Friday, July 1, 2016

CPT CODE A9270 , K0672, K0901 - REVENUE CODE 0637 - self administered drug codes

cpt code and description

A4466 - Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each

A9270 - Non-covered item or service

K0672 - Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each

K0901 - Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

K0902 - Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

L1810 - Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise How to bill non-covered self-administered drugs

The Centers for Medicare & Medicaid Services (CMS) provides instructions to contractors regarding Medicare payment for drugs and biologicals incident-to a physician’s service. The instructions also provide the contractor with a process for understanding if an injectable drug is “usually” self-administered (to mean a drug you would normally take on your own) and therefore not covered by Medicare.

• The term “usually” means that the drug is self-administered more than 50 percent of the time for all Medicare beneficiaries who use the drug, and are considered excluded from coverage.

Providers are not required to bill non-covered self-administered drugs, unless requested by the beneficiary or secondary insurance. If a line item denial is required that holds the beneficiary liable for the non-covered self-administered pharmacy services, the outpatient claim should be submitted as follows:

• Revenue code 0637

• HCPCS code that describes the services rendered; or,

• Use A9270 ( non-covered item or service) when there is no other appropriate code

• Modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit)

• Reason code 31324 will append to the line item when the GY modifier is present, and holds the beneficiary liable

• Reason code 31947 will apply to the line item when the GY modifier is not present, and holds the provider liable

• Advanced beneficiary notice (ABN) is not required

• Charges non-covered

• Do not submit the charges as covered



The outpatient code editor (OCE) status indicator is ‘E’ (non-covered) when revenue code 0637 is submitted without a HCPCS. In order to bypass the return to provider (RTP) reason code W7050 (non-covered based on statutory exclusion), the charges must be submitted as non-covered or as outlined above.

• Reason code 31947 will apply to the line item when the charges are submitted as non-covered without a HCPCS, and holds the provider liable


Clarification on Use of A9270

HCPCS code A9270, Non-covered item or service, will remain an active code and valid for Medicare. A processing note will be added to the HCPCS file that states, “Only for use on bills submitted by DMEPOS suppliers.”


The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is  available. In cases where there is no specific procedure code to describe services, a “not otherwise classified code” (NOC) must be used with either the GY or GZ modifier.

The A9270 will no longer be accepted for services or items billed to carriers.



Use of the GA, GY, and GZ Modifiers for Items and Supplies Billed to DMERCs The new GY modifier must be used when suppliers want to indicate that the item or supply is statutorily non-covered (as defined in the Program Integrity Manual (PIM) Chapter 1, §2.3.3.B) or is not a Medicare benefit (as defined in the PIM, Chapter 1, §2.3.3.A).

The new GZ modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

The GA modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they do have on file an ABN signed by the beneficiary.

The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe items or supplies, a NOC must be used with either the GY or GZ modifiers.

In cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the HCPCS code A9270 must be used by suppliers to bill for statutorily non-covered items and items that do not meet the definition of a Medicare benefit .

The information in this CR supercedes all information found in CR 1371, Transmittal B-01-30, Deletion of the HCFA Common Procedure Coding System (HCPCS) Codes A9160, A9170, and A9190 and the GX Modifier and Replacement with New Codes and Modifiers; Status Change to HCPCS Code A9270.

This Program Memorandum (PM) provides an explanation on the use of the new GY and GZ modifiers. These modifiers were developed to allow practitioners and suppliers to bill Medicare for items and services that are statutorily non-covered or do not meet the definition of a Medicare benefit and items and services not considered reasonable and necessary by Medicare. It also provides an explanation on the use of the GA modifier. The new modifiers will become effective January 1, 2002, with the annual HCPCS update. The Q3015 and Q3016 described in CR 1371 will not be implemented.

Use of the A9270

Effective January 1, 2002, the A9270, Noncovered item or service, under no circumstances will be accepted for services or items billed to local carriers. However, in cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the A9270 must continue to be used by suppliers to bill DMERCs for statutorily non-covered items and items that do not meet the definition of a Medicare benefit.




X-Ref Requirement # Instructions 3416.1 (1) Is a currently established processing requirement—re: CWF, see NOTE below, and (2) and (3) are new. Note that the default in FISS for denied items when  liability is not specified is provider, not beneficiary. Currently, there are no claim-level indicators required by Medicare to indicate provider liability valid on  all outpatient types of bills (for list of outpatient bill types, see 100- 04/1/60.4). Current line-level indicators of provider liability on noncovered lines are  modifiers -EY, -GZ, -QL, -TQ, and the HCPCS code A9270, IF no modifier is present with A9270 indicating beneficiary liability.

NOTE: The following was confirmed by the CWF maintainer: if the outpatient claim is totally noncovered with N NO-Pay Code then the requirement does not impact CWF, this is already in  place. If any other No-Pay codes are applied, the claim will notbypass the edits in CWF.

A9270 Noncovered item or service

FI/RHHI systems will accept this code, which, since it is noncovered by Medicare by definition, will be denied in all cases. Liability will rest with the provider, unless a modifier is used to assign liability to the beneficiary (i.e., -GL, -GY, -TS), when the beneficiary has been informed, prior to service delivery, that he/she may be liable for payment. Note –GA of –KB cannot be used with this code since they requires covered charges. Modifiers most likely to be used with ABNs or noncovered charges or liability notices are listed below.

The issue of ABNs arises when billing cosmetic procedures.

In that situation, report the diagnosis as V50.9,-cosmetic non-covered and also report the CPT procedure code performed. Append the GY modifier, which indicates that it is a non-covered service, to the procedure code. The benefit of this modifier is the patient will receive a remittance advice stating their financial responsibility. If the patient requests a non-covered claim to be filed to Medicare, the provider must comply.

It’s not suggested to report A9270, Non-covered service, to Medicare especially with a GA modifier because the Medicare remittance advice will state the claim needs to be forwarded to the Durable Medical Equipment carrier (DMERC) since the code submitted is a HCPCS code.

Coding Clarifications:

For all providers, each line item billed as not covered must be identified with a HCPCS code and associated modifier. This includes all OPPS packaged items and those items traditionally not billed with HCPCS codes in the past.

o Report the most specific HCPCS code available to describe the item or service.
o If no specific HCPCS code exists, report HCPCS code A9270 Noncovered item or service. All providers may report this code when applicable.

o HCPCS code A9270 code is by definition, not covered and the item will be immediately denied. The Provider will be held liable for items or services billed with HCPCS code A9270 unless an organizational predetermination notification is received.


Value Codes (FLs 39-41), A4, A5 and A6 are used to report the dollar amount included in covered charges for selfadministered drugs. Amounts for Noncovered charges should be reflected in the Noncovered charge column (FL 48) aligned with this revenue code.

 The self-administered drug Insulin, administered in an emergency situation to a patient in a diabetic coma, should be billed using this revenue code.

o Also, report the appropriate TOB code (FL 4) 013x or 085x.

o Enter Value code A4 and its related dollar amount in FLs 39-41. This should be the amount included in covered charges (FL 47) for the ordinarily noncovered, self-administrable drug, insulin.

o The costs of inpatient self-administrable drugs are included in the inpatient MS-DRG payment and should not be billed to the patient.


 If revenue code 0637 is reported on an outpatient claim without a HCPCS code, it will be processed as a noncovered service when no HCPCS codes are present.


Self-Administered By the Patient:  The term “by the patient” means Medicare beneficiaries as a collective whole. The contractor includes only the patients themselves and not other individuals (that is, spouses, friends, or other care-givers are not considered the patient). The determination is based on whether the drug is self-ministered by the patient a majority of the time that the drug is used on an outpatient basis by Medicare beneficiaries for medically necessary indications. The contractor ignores all instances when the drug is administered on an inpatient basis.


Usually Self-Administered: If a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage. In arriving at a single determination as to whether a drug is usually self-administered, contractors should make a separate determination for each indication for a drug as to whether that drug is usually self-administered. After determining whether a drug is usually self-administered for each indication, contractors should determine the relative contribution of each indication to total use of the drug (i.e., weighted average) in order to make an overall determination as to whether the drug is usually self-administered. For example, if a drug has three indications, is not self-administered for the first indication, but is self-administered for the second and third indications, and the first indication makes up 40 percent of total usage, the second indication makes up 30 percent of total usage, and the third indication makes up 30 percent of total usage, then the drug would be considered usually selfadministered.

Q: What if a beneficiary wants to appeal the denial of a self-administered drug?

A: If a beneficiary’s claim for a particular drug is denied because the drug is subject to the “selfadministered drug” exclusion, the beneficiary may appeal the denial. Because it is a “benefit category” denial and not a denial based on medical necessity, an advance notification of denial is not required. A “benefit category” denial (i.e., a denial based on the fact that there is no benefit category under which the drug may be covered) does not trigger the financial liability protection provisions of Limitation On Liability (under §1879 of the Act). Therefore, physicians or providers may charge the beneficiary for an excluded drug.


Q: How often will M&R review the list of self-administered drugs?

A: CMS expects that review of injectable drugs will be performed on a rolling basis and no less frequently than annually.



CODING GUIDELINES:

Procedure codes A4347 and K0132 are not valid for claims submitted to the DMERC. When billing for male external catheters, use code K0410 or K0411 and one unit of service for each catheter supplied.

Irrigation solutions containing antibiotics and chemotherapeutic agents should be coded A9270. Irrigating solutions such as acetic acid or hydrogen peroxide which are used for the treatment or prevention of urinary obstruction should be coded XX005.

Adhesive strips or tape used with code K0411 (Male external catheter, with adhesive strip, each) should not be billed separately. Adhesive strips and tape used in conjunction with code K0410 (Male external catheter, with adhesive coating, each) should be billed with code A4335.

Procedure code A4329 is not valid for claim submission to the DMERC. Components should be billed by individual codes.

Code A4454 (Tape, all types, all sizes) is not valid for claim submission to the DMERC. Code K0265 should be used instead.

Procedure codes K0133-K0136 are not valid for claims submitted to the DMERC. Use code A4351 in place of K0133 or K0135. Use code A4352 in place of K0134 or K0136.

Code A5149 is not valid for claims submitted to the DMERC. Use code A4335 for miscellaneous incontinence supplies. An external catheter that contains a barrier for attachment should be coded using A4335.

Codes A5113 and A5114 are for replacement leg straps used with a urinary leg bag (A4358, A5105, or A5112). These codes are not used for a leg strap for an indwelling catheter.

Codes for ostomy barriers (A5119, K0137-K0139) should not be used for skin care products used in the management of  urinary incontinence.

In the following table, the column I code includes the items identified by the codes in column II. The Column I code must be used instead of multiple column II codes when the items are provided at the same time.

Column I Codes II

A4311 A4310, A4338 A4312 A4310, A4344 A4313 A4310, A4346 A4314 A4310, A4311, A4338, A4354, A4357, K0280 A4315 A4310, A4312, A4344, A4354, A4357, K0280 A4316 A4310, A4313, A4346, A4354, A4357, K0280 A4354 K0280 A4357 K0280 A4358 A5113, A5114, K0280 A5112 A5113, A5114 A5105 A4358, A4359, A5112, A5113, A5114, K0280 K0411 K0265 XX004 A4310, A4351

If a code exists that includes multiple products, that code should be used in lieu of the individual codes

HCPCS CODES:

E0607 - Home blood glucose monitor
E0609 - Blood glucose monitor with special features (eg., voice synthesizers, automatic timers, etc.)
A4244 - Alcohol or peroxide, per pint
A4245 - Alcohol wipes, per box
A4246 - Betadine or pHisohex solution, per pint
A4247 - Betadine or iodine swabs/wipes, per box
A4250 - Urine test or reagent strips or tablets (100 tablets or strips)
A4253 - Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4256 - Normal, low and high calibrator solution/chips
A4259 - Lancets, per box
A9270 - Non covered item or service
K0131 - Spring-powered device for lancet
XX002 - Blood glucose test or reagent strip for home blood glucose monitor, per 25 strips
XX003 - Platforms for home blood glucose monitor, 50 per box
COVERAGE AND PAYMENT RULES:

Home blood glucose monitors are covered for patients who are insulin-treated diabetics and who can better control their blood glucose levels by frequently checking these levels and appropriately contacting their attending physician for advice and treatment.

A blood glucose monitor with special features is covered for patients who additionally have severe visual impairment ( 20/ 200).

Coverage of home blood glucose monitors is limited to patients meeting the following conditions:

1) The patient must be an insulin-treated diabetic;

2) The patient’s physician states that the patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to use the equipment and monitor the patient to assure that the intended effect is achieved. This is permissible if the record is properly documented by the patient’s physician; and

3) The device is designed for home rather than clinical use. Blood glucose monitors with such features as voice synthesizers, automatic timers, and specially designed arrangements of supplies and materials to enable the visually-impaired to use the equipment without assistance (E0609) are covered when the following conditions are met:

1) The patient and device meet the three conditions listed above for coverage of standard home blood glucose monitors; and

2) The patient’s physician certifies that he or she has a visual impairment severe enough to require use of this special monitoring system.

Lancets (A4259) and blood glucose test, reagent strips (A4253) and spring powered device for lancets (K0131) are covered for patients for whom the glucose monitor is covered. More than one spring powered device (K0131) per 6 months will rarely be medically necessary. More than 100 test strips (A4253) and 100 lancets (A4259) per month will rarely be medically necessary. The need for more than these amounts should be documented in the physician’s record and noted on the order kept on file by the supplier.

Alcohol or peroxide (A4244, A4245), Betadine or pHisohex (A4246, A4247) are noncovered since these items are not required for the proper functioning of the device. Urine test reagent strips or tablets (A4250) are noncovered since they are not related to this equipment. Glucose monitors and related supplies billed without a ZX modifier (see Documentation section) will be denied as not medically necessary.

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