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

Tuesday, June 20, 2017

CPT 90801, 90806, 90862 - Psychotherapy codes

CPT Code Description

90801 Interview evaluation

90804 Individual therapy 20 – 30 min

90806 Psychotherapy

90807 Psychotherapy with medical evaluation and management

90862 Pharmacologic management

New and Deleted Procedure Codes

The following psychiatric services procedure codes will be discontinued and replaced as indicated:

Category 2012 Procdure Codes 2013 Procedure Codes

90801                 90791, 90792
90802 90791, 90792
90804, 90816 90832
90806, 90818 90834
90808, 90821 90837

Psychiatric Diagnostic Interview Examination (CPT code 90801):

An E/M service may be substituted for the initial interview procedure, including consultation CPT codes, (CPT codes 99241-99263), provided required elements of the E/M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice. E/M CPT codes do not include a psychotherapy service.

B. Interactive Psychiatric Diagnostic Interview Examination (CPT code 90802):

CPT codes 90802, 90810-90815, 90823-90829 and 90857 may also be covered for any psychiatric disorder as specified in the “ICD-9-CM codes that Support Medical Necessity”
section for adults who also have one of the conditions as specified in the Local Coverage Determination. Both the primary psychiatric diagnosis and secondary communication disorder must be submitted on the claim.

Understanding the Diagnosis and Treatment of Depression

In an effort to identify ways that we may help to improve Member anti-depression medication compliance, a research study was designed and conducted by TideWatch Partners, LLC to examine the diagnosis and treatment of depression. The study gathered insights from providers, primary care physicians (PCP) and behavioral health specialists, specifically psychiatrists, about
their experience treating patients who have been diagnosed with depression.

The objectives of this study were to:

• Gain an understanding of the depression diagnosing process, including diagnostic tools and methods, and treatment plan development

• Identify barriers to Member compliance with anti-depression medications

• Assess ways that Oxford might help Members overcome these barriers Analysis of the survey showed that, among other issues, clarifying and educating providers about referrals specific to depression might help eliminate some of the perceived barriers. The following list is a summary of information that will assist you when referring Oxford Members for behavioral healthcare.

• All inpatient behavioral health services require precertification

• Outpatient behavioral health services require precertification or a PCP referral when provided to all Members, excluding Members of New Jersey small group and Individual plans

• Services provided to Members of New Jersey small group gated plans and New Jersey Individual gated plans require a referral only

• Services provided to Members of New Jersey small group non-gated plans and New Jersey Individual non-gated plans do not require a referral or precertification

• Members may obtain referrals for outpatient behavioral health services through their PCP or by calling Provider Services at 800-666-1353

Please note: Members who obtain a referral from the Behavioral Health Department do not need to go to their PCP.

• Medication management may be authorized once a month or 12 times in one year for Members who are stabilized on medication; however, if more sessions are required to stabilize a patient, providers may request additional sessions by calling the Behavioral Health Department at 800- 201-6991

• A list of participating specialists (including psychiatrists, social workers and nurse practitioners) is available through the Doctor Search tool on www.oxfordhealth.com or by calling Provider Services at 800-666-1353 



Monday, June 12, 2017

CPT 19380, 19328, 19330 - Breast repair reconstruction

CPT Code Description

19328 Removal of intact mammary implant

19330 Removal of mammary implant material

19355 Correction of inverted nipples

19370 Open periprosthetic capsulotomy, breast

19371 Periprosthetic capsulectomy, breast

19380 Revision of reconstructed breast


COVERAGE RATIONALE

Indications for Coverage

If the member's condition meets the Women's Health and Cancer Rights (WHCRA) criteria, please refer to the policy titled Breast Reconstruction Post Mastectomy.

Criteria for a Coverage Determination as Reconstructive and Medically Necessary:

Removal of breast implants with capsulectomy/capsulotomy for symptomatic capsular contracture is considered reconstructive and medically necessary when the following criteria are met:

** Baker grade III or IV capsular contracture; Baker Grading System for Capsular Contracture

o Grade I - breast is soft without palpable thickening

o Grade II - breast is a little firm but no visible changes in appearance

o Grade III - breast is firm and has visible distortion in shape

o Grade IV - breast is hard and has severe distortion or malposition in shape; pain/discomfort may be associated with this level of capsule contracture (ASPS, 2005)

** Limited movement leading to an inability to perform tasks that involve reaching or abduction. Examples include retrieving something from overhead, combing one's hair, reaching out or above to grab something to stabilize oneself.

Removal of a deflated saline breast implant shell is considered cosmetic and is not medically necessary unless the implants were done post-mastectomy. Refer to the policy titled Breast Reconstruction Post Mastectomy.

Correction of inverted nipples is considered reconstructive and medically necessary when one of the following criteria are met:

** Member meets the Women's Health and Cancer Rights Act (WHCRA) criteria (refer to the policy titled Breast Reconstruction Post Mastectomy for details); or

** Documented history of chronic nipple discharge, bleeding, scabbing or ductal infection. Note: If the correction of congenital inverted nipples may be covered based on the state mandates or member specific benefit plan document. See Congenital Anomaly definition below.


Revision of a reconstructed (CPT Code 19380) breast is considered reconstructive and medically necessary when the original reconstruction was done for mastectomy or other covered health service.

Refer to the Applicable Codes section below for a list of codes that meet the criteria for a reconstructed breast. Breast reconstruction done for Poland Syndrome (see definition below) is reconstructive. Although no functional impairment may exist for the breast reconstruction for Poland Syndrome, this has been deemed reconstructive surgery.

Removal of a ruptured silicone gel breast implant is covered regardless of the indication for the initial implant placement.


Additional Information

Tissue protruding at the end of a scar ("dog ear"/standing cone), painful scars or donor site scar revisions must be reviewed to determine if the procedure meets reconstructive guidelines.


Coverage Limitations and Exclusions

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.



** Cosmetic breast procedures are excluded from coverage. Examples include but are not limited to:

o Replacement of an existing breast implant if the earlier breast implant was performed as a cosmetic procedure . (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. Refer to the Breast Reconstruction Post Mastectomy policy.)

o Breast reduction surgery that is determined to be a cosmetic procedure. This exclusion does not apply to breast reduction surgery which we determine is requested to treat a physiologic functional impairment or to coverage required by the Women's Health and Cancer Right's Act.

o Breast surgery only for the purpose of creating symmetrical breasts except when post mastectomy.

o Breast prosthetics or replacement following a cosmetic breast augmentation.

** Revision of a prior reconstructed breast due to normal aging does not meet the definition of a covered reconstructive health service.



DEFINITIONS

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Poland Syndrome: A rare, nonfamilial anomalad of unknown cause. The components of the syndrome include absence of the pectoralis major muscle, absence or hypoplasia of the pectoralis minor muscle, absence of costal cartilages, hypoplasia of breast and subcutaneous tissue (including the nipple complex), and a variety of hand anomalies. The most common chest wall reconstructive procedure in Poland’s is rotation of the latissimus dorsi muscle to reconstruct the anterior chest wall deficiency and anterior axillary fold.

Note: Poland Syndrome does not include tuberous breasts or developmental breast asymmetry.

Sickness: physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse)

Wednesday, May 24, 2017

CPT code 44970, 44960, 44950

CPT Code Description Appendectomy Code Family

44950 Appendectomy

44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure)

44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis

44970 Laparoscopy, surgical, appendectomy When any single or multiple physician or other health care professional reports a code from the Once in a Lifetime Procedures list, that code or any code from the same Code Family will be reimbursed only once during a patient’s lifetime. In the appendectomy example, a single code from the Appendectomy Code Family will be reimbursed only once during a patient’s lifetime, because each person has only one appendix and can have only one appendectomy during his or her lifetime.

REIMBURSEMENT GUIDELINES

Oxford will reimburse certain procedures only once during a patient’s lifetime. Once in a Lifetime Procedures are not limited to a single CPT code, but may be represented by Code Families, which are a group of CPT codes that describe the same or similar type of service. Under this policy, Oxford provides reimbursement for only one procedure from a designated Code Family during a patient’s lifetime.

For example, there are four separate appendectomy CPT codes that can be used, based upon the particular circumstance, to report the removal of the appendix. The four codes, listed below, make up the Code Family that describes the removal of an appendix.



Modifiers

There may be situations that require the code(s) for a Once in a Lifetime Procedure to be submitted more than once during a patient’s lifetime. In such cases, more than one Once in a Lifetime Procedure, whether the same code or a different code from the same Code Family will be considered separately for reimbursement if reported with one of the following modifiers:

Modifier Description

53 Discontinued procedure

55 Postoperative management only

56 Preoperative management only

58 Staged or related procedure or service by the same physician

For additional information related to the percentage of the allowable fee to be paid when one of these modifiers is appended to a claim for a subsequent procedure, please refer to the Discontinued Procedure policy, Split Surgical Package policy and/or Global Days policy.


DEFINITIONS

Code Family: A group of CPT codes that describe the same or similar type of service.

Once in a Lifetime Procedure: A procedure that can be performed by a physician(s) or other health care professional(s) only once in a patient’s lifetime.


QUESTIONS AND ANSWERS


Q: Would there ever be an instance where a CPT code for a Once in a Lifetime Procedure may be reported more than once?

A: Yes, there are instances where a CPT code for a Once in a Lifetime Procedure may be reported more than once. Modifiers may be used to indicate a procedure or service has been altered in some way, but not changed in its actual code description. For example, by definition, modifier 53 (Discontinued Procedure) is to be used when a procedure is terminated for unforeseeable circumstances. Per coding guidelines, the procedure code would be initially reported with modifier 53 appended to the CPT code to indicate the discontinued procedure and then at a later time, the CPT code would be submitted again when (if) the procedure took place in its entirety.



2 Q: How is a Once in a Lifetime Procedure reimbursed when reported by two different physicians on different dates of service?

A: When any physician or other health care professional reports a code from the Once in a Lifetime Procedures policy list on multiple dates of service excluding the same date of service, the code will be reimbursed only once. Oxford follows a "first in, first out" claim payment methodology in determining which claim will be considered for reimbursement when duplicate claims are received.

3 Q: What if two different physicians each report the same procedure on the same date of service for the same patient from the Once in a Lifetime Procedures list? 

A: The Once in a Lifetime procedure codes are subject to duplicate billing when reported by the same or different providers.



Wednesday, May 10, 2017

CPT 30400, 30410, 30420 & 30465 - Rhinoplasty procedures

CPT Code Description

Rhinoplasty

30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

30420 Rhinoplasty, primary; including major septal repair

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip only

30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip, septum, osteotomies Repair of Vestibular Stenosis

30465 Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)

Rhinophyma

30120 Excision or surgical planing of skin of nose for rhinophyma Lysis Intranasal Synechia

30560 Lysis intranasal synechia Septal Dermatoplasty

30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)


RHINOPLASTY AND OTHER NASAL SURGERIES


INSTRUCTIONS FOR USE

This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. 



CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.

Benefit Type General benefits package

Referral Required

(Does not apply to non-gatekeeper products)

No

Authorization Required

(Precertification always required for inpatient admission) Yes

Precertification with Medical Director Review Required Yes1 Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required)

Outpatient, Office

Special Considerations 1Precertification with review by a Medical Director or their designee may be required.

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if 
applicable.



Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

COVERAGE RATIONALE

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.

Indications for Coverage

Rhinoplasty-Primary (CPT 30410, 30420)

Rhinoplasty-primary is considered reconstructive and medically necessary when all of the following criteria are present:

** Prolonged, persistent obstructed nasal breathing due to nasal bone and septal deviation that are the primary causes of an anatomic mechanical nasal airway obstruction, and

** The nasal airway obstruction cannot be corrected by septoplasty alone as documented in the medical record, and 

** Photos clearly document the nasal bone/septal deviation as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway 
obstruction by centralizing the nasal bony pyramid (30410) and also straightening the septum (30420), and

** One of the following is present:

o Nasal fracture with nasal bone displacement severe enough to cause nasal airway obstruction, or

o Residual large cutaneous defect following resection of a malignancy or nasal trauma, and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy. 


Rhinoplasty-Tip (CPT 30400)

Rhinoplasty-tip is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:

** Prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic mechanical nasal airway obstruction (this code is usually cosmetic), and

** Photos clearly document tip drop as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam (acute columellar-labial angle), and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by lifting the nasal tip, and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and 

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.

Rhinoplasty-Secondary (CPT 30430, 30435, 30450)

Rhinoplasty-secondary is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:

** Required as treatment of a complication/residual deformity from primary surgery performed to address a functional impairment when a documented functional impairment persists due to the complication/deformity (these codes are usually cosmetic), and

** Photos clearly document the secondary deformity/complication as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by correcting the deformity or treating the complication. (These codes are usually cosmetic), and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and 

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.


DEFINITIONS

When applicable, please refer to the member specific benefit plan document for definitions. 

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth.

External Nasal Valve, NARES: Lateral Crus (wing) of the lower lateral (alar) cartilage. 

Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life function. Mechanical Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity.

Prolonged, Persistent Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) that has not responded to six weeks of medical management such as nasal steroids, antihistamines, and decongestants.

Elimination of rhinitis medicamentosa as a cause for airway obstruction.

Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, 'is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Rhinitis Medicamentosa (RM): A condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) and certain oral medications (e.g., sympathomimetic amines and various 2-imidazolines) that constrict blood vessels in the lining of the nose.

Septal Dermatoplasty: The physician removes diseased intranasal mucosa and replaces it with a separately reportable split thickness graft. The surgery is performed on one nasal side. A lateral rhinotomy is made to expose the intranasal mucosa. The diseased mucosal tissue is excised from the septum, nasal floor, and anterior aspect of the inferior turbinate. A split thickness graft is sutured to the recipient bed, covering the exposed cartilage and submucosal surfaces. Gauze packing and splints are placed in the grafted nasal cavity.

Synechia: An adhesion of parts, typically the nasal side wall to the septum. 

Tuesday, March 21, 2017

CPT g0180 - Care plan oversight services



Care Plan Oversight Services


Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients.

Separate payment is allowed for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services.

Submit HCPCS code G0179 for re-certification after a patient has received services for at least 60 days (or one certification period). HCPCS code G0179 may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be filed on the same date of service as the supervision service HCPCS codes (G0181 or G0182).
HCPCS Codes

G0179: MD re-certification HHA PT

G0180: MD certification HHA patient

G0181: Home health care supervision

G0182: Hospice care supervision

How to submit a claim

Submit CPT codes 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter

HHA / Hospice Provider Number: The requirement to include the HHA or Hospice provider number on a care plan oversight claim for HCPCS codes G0181 and G0182 is waived until further notice, and as a result, claims submitted with the number will be rejected.

Dates of service: for HCPCS codes G0181 and G0182, submit the first and last date during which documented care planning services were actually provided during the calendar month.

Do not submit the first and last calendar date of the month unless services were provided on those dates)
Submit the claim after the end of the month in which the service is performed

Report care planning only once per calendar month

Report only one month's services per line item

Dates of service: for HCPCS codes G0179 and G0180, submit the date physician signed the certification or re-certification

Documentation

Claims for care plan oversight services will be denied when review of the beneficiary claims history fails to identify a covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service
Medical records for these service must indicate:
The physician spent 30 minutes or more for countable care planning activities
The specific service furnished, including the date and length of time

Monday, March 20, 2017

cpt 66821 - YAG capusulotomy surgery

CPT/HCPCS Codes

Group 1 Codes:

66821 After cataract laser surgery

Coverage Indications, Limitations, and/or Medical Necessity

Indications

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

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

Limitations 

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

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



Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:

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

N/A


ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

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

Friday, March 10, 2017

CPT 19318, 77059 - Surgery, Breast reduction mammplasty, MRI procedure


CPT/HCPCS Codes



11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm (List separately in addition to code for primary procedure)
11970 Replacement of tissue expander with permanent prosthesis
11971 Removal of tissue expander(s) without insertion of prosthesis
19316 Mastopexy
19318 Reduction Mammoplasty (see Section B for other indications)
19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation; with prosthetic implant
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy  or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350 Nipple/areola reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19361 Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant
19364 Breast reconstruction with free flap
19366 Breast reconstruction with other technique
19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;
19368 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)
19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site
19370 Open periprosthetic capsulotomy, breast
19371 Periprosthetic capsulectomy, breast
19380 Revision of reconstructed breast
19396 Preparation of moulage for custom breast implant (not covered for Priority Health Medicaid)
Coverage Indications, Limitations, and/or Medical Necessity

Background:

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

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

help ameliorate symptoms caused by hypertrophy or

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

Indications:

Reduction mammaplasty is considered medically necessary:

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

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

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

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

AND:

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


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

Limitations

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

Indications of coverage must be met.




Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

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

N/A



Breast Implant Removal
1. Removal of breast implants that were placed for reconstruction after mastectomy, injury, congenital asymmetry, or augmentation mammoplasty is a covered benefit for the following indications:

a. Implants with recurrent infection
b. Extruded implants
c. Baker Class IV Contracture, associated with severe pain, or
d. Breast cancer, new or recurrent (mastectomy and lumpectomy can be done with an implant in place, however, if a breast malignancy is discovered and the surgeon has requested coverage for removal, it is appropriate to provide coverage).
e. Implant rupture
2. Replacement/reinsertion of a breast implant is a covered benefit only if the original placement surgery would have been a covered benefit (e.g. if original prosthesis was placed due to cancer surgery, replacement of the prosthesis is a covered benefit; if original surgical indication was cosmetic augmentation, replacement of the prosthesis is not a covered benefit).
3. Removal of breast implants for the following conditions has been determined to not be medically necessary, and therefore, not a covered benefit:
a. Breast malposition/asymmetry
b. Baker Class II or III Contracture*
c. Patient anxiety related to the possibility of developing systemic disease, or anxiety related to the influence of breast implants on a current "autoimmune disease". It has not been proven that individuals with breast implants are at an increased risk of developing a systemic disease, or that the implants influence the current status of the systemic disease.
4. Pain is frequently cited an indication for removal. The requesting physician should supply clinical information related to the degree of contracture (Baker classification*), or describe the etiology of the pain.

* Various systems have been used to classify breast contractures, but the most commonly used is the Baker classification. Four grades are described as follows:
Grade I Augmented breast feels soft as a normal breast
Grade II Augmented breast is less soft and implant can be palpated, but is not visible
Grade III Augmented breast is firm, palpable and the implant (or distortion) is visible
Grade IV Augmented breast is hard, painful, cold, tender and distorted

Reduction Mammoplasty

Unilateral and bilateral reduction mammoplasty is a covered benefit according to InterQual criteria.

For augmentation mammoplasty for asymmetry that is not cancer related see
C. Breast Reconstruction and Revision below. Limitations and Exclusions:
a. Mastopexy procedures (e.g. breast ptosis) are not a covered benefit. These procedures are considered to be cosmetic in nature and not performed to relieve pain due to macromastia.
b. Reduction mammoplasty for cosmetic purposes (to improve  appearance) is not a covered benefit.

Breast Reconstruction and Revision

This section applies to reconstruction and revision for breast cancer. It would also apply to women at high risk of breast cancer who require prophylactic mastectomy.

Initial reconstruction can occur immediately after a mastectomy or be delayed until a patient undergoes radiation or chemotherapy or determines whether she wants breast reconstruction. Some women will opt for immediate breast reconstruction after mastectomy, while some may prefer delayed reconstruction. While some reconstructions can be completed in a single procedure, other techniques may require two or more surgical procedures for completion of the reconstructive process.

Further clarification of coverage for breast reconstruction and revision is outlined below.

1. Coverage for the breast affected by cancer, as well as for the breast(s) removed prophylactically (including bilateral prophylactic mastectomies).

The following are covered benefits:
a. Treatment for complications of breast reconstruction including cellulitis, other infections, and lymphedema.
b. Revisions required by surgical complications including infection, hematoma or seroma, or skin or flap necrosis.
c. Capsulotomies/capsulectomies for pain or contractures (see II. A. Breast Implant Removal above) for coverage criteria.
d. Prosthesis removal for pain, contractures, rupture, leakage or infection. (see II. A. Breast Implant Removal above) for coverage criteria.
e. Scar revisions are only covered if one of the following apply:
i. The scar resulted from a serious complication such as infection or wound dehiscence from surgery or post-op period
ii. The scar revision is an integral (not incidental) part of another covered procedure

Breast Reconstruction and Revision

This section applies to reconstruction and revision for breast cancer. It would also apply to women at high risk of breast cancer who require prophylactic mastectomy.

Initial reconstruction can occur immediately after a mastectomy or be delayed until a patient undergoes radiation or chemotherapy or determines whether she wants breast reconstruction. Some women will opt for immediate breast reconstruction after mastectomy, while some may prefer delayed reconstruction. While some reconstructions can be completed in a single procedure, other techniques may  require two or more surgical procedures for completion of the reconstructive process. Further clarification of coverage for breast reconstruction and revision is outlined below.

1. Coverage for the breast affected by cancer, as well as for the breast(s) removed prophylactically (including bilateral prophylactic mastectomies).

The following are covered benefits:
a. Treatment for complications of breast reconstruction including cellulitis, other infections, and lymphedema.
b. Revisions required by surgical complications including infection, hematoma or seroma, or skin or flap necrosis.
c. Capsulotomies/capsulectomies for pain or contractures (see II. A. Breast Implant Removal above) for coverage criteria.
d. Prosthesis removal for pain, contractures, rupture, leakage or infection. (see II. A. Breast Implant Removal above) for coverage criteria.
e. Scar revisions are only covered if one of the following apply:
i. The scar resulted from a serious complication such as infection or wound dehiscence from surgery or post-op period
ii. The scar revision is an integral (not incidental) part of another covered procedure

Breast reconstruction surgery is also a covered benefit when incidental to disease and/or injury if:
a. a functional impairment is established and surgery is intended to correct the functional impairment OR
b. breast reconstructive surgery is performed to correct asymmetry of a breast when surgery has been performed on the other breast incidental to disease or injury.

Prior Authorization Requirements for Medicaid members (all of the following are required). The following documentation should be provided by the requesting physician:
a. Patient’s age
b. Physical description of the enlarged breast including symmetry, mass, induration and size
c. Medical history assessing the differential diagnosis including chronic diseases and medications
d. Previous work-up including mammogram and fine needle aspirate, where appropriate for evaluation of unilateral gynecomastia or masses.
e. High-quality original photographs for evaluation of the gynecomastia grade.

Digital Breast Tomosynthesis (DBT)

a. A screening DBT is considered medically necessary for individuals that have dense breasts.
b. A diagnostic DBT is considered medically necessary for individuals that have abnormal mammogram findings that require further imaging

Breast Reconstruction and Revision

Breast reconstruction surgery includes those surgical procedures which are intended to restore the normal appearance of the breast. This restoration occurs after surgery, accidental injury, or trauma.

Mastectomy for cancer is the most common reason women seek breast reconstruction, but other conditions such as severe post radiation changes or congenital deformities are other reasons that a woman may seek breast reconstruction.

Techniques of reconstruction include: tissue expansion, flap reconstruction, nipple areola reconstruction with subsequent implantation of a breast prosthesis. The tissue expander is a balloon-like device which is surgically placed under the chest tissue to create a breast-shaped space for the breast implant. Flap reconstruction allows for reconstruction using the patient’s own tissues. Donor flap sites include the back, lower abdomen, buttocks, or lateral hip region. For a latissumus flap the latissimus dorsimuscle is used. This muscle is frequently used for reconstruction surgery due to its large size and versatility. For a TRAM flap (transverse rectus abdominus musculocutaneous flap) excess abdominal tissue is tunneled under the skin from the lower abdomen to the chest and used to replace the breast tissue. For a free flap, tissue from other body sites (such as buttock or lateral thigh region) is transferred to the chest.

Although breast reconstruction is a cosmetic procedure, there are both Federal and Michigan state laws requiring health plans to cover breast reconstruction in certain defined circumstances. The federal and state requirements differ. 

Pathological gynecomastia is associated with both androgen deficiency and estrogen excess. Both causes may be due to medications, diseases related to endocrinologic abnormalities, tumors, chronic disease, chromosomal abnormalities, familial disorders, and other miscellaneous conditions. While there is  always a concern when a mass is present, breast cancer accounts for only 0.2 percent of all malignancies in male patients. A suspicious mass or lesion requires biopsy.

Gynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scales:

Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola.

Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.

Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. Grade IV Marked breast enlargement with skin redundancy and feminization of the breast

Screening Mammography and Breast MRI
Screening Mammography
Screening mammography involves radiographic (X-ray) examination of the breast

performed at regular intervals, usually every 1 to 2 years, to detect breast cancer before it displays signs or symptoms. The goals of screening mammography for average risk  women without any symptoms are to reduce breast cancer morbidity and mortality (illness and death). This can be accomplished by the accurate detection of the disease before it has metastasized (spread from the breast to another part of the body), when treatment can be less aggressive, and when the likelihood of long-term remission (decrease in symptoms) or cure is the highest.

According to the State of Michigan Insurance Code, breast cancer screening is defined as mammography using a standard 2-view per breast, low-dose radiographic examination of the breasts, and using equipment designed and dedicated specifically for mammography, in order to detect unsuspected breast cancer.

The Insurance Code goes on to define breast cancer diagnostic services as procedures intended to aid in the diagnosis of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to mammogram, mammography, surgical breast biopsy, and pathologic examination and interpretation.

Breast MRI

Women with inherited mutations of the BRCA1 or BRCA2 gene have the highest risk of breast cancer. They make up 5 to 10 percent of women with breast cancer and are also at increased risk for ovarian cancer. The cumulative risk of breast cancer in women with BRCA1 mutations is 3.2 percent by the age of 30 years, 19.1 percent by the age of 40, 50.8 percent by the age of 50, 54.2 percent by the age of 60, and 85.0 percent by the age of 70; the cumulative lifetime risk for carriers of BRCA1 or BRCA2 mutations is 50 to 85 percent.

Screening mammography detects less than half of the breast cancers in mutation carriers, perhaps owing to young age, dense breasts, or pathological features of the tumor. Cancers in mutation carriers grow rapidly; half of them appear in the intervalbetween annual mammograms. The median size of such "interval cancers" is 1.7 cm,  and half have spread to axillary lymph nodes by the time they are detected. It has been suggested that supplementing mammography with other imaging techniques, shorter screening intervals, or both may be valuable in mutation carriers. Liberman, L. “Breast Cancer Screening with MRI—What are the Data for Patients at High Risk?” New England Journal of Medicine, 351; 5, July 29, 2004, pp. 497-500.

D07.30 Carcinoma in situ of unspecified female genital organs
Z40.01 Encounter for prophylactic removal of breast
Z42.1 Encounter for breast reconstruction following mastectomy
Z42.8 Encounter for other plastic and reconstructive surgery
following medical procedure or healed injury\
Z85.3 Personal history of malignant neoplasm of breast
Z90.10 – Z90.13 Acquired absence of breast and nipples
Z98.82 Breast implant status
N64.89 Other specified disorders of breast
T85.44xA - T85.44xS Capsular contracture of breast implant,
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
T85.41xA - T84.49xS Mechanical complication of breast prosthesis and implant
T85.79xA - T85.79xS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts
T85.828A-T85.828S Fibrosis due to other internal prosthetic devices, implants and grafts
T85.848A-T85.848S Pain due to other internal prosthetic devices, implants and grafts
T85.898A-T85.898S Other specified complication of other internal prosthetic devices, implants and grafts


Indications for Coverage

Breast reconstruction is covered for Members who have a Mastectomy with or without a diagnosis of cancer. Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy, and segmentectomy), simple, and radical.

This benefit does not include aspirations, biopsy (open or core), excision of cysts, fibroadenomas or other benign or malignant tumors, aberrant breast tissue, duct lesions, nipple or areolar lesions, or treatment of gynecomastia.

There is not a time frame in which the Member is required to have the reconstruction done post Mastectomy under the Women’s Health and Cancer Rights Act of 1998.

In accordance with Federal and State mandates, the following services are covered:
* Reconstruction of the breast on which the Mastectomy was performed
* Surgery and reconstruction of the other breast to produce a symmetrical appearance, including nipple tattooing
* Prosthesis (Implanted and/or external)
* Treatment of physical complications of Mastectomy, including lymphedema Various surgical techniques are used for breast reconstruction, including but not limited to:
* Insertion of FDA approved breast implants and tissue expanders
* Breast Implants and tissue expanders post Mastectomy with or without skin substitutes, approved by the FDA, including but not limited to: Alloderm, Allomax or FlexHD are a covered benefit
* Transverse Rectus Abdominus Myocutaneous Flap (TRAM)
* Latissimus Dorsi Flap (LD)
* Deep Inferior Epigastric Perforator (DIEP) Flap
* Gluteal Flap (GAP free flap)


Breast MRI

* Breast MRI is usually bilateral (CPT®77059) or can be unilateral (CPT®77058) in some after mastectomy, per physician request.

* MRI guided breast biopsy (CPT®19085) includes the imaging component. Additional lesions should be billed using CPT®19086.

* MRI Breast can be repeated at least 6 months after an MRI directed breast biopsy to document successful lesion sampling if histology is benign and nonspecific, equivocal or uncertain.

Breast MRI - Practice Notes

Although breast MRI has superior sensitivity in identifying new unknown malignancies, it carries a significant false positive risk when compared to mammogram and ultrasound. Incidental lesions are seen on 15% of breast MRI’s and increase with younger age The percentage of incidental lesions that turn out to be malignant varies from 3% to 20% depending on the individual population. Cancer is identified by breast MRI in only 0.7% of those with “inconclusive mammographic lesions

Breast Reconstruction

* CTA or MRA of the body part from which the free tissue transfer flap is being taken, can be performed for breast reconstruction preoperative planning.2,3
o For example, CTA (CPT®74175 and CPT®72191) or MRA (CPT®74185 and CPT®72198) of the abdomen and pelvis for Deep Inferior Epigastric Perforators (DIEP) flap
* There is currently insufficient evidence-based data to support the need for routine advanced imaging for TRAM flaps or other flaps performed on a vascular pedicle

 CAD for Breast MRI

* The use of CAD with breast MRI is currently considered investigational, experimental, and/or unproven.
o 3D rendering codes (CPT®76376 or CPT®76377) should not be used in conjunction with code 0159T

Breast MRI is NOT Indicated

* Breast MRI should not be used to determine biopsy recommendations for suspicious or indeterminate lesion(s) that can be readily biopsied, either using imaging guidance or physical exam, such as palpable masses and microcalcifications.

* MRI should not be used for routine surveillance in individuals with history of breast cancer, unless there are physical exam, imaging findings, recurrent, or residual disease at the mastectomy site

Breast MRI Indications

* Breast MRI is indicated for breast augmentation, breast implants (saline or silicone), breast reconstruction, free injection, and capsular contracture to:
o Evaluate or confirm breast implant rupture when mammography or ultrasound is uninterpretable6
* If leakage is detected on MRI or any other modality, the implant(s) should be removed and no further surveillance MRI of the affected breast(s) is indicated.
* Surveillance for silent/asymptomatic rupture of silicone implants is considered investigational.
* Cigna does not cover surveillance MRI for breast implants if they were placed as part of purely cosmetic surgery.
* Annual breast MRI is indicated for high risk histologies:
o Atypical ductal hyperplasia (AD); Atypical lobular hyperplasia (ALH); Lobular carcinoma in situ (LCIS)
* Equivocal or Occult Findings
o Radiologist Report Recommendation for Breast MRI and one of the following:
* Inconclusive or conflicting findings on mammography or ultrasound of a lesion that is not a palpable mass
o A probably benign lesion on MRI (MRI BI-RADSTM 3) should undergo repeat MRI in 6 months.

Friday, March 3, 2017

cpt 88341, 88342 - Lyncy syndrome

CPT/HCPCS Codes  Group 1 Codes:

81210 Braf gene

81292 - 81300 Mlh1 gene full seq - Msh6 gene dup/delete variant

81317 - 81319 Pms2 gene full seq analysis - Pms2 gene dup/delet variants

81403 Mopath procedure level 4


Group 2 Codes:


81301 Microsatellite instability

88341 Immunohisto antibody slide

88342 Immunohisto antibody stain

88344 Immunohisto antibody slide
Coverage Guidance

Background

I. Lynch Syndrome (LS)

This policy limits Lynch syndrome (LS) genetic testing to a stepped approach for Microsatellite Instability and Immunohistochemistry (MSI/IHC) screening, BRAF gene mutation, MLH1 gene promoter hypermethylation and targeted mismatch repair (MMR) germ-line gene testing to patients suspected of having LS. 

Most colorectal cancer is caused by non hereditary somatic mutations. Individuals with LS (aka hereditary nonpolyposis colorectal cancer (HNPCC)) are predisposed to cancer due to having inherited or de novo germ-line mutations in DNA repair genes, that result in an accelerated accumulation of somatic mutations. LS, the most common hereditary cause of colorectal cancer, accounts for 2-3% of all colorectal cancers, followed by familial adenomatous polyposis (FAP) which accounts for <1 and="" colorectal="" div="" frequency="" is="" malignancies="" mutyh-associated="" nbsp="" occurrence="" of="" polyposis="" rare.="" very="" whose="">

LS is an autosomal dominant familial cancer syndrome caused by mutations in multiple susceptibility genes (e.g., MLH1, MSH2, MSH6, PMS2, EPCAM), and is associated with an increased lifetime risk for colorectal cancer (CRC) and other malignancies within the tumor spectrum including at least endometrial, ovarian, gastric, small bowel, urothelial, hepatobiliary tract, sebaceous and pancreatic cancers. Current literature suggests LS annually affects 28,000 individuals. In individuals with LS, the lifetime risk of colon cancer may be as high as 75% by the age of 70 years, with an average age onset of 45 years in MLH1 and MSH2 mutation carriers. While the incidence of adenomas in individuals with LS is similar to that in the general population, the high rate of colorectal cancer is due to an acceleration of the adenoma to carcinoma sequence. 

Cancer risks associated with LS are largely derived from family studies. Mutations in MLH1 and MSH2 account for 70-90% of families with LS. The risk of colon and endometrial cancer is less in MSH6 and PMS2 mutation carriers, although the cancer risk may not be lower for MSH6 carriers if one takes the data out to age 80. While individuals with a single MLH1, MSH2, MSH6 and PMS2 mutation develop cancers in mid-life, individuals with biallelic MLH1, MSH2, MSH6 and PMS2 mutations have a distinctive phenotype and tumor spectrum, and often develop cancer as early as the first decade of life. 

First-degree relatives of mutation carriers have a 50% probability of having the same germ-line mutation. Despite the high penetrance of CRC and endometrial cancer and recommendations of consideration for screening unaffected first-degree relatives following diagnosis of an LS proband, testing of genetic carriers who are unaffected with a Lynch related cancer is not a Medicare benefit, and is statutorily excluded from coverage. 

II. Testing Strategy for Patients with Personal History of Colorectal Cancer

Step 1: Patient selection 

Patients with colorectal and/or endometrial cancer suspected of LS must undergo a comprehensive review of physical findings and a complete personal and family history. 

In 1989, the Amsterdam criteria defined what is known as Hereditary Non-polyposis Colon Cancer Syndrome, and in 1999, the criteria were revised to include extra-colonic tumors (Table 1). Today we know there are two distinct groups comprising HNPCC: those with hereditary DNA mismatch repair germ-line mutations, known as Lynch Syndrome, and those with normal DNA mismatch repair, known as Familial Colorectal Cancer Type X. 

Table 1. Amsterdam Criteria II (ACII)

There should be at least three relatives with CRC or with a Lynch syndrome-associated cancer: endometrial, small bowel, ureter or renal pelvis cancer.
One relative should be a 1st-degree relative of the other two,
At least two successive generations should be affected,
At least one tumor should be diagnosed before age 50 years,
FAP should be excluded in the CRC case, if any,
Tumors should be verified by histopathological exam

Approximately 50% of families meeting the ACII criteria have a mutation in an MMR gene. However, these criteria are very stringent and miss as many as 68% of patients with LS. 

In 1997, the Bethesda guidelines were developed to identify individuals with CRC who should be tested for MSI. In 2002, the guidelines were revised (Table 2) to clarify selection criteria for microsatellite instability (MSI) testing and mismatch repair (MMR) protein expression by immunohistochemistry (IHC). Screening tumors of patients meeting the Bethesda guidelines for MSI was shown to be cost-effective with newly diagnosed CRC. 

Table 2 - Revised Bethesda Guidelines 

Meeting any of the following are sufficient for consideration of MSI/IHC testing
CRC diagnosed under age 50
Presence of synchronous, or metachronous CRC or other Lynch-associated tumor, regardless of age
CRC with MSI-H histology diagnosed in an individual who is < age 60
CRC diagnosed with one or more 1st-degree relatives with a Lynch-related tumor, with one of the cancers diagnosed under age 50
CRC diagnosed in two or more 1st- or 2nd-degree relatives with a Lynch-related tumor, regardless of age

If a patient meets standards for LS testing in Step 1, (i.e., meets ACII or Revised Bethesda guidelines), the physician should proceed to Step 2 and 3. 

Step 2: Immunohistochemistry (IHC) testing for LS Screening

The use of IHC to detect loss of DNA mismatched repair (MMR) protein expression complements MSI to screen patients for defective MMR (dMMR), including both sporadic dMMR and LS dMMR. IHC allows detection of loss of protein expression for the MLH1, MSH2, MSH6 and PMS2 genes. Loss of MMR protein expression is detected by the absence of nuclear staining in the tumor cells and the presence of nuclear staining in lymphocytes and normal colon crypt epithelial cells. 

The MMR proteins are present as heterodimers ( MLH1 pairs with PMS2, and MSH2 pairs with MSH6). Knowledge of MMR protein expression loss patterns allows a logical and cost effective “directed” testing appropriate for germ-line mutation analysis. As a general rule, loss of expression of MLH1 or MSH2 is associated with loss of their partners. For example, mutation of the MLH1 gene generally leads to loss of expression of both the MLH1 and PMS2 proteins. However, loss of PMS2 or MSH6 due to a germ-line mutation is associated only with loss of the mutated protein. For example, mutation of the PMS2 gene leads to loss of expression of only the PMS2 protein. 

If IHC is done first and is abnormal, MSI testing is not warranted. Often IHC is done first because of its rapid turn-around and minimal amount of tissue required. If IHC demonstrates loss of protein expression for the MLH1, MSH2, MSH6 and PMS2 genes, the following test results direct further testing:
MLH1 loss by IHC, test for BRAF gene mutation (Step 4) or test for MLH1 promoter, (Step 5)
MSH2/MS6 loss by IHC, perform MSH2 germ-line testing (Step 6)

If IHC test results are normal, there remains a small chance of high levels of microsatellite instability (MSI-H), so both IHC and MSI would be needed to rule out LS in a clinically suspicious setting.

Step 3: Microsatellite Instability (MSI) Analysis for LS Screening

MSI analysis for screening LS microsatellites are short repeated segments of DNA spread throughout the genome. Under normal conditions, the MMR gene complex (MLH1, MSH2, MSH6 and PMS2 genes) corrects mismatched base pairs that occur during the final stage of DNA replication. When the MMR complex is functioning normally, all cells show an identical pattern of microsatellite lengths. When the MMR complex is non-functioning, due to two hits of any type, random mutations accumulate in microsatellites, leading to differences in microsatellite lengths (microsatellite instability, MSI). Therefore, MSI indicates loss-of-function defects in a MMR protein, which may be due to somatic mutations, germ-line MMR gene mutations, allelic loss, or to epigenetic down-regulation. MSI is usually associated with absence of protein expression of one or more of the MMR proteins ( MLH1, MSH2, MSH6M and PMS2). 

DNA from paraffin-embedded tumor tissue and normal tissue or peripheral blood is used for MSI analysis. A microsatellite is considered unstable if the distribution of the tumor fragments differs from that of the normal tissue. Noncancerous tissue in individuals with LS does not show MSI because normal tissue is heterozygous for the germ-line mutation. 

Levels of MSI in colon tumors are classified as: 
MSI-H> - 30% or more of a tumor’s markers are unstable;
MSI-L - > one but < 30% of a tumor’s markers are unstable; 
MSS - no loci are unstable.

MSI-L and MSS indicates the MMR mechanism is functioning adequately. Virtually all CRC tumors from individuals with LS demonstrate MSI-H. However, MSI-H is NOT diagnostic of LS as MSI-H can be observed in roughly 15% of sporadic colorectal cancers. In other Lynch tumors, the % level of MSI-H is less consistent and is inadequately studied. 

As indicated above, MSI testing is not necessary if IHC demonstrates loss of protein expression for the MLH1, MSH2, MSH6 and PMS2 genes. If IHC test results are normal, there remains a small chance of high levels of microsatellite instability (MSI-H), so both IHC and MSI should be performed to rule out LS in a clinically suspicious setting such as meeting a Revised Bethesda guideline. Additionally, some individuals with MSH6 germ-line mutations do not manifest the MSI-H phenotype. This finding supports the diagnostic strategy to screen suspected LS patients with CRC by both MSI and IHC. Immunohistochemistry (IHC) can be used to identify whether the protein products of MLH1, MSH2, MSH6 and PMS2 genes are present or absent. Individuals with tumors that display high levels of MSI or loss of expression of MMR proteins by IHC are then referred for targeted germ-line mutation. 

Steps 4 and/or 5 apply only for tumors that are negative for MLH1 protein expression by IHC. 

Step 4: BRAF V600E (BRAF) Mutation Testing 

BRAF mutation testing and MLH1 promoter methylation studies distinguish between sporadic dMMR and LS dMMR. This is because BRAFM mutation and MLH1 PHM are very seldom seen in LS. BRAF mutation testing of the CRC tumor is associated with the presence of an epigenetic alteration (i.e., hypermethylation of MLH1) and either finding excludes germ-line MMR gene mutation (eg., LS). 

Step 5: MLH1 Promoter Hypermethylation ( MLH1 PHM)

The combination of MLH1 PHM and a BRAF mutation in tumors rules out LS and no further molecular analysis is warranted. Tumors with MLH1 PMH identify dMMR which will most often be sporadic, but its presence does not fully rule out LS. However, there have been rare reports of MLH1 hypermethylation as a second hit in LS and there are new reports of constitutional MLH1 methylation. As a rule, discovery of MLH1 PHM indicates the tumor is not due to Lynch syndrome. 

The following combinations of BRAF and MLH1 promoter methylation test results direct further testing in individuals with CRCs with loss of IHC expression of MLH1/PMS2:
If BRAF mutation is present, no further testing is medically necessary; LS is ruled out.
If BRAF mutation is absent, MLH1 promoter methylation testing is indicated and directs the following testing:
If MKH1 is hypermethylated, germline MLH1 is not medically necessary.
If the MLH1 promoter is hypermethylated and ACII if fulfilled, germ-line MLH1 may still be considered (2nd hit scenario). 
If the MLH1 promoter is normally methylated, and BRAF is negative for mutation then germ-line MLH1 testing is medically indicated. 


Note: There is variability in laboratory preference for BRAF and MLH1 promoter testing sequence. Although BRAF is generally cheaper and faster, some labs test MLH1 PHM first because it is more sensitive for detection of sporadic dMMR. 

In a study by Gausachs (2012), when MLH1 PHM testing is used in conjunction with BRAF mutation testing, the cost per additional mutation detected when using hypermethylation analysis was lower than that of BRAF and germinal MLH1 mutation analysis. Somatic hypermethylation of MLH1 is an accurate and cost-effective pre-screening method in the selection of patients that are candidates for MLH1 germ-line analysis when LS is suspected and MLH1 protein expression is absent.

Step 6: Targeted MMR ( MLH1, MSH2, MSH6 and PMS2 gene) Germ-line and EpCAMTesting

Step 6A: MLH1 Testing

When IHC shows loss of both MLH1 and PMS2, further genetic testing of PMS2 is not indicated, as no cases have been reported of a PMS2 germ-line mutation when IHC showed a loss of both MLH1 and PMS2. PMS2 mutations have only been detected when IHC shows a loss of PMS2 only. If MLH1 gene mutationgeme-line is positively identified, then LS is diagnosed and further testing of the patient is not medically necessary. 

Step 6B: MSH2 Testing

When IHC shows loss of MSH2 and MSH6, genetic testing should start with analysis of the MSH2 gene, given its frequency of germ-line mutation in LS. If MSH2 germ-line mutation is identified, then LS is diagnosed, and further testing of the patient is not medically necessary. 

However, if genetic testing for germ-line mutations in MSH2 is negative, analysis for deletion in the EpCAM gene should be performed (Step 7). If EpCAM is also negative, genetic testing of MSH6 should be performed (Step 6C). The presence of MSI and the loss of MSH2/MSH6 strongly indicate a MMR germ-line defect. 

Step 6C: MSH6 Testing

When IHC shows loss of just MSH6, it suggests a germ-line mutation in MSH6 and genetic testing of that gene is indicated. As previously noted, MSH6 CRC tumors can be MSI-H, MSI-L or MSS. This pitfall illustrates the utility of IHC for MMR protein expression. If MSH6 germ-line mutation is identified, then LS is diagnosed, and further testing of the patient is not medically necessary. 

Step 6D: PMS2Testing

If IHC shows PMS2 loss only, germ-line testing for PMS2 mutations is indicated. No cases of a PMS2 germ-line mutation have been identified after IHC showed a loss of both MLH1 and PMS2. If PMS2 germ-line mutation is identified, then LS is diagnosed, and further testing of the patient is not medically necessary.

Step 7: EpCAM Testing

Recently, deletions in a portion of the EpCAM gene were found in a subset of families with LS with a loss of MSH2 by IHC. A common deletion in the 3’ region of EpCAM causes somatic hypermethylation of MSH2, as the 2 genes are adjacent to one another on chromosome 2. Approximately 20% of patients with absence of MSH2 and MSH6 protein expression by IHC, but without MSH2 or MSH6 mutation, will have germ-line deletions in EpCAM. Early estimates suggest that germ-line mutations in EpCAM may account for approximately 6% of LS cases and possibly as high as 30% when IHC shows a loss of MSH2.

Note: Many labs incorporate EpCAM detection their MSH2 dup/deletion analysis. 


Indications

IHC and/or MSI Testing

LS tumor screening with IHC or MSI on colorectal and/or endometrial tumors is considered medically necessary and covered by Medicare for the following indications: 
Individual with colorectal or endometrial cancer whose family meets the ACII or revised Bethesda guidelines**, OR 
Individual with endometrial cancer diagnosed before age 50.

For coverage, the treating physician/pathologist is expected to follow the stepped approach outlined for LS screening and targeted MMR testing in this policy. Germ-line testing includes sequence and duplication-deletion analysis for a given gene. 

MMR Germline Gene Mutation Testing Exception

If a lab is unable to perform the stepped testing approach outlined in this LCD, multiple germ-line gene testing will be covered by Medicare only for one or more of the following findings:
MSI/IHC testing yields normal IHC and MSI-H, suggesting LS 
If tumor is not available or determined by a pathologist to be inadequate to assess DNA MMR deficiency by MSI or IHC, then MMR germ-line testing can be conducted on blood if the individual fulfills the ACII or revised Bethesda guidelines. 
CRC tumor diagnosis prior to Medicare eligibility AND tumor sample no longer available AND individual meets ACII or revised Bethesda guidelines or was diagnosed with endometrial cancer before 50 

If targeted gene testing is not possible, MLH1 and MSH2 testing should be performed first, since these two genes account for the majority of germ-line mutations. If no mutation is identified in MLH1 or MSH2, testing of MSH6 is indicated. If no mutation is identified in MSH6, testing of PMS2 may be considered. 

Testing for Known Familial Variant 

Testing for a specific known familial variant is considered medically necessary and covered only when the individual being tested has signs and symptoms of a Lynch-associated cancer AND has a blood relative with the specific disease-causing mutation for LS.


Limitations 

This LCD does not imply that testing family members of a known familial variant is not medically warranted. The scope of the Medicare benefit requires the beneficiary to have signs and symptoms of disease. Coverage of molecular testing for LS for carrier status or family studies is considered screening and is statutorily excluded from coverage.

Universal testing of CRC and endometrial cancers by MSI/MMR protein expression by IHC is not a Medicare benefit.




Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable




Revenue Codes:


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

99999 Not Applicable

Sunday, February 26, 2017

CPT CODE 92526, 92610, 92611 - Dysphagia swallowing

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

92508 Speech/hearing therapy
92526 Oral function therapy
92610 Evaluate swallowing function
92611 Motion fluoroscopy/swallow
92612 Endoscopy swallow tst (fees)
92616 Fees w/laryngeal sense test

Evaluation of oral and pharyneal swallowing function (CPT 92610)

The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx.

The clinical examination may include:
a) history of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder;
b) medical status including nutritional and respiratory status;
c) oral anatomy/physiology (labial control, lingual control, palatal function);
d) pharyngeal function;
e) laryngeal function;
f) ability to follow directions; alertness
g) efforts and interventions used to facilitate normal swallow; (compensatory strategies such as chin tuck, dietary changes, etc.)
h) identifying symptoms during attempts to swallow


The clinical examination can be divided into two phases:

1. The preparatory examination with no swallow, and
2. The initial swallow examination with actual swallow while physiology is observed

Note: Based on the findings, an instrumental exam may be recommended.

Treatment of swallowing and dysfunctional or oral function for feeding (CPT 92526)

This involves the treatment for impairments/functional limitations of mastication, the preparatory phase, oral phase, pharyngeal stage, and esophageal phase of swallowing. Make appropriate recommendations regarding diet and compensatory techniques and instruct in direct/indirect therapies to facilitate oral motor control for feeding.

Coverage Indications, Limitations, and/or Medical Necessity

Dysphagia is a swallowing disorder that may be due to various neurological, structural, and cognitive deficits. Dysphagia may be the result of head trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, and encephalopathies. While dysphagia can afflict any age group, it most often appears among the elderly. Dysphagia services are covered under Medicare by therapists, regardless of the presence of a communication disability.

Indications

General Therapy Guidelines

The conditions of coverage and payment must be met as outlined in the Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.1.

Speech therapy services for dysphagia are either rehabilitative or maintenance related. The documentation must clearly indicate if skilled therapy services are being provided for rehabilitative purposes or maintenance. Rehabilitative therapy includes services designed to address recovery or improvement in function. Rehabilitative therapy services may be covered if the documentation indicates that the skills of the therapist are needed and are provided and if the documentation indicates by objective measurements that improvements are being made, or a decrease in severity is present, or rationalization for an optimistic outlook is present to justify continued treatment. For coverage requirements for maintenance related services, see number 7 below.

Dysphagia services are covered, provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified therapist. Services normally considered to be a routine part of nursing care are not covered.

For rehabilitative therapy, the goal is for a patient to return to the highest level of function realistically attainable and within the context of the disability. The skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc.

Covered dysphagia services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan of care must be certified/approved by the Physician/NPP.

In order for the plan of care to be covered, it must address a condition for which dysphagia services are an accepted method of treatment, as defined by standards of medical practice.

For rehabilitative therapy, there must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the physician’s assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified therapist. For maintenance therapy, the documentation must clearly indicate that:

the skills of the therapist must be necessary to establish a safe and effective maintenance program in connection with a specific disease state, or
the services required to maintain the patient’s current function or to prevent or to slow further deterioration are of such complexity and sophistication that the skills of a therapist are required, or

the particular patient’s special medical complications require the skills of a therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration.

The therapist must document the patient’s functional limitations in terms that are objective and measurable. The therapist must document the therapeutic short and long term goals in terms that are objective and measurable. Dysphagia services are not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist.

Rehabilitative speech therapy services for dysphagia are not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate. Establishing or designing a maintenance program or instructing the patient or appropriate caregiver in a maintenance program is not covered if the specialized skill, knowledge and judgment of a therapist are not required. Performance of a maintenance program by the therapist is not covered if the maintenance procedures do not require the skills of a therapist or the patient’s medical complications are not complex to require the skills of a therapist to perform the maintenance procedures. The skills of a therapist are not generally required to maintain function. In addition, establishing, designing or performing a maintenance program is not covered if the patient would not benefit from it or refuses to participate.

Rehabilitative speech therapy services for dysphagia are not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected.

The design of a maintenance regimen/home swallowing program to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary if the skills of the therapist are required. Limited services may be considered reasonable and necessary to establish and assist the patient and/or caregiver with the implementation of a maintenance program. No more than 2-4 visits for completion of the maintenance program and instruction of the patient and supportive personnel or family are considered medically necessary without significant documentation. Documentation must indicate that the maintenance program has been designed for the patient's level of function and instructions to the patient and supportive personnel have been completed for them to safely and effectively carry them out. The initiation of a maintenance program should occur early in a course of therapy.
Dysphagia services are not covered to treat Skilled Nursing Facility patients whose care can safely and effectively be rendered by the Skilled Nursing Facility’s trained professional staff.

Dysphagia services are not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the therapist. For example, the patient with a TIA with swallowing deficits that are resolving.
Dysphagia services provided to screen patients who might need or benefit from dysphagia services intervention (i.e. screening) are not covered.
Dysphagia services visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient’s condition improves.

Dysphagia services which are duplicative of other concurrent rehabilitation services are not covered.
Services which are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.

The educational component of treatment is included in the service described by the specific CPT code; therefore, there is no separate coverage for education.
Documentation of services is part of the coverage of the respective CPT; therefore, there is no separate coverage for time spent on documentation.
The ICD-10 coverage section of this LCD is meant to include 'functional' diagnoses. The functional diagnosis, not necessarily the clinical diagnosis, conveys coverage.

General Dysphagia Guidelines


If the documentation supports that the services required the skills of a therapist and that the skills of a therapist were provided, speech therapy services for dysphagia may be indicated for the following:

History of aspiration problems or aspiration pneumonia, or definite risk for aspiration, reverse aspiration, chronic aspiration, nocturnal aspiration, or aspiration pneumonia.
Nasal regurgitation, choking, frequent coughing up food during swallowing, wet or gurgly voice quality after swallowing liquids or delayed or slow swallow reflex.
Presence of oral motor disorder.

Impaired salivary gland performance and/or presence of local structural lesion in the pharynx resulting in marked oropharyngeal swallowing difficulties.

Dyscoordination, sensation loss, postural difficulties, or other neuromotor disturbances affecting oropharyngeal abilities necessary to close the buccal cavity and/or bite, chew, shape and squeeze the bolus into the upper esophagus, while protecting the airway.

Post-surgical reaction with specific signs, symptoms, and concerns supported in the documentation for the specific need of a qualified therapist to intervene.

Documented significant weight loss (5% in 1 month, 10% in 6 months) with documentation to support that the weight loss is directly related to reduced oral intake as a consequence of dysphagia, not merely reduced appetite (related to other medical/surgical illnesses, i.e. cachexia) or fluid shifting.

Existence of other conditions such as presence of tracheotomy or endotracheal tubes, ventilation management, nasogastric feeding or other enteral feeding, reduced or inadequate laryngeal elevation, labial closure, velopharyngeal closure, or pharyngeal peristalsis and cricopharyngeal dysfunction.

Dysphagia Evaluation


CPT 92610 - Evaluation of oral and pharyngeal swallowing
This evaluation is a clinical (usually bedside) one that does not involve the interpretation of dynamic radiologic studies or endoscopic studies.
The evaluation typically includes a bedside assessment of oral-motor functioning and signs and symptoms of pharyngeal dysphagia.
The evaluation is covered again after treatment has been initiated only if there is a change in the patient's overall condition of such significance that the plan of care cannot meet the beneficiary's goals with re-evaluation.
This code is an untimed code; therefore, only 1 unit is covered when reasonable and necessary.

Additional Documentation Requirements

History
Oral sensorimotor exam
Cervical auscultation
Positioning
Current eating status including onset and duration of problem
Clinical observations such as:
Presence of a feeding tube;
Paralysis; Oral, pharyngeal, laryngeal
Coughing or choking;
Oral motor structure and function;
Oral sensitivity;
Muscle tone;
Oropharyngeal reflexes;
Swallowing function;
Positioning;
Laryngeal function and vocal quality and loudness; and
Cognition and communication skills
Diagnosis that describes the phase of swallow affected
Recommendations for further assessment or treatment/intervention
Dysphagia Instrumental Assessment


An instrumental assessment (e.g. Modified Barium Swallow Study, Flexible Fiberoptic Endoscopic Evaluation of Swallowing) may be indicated for patients with suspected (e.g. observations by clinical or support personnel of choking with meals, excessive drooling, etc.), or who are at high risk for pharyngeal dysphagia. Dysphagia treatment may occur prior to the instrumental assessment. The final analysis and interpretation of a instrumental assessment should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan, including compensatory swallowing techniques and/or postures and food and/or fluid texture modification. An instrumental assessment is not indicated if findings from the clinical evaluation fail to support a suspicion of dysphagia; or, when findings from the clinical evaluation suggest dysphagia but include either of the following: (1) the patient is unable to cooperate or participate in an instrumental evaluation; or (2) the instrumental examination would not change the clinical management of the patient. Absence of instrumental evaluation does not preclude the patient from receiving dysphagia treatment. An instrumental assessment is not covered as a screening tool and should be considered only if (a) an appropriate referral for dysphagia by a qualified clinician is made and (b) the dysphagia evaluation supports proceeding with an instrumental assessment.

CPT 92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording
This assessment is covered one time after the therapist determines, based on the results of the initial evaluation (CPT 92610) that the patient requires and could benefit from further evaluation and treatment. This evaluation is not covered more than once unless the documentation supports there has been significant clinical change that would impact the course of therapy.

Goals for this evaluation include identifying structural causes of dysphagia, assessing the functional integrity of the oropharyngeal swallow, evaluating the risk of aspiration, and determining if the pattern of dysphagia is amenable to therapy. The effects of compensatory maneuvers and diet modification on aspiration prevention and/or bolus transport during swallowing are able to be studied radiographically to determine a safe diet and to maximize efficiency of the swallow.

This code is an untimed code, therefore, only 1 unit is covered when reasonable and necessary.
The patient’s medical record should show evidence that the referring/attending qualified clinician ordered this test.

If the plan of treatment by the treating therapist is based on the results of a report not issued by the treating therapist then the results of the test or the test report should be part of the medical record.
CPT 92612 - Flexible Fiberoptic Endoscopic Evaluation Of Swallowing By Cine Or Video Recording
Endoscopic evaluation of swallowing by cine or video recording (also called Fiberoptic Endoscopic Evaluation of Swallowing (FEES) utilizes the fiberoptic nasopharyngolaryngoscope to evaluate the pharyngeal swallow. Detailed information regarding swallowing function and related functions of structures within the upper aerodigestive tract are obtained. Therapeutic maneuvers are attempted during this examination to determine a safe diet and to maximize the efficiency of the swallow.
This assessment is covered one time after the therapist determines, based on the results of the initial evaluation (CPT 92610) that the patient requires and could benefit from further evaluation and treatment. This evaluation is not covered more than once unless the documentation supports there has been significant clinical change that would impact the course of therapy.

The clinician performing this service should be appropriately trained.

The patient’s medical record should show evidence that the referring/attending qualified clinician ordered this test.

This is an untimed code and is covered for only 1 unit when reasonable and necessary.
If the plan of treatment by the treating therapist is based on the results of a report not issued by the treating therapist then the results of the test or the test report should be part of the medical record.


Additional Documentation Requirements


Detailed findings of the endoscopic exam

CPT 92616 - Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing by cine or video recording
This procedure, known as FEESST, is a modification of FEES, with the addition of specialized equipment that quantifies the sensory threshold in the larynx. Velopharyngeal closure, anatomy of the base of the tongue and hypopharynx, abduction and adduction of the vocal folds, status of pharyngeal musculature and the patient's ability to handle his/her own secretions are assessed.
All bullets under CPT 92612 above, are applicable to CPT 92616.

Additional Documentation Requirements


Detailed findings of the endoscopic exam

Dysphagia Treatment

CPT 92526 Treatment of Swallowing

The Plan of Treatment should delineate goals and type of care planned which specifically addresses each problem identified in the assessment, such as:
Compensatory swallowing techniques;
Proper head and body positioning;
Amount of intake per swallow;
Means of facilitating the swallow;
Appropriate diet;
Food consistencies (texture and size);
Feeding techniques and need for self-help eating/feeding devices;
Patient caregiver training in feeding and swallowing techniques;
Facilitation of more normal tone or oral facilitation techniques;
Oromotor and neuromuscular facilitation exercises to improve oromotor control;
Training in laryngeal and vocal cord adduction exercises;
Oral sensitivity training

For oralpharyngeal or esophageal (upper one-third) phase of swallowing, documentation should include one or more of the following:

History of aspiration problems, suspected aspiration, or definite risk of aspiration;
Presence of oral motor disorder;
Impaired salivary gland performance and/or presence of local structural lesion in the pharynx resulting in marked oropharyngeal swallowing difficulties;
Dyscoordination, sensation loss, postural difficulties, or other neuromotor disturbances affecting oropharyngeal abilities necessary to close the buccal cavity and/or bite, chew, suck, shape, and squeeze the food bolus into the upper esophagus, while protecting the airway;
Post-surgical reaction with specific signs, symptoms and concerns;
Documented significant weight loss directly related to reduced oral intake as a consequence of dysphagia; and
Existence of other conditions such as the presence of tracheotomy or endotracheal tubes ventilation management, nasogastric feeding tube, reduced or inadequate laryngeal elevation, labial closure, velopharyngeal closure, or pharyngeal peristalsis and cricopharyngeal dysfunction.

For esophageal (lower two thirds) phase of swallowing, documentation should consider the following:

Esophageal dysphagia (lower two thirds of the esophagus) is regarded as difficulty in passing food from the esophagus to the stomach. If peristalsis is inefficient, patients may complain of food getting stuck or of having more difficulty swallowing solids than liquids. Sometimes these patients will experience esophageal reflux or regurgitation if they lie down too soon after meals.
Inefficient functioning of the esophagus during the esophageal phase of swallowing is a common problem in the geriatric patient. Swallowing disorders occurring only in the lower two thirds of the esophageal stage of the swallow have not generally been shown to be amenable to swallowing therapy techniques and should not be submitted. An exception might be made when discomfort from reflux results in food refusal. A therapeutic feeding program in conjunction with medical management may be indicated and could constitute reasonable and necessary care. You may submit for payment a reasonable and necessary assessment of function, prior to a conclusion that difficulties exist in the lower two thirds of the esophageal phase, even when the assessment determines that skilled intervention is not appropriate.

Routine periodic progress reports are considered part of the on-going treatment sessions and are not reimbursable.
CPT 92508 Group Dysphagia Therapy

Group therapy coverage for dysphagia is covered using CPT 92508 and can be covered if the following criteria are met:
Rendered under an individualized plan of care;
Has less than five group members;
Does not represent the entire plan of treatment;
Requires the skills of a licensed therapist
Promotes independent swallowing

Additional Documentation Requirements

Documentation of the specific skilled treatments used in the group and how they relate to the Plan of Care
Documentation of number of members in group
Limitations
The patient's attending physician/NPP has established a diagnosis of dysphagia after a proper medical evaluation and/or in consultation with treating therapist.
Noncovered services include:
Screening assessments
Nondiagnostic/non therapeutic routine, repetitive observation or cueing services;
Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat;
Procedures which can be safely and effectively carried out with the beneficiary by any non-professional (family or restorative aid) after instruction is completed;
Procedures performed on patients with chronic progressive diseases (e.g., Parkinson's disease, Huntington's disease, Wilson's disease, Multiple Sclerosis or Alzheimer's disease) without documentation to support short-term assistance teaching or instruction which would require the skills of the therapist for a maintenance program. The establishing, designing and instruction of a maintenance program is not covered if the patient would not benefit from it or refuses to participate.
E-stim as a sole modality is noncovered. However, when used during dysphagia treatment (CPT 92526) along with other reasonable and necessary services, it may be performed. It should not be billed as unattended e-stim (HCPCS G0283).




Exceptions for Evaluation Services

Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate:

92521, 92522 , 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004. These codes will continue to be reported as outpatient therapy procedures as listed in the Annual Therapy Update for the current year at: http://www.cms.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage. They are not diagnostic tests. Definitions of evaluations and documentation are found in Pub. 100-02, sections 220 and 230.

Other Services. There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline. For example, see the CSC - Therapy Cap Report, 3/21/2008, and CSC – Therapy Edits Tables 4/14/2008 at www.cms.hhs.gov/TherapyServices (Studies and Reports), or more recent utilization reports. Professional literature and guidelines from professional associations also provide a basis on which to estimate whether the type, frequency, and intensity of services are appropriate to an individual. Clinicians and contractors should utilize available evidence related to the patient’s condition to justify provision of medically necessary services to individual beneficiaries, especially when they exceed caps. Contractors shall not limit medically necessary services that are justified by scientific research applicable to the beneficiary. Neither contractors nor clinicians shall utilize professional literature and scientific reports to justify payment for continued services after an individual’s goals have been met earlier than is typical. Conversely, professional literature and scientific reports shall not be used as justification to deny payment to patients whose needs are greater than is typical or when the patient’s condition is not represented by the literature.



ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

C01 - C02.8 - Opens in a new window Malignant neoplasm of base of tongue - Malignant neoplasm of overlapping sites of tongue
C04.0 - C04.8 - Opens in a new window Malignant neoplasm of anterior floor of mouth - Malignant neoplasm of overlapping sites of floor of mouth
C05.0 - C05.1 - Opens in a new window Malignant neoplasm of hard palate - Malignant neoplasm of soft palate
C15.3 Malignant neoplasm of upper third of esophagus
C32.0 - C32.9 - Opens in a new window Malignant neoplasm of glottis - Malignant neoplasm of larynx, unspecified
E01.0 Iodine-deficiency related diffuse (endemic) goiter
E01.2 Iodine-deficiency related (endemic) goiter, unspecified
F44.4 Conversion disorder with motor symptom or deficit
I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage
I69.191 Dysphagia following nontraumatic intracerebral hemorrhage
I69.291 Dysphagia following other nontraumatic intracranial hemorrhage
I69.391 Dysphagia following cerebral infarction
I69.891 Dysphagia following other cerebrovascular disease
I69.991 Dysphagia following unspecified cerebrovascular disease
J38.00 - J38.02 - Opens in a new window Paralysis of vocal cords and larynx, unspecified - Paralysis of vocal cords and larynx, bilateral
J69.0 Pneumonitis due to inhalation of food and vomit
K21.9 - K22.0 - Opens in a new window Gastro-esophageal reflux disease without esophagitis - Achalasia of cardia
K22.2 Esophageal obstruction
K22.4 - K22.5 - Opens in a new window Dyskinesia of esophagus - Diverticulum of esophagus, acquired
K22.70 - K22.719 - Opens in a new window Barrett's esophagus without dysplasia - Barrett's esophagus with dysplasia, unspecified
K94.30 - K94.33 - Opens in a new window Esophagostomy complications, unspecified - Esophagostomy malfunction
R13.0 Aphagia
R13.11 - R13.14 - Opens in a new window Dysphagia, oral phase - Dysphagia, pharyngoesophageal phase
R63.3 Feeding difficulties
Z93.0 Tracheostomy status
Z96.3 Presence of artificial larynx

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