Showing posts with label CPT code. Show all posts
Showing posts with label CPT code. Show all posts

Monday, September 12, 2016

CPT CODE 98960, 98961, 98962 - Not separately payable

CPT  code definitions:

• 98960 -- education & training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

• 98961 -- 2-4 patients - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patient


• 98962 -- 5-8 patients - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients


Avoid claim errors for current procedural terminology codes 98960, 98961 and 98962

First Coast Service Options (First Coast) has recently seen a large number of Part A outpatient claim errors for current procedural terminology (CPT®) codes 98960, 98961 and 98962. Providers are reminded that professional services paid under the Medicare physician fee schedule (MPFS) for these codes are bundled or not valid for Medicare purposes. The Centers for Medicare & Medicaid Services (CMS) published relative values units (RVU) as a courtesy, since many private payers use this methodology when establishing their payment rates.

The CPT codes 98960, 98961 and 98962 are not separately billable services, and are either bundled into another service reported on the same day or are simply not covered. Do not report these codes to Medicare, unless required for secondary insurance.

• Verify the patient’s records to ensure you are billing the correct CPT® code

• Submit the charges as non-covered when a denial is required for the secondary payer


Separately Reimbursed:

Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioner when the lactation consultation is the only service provided and performed by a certified lactation consultant under the general supervision of a licensed MD/DO or midlevel practitioner.

Not Separately Reimbursed:

Lactation consultations (98960) are considered not separately reimbursed and part of the E & M service when it is provided at the same time as an E&M visit.

99201-99215
99381-99397

Lactation consultations will deny as not separately reimbursed for members ( HCR and NHCR participants) when filed with a non-covered diagnosis.

If the service is provided by a Homecare Agency, the service is covered as part of the homecare
Per Diem.


Effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare will implement a new policy denying reimbursement of non-physician health care professional medicine services when reported by physicians. Supported by the AMA, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by non-physician health care professionals:


• Education and training for patient selfmanagement (CPT codes 98960-98962)


Visit Limits: 

Reimbursement is allowed for 1 (one) lactation consult in a hospital outpatient setting (clinic) and 2 (two) in the physician office setting. This also applies to multiple deliveries.

CPT code 98960 should only be filed with an ICD-9-CM diagnosis code for a lactation disorder listed below:

98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient


Reimbursement Guidelines

The American Medical Association Current Procedural Terminology (CPT®) Professional Edition gives the following instruction for code selection: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.” The American Medical Association (AMA) has developed specific CPT codes intended for use by qualified health care professionals who are not Physicians to report their services. In some instances the intended use of a procedure or service is within the description of the code. For example CPT 98960 describes education and training for patient selfmanagement by a qualified, nonphysician health care professional. In other instances the AMA has included parenthetical information in the CPT book as with CPT 96040 which says  “These services are provided by trained genetic  counselors and may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family.”

Conversely, the AMA instructs Physicians who provide genetic counseling and education, risk factor reduction intervention or medical nutrition therapy to use the appropriate evaluation and management codes to report these services. Existing evaluation and management codes include services such as taking a patient’s health and family history and counseling. Therefore, in accordance with correct coding guidelines, UnitedHealthcare will not reimburse nonphysician health care professional service codes listed in the Code Section below when reported by a Physician, because these codes are intended for use by nonphysician health care professionals. Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy, education and training for patient self-management or medication therapy management should report these services using appropriate evaluation and management codes



Reimbursement Guideline from UHC

UnitedHealthcare Community Plan will reimburse for Telehealth services which are recognized by CMS when reported with modifier GT (Interactive Telecommunications). In addition, UnitedHealthcare Community Plan recognizes that medical genetics and genetic counseling services (CPT code 96040), education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum (CPT codes 98960-98962), and alcohol and/or substance abuse screening and brief intervention services (CPT codes 99408-99409) can be effectively performed via Interactive Audio and Video Telecommunications systems; these codes will be allowed for reimbursement when reported with modifier GT. UnitedHealthcare Community Plan will also reimburse CPT codes 0188T and 0189T when these codes are reported with or without a GT modifier, since the description for these codes indicates a Telehealth service and the technology used.

Any other service reported with modifier GT that is not recognized by CMS will not be reimbursed.

UnitedHealthcare Community Plan Codes Recognized with Modifier GT

UnitedHealthcare will consider reimbursement for a procedure code/modifier combination using modifier GQ to report Asynchronous Telecommunications only when the modifier has been used appropriately.

Coding relationships for modifier GQ are administered through the UnitedHealthcare Procedure to Modifier Policy. UnitedHealthcare Community Plan will not reimburse for HCPCS code T1014 (Telehealth transmission, per minute, professional services bill separately) because these services are included in Telehealth services.

Telemedicine Services

Telephone Calls UnitedHealthcare Community Plan follows CMS guidelines and does not reimburse for telephone charges submitted with CPT codes 98966-98968 or 99441-99443 because they do not involve direct, in-person patient contact.

Internet Services

UnitedHealthcare Community Plan follows CMS guidelines and does not reimburse for CPT codes 98969 and 99444 (Online Medical Evaluation), because these services do not involve direct, in-person patient contact.

Consultation Services

UnitedHealthcare Community Plan follows CMS guidelines and does not reimburse for interprofessional telephone/Internet assessment and management services reported with CPT codes 99446-99449 because they do not involve direct, in-person patient contact.

Monday, September 5, 2016

Ophthalmologist CPT code list

Code           Ophthalmology Description        Comments

65771 Radial keratotomy Not reimbursed

65782 Ocular surface reconstruction

65855 Trabeculoplasty by laser surgery, one or more sessions

66179 Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft

66184 Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft

66761 Iridotomy, iredectomy by laser surgery

66990 Use of ophthalmic endoscope (add-on code intended to be reported with a specified list of other intraocular surgical procedures)
May only be billed and reimbursed with codes: 65820, 65875, 65920, 66985, 66986, 67036, 67039, 67040, 67041- 67043, 67107, 67108, 67110 and 67113 67101, 67105 Retinal repair 67141; 67145 Prophylaxis of retinal detachment without drainage, one or more sessions;

67101, 67105 Retinal repair

67141; 67145 Prophylaxis of retinal detachment without drainage, one or more sessions; cryotherapy, diathermy; photocoagulation

67208, 67210, 67218  Destruction of localized lesion of retina; one or more sessions; cryotherapy, diathermy; photocoagulation; radiation

67220 Destruction of localized lesion of choroids (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions 67221 Photodynamic therapy 67225 Photodynamic therapy, second eye, at single session 67227, 67228 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotheraphy, diathermy; photocoagulation 76514 Corneal pachymetry Reimbursement is limited to one test per member, per lifetime, for only the following diagnosis codes:
ICD-9 Covered Indications

364.22, 364.77, 365.00– 365.99, 371.20, 371.23, 371.57, 371.58

ICD-10 Covered Indications

92015 Determination of refraction Refraction services will not be reimbursed separately when performed on the same day as an eye exam or an E&M service.

92020 Gonioscopy

92071 Fitting of contact lens for treatment of ocular surface disease

Reimbursement is limited to one fitting per member, per lifetime for only the following diagnosis codes when submitted as the primary diagnosis:
ICD-9 Covered Indications

053.21, 054.42, 054.43, 279.52, 351.0-351.9, 370.33, 370.34, 370.35, 371.81, 375.15, 694.61, 695.13, 695.14, 695.15, 710.2, 743.45, 940.0-940.9

ICD-10 Covered Indications (continued)


92072 Fitting of contact lens for management of keratoconus, initial fitting

Reimbursement is limited to one fitting per member, per lifetime for only the following diagnosis codes when submitted as the primary diagnosis:
ICD-9 Covered Indications
371.60-371.62, 918.1
ICD-10 Covered Indications

92082, 92083 Visual field exam, intermediate and comprehensive

92100 Tonometry

92136 Ophthalmic biometry by partial coherence interferometry

92225, 92226 Ophthalmoscopy

92230, 92235 Fluorescein angioscopy

92240 Indocyanine-green angiograpny

92250 Fundus photography

92260 Opthalmodynamometry

92265 Needle oculoelectromyography

92270 Electro-oculography

92275 Electroretinography

92283 Extended color vision examination

92284 Dark adaptation examination

92285 External ocular photography

92286, 92287 Special anterior segment photography

92313 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens Reimbursement is limited to only the following diagnosis codes:
ICD-9 Covered Indications
053.21, 054.42, 054.43, 279.52, 351.0-351.9, 370.33, 370.34, 370.35, 371.81, 375.15, 694.61, 695.13, 695.14, 695.15, 710.2, 743.45, 940.0-940.9


92499 Unlisted ophthalmological service or procedure Not reimbursed in addition to an E&M service when billed for preferential looking test.

99026, 99027 Hospital mandated physician on call services Not reimbursed

99173 Screening test of visual acuity Not reimbursed when billed with an E&M service

99177 Instrument-based ocular screening (e.g., photoscreening,automated-refraction), bilateral; with on-site  analysis

Temporary or permanent lacrimal duct implants Provider liable — payment included in the allowance of another service

J0585 - J0588 Botulinum toxin type A or B Botulinum A and B toxins Medical Policy

J3490 Unclassified drugs NDC is required.

J7311 Fluocinolone Acetonide, intravitreal implant
Retisert. Clinical documentation that supports the covered condition is required. First time claim submissions can be submitted on paper with operative notes for consideration. If notes are not submitted, the claim will deny requesting notes. (continued)

V2500 Contact lens, PMMA , spherical, per lens Reimbursement is limited to only the following diagnosis codes:

ICD-9 Covered Indications

053.21, 054.42, 054.43, 279.52, 351.0-351.9, 370.33, 370.34, 370.35, 371.60-371.62, 371.81, 375.15, 694.61, 695.13, 695.14, 695.15, 710.2, 743.45, 918.1, 940.0-940.9

ICD-10 Covered Indications

V2501 Contact lens, PMMA , toric or prism ballast, per lens

V2502 Contact lens PMMA , bifocal, per lens

V2503 Contact lens, PMMA , color vision deficiency, per lens

V2510 Contact lens, gas permeable, spherical, per lens

V2511 Contact lens, gas permeable, toric, prism ballast, per lens

V2512 Contact lens, gas permeable, bifocal, per lens

V2520 Contact lens, hydrophilic, spherical, per lens

V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens

V2522 Contact lens, hydrophilic, bifocal, per lens

V2523 Contact lens, hydrophilic, extended wear, per lens

V2530 Contact lens, scleral, gas impermeable, per lens

V2531 Contact lens, scleral, gas permeable, per lens

V2785 Processing, preserving and transporting corneal tissue

V2787 Astigmatism-correcting function of intraocular lens Not reimbursed

V2788 Presbyopia correcting function of intraocular lens

Wednesday, August 31, 2016

CPT CODE 20552, 20553 - Trigger point injection


CPT Description

20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

Trigger Point Injections are used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Trigger points may irritate the nerves around them and cause pain at the site of the  trigger point or the pain can be felt in other parts of the body, including the back and neck. Trigger point injections involve injection of local anesthetic, saline, dextrose, and/or cortisone into the trigger point.

Harvard Pilgrim reimburses contracted providers for trigger point injections when medically necessary and appropriate.

Harvard Pilgrim Health Care payment policy is consistent with CMS LCD Trigger Point Injection policy, American Academy of Craniofacial Pain, Agency for Healthcare Research and Quality (AHRQ) guidelines.


Limitations

Acupuncture is not a covered service, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered (whether an acupuncturist or other provider renders the service). Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered.

Only one code from 20552 or 20553 should be reported on any particular day, no matter how many sites or regions are injected.

When a given site is injected, it will be considered one injection service, regardless of the number of injections administered.

Covered for 20552 and 20553:

Prerequisite(s)

Applicable Harvard Pilgrim referral, notification and authorization policies and procedures apply. Refer to Referral, Notification and  authorization for more information.

covered indications may include, but are not limited to:

• Central pain syndrome

• Other acute pain

• Other chronic pain

• Cervicalgia

• Other disorders of the back

• Rheumatism excluding the back

• Myalgia and myositis, unspecified



Member Cost-Sharing

Services subject to applicable member out-of-pocket cost (e.g., co-payment, coinsurance, deductible).

Coverage Indications, Limitations, and/or Medical Necessity

Myofascial trigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); each of these single muscle syndromes is responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore, upon the detailed history and thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis:
history of onset and its cause (injury, sprain, etc.);

distribution of pain;

restriction of movement;

mild muscle specific weakness;

focal tenderness of a trigger point;

palpable taut band of muscle in which trigger point is located;

local taut response to snapping palpitation; and

reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point.

The goal is to identify and treat the cause of the pain and not just the symptom of pain.
After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:
medical management, including the use of anti-inflammatory agents, tricyclics, etc.;

stretch and use of coolant spray followed by hot packs and/or aerobic exercises;

application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible);

deep muscle massage;

injection of local anesthetic into the muscle trigger points:
as the initial or the only therapy when a joint movement is mechanically blocked, as is the case of coccygeus muscle, or when a muscle cannot be stretched fully, as is the case of the lateral pterygoid muscle;

as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., use of medications, stretch and spray.

NOTE: For all conditions, the actual area must be reported specifically and must be documented in the medical record. Using a non-specific diagnosis code to support injections of multiple areas of the body, rather than more specific diagnosis codes, may result in denial of payment.
Known trigger points may be treated at frequencies necessitated by the nature and the severity of associated symptoms and signs.

Per national Medicare regulations acupuncture is not a covered service, even if provided for treatment of established trigger point:
Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service whether the service is rendered by an acupuncturist or any other provider;

providers of acupuncture services should inform the beneficiary that such services will not be covered; and

prolotherapy is not covered by Medicare and cannot be billed under the trigger point injection code.

If the service has been provided for a diagnosis that is not listed in the covered diagnosis codes section, the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient's medical records and this must be provided at the review level for consideration.

The diagnosis codes listed as covered should only be used for purposes of this policy when a trigger point is injected.

Documentation must be maintained noting the anatomic location of the injection site(s).


Group 1 Codes

ICD-10 CODE DESCRIPTION

M46.01 Spinal enthesopathy, occipito-atlanto-axial region

M46.02 Spinal enthesopathy, cervical region

M46.03 Spinal enthesopathy, cervicothoracic region

M46.04 Spinal enthesopathy, thoracic region

M46.05 Spinal enthesopathy, thoracolumbar region

M46.06 Spinal enthesopathy, lumbar region

M46.07 Spinal enthesopathy, lumbosacral region

M46.08 Spinal enthesopathy, sacral and sacrococcygeal region

M46.09 Spinal enthesopathy, multiple sites in spine

M53.82 Other specified dorsopathies, cervical region

M60.811 Other myositis, right shoulder

M60.812 Other myositis, left shoulder

M60.821 Other myositis, right upper arm

M60.822 Other myositis, left upper arm

M60.831 Other myositis, right forearm

M60.832 Other myositis, left forearm

M60.841 Other myositis, right hand

M60.842 Other myositis, left hand

M60.851 Other myositis, right thigh

M60.852 Other myositis, left thigh

M60.861 Other myositis, right lower leg

M60.862 Other myositis, left lower leg

M60.871 Other myositis, right ankle and foot

M60.872 Other myositis, left ankle and foot

M60.88 Other myositis, other site

M60.89 Other myositis, multiple sites

M75.81 Other shoulder lesions, right shoulder

M75.82 Other shoulder lesions, left shoulder

M76.31 Iliotibial band syndrome, right leg

M76.32 Iliotibial band syndrome, left leg

M76.811 Anterior tibial syndrome, right leg

M76.812 Anterior tibial syndrome, left leg

M77.51 Other enthesopathy of right foot

M77.52 Other enthesopathy of left foot

M77.9 Enthesopathy, unspecified

M79.0 Rheumatism, unspecified

M79.1 Myalgia

M79.7 Fibromyalgia



Indications and Limitations of Coverage and/or Medical Necessity

Injection of a tendon sheath, ligament or trigger point consists of an anesthetic agent and/or steroid agent injected into an area for the management of pain. This Local Coverage Determination only addresses the injection of trigger points. Trigger points are areas of taut muscle bands or palpable knots of the muscle, that are painful on compression and can produce referred pain, referred tenderness, and/or motor dysfunction. A trigger point may occur in any skeletal muscle/fascia in response to strain produced by acute or chronic overload. Pain from trigger points can be mild to severe. When trigger point pain is severe and unresponsive to non-invasive treatments (e.g., anti-inflammatory medications, physical therapy, etc.), trigger point injections with local anesthetic and/or a steroid agent may be helpful.

Besides injection into trigger points, local injections are useful in the treatment of pain or dysfunction due to inflammation or other pathological changes of tendon sheaths, and ligaments. Findings may include pain on motion or palpation, swelling, friction rubs and/or catches. Injections; single or multiple trigger point(s), one or two muscle(s) (20552) or single or multiple trigger point(s), three or more muscle(s) (20553)

The injection of trigger point(s) will be considered to be medically reasonable and necessary for the treatment of trigger points that are unresponsive to non-invasive treatments or when non-invasive methods of treatment are contraindicated. The medical record should clearly reflect all methods attempted and the results. If treatments are contraindicated, the medical record should indicate why the trigger point(s) is not amenable to other therapeutic modalities.

Non-invasive treatments may include, but are not limited to:
• Medications (non-steroidal anti-inflammatory drugs, muscle relaxants, etc.)

• Physical therapy (massage, heat or ice, stretching, etc.)

• Activity modification

• Home exercise instruction

Repeat trigger point injections may be necessary when there is evidence of persistent pain or inflammation. Evidence of partial improvements to the range of motion in any muscle area after an injection would justify a repeat injection. Again, the medical record should clearly reflect the medical necessity for repeated injections.

It is not recommended that trigger point injections be used on a routine basis for patients with chronic non-malignant pain syndromes. In addition, several studies indicated that when additional injections are required in a series, other therapies (e.g., medications, physical therapy) in addition to the injections may be beneficial.

CPT/HCPCS Codes


20552 Injection(s); single or multiple trigger point(s), one or two muscle(s)

20553 single or multiple trigger point(s), three or more muscle(s)


Utilization Guidelines


The frequency at which trigger point injection(s) are performed is dependent on the clinical presentation of the patient. However, it is generally expected that the patient’s response to the previous injection is important in deciding whether to proceed with additional injections. If the patient has achieved significant benefit after the first injection, an additional injection would be appropriate for reoccurring symptoms. (Repeated injections may be justified by evidence of improvement, such as reduction in pain, muscle tenderness, spasm; or improvement in the range of motion.)

Multiple trigger points may be injected during any one session (see procedure codes 20552 and 20553). Some trigger points may need to be re-injected weekly or monthly for brief intervals consisting of a few months, depending on the results of the  injections and the relief of pain that the injection provides. If therapeutic effect  is achieved, medical literature supports that no more than three sets (or sessions) of injections should be performed during one year. If the patient experiences no symptom relief or functional improvement after two to three injections into a muscle, repeated injections into that muscle are not recommended. It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Wednesday, August 17, 2016

CPT CODE 80047, 80048

Basic Metabolic Panel (Calcium, total), 80048

CPT coding guidelines indicate that a Basic Metabolic Panel (Calcium, total), CPT code 80048 should not be reported in conjunction with 80053. If a submission includes CPT 80048 and CPT 80053, only CPT 80053 will be reimbursed. There are 2 configurations for a Basic Metabolic Panel (Calcium, total), CPT code 80048:

A submission that includes 5 or more of the following laboratory component codes by the same individual physician or other health care professional for the same patient on the same date of service is a reimbursable service as a Basic Metabolic Panel (Calcium, total), CPT code 80048.
Panel Code - 80048

Effective January 1, 2008, the CPT Editorial Panel created a new code 80047 Basic metabolic panel (Calcium, ionized) which is an automated multi-channel chemistry (AMCC) code and is currently included in the automated multi-channel chemistry code (AMCC) Panel Payment Algorithm. The new code 80047 is comprised of eight component test codes (see table below). Also, new code 80047 is not a replacement for code 80048 Basic metabolic panel. Both codes 80048 and 80047 are included in the 2008  clinical laboratory fee schedule.

 In order to determine payment for the new code 80047, using the AMCC Panel Payment Algorithm, existing code 82330, Calcium; ionized, will be added as an AMCC panel code. Payment code ATP23 has also been included in the clinical laboratory fee schedule data file to correspond to the AMCC panel code addition.

CPT code 80047 Basic metabolic panel (Calcium, ionized) comprises:

• Calcium; ionized (82330)
• Carbon dioxide (82374)
• Chloride (82435)
• Creatinine (82565)
• Glucose (82947)
• Potassium (84132)
• Sodium (84295)
• Urea Nitrogen (BUN) (84520)

For ESRD dialysis patients, CPT code 82330 Calcium; ionized shall be included in the calculation for the 50/50 rule as defined in Pub. 100-04, Chapter 16, Section 40.6. When CPT code 82330 is billed as a substitute for CPT code 82310, Calcium; total, it shall be billed with modifier CD or CE. When CPT code 82330 is billed in addition to CPT 82310, it shall be billed with CF modifier.

CPT panel code 80047 cannot be billed for services ordered through an ESRD facility. All tests billed for services ordered through an ESRD facility must be billed individually, not in an organ disease panel.



Basic Metabolic Panel (Calcium, total), 80048


CPT coding guidelines indicate that a Basic Metabolic Panel (Calcium, total), CPT code 80048 should not be reported in conjunction with 80053. If a submission includes CPT 80048 and CPT 80053, only CPT 80053 will be reimbursed. There are 2 configurations for a Basic Metabolic Panel (Calcium, total), CPT code 80048:

1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Basic Metabolic Panel (Calcium, total), CPT code 80048.


Panel Code  Code Description Must contain 5 or more of the following Component Codes for the same patient on the same date of service


82310 Calcium; total
82374 Carbon Dioxide (bicarbonate)
82435 Chloride; blood
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)
84132 Potassium; serum, plasma or whole blood
84295 Sodium; serum, plasma or whole blood
84520 Urea nitrogen (BUN)



A submission that includes an Electrolyte Panel, CPT code 80051 plus 1 or more of the following laboratory component codes by the same individual physician or other health care professional for the  same patient on the same date of service is a reimbursable service as a Basic Metabolic Panel (Calcium, total) CPT code 80048.

Panel Code - 80048

Code Description 
Includes the following panel:
. 80051     - Electrolyte Panel
.Plus 1 or more of the following component codes for the same patient on the same date of service:
.82310     - Calcium; total
.82565     - Creatinine; blood
.82947     - Glucose; quantitative, blood (except reagent strip)
.84520     - Urea nitrogen; quantitative


UHC Guideline

Organ or Disease-Oriented Laboratory Panel Codes

The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, and 80076. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare Community Plan uses CPT coding guidelines to define the components of each panel.

UnitedHealthcare Community Plan also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician or Other Health Care Professional. The Professional Edition of the CPT ® book, Organ or DiseaseOriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."

For reimbursement purposes, UnitedHealthcare Community Plan differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare Community Plan will deny the individual Component Codes and require  the provider to submit the more comprehensive Panel Code. as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80061, 80069, 80074 and 80076 identify the Component Codes that UnitedHealthcare Community Plan will require the submission of the specific panel.

Basic Metabolic Panel (Calcium, total), 80048

CPT coding guidelines indicate that a Basic Metabolic Panel (Calcium, total), CPT code 80048 should not be reported in conjunction with 80053. If a submission includes CPT 80048 and CPT 80053, only CPT 80053 will be reimbursed. There are 2 configurations for a Basic Metabolic Panel (Calcium, total), CPT code 80048:

1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Basic Metabolic Panel (Calcium, total), CPT code 80048.

Panel Code Component Code Code Description

80048 Basic Metabolic Panel (Calcium, total), 80048 Must contain 5 or more of the following Component Codes for the same patient on the same date of service

82310 Calcium; total
82374 Carbon Dioxide (bicarbonate)
82435 Chloride; blood
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)
84132 Potassium; serum, plasma or whole blood
84295 Sodium; serum, plasma or whole blood
84520 Urea nitrogen (BUN)


Indications and Limitations of Coverage and/or Medical Necessity

Two of the panel codes are similar in that they include laboratory studies that evaluate the bodyys effectiveness in carrying on its metabolic processes. The component tests included in one or both of the metabolic panels are: Carbon dioxide, chloride, creatinine, glucose, potassium, sodium, urea nitrogen, albumin, bilirubin, calcium, alkaline phosphatase, total protein, and aspartate aminotransferase.

The indications for the metabolic panels are the indications for each individual test. Brief descriptions of the component laboratory tests follow:

Albumin is the most abundant protein in human plasma, representing 40% to 60% of the total protein. It is synthesized in the liver. The chief biological functions of albumin are to transport and store a wide variety of ligands, to maintain the plasma oncotic pressure, and to serve as a source of endogenous amino acids.

Hyperalbuminemia is of little diagnostic significance except in dehydration. Hypoalbuminemia, however, is very common in many conditions such as liver disease; tissue damage and inflammation; malabsorption syndromes; malnutrition; protein loss in urine, feces, or through skin due to burns; and ascites.

Bilirubin, total or direct, is one of a number of tests useful in the assessment of liver function. Bilirubin is produced from the catabolism of the heme molecule.

A number of inherited and acquired diseases affect one or more of the steps involved in the production, uptake, storage, metabolism, and excretion of bilirubin. The most commonly occurring form of unconjugated hyperbilirubinemia is physiological jaundice of the newborn. Both conjugated and unconjugated bilirubin are retained in hepatobiliary diseases. When any portion of the biliary tree becomes blocked or abnormally permeable, biliary passage of bilirubin and of all other components of bile is retarded. Examples of these conditions include sclerosing cholangitis; primary biliary cirrhosis; sarcoidosis; hepatic carcinomas; carcinoma of the head of the pancreas, common bile duct, or ampulla of Vater; choledocholithiasis; and common duct strictures.

Calcium is found in three main body compartments: bone, soft tissue, and extracellular fluid. In blood, virtually all of the calcium is in plasma. The concentration of calcium as well as inorganic phosphate and magnesium in plasma is dependent on the balance between rates of bone mineral deposition, bone resorption, intestinal absorption, and renal clearance. Parathyroid hormone and 1,25-dihydroxyvitamin D are the two primary regulators of these processes and the concentration of these ions in plasma.

Alkalosis leads to an increase in binding and a decrease in free calcium; conversely, acidosis leads to a decrease in binding and an increase in free calcium. A decrease in the serum free calcium concentration causes increased neuromuscular excitability and tetany; whereas an increased concentration reduces neuromuscular excitability. Calcium is also important in muscle contraction and is a second messenger affecting enzyme activity and hormone secretion.

Carbon Dioxide is transported in the blood in several forms. The most abundant and important is bicarbonate in the plasma. Alterations of bicarbonate dissolved in plasma are characteristic of acid-base imbalance. The nature of the imbalance cannot, however, be inferred from the carbon dioxide value itself; its value has significance only in the context of other electrolytes and pH that have been determined simultaneously.

Increases in total carbon dioxide occur in metabolic alkalosis due to severe vomiting, hyperkalemic states, or excessive intake of alkali, as well as in respiratory acidosis, especially when compensated. Decreases are associated with renal failure, renal tubular acidosis which coexist in hyperchloremia, diarrhea, states of poor tissue perfusion, and respiratory alkalosis.

Chloride is the major extracellular anion and is significantly involved in maintenance of water distribution, osmotic pressure, and anion-cation balance in the extracellular fluid compartment.

Hypochloremia is observed in chronic pyelonephritis and metabolic acidoses caused by conditions such as diabetic ketoacidosis or renal failure. In addition, persistent gastric suction and prolonged vomiting result in significant loss of chloride ions. Other conditions associated with hypochloremia include hyperaldosteronism, bromide intoxication, and cerebral salt- wasting after head injury. Hyperchloremia occurs with dehydration, renal tubular acidosis, acute renal failure, metabolic acidosis associated with prolonged diarrhea and loss of sodium bicarbonate, diabetes insipidus, adrenocortical hyper function, hyperparathyroidism, and salicylate intoxication. Extremely high dietary intake of salt and over treatment with saline solutions are also causes of hyperchloremia.

Creatinine is a metabolic by-product of muscle contraction. The amount of endogenous creatinine produced is proportional to muscle mass and varies with age and sex. Daily excretion of creatinine can be 10% to 30% greater as a result of dietary intake of creatine and creatinine in meats. The excretion rate in any one person, in the absence of renal disease, is relatively constant and parallels endogenous production.

Creatinine clearance is performed by obtaining urine specimens over a period of time and also a blood specimen at sometime during that collection period. Estimations of creatinine clearance can be obtained from the plasma creatinine level. In patients with advanced renal failure, plasma creatinine levels are used as an adjunct to managing the administration of potentially toxic drugs that are cleared by the kidneys.

Plasma creatinine levels are used in conjunction with a plasma urea
determination in discriminating between prerenal and postrenal increases in blood urea.

Hyperglycemia or an elevation in blood glucose is produced by a group of metabolic disorders of carbohydrate metabolism called diabetes mellitus. A subclass of the condition includes patients in whom hyperglycemia is due to a specific underlying disorder, such as pancreatic disease with endocrine insufficiency; hormonal disorder; certain genetic syndromes; insulin receptor abnormalities; or the administration of hormones or drugs known to cause hyperglycemia.

Blood glucose testing is performed to diagnose hypoglycemia, to diagnose hyperglycemia, and to aid in the management of diabetes mellitus. Blood glucose testing is not paid for by Medicare when performed for screening purposes in asymptomatic individuals.

Alkaline Phosphatase (ALP) is present in practically all tissues of the body, especially at or in the cell membranes, and it occurs at particularly high levels in intestinal epithelium, kidney tubules, bone (osteoblasts), liver, and placenta. Although the precise metabolic function of the enzyme is not yet understood, the enzyme is closely associated with the calcification process in bone.

Serum ALP measurements are of particular interest in the investigation of hepatobiliary disease and bone disease associated with increased osteoblastic activity. The response of the liver to any form of biliary obstruction is to synthesize more ALP. Among the bone diseases, the highest levels of serum ALP activity are encountered in Pagets disease (osteitis deformans) as a result of the action of the osteoblastic cells as they try to rebuild bone that is reabsorbed by the uncontrolled activity of osteoclasts. Moderate rises are observed in osteomalacia. Very high enzyme levels are present in patients with osteogenic bone cancer. Secondary deposits in bone from malignancies in other sites vary in the extent to which they stimulate osteoblastosis and the ensuing elevation in the serum levels of ALP.

Potassium is the major cation within the cell. The intracellular potassium concentrations are considerably higher than serum potassium levels. This ratio is the most important determinant in maintaining membrane electrical potential in excitable neuromuscular tissue.

The serum potassium level is a blood test which reveals the bodys (serum) potassium level and is helpful in diagnosing potassium imbalances as related to medical conditions (such as complications of diabetes mellitus, complications of acute renal failure, hypokalemia and/or hyperkalemia).

This test is also utilized to monitor the efficacy of medical interventions or treatments specific to the condition under treatment.

Sodium ions are the major cations of extracellular fluid and play a major role in maintaining the normal distribution of water and the osmotic pressure in the extracellular fluid compartment. The average diet contains many times more than the body requirement of sodium. The excess is excreted by the kidneys.

Hyponatremia may be the result of excessive sweating, prolonged vomiting, persistent diarrhea, or salt-losing enteropathies. Renal loss due to diminished tubular reabsorption may be caused by inappropriate choice, dose, or use of diuretics; by primary or secondary deficiency of aldosterone, and other mineralocorticoids; or severe polyuria.

Hyponatremia is common in metabolic acidosis (diabetic ketoacidosis). Dilutional hyponatremia is secondary to excessive retention of water and occurs in edema, ascites from chronic cardiac failure, uncontrolled diabetes, hepatic cirrhosis, nephrotic syndrome, and malnutrition.

Proteins have numerous biological functions that are important and varied. Enzymes catalyze biochemical transformations essential to metabolism; protein, poly peptides, and oligopeptide hormones regulate metabolism; antibodies and components of the complement system protect against infection. Plasma proteins maintain the oncotic pressure of plasma; they transport hormones, vitamins, metals, and drugs, often serving as reservoirs for their release and use; apoliproteins solubilize lipids; hemoglobin carries oxygen; protein coagulation factors control hemostasis.

Most proteins, with the exception of immunoglobulins and protein hormones, are synthesized in the liver. Disease often alters the amount and proportions of plasma proteins in body fluids in characteristic ways.

The two general causes in alterations of serum total protein are a change in the volume of plasma water and a change in the concentration of one or more of the specific proteins in the plasma. Hyperproteinemia is noted in dehydration due to inadequate water intake or to excessive water loss, as in severe vomiting, diarrhea, Addison's disease, or diabetic acidosis. Increases in plasma water volume is reflected as relative hypoproteinemia and physiologically when a recumbent position is assumed.

Urea is the major nitrogen-containing metabolic product of protein catabolism in humans. More than 90% of urea is excreted through the kidneys, with the remaining lost primarily through the gastrointestinal tract and skin. In a normal kidney, 40% to 70% of the urea moves passively out of the renal tubule and into the interstitium, ultimately to re-enter plasma.

A wide variety of renal diseases with different permutations of glomerular, tubular, interstitial, or vascular damage can cause an increase in plasma urea concentration. However, the usefulness of urea as an independent indicator of renal function is limited by the variability of its blood levels as a result of nonrenal factors. Mild dehydration, high protein diet, increased protein catabolism, muscle wasting as in starvation, reabsorption of blood proteins after gastrointestinal hemorrhage, treatment with cortisol or its synthetic analogs, and decreased perfusion of the kidneys may cause an increased blood urea that is called prerenal. Postrenall increases in blood urea is caused by conditions that obstruct urine outflow through the ureters, bladder, or urethra. The principle clinical utility of plasma urea determination lies in its measurement in conjunction with the measurement of plasma creatinine and in discrimination between prerenal and postrenal increases in blood urea.

Aspartate aminotransferase (AST) are a group of enzymes that are involved in the metabolism of amino acids. Isoenzyme of AST are present in the cytoplasm and the mitochondria of cells. Severe tissue damage and even a mild degree of liver tissue injury results in the release of mitochondrial isoenzyme.

In viral hepatitis and other forms of liver disease associated with hepatic necrosis, levels of serum AST are elevated even before the clinical signs and symptoms of disease, such as jaundice appear. Moderately increased levels of AST activity may also be observed in extrahepatic cholestasis. Levels observed in cirrhosis vary with the status of the cirrhotic process. Elevations also occur in patients with primary or metastatic carcinoma of the liver. AST levels are also elevated in other conditions such as myocardial infarction, progressive muscular dystrophy, pulmonary emboli, acute pancreatitis, crushed muscle injuries, gangrene, and hemolytic disease.

Alanine Aminotransferase (ALT) are part of a group of enzymes that are involved in the metabolism of amino acids. ALT is found primarily in the liver, although significant amounts are also present in the kidney. ALT is thought to be predominantly nonmitochondrial.

The chief application of a determination of this serum enzyme is in the diagnosis of hepatocellular disease. It has been postulated that, in mild hepatocellular injury, when the hepatocyte plasma but not the mitrochondrial membrane is damaged, cytoplasmic ALT and AST are released into the serum. With more severe hepatocellular injury, mitochondrial membrane damage may result in the release of mitochondrial AST, elevating the AST/ALT ratio. Since ALT is found primarily in the liver, in patients with myocardial infarction, elevations of the serum levels of ALT are only slight or absent.

The ratio of AST to ALT, or DeTitus quotient, is normally 1 or slightly more. An abnormal AST/ALT ratio can be used in diagnosing a variety of conditions such as alcoholic liver disease, viral hepatitis, and metastatic carcinoma to the liver.

Limitations of coverage include ordering a metabolic panel test when one or more of its component tests are not medically necessary and reasonable in the management of the patients condition. In this case, individual tests should be ordered by the physician specific for the patients needs. In addition, the test must be ordered by a physician treating the patient or non-physician practitioners (within their scope of practice) treating the patient.


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.

Wednesday, June 22, 2016

CPT CODE G0839 and who is covered benefit

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)


HCPCS/CPT Codes
G0389 – Ultrasound exam for AAA screening


ICD-10-CM Codes
See https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual Change Requests (CRs) and coding translations for ICD-10


Who Is Covered

Medicare beneficiaries:
• With certain risk factors for AAA; and
• Who receive a referral from their physician, physician assistant, nurse
practitioner, or clinical nurse specialist


Frequency
Once in a lifetime


Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Tuesday, May 31, 2016

CPT CODE G0123, G0141, P3000, P3001, 88155, 8814 Q0091 - covered ICD 10 CODE

Screening Pap Tests

HCPCS/CPT Codes

G0123, G0124, G0141, G0143, G0144,

G0145, G0147, G0148 – Screening  cytopathology, cervical or vaginal

G0123 - Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

P3000 – Screening Pap smear by technician under physician supervision

P3001 – Screening Pap smear requiring interpretation by physician

Q0091 – Screening Pap smear; obtaining, preparing and conveyance to lab



88155 Cytopathology, slides, cervical or vaginal definitive hormonal evaluation (e.g. maturation index, karyopyknotic index, estrogenic index). List separately in addition to code(s) or other technical and interpretive services. n/a as on clinical lab fee schedule n/a n/a n/a n/a n/a 16,202 Like 88141, P3001, G0124 is an add-on code, billed with primary screening methodology code.

88141 Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician

88142 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

88147 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision

ICD-10-CM Codes

High risk – Z77.22, Z77.9, Z91.89, Z72.89,
Z72.51, Z72.52, AND Z72.53
Low risk – Z01.411, Z01.419, Z12.4, Z12.72,
Z12.79, and Z12.89


Who Is Covered

All female Medicare beneficiaries


Frequency
• Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past 3 years; or
• Every 2 years for women at normal risk


Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived


Indications and Limitations of Coverage and/or Medical Necessity

Screening Pap Smears, Pelvic and Breast Examinations 

A screening Pap smear and pelvic examination (including clinical breast examination) is covered by Medicare Part B for a woman if she has not had such an examination in the preceding 3 years (i.e., none paid by Medicare during the preceding 35 months following the month in which her last Medicare-covered screening pelvic examination was performed and found to be normal). Use ICD-9-CM code V76.2 to indicate low risk.

A screening Pap smear and pelvic examination (including clinical breast examination) is covered by Medicare Part B for a woman if she has not had such an examination in the preceding 1 year (i.e., none paid by Medicare during the preceding I 1 months following the month in which her last Medicare-covered screening pelvic examination was performed and found to be normal) when ordered by a physician (or authorized practitioner) under one of the following high risk conditions:

There is evidence (based on the medical history and other findings) that she is at high risk of developing cervical cancer and her physician (or qualified nonphysician practitioner) recommends that she have the test performed more frequently than every 3 years.

The woman is of childbearing age and has had a Pap smear during any of the preceding 3 years that indicated the presence of cervical or vaginal cancer or other abnormality.

High risk factors for cervical and vaginal cancer are:

Early onset of sexual activity (under 16 years of age);

Multiple sexual partners (five or more in a lifetime);

History of sexually transmitted disease (including the human immunodeficiency virus (HIV));

Fewer than three negative Pap smears within the previous 7 years;

Prenatal exposure to diethylstilbestrol - Exposed daughters of women who took

DES during pregnancy.


Use ICD-9-CM codeVl5.89 to indicate high risk.



C. A screening pelvic examination (including a clinical breast examination) (G0101) must include and document at least seven of the following eleven elements:

Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge.

Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses.

Pelvic examination (with or without specimen collection for smears and cultures) including:

External genitalia (for example, general appearance, hair distribution, or lesions)

Urethral meatus (for example, size, location, lesions, or prolapse)

Urethra (for example, masses, tenderness, or scarring).

Bladder (for example, fullness, masses, or tenderness).

Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)

Cervix (for example, general appearance, lesions, or discharge).

Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)

Adnexa/parametria (for example, masses, tenderness, organomegaly, or modularity)

Anus and perineum.


D. Screening Services Coverage and Reimbursement

Effective January 1, 1999, G0101 is allowed with an E/M visit if the visit is significant and separately identifiable service.

When both are appropriately provided at the same encounter, modifier 25 is appended to the E/M service code.

Effective April 1, 1999, Q0091 and a separately identifiable E/M service may be billed by the same physician on the same day. Modifier 25 is appended to the E/M service code. In this circumstance, the Part B deductible would apply to the E&M service.

For routine physical exams or preventative medicine services (99381-99499) furnished in conjunction with a medically necessary visit or covered screening pelvic exam, the following apply:

The physician may bill Medicare for a significant and separately identifiable service, using an evaluation and management E/M code.

Limiting charge, assignment and deductible rules apply to the covered portion of the visit.
The beneficiary may be billed for the non-covered portion of the visit using the preventive service E/M codes.

The amount that may be billed to the beneficiary, for the portion the of noncovered the visit, must be the amount by which provider’s current established visit charge for exceeds his/her established the noncovered charge for the service.covered.

Medicare Part B payment is made for the covered service as the lesser of the fee-schedule amount and the physician’s actual charge for the service.

Advance notice of non-coverage to the beneficiary is not required because Medicare coverage of routine physical examinations is denied on the basis of statutory exclusion.

Effective 01/01/98, the Part B deductible for screening Pap smear and pelvic examination services paid under the physician fee schedule is waived, subject to certain frequency and payment limitations.

G0123, G0143, G0147, G0148 and P3000 are paid under the clinical diagnostic laboratory fee schedule.

G0124, G0141 and P3001 are paid under the physician fee schedule.



Diagnostic Pap Smears 

Diagnostic Pap Smears may be covered for the following conditions:

Previous cancer of the cervix, uterus, or vagina that has been or is presently being treated;

Previous abnormal Pap smear;

Abnormal findings of the vagina, cervix, uterus, ovaries, or adnexa;

Any significant complaint by the patient referable to the female reproductive system; or

Any signs or symptoms that might in the physician’s judgment reasonably be related to a gynecologic disorder.

The physician performing the test would determine which method (monolayer cell preparation collected in preservative fluid, TBS or other) is medically necessary to  achieve the best results for screening or diagnostic Pap smears.

Limitations:

CPT/HCPCS procedure codes G0124, G0141, P3001, and 88141 are payable by the Part B carrier in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), and independent laboratory (81).

CPT/HCPCS procedure codes G0123, G0143, G0147, G0148, P3000, 88142, 88143,88147,88148,88150,88152,88153,88154,88155,88164,88165,88166, and 88167 are payable by the Part B carrier in the following places of service: office (11), ambulatory surgical center (24), and independent laboratory (81).

CPT/HCPCS procedure code G0101 is payable in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32), and custodial care facility (33).

CPT/HCPCS procedure code Q0091 is payable in the following places of service: office (11) and ambulatory surgical center (24).


Deductible and Copayment/Coinsurance waived (when billed with appropriate diagnosis code): 

* Screening Pap Tests (G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091)

* Screening Pelvic Examinations (G0101)

Providers must report one of the following diagnosis codes for a screening pelvic examination and/or screening Pap test:

* High Risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within past 3 years will be covered annually: V15.89 (ICD-10-CM DRAFT CODES; EFFECTIVE 10/01/2015: Z77.128, Z77.21, Z77.9, Z91.89, Z92.89)

* Low Risk covered every 24 months: V72.31, V76.2, V76.47, V76.49(ICD-10-CM DRAFT CODES;

EFFECTIVE 10/01/2015: Z01.411, Z01.419, Z12.4, Z12.72, Z12.0, Z12.79, Z12.89)

Beginning January 1, 2014, Paramount will follow Medicare guidelines and will no longer cover preventive services identified in the CPT code range 99381-99397 for Paramount Elite members. Medicare discontinued coverage of the above mentioned codes January 1, 2011 and offered alternative HCPCS codes. At times, providers may perform well-woman services in addition to a problem-oriented E/M service. If Q0091 and G0101 are reported solely for the purpose of an unrelated screening service, they may be separately reimbursed in addition to the problem-oriented E/M service. The documentation must clearly support a significant, separately identifiable service.


Reimbursement Guidelines

A. For Moda Health Medicare Advantage plans:

The provider performing the Pap/pelvic/breast exam visit may submit procedure codes G0101 and Q0091.

* G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination)

*  Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory)

If a screening rectal exam is performed as part of the Pap/pelvic/breast exam, it is considered incidental and may not be separately reported.

The laboratory performing the Pap test may bill the appropriate lab and pathology procedure code(s) for examining the Pap smear specimen (e.g. 88141-88155, 88164-88167, 88174- 88175).

Preventive medicine codes (e.g. 99397, 99397-52) billed with a gynecological diagnosis code (e.g. ICD-9 V72.31 or ICD-10 Z01.419) will be denied as a provider write-off.

Additional preventive services (e.g. a screening rectal exam, a health risk assessment, ordering covered preventive/screening labs and tests, or other assessment of a non-symptomatic Member) are covered as part of an annual comprehensive preventive exam under the Member’s Annual “Wellness” visit benefit.

* Do not request a pre-service organizational determination of non-coverage in order to have the member pay for these services out-of-pocket, as these are not non-covered services.

* These services are covered as part of the Annual “Wellness” visit, but are not part of a Pap/pelvic/breast exam.

Report any additional clinical breast exams over and above the annual Pap/pelvic/breast exam which are deemed clinically necessary with the appropriate problem-oriented E/M service code and diagnosis codes to indicate the Medical conditions or symptoms involved.

Because of the technical nature of processing and interpreting a Pap smear or specimen for cytopathology, pathologists are the only physician specialty reimbursed with the following exception: Exception: Other physician specialties equipped to perform Pap smears in their offices must have modifier PO on the claim form. Procurement and handling of the Pap smear or specimen for cytopathology is considered part of the evaluation and management of the client and is not reimbursed separately.

A pathologist must report the place of service (POS) according to where the Pap smear is interpreted: POS 1 (office), POS 3 (inpatient), POS 5 (outpatient), or POS 6 (independent laboratory). Procedure codes 88141, 88142, 88143, 88147 through 88155, 88164 through 88167, 88174, and 88175 are reimbursed only to pathologists and CLIA-certified laboratories whose directors providing technical supervision of cytopathology services are pathologists.

The following procedure codes are payable for gynecological cytopathology services:

Procedure Codes 88141 88142 88143 88147 88148 88150 88152 88153 88154 88155 88164 88165 88166 88167 88174 88175

Procedure code 88155 is a benefit, but is not reimbursed when billed in addition to cyptopathology procedure codes 88142, 88143, 88147 through 88154, 88164 through 88167, 88174, and 88175. The interpretation portion of any gynecological cytopathology test must be reported using only procedure code 88141. Reimbursement is restricted to laboratories and pathologists. It is reimbursed in addition to cytopathology procedure codes 88142, 88143, 88147 through 88154, 88164 through 88167, 88174, and 88175. Procedure code 88141 is reimbursed only to a physician. It is denied when billed by a pathologist in conjunction with the total component for cytopathology procedures (procedure codes 88142 through 88143, 88147 through 88155, 88164 through 88167, 88174, and 88175). Procedure code 88155 is a benefit, but is not reimbursed when billed in addition to the cytopathology procedure codes 88142 through 88154, 88164 through 88167, 88174, and 88175.


 HCPCS code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) describes the services necessary to procure and transport a pap smear specimen to the laboratory. If an evaluation and management (E&M) service is performed at the same patient encounter solely for the purpose of performing a screening pap smear, the E&M service is not separately reportable. However, if a significant, separately identifiable E&M service is performed to evaluate other medical problems, both the screening pap smear and the E&M service may be reported separately. Modifier 25 should be appended to the E&M CPT code indicating that a significant, separately identifiable E&M service was rendered.”


POLICY 

The Health Plan considers certain screening services to be a component of preventive medicine services or annual GYN examinations.1 When reported with problem oriented E/M services, the screening service should be considered when determining the appropriate level of E/M services to report. Therefore, a screening service reported on the same date of service with preventive medicine ervices, annual GYN examinations, and/or problem oriented E/M are not eligible for separate reimbursement even when reported with modifiers -25 or -59. (See also our Bundled Services and Supplies and Modifier 59 reimbursement policies.)

For the purpose of this policy, screening services include:

• G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

• G0102 Prostate cancer screening; digital rectal examination

• Q0091 Screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory



CODE                 RULE        CODE

G0123

Incidental

88141


Raionale for Edit:

Anthem Central Region bundles G0123, G0143, G0144, G0145, G0148 and P3000 as incidental with 88141, 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175. Based on the National Correct Coding Edits, codes G0123, G0143, G0144, G0145, G0148 and P3000 are listed as component codes to codes 88141, 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175. Therefore, if G0123, G0143, G0144, G0145, G0148 and P3000 is submitted with 88141 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175--only 88141 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175 reimburses.


Anthem Central Region bundles G0124 as incidental with 88141. Based on the National Correct Coding Edits, code G0124 is listed as a component code to code 88141. Therefore, if G0124 is submitted with 88141-- only 88141 reimburses.

Anthem Central Region bundles 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166,  88167, 88174, 88175, G0147, G0148, P3000 or P3001with G0124. Based on the National Correct Coding Edits, codes 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0147, G0148, P3000 or P3001 are listed as component codes to code G0124. Therefore, if 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0147, G0148, P3000 or P3001 is submitted with G0124--only G0124 reimburses.


Well woman Exam POLICY

Well Woman Exams do not require prior authorization.

Advantage

Well woman exams (G0101, Q0091, S0610, S0612) are covered when billed with a family planning diagnosis code (V25.01-V25.9). (ICD-10-CM DRAFT CODES; EFFECTIVE 10/01/2015: Z30.011, Z30.013, Z30.014, Z30.018, Z30.019, Z30.012, Z30.02, Z30.09, Z30.430, Z30.432, Z30.433, Z30.2, Z30.8, Z30.40, Z30.41, Z30.431, Z30.49, Z30.42, Z30.49, Z30.8, Z30.9)

Well woman exams are considered a form of an evaluation and management (E/M) service and will be denied if reported with other E/M procedure codes for the same date of service.

Modifier –SA may be used to indicate that a nurse practitioner rendered the service in collaboration with a physician

Modifier –SB may be used to indicate that a nurse midwife provided the service
Elite  Deductible and Copayment/Coinsurance waived (when billed with appropriate diagnosis code):

* Screening Pap Tests (G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091)

* Screening Pelvic Examinations (G0101)



CODING/BILLING INFORMATION

The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

HCPCS CODES

G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

Sunday, May 22, 2016

CPT 87491, 87591 - sexually transmitted infection - STI screening

Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs

HCPCS/CPT Codes

86631, 86632, 87110, 87270, 87320, 87490,
87491, 87810 – Chlamydia
87590, 87591, 87850 – Neisseria gonorrhoeae
87800 – Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
86592 – Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86593 – Syphilis test, non-treponemal, quantitative
86780 – Treponema pallidum
87340, 87341 – Hepatitis B (hepatitis B surface antigen)
G0445 – Semiannual high intensity behavioral counseling to prevent STIs, individual, face-toface, includes education skills training & guidance on how to change sexual behavior, 30 minutes


ICD-10-CM Codes

Z11.3, Z72.89, Z72.51, Z72.52, Z72.53, Z34.00,
Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82,
Z37.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90,
O09.91, O09.92, and O09.93


Who Is Covered

Certain Medicare beneficiaries who are:

• Sexually active adolescents and adults at increased risk for STIs; and • Referred for this service by a primary care provider and provided by a Medicare-eligible

primary care provider in a primary care setting

NOTE: More information on covered beneficiaries and a definition of “increased risk for STIs” can be found in the Medicare National Coverage Determinations Manual, Publication 100-03, Chapter 1, Section 210.10.

Frequency

• One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant

• One annual occurrence of screening for syphilis in men at increased risk

• Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for

STI screening CODES

CPT Code 86631: Antibody; Chlamydia
CPT Code 86632: Antibody; Chlamydia, IgM
CPT Code 86780: Antibody; Treponema pallidum
CPT Code 87110: Culture, Chlamydia, any source
CPT Code 87270: Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis
CPT Code 87320: Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis
CPT Code 87340: Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg)
CPT Code 87341: Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) neutralization
CPT Code 87490: Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique
CPT Code 87491: Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
CPT Code 87590: Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhea, direct probe technique
CPT Code 87591: Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhea, amplified probe technique
CPT Code 87800: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
CPT Code 87810: Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis
CPT Code 87850: Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhea


STIs and continued increased risk for the second screening

• One occurrence per pregnancy of screening for syphilis in pregnant women; up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs


• One occurrence per pregnancy of screening for hepatitis B in pregnant women; one additional occurrence at delivery if at continued increased risk for STIs

• Up to two 20-30 minute, face-to-face HIBC counseling sessions annually Beneficiary Pays
• Copayment/coinsurance waived

• Deductible waived


Chlamydia Infection Screening

Procedure Code(s): 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87801, 87810, 36415, 36416

Diagnosis Code(s):

• ICD-9: V70.0, V73.88, V73.98, V74.5, V75.9,

• ICD-10: Z00.00, Z00.01, Z11.3, Z11.8, Z11.9, Z20.2 OR Pregnancy (see list at end of section).

Most read cpt modifiers