment bill, electronic or hard copy, for all individual credit balances that pertain to open cost reporting periods. The FI will ensure that the monies are not collected twice.

• Submission of the detail information on the CMS-838 will not be accepted by the FI as an  adjustment bill.

• Claim adjustments, whether as payment or in connection with a check, must be submitted as adjustment bills (electronic or hard copy). If the claim adjustment was submitted electronically, this must be shown on the CMS-838 (see instructions for column 11).

• There is a limited exception for MSP credit balances. Federal regulations at 42 CFR 489.20(h) state that “if a provider receives payment for the same services from Medicare and another payer that is primary to Medicare…” the provider must identify MSP related credit balances in the report for the quarter in which the credit balance was identified, even if repayment is not required until after the date the report is due. If the provider is not submitting a payment (by check or adjustment bill) for an MSP credit balance with the CMS-838 because of the 60-day rule, the provider must furnish the date thecredit balance was received. Otherwise, the FI must assume that the payment is due and will issue a recovery demand letter and accrue interest without taking this 60-day period into consideration.

• If the amount owed Medicare is so large that immediate repayment would cause financial hardship, you may contact your FI regarding an extended repayment schedule.

Records Supporting CMS-838 Data

Develop and maintain documentation that shows that each patient record with a credit balance (e.g., transfer, holding account) was reviewed to determine credit balances attributable to Medicare and the  amount owed, for the preparation of the CMS-838. At a minimum, your procedures should:

• Identify whether the patient is an eligible Medicare beneficiary;
• Identify other liable insurers and the primary payer;
• Adhere to applicable Medicare payment rules; and
• Ensure that the credit balance is due and refundable to Medicare.

NOTE: A suspension of Medicare payments may be imposed and your eligibility to participate in the Medicare program may be affected for failing to submit the CMS-838 or for not maintaining documentation that adequately supports the credit balance data reported to CMS. Your FI will review your documentation during audits/reviews performed for cost report settlement purposes.

Provider Based Home Health Agencies (HHAs)

Provider-based HHAs are to submit their CMS-838 to their Regional Home Health Intermediary even though it may be different from the FI servicing the parent facility.

Exception for Low Utilization Providers

Providers with extremely low Medicare utilization do not have to submit a CMS-838. A low utilization provider is defined as a facility that files a low utilization Medicare cost report as specified in PRM-I, section 2414.4.B, or files less than 25 Medicare claims per year.

Compliance with MSP RegulationsMSP regulations at 42 CFR 489.20(h) require you to pay Medicare within 60 days from the date you receive payment from another payer (primary to Medicare) for the same service. Submission of the CMS-838 and adherence to CMS’ instructions do not interfere with this rule. You must repay credit balances resulting from MSP payments within the 60-day period.

Report credit balances resulting from MSP payments on the CMS-838 if they have not been repaid by the last day of the reporting quarter. If you identify and repay an MSP credit balance within a reporting quarter, in accordance with the 60-day requirement, do not include it on the CMS-838; i.e., once payment is made, a credit balance would no longer be reflected in your records.

If an MSP credit balance occurs late in a reporting quarter, and the CMS-838 is due prior to expiration of the 60-day requirement, include it in the credit balance report. However, payment of the credit balance does not have to be made at the time you submit the CMS-838, but within the 60 days allowed.




Instructions to Fiscal Intermediaries (FIs) for the Medicare Credit Balance Report

General In accordance with section §1815(a) and §1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program. In addition, §1866(a) (1) (C) of the Act requires participating providers to furnish information about payments made to them and to refund any monies incorrectly paid. In accordance with these provisions, providers are to complete a Medicare Credit Balance Report (CMS-838) to ensure that monies owed to Medicare are repaid in a timely manner.

Fiscal intermediaries (FIs) are responsible for monitoring and ensuring provider compliance with the credit balance reporting process. This responsibility includes the following activities: ensure that providers submit properly completed CMS-838 reports on time, claims adjustments to Medicare credit balances are properly made, payments to providers are suspended for untimely submission of CMS-838 reports, demand letters are appropriately issued to providers that have not repaid their Medicare credit balances, and outstanding Medicare credit balances are included in Medicare financial reports.

Medicare Credit Balance Report (CMS-838)

Providers use the quarterly CMS-838 report to disclose Medicare credit balances. They determine the number and amount of these balances for refunding the Medicare program. Generally, when a provider  receives an improper or excess payment for a claim, it is reflected in their accounting records (patientaccounts receivable) as a “credit.” However, Medicare credit balances include money due to the program regardless of its classification in a provider’s accounting records. For example, if a provider maintains credit balance accounts for a stipulated period such as 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider is responsible for identifying and repaying all of the monies from these credit balance accounts to the Medicare program.

The current version of the Medicare Credit Balance Report (Certification Page and Detail Page) and instructions for its completion are available at www.cms.hhs.gov/forms. This report is identified as CMS Form 838 on the CMS Web site, and a replica of this form is in section 20 of this chapter.FIs are charged with the responsibility for performing all necessary activities to implement these instructions.

Providers must pay all amounts owed (column 9 of the Detail Page) at the time the credit balance report is submitted. Payment must be submitted with the report and may be made by check or adjustment bill.

• Submission of the completed Detail Page by itself does not constitute a claim adjustment. The claim adjustment (i.e., adjustment bill) must be submitted separately, either electronically or by hard copy (e.g., UB-92). The instructions for column 11 of the Detail Page reflect the type of payment made.

• If the credit balances are repaid by check, the provider must still submit adjustment bills for any individual credit balances. (The FI will ensure that the monies for these balances are not collected twice.)

FI Internal Controls

The FI’s Chief Financial Officer for Medicare Operations shall ensure that all FI credit balance reporting related processes and activities are completed timely and accurately.


Minimum Requirements for Internal Controls


A. A designated centralized area to receive Medicare credit balance reports.

B. FIs shall have all CMS-838 reports and accompanying documents retained in the centralized area. The sole exceptions are the originals of the accompanying check and/or accompanying claim adjustment bill.

• A copy of any accompanying check or accompanying claim adjustment bills must be retained with the other original documents.

• All other documents must be copied if the information they contain is needed by another area for the resolution of any matter involving provider credit balance reports.

• The envelopes shall be retained or copied to substantiate the date of receipt of the CMS-838 report.

NOTE: FIs may convert these materials into image files (e.g., PDF files) for electronic storage and archival purposes.

C. Faxed credit balance reports that are within 30 calendar days of the close of each calendar quarter should be accepted as timely.

• Retain the coversheet to substantiate the date of receipt of the CMS-838 report.

NOTE: When the FI accepts faxes, the FI shall ensure that these faxes are received over electronically secure transmission lines, and placed in a limited access work area.

D. The FI shall designate a point of contact for receipt and the resolution of credit balance reporting related issues. This individual is to verify that all FI activities related to credit balance reporting are completed timely and accurately in all areas of the FI.

E. The FI shall have a listing of all providers required for submitting the CMS-838. FIs shall have written procedures to ensure this listing is reviewed and updated each calendar year quarter.

F. Written policies and procedures for monitoring and validating receipt of timely, accurate, and complete CMS-838s from all providers.

For example:

• Is the name and title of the certifying officer or administrator of the provider on the Certification Page, and are all data fields completed for Medicare credit balances on the Detail Page? Did the Detail Page come with an accompanying check and/or appropriate hard copy or electronic adjustment bills?

• Were the monies for the reported credit balances timely recouped to the Medicare Trust Fund?

G. FIs shall have appropriate tracking and/or reports for provider credit balances reporting related activities.

For example:

• Such as related claims adjustments, Suspension Warning Letters and suspensions, verification of low Medicare utilization providers with claims data, demand letters, financial reporting, credit balance summary reports, etc., that have been performed with respect to credit balance reports due or received for a given calendar year quarter.


H. The FI shall have internal controls in place to ensure the accurate and timely processing and reporting of credit balances.

• The time frame for processing claims adjustments for Medicare credit balances from start to finish is 90 days from the receipt date of acceptable credit balance reports. (Contact your RO if you need additional time.)

I. A desk guide or manual with published internal control policies and standard operating procedures for implementing the credit balance reporting process.Suspension Warning Letter (FI Action if a Credit Balance Report is not Submitted)


A. The FI shall issue a Suspension Warning Letter if it does not receive a credit balance report from a provider by the 15th calendar day after 30 calendar days from the end of each calendar year quarter (45 calendar days from the end of each calendar year quarter).

• The Suspension Warning Letter shall state that the FI will suspend all claims payments at 100% in 15 calendar days from the date of issuance of this letter if the credit balance report is not received during this time period.

• This suspension will continue until the FI receives a credit balance report.

• The FI shall ensure that any necessary suspensions are implemented timely and maintained, as appropriate. (Refer to Pub. 100-06, Chapter 4, §§40 - 40.2). In addition, Federal regulations at 42 CFR §405.372 require that the provider be notified of the intention to suspend payment and the reasons for the suspension.

B. The FI shall have the responsibility to ensure that if providers change from submitting a low utilization cost report to a full cost report, then they shall comply with all credit balance reporting requirements. NOTE: A provider with extremely low Medicare utilization does not have to submit the CMS-838 form. A low utilization provider is defined as a facility that files a low utilization Medicare cost report or files less than 25 Medicare claims per year.


Issuance of a Notification/Rejection Letter to Providers Regarding Non-Payment of Medicare Credit Balances or Missing/Inaccurate Information on the CMS-838 Report


A. The FI shall have a process in place to resolve non-payment of Medicare credit balances or missing/ inaccurate information on received CMS-838 reports.

For example:

• Review each credit balance entry individually on the CMS-838 report to determine whether it is missing information such as: is it being repaid by check or hardcopy adjustment bill?

• Contacting the provider via telephone, to obtain missing information on the CMS-838 report. (Phone calls should be documented).

• If the FI is successful at reaching the provider, the provider may fax over the requested information at the FI’s discretion.

B. If the FI is unsuccessful in reaching the provider within 30 calendar days from the due date of the CMS838 report, the FI should issue a letter on the thirtieth day after the due date of the CMS-838 report.

• This letter shall state that the FI will place the provider on 100% withhold up to the total amount owed if the provider does not send a check or adjustment bills for these balances in 15 calendar days from the date of this letter.

• After the Notification/Rejection letter has been sent and the provider is placed on 100% withhold up to the total amount owed and a balance remains outstanding 60 days after the due date of the CMS838, the FI must issue a demand letter to the provider. Refer to Section 10.6 - FI Issuance of a Credit Balance Demand Letter.



FI Issuance of a Credit Balance Demand Letter 

When a Medicare credit balance is not fully recovered to the Medicare Trust Fund through the adjustment bill process (or through check submission) and this balance remains outstanding 60 days after the due date of the CMS-838, the FI shall issue a demand letter to the provider.

• The FI shall issue demand letters within 60 calendar days from the due date of the CMS-838 report.

• If a full payment is not received 15 days after the date of the first demand letter, the FI shall start the 100% withholding of claims payment up to the total amount owed on day 16, (if they haven’t already placed providers on 100% from their 1st Notification/Rejection letter) Refer to Pub. 100-06, Chapter 4, §§40 and 40.1.

• If no response is received from the provider within 30 days after the date of the first demand letter, follow the existing instructions in Pub. 100-06, Chapter 4, §§10 and 20.

• If the provider believes that prompt repayment of the amount owed Medicare is so large that it will cause financial hardship, the provider may complete a request for an extended repayment schedule in accordance with Pub. 100-06, Chapter 4, §50.

• Contact your Regional Office (RO) for guidance on specific provider issues as needed. Refer to Pub. 100-06, Chapter 3, §40.2 for sample Demand Letter for Claims Accounts Receivables. For MSP, refer to Pub. 100-05, Chapter 7, §60.10.1 “Intent to Refer” letter.

10.7 - Interest Assessment for Non-MSP and MSP Medicare Credit Balances (Rev. 99, Issued: 06-30-06; Effective/Implementation Dates: 10-02-06) Calculation of Interest on Medicare Credit Balances Effective October 1, 2004, 42 CFR § 405.378 and 411.24 (m) (l) was amended to change how interest is calculated on Non-MSP/MSP recoveries. Section 1862(b)(2)(B)(i) of the Act provides express authority to assess interest on MSP debts. Under this new rule, interest is assessed for each full 30-day period thatpayment is not made on time. This change applies to debts established on or after October 1, 2004.

A. Assessment of Interest on Non-MSP Credit Balances Interest on Non-MSP debts established prior to October 1, 2004 will continue to be assessed under the former method, until the debt is recovered in full. NOTE: Refer to Pub. 100-06, Chapter 4, §30.3 – Non-MSP (Debt Collection).

B. Assessment of Interest on MSP Credit Balances Refer to Pub. 100-05, Chapter 7, revised §30.1.5- “Interest on MSP Recovery Claims” for information on the calculation of interest.




Monday, February 17, 2020

Post operative period billing guidelines - Modifier usage


POST-OPERATIVE PERIOD BILLING

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

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

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

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

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

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

• Practice in a group of ten or more practitioners;

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

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

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

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

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


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

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

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

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

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

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

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

Critical Care

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


Special Reporting for Certain Practitioners for CPT code 99024

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

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

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

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

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

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

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

Thursday, January 30, 2020

CPT G0121, G0122, G0328, G0464

Procedure code and description

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

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

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

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

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

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


Medicare billing Guidelines

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

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

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


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


Screening colonoscopy

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

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

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


Denial codes


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

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

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

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

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

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

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



Thursday, December 19, 2019

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

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

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

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

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

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

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


Subsequent Observation Care

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

Observation Care Discharge Services

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

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

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

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

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



Question and answers



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

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


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


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

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


Reimbursement Guidelines from Aetna Medicaid

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

Applicable Codes/Conditions of Coverage

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


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

Day 1-The First Da
y

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

The Middle Days

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

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

The Discharge Day

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

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


Wednesday, November 13, 2019

ST Join INJECTION CPT code - 27096, G0259, G0260


CPT Description

64450 Injection, anesthetic agent; other peripheral nerve or branch

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

G0259 Injection procedure for sacroiliac joint, arthrography.

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

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




Billing and Coding Guidelines


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

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


General

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

Spinal Cord Stimulators Description


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

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

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

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


Indications and Limitations of Coverage and/or Medical Necessity

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

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

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


Subject: Sacroiliac Joint Injections


DESCRIPTION:


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

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

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

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

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

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

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

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


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

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

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

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