Showing posts with label ICD 10. Show all posts
Showing posts with label ICD 10. Show all posts

Monday, September 11, 2017

pyelonephritis icd 10 code


N10 Acute tubulo-interstitial nephritis

Includes: acute infectious interstitial nephritis acute pyelitis acute pyelonephritis acute tubular necrosis hemoglobin nephrosis myoglobin nephrosis Use additional code (B95-B97), to identify infectious agent.

N11 Chronic tubulo-interstitial nephritis

Includes: chronic infectious interstitial nephritis chronic pyelitis chronic pyelonephritis Use additional code (B95-B97), to identify infectious agent.

N11.0 Nonobstructive reflux-associated chronic pyelonephritis Pyelonephritis (chronic) associated with (vesicoureteral) reflux

Excludes1: vesicoureteral reflux NOS (N13.70)

N11.1 Chronic obstructive pyelonephritis

Pyelonephritis (chronic) associated with anomaly of pelviureteric junction
Pyelonephritis (chronic) associated with anomaly of pyeloureteric junction
Pyelonephritis (chronic) associated with crossing of vessel
Pyelonephritis (chronic) associated with kinking of ureter
Pyelonephritis (chronic) associated with obstruction of ureter
Pyelonephritis (chronic) associated with stricture of pelviureteric junction
Pyelonephritis (chronic) associated with stricture of ureter
Excludes1: calculous pyelonephritis (N20.9) obstructive uropathy (N13.-)

N11.8 Other chronic tubulo-interstitial nephritis Nonobstructive chronic pyelonephritis NOS

N11.9 Chronic tubulo-interstitial nephritis, unspecified


Chronic interstitial nephritis NOS
Chronic pyelitis NOS
Chronic pyelonephritis NOS

N12 Tubulo-interstitial nephritis, not specified as acute or chronic Includes: interstitial nephritis NOS pyelitis NOS pyelonephritis NOS Excludes1: calculous pyelonephritis (N20.9)

N13 Obstructive and reflux uropathy

Excludes2: calculus of kidney and ureter without hydronephrosis (N20.-) congenital obstructive defects of renal pelvis and ureter (Q62.0-Q62.3) hydronephrosis with ureteropelvic junction obstruction (Q62.1) obstructive pyelonephritis (N11.1)

N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified

Excludes1: Hydronephrosis with ureteral stricture with infection (N13.6)

N13.2 Hydronephrosis with renal and ureteral calculous obstruction Excludes1: Hydronephrosis with renal and ureteral calculous obstruction with infection (N13.6)

N13.3 Other and unspecified hydronephrosis

Excludes1: hydronephrosis with infection (N13.6)

N13.30 Unspecified hydronephrosis

N13.39 Other hydronephrosis

Friday, July 28, 2017

ICD 10 code for conjunctivitis - H10


The most common codes that will be used in Primary Care are related to conjunctivitis. The two categories related to conjunctivitis are found in the table below, but the most commonly used codes are:

• H10.0 Mucopurulent conjunctivitis

• H10.01- Acute follicular conjunctivitis

• H10.02- Other mucopurulent conjunctivitis

• H10.1- Acute atopic conjunctivitis

• H10.2 Other acute conjunctivitis

• H10.21- Acute toxic conjunctivitis

• H10.22- Pseudomembranous conjunctivitis

• H10.23- Serous conjunctivitis, except viral (B30.-)

• H10.3- Unspecified acute conjunctivitis

• H10.4 Chronic conjunctivitis

• H10.40- Unspecified chronic conjunctivitis

• H10.41- Chronic giant papillary conjunctivitis

• H10.42- Simple chronic conjunctivitis

• H10.43- Chronic follicular conjunctivitis

• H10.44 Vernal conjunctivitis

• H10.45 Other chronic allergic conjunctivitis


 Examples:

• Conjunctivitis: H10

• Dry Eye: H04

• Glaucoma: H40

• Retinal Disorders: H33, H34, H35

• First three digits after decimal

• Position 4, or 4 & 5: One or two digits indicating the etiology, or cause, of the condition, e.g., chronic allergic (cause) for conjunctivitis (category).

• Next, one digit that gives location, i.e., which eye:right, left, or bilateral (both).

o While a laterality location code is not required for every diagnosis, we will see it on most eye codes.

o A few codes require location be noted by lid rather than eye.

o Laterality code will be in position 5 or 6,depending upon if there are 1 or 2 digits before denoting cause.


Billing scenario

A patient who is being followed by her Ophthalmologist during the post-op of cataract surgery comes in for an additional visit because she has developed conjunctivitis. The conjunctivitis is unrelated to the cataract surgery and necessitated an additional visit over and above her regular post-op check-ups. The E/M code for the visit is billed to the insurance carrier with a -24 modifier and the diagnosis code used is 372.02 for Acute Conjunctivitis.

Modifier – 24: ICD-10

1. H10.012 Acute conjunctivitis: acute follicular, LEFT eye

2. H26.121 Traumatic cataract: partially resolved RIGHT eye

A54.30 Gonococcal infection, eye, unspecified

A54.31 Gonococcal conjunctivitis

A54.32 Gonococcal iridocyclitis

A54.33 Gonococcal keratitis

A54.39 Gonococcal eye infection, other

H10.***: Conjunctival conditions EyeCodingForum.com 19

H10.011 Acute follicular conjunctivitis, right eye

H10.021 Other mucopurulent conjunctivitis, right eye

H10.11 Acute atopic conjunctivitis, right eye

H10.211 Acute toxic conjunctivitis, right eye

H10.221 Pseudomembranous conjunctivitis, right eye

H10.231 Serous conjunctivitis, except viral, right eye

H10.31 Unspecified acute conjunctivitis, right eye

H10.401 Unspecified chronic conjunctivitis, right eye

H10.***: Conjunctival conditions

• Pingueculitis is an inflammed pinguecula [ H11.151].

H10.411 Chronic giant papillary conjunctivitis (GPC), right eye

H10.421 Simple chronic conjunctivitis, right eye

H10.431 Chronic follicular conjunctivitis, right eye

H10.501 Unspecified blepharoconjunctivitis, right eye

H10.511 Ligneous conjunctivitis, right eye

H10.521 Angular blepharoconjunctivitis, right eye

H10.531 Contact blepharoconjunctivitis, right eye

H10.811 Pingueculitis, right eye



Allergic conjunctivitis is uncomfortable  enough on its own, and the addition of contact lenses tends to further exacerbate the problem. Most of your contact lens wearers will hate the idea of switching back to their glasses for allergy season, so consider some alternatives to making the switch from contacts to glasses.

We see many patients who present to our offi ces with complaints of red eye, or “pink eye,” as they like to call it. Sportscaster Bob Costas came down with a case of it during last month’s 2014 Winter Olympics that made headlines worldwide. While the majority of red eye presentations are caused by various types of conjunctivitis—which is the emphasis of this discussion—it is important to fi rst rule out other possible etiologies prior to initiating treatment for conjunctivitis.  The primary types of conjunctivitis are bacterial, viral, allergic and Chlamydial—with viral and allergic being the most common. A careful evaluation of the patient’s symptoms and clinical signs should enable the practitioner to arrive at a proper diagnosis. 

It is important to fi rst determine  the type of conjunctivitis present before selecting the most appropriate treatment. This depends on the practitioner’s ability to accurately assess the patient’s symptoms and distinguish the clinical signs. Both of these tasks can pose signifi cant challenges for the clinician.

It is usually best to have the patient defi ne itching. For example, ask the patient if the sensation they feel itches like a mosquito bite. Many patients use itching as a broader term and actually may be experiencing a mild scratchiness, which would be more consistent with an infectious process or ocular surface disease, rather than allergic conjunctivitis.  

Another challenge is the overlap of a patient’s symptoms. For example, the chemical mediators released by chronic allergic conjunctivitis may induce a superficial punctate keratitis, which becomes more symptomatic than the original itching complaint. Additionally, keep in mind that itching of the eye itself is the hallmark sign of allergic conjunctivitis. Itching of the eyelids or lid margins may stem from etiologies related to lid disease rather than allergy 

A thorough evaluation of the red eye needs to discern whether the redness is due to hyperemia of the superfi cial conjunctival vessels or injection of the deeper episcleral and/or scleral vessels. Conjunctival hyperemia may indicate an increased permeability of these vessels, leading to the exudative response. Conjunctivitis alone typically does not induce limbal injection. If a determination can not be made solely with slit-lamp observation, the practitioner can always instill a vasoconstrictor and look for blanching of the vessels. Conjunctival vessels will blanch completely, episcleral vessels may partially or totally blanch and scleral vessels will not blanch at all.

Most conjunctivitis cases exhibit an exudative response. Findings may include serous production (i.e., tearing); mucoid, mucopurulent or purulent discharge; fi brinous material or hemorrhage. The serous response may also lead to conjunctival chemosis. Serous discharge or excessive tearing is usually seen with allergic, toxic or viral conjunctivitis, while mucopurulent and/or purulent exudate
is more associated with bacterial and Chlamydial conjunctivitis.

Excessive mucous can be generated  in any type of conjunctivitis, depending upon the severity of the infl ammatory response and irritation to the conjunctival goblet cells. Pseudomembrane formation is due to fi brin in the exudative material; it indicates a higher degree of infl ammation. 

Pseudomembrane material should always be removed, as there is risk of it becoming a true conjunctival membrane. This risk is due to delayed healing of the infl amed tissue secondary to decreased extracellular fi brinolysis. Pseudomembranes are most frequently associated with epidemic keratoconjunctivitis adenoviral disease, but can also be seen with certain bacterial conjunctivitis, such as streptococcal pneumonia or Gonococcus infection. The presence of pseudomembranes always indicates a need for topical steroids as part of the treatment plan. Conjunctival hemorrhages can be seen with any infectious etiology 


Tissue findings in conjunctivitis can manifest as either a papillary or follicular response. Papillae, typically seen in bacterial infection as a response to chronic irritation or allergy, are raised tissue masses found on the palpebral conjunctiva with a central vessel and are created by a focal infi ltration of infl ammatory cells. The type of infl ammatory cell depends on the underlying etiology—for example, eosinophils in allergic conditions vs. neutrophils in bacterial disease. 

Follicles represent expansions of the lymph system with a blisterlike appearance and a central avascular zone with the conjunctival vasculature otherwise following its normal course over the follicle. Follicles are seen in viral, Chlamydial and toxic conditions. In viral conjunctivitis, follicles form in response to viral particles having entered the lymph system, which also creates the localized preauricular lymph node response.

The clinical evaluation of conjunctivitis should also include an assessment of the eyelids, cornea and relevant lymph nodes. Eyelid edema can be seen with any type of conjunctivitis, depending on the severity of the infl ammatory response. While most presentations of conjunctivitis do not affect the cornea, a careful corneal assessment should be performed to rule out any associated punctate keratopathy, dendrites or corneal infi ltrates. Their presence may illuminate a more precise diagnosis or help to better explain patient symptoms. For example, an associated punctate keratopathy may explain the patient’s complaints of a gritty or scratchy feeling. 

The preauricular and submaxillary lymph nodes should always be palpated to rule out enlargement and/or tenderness during a workup for conjunctivitis. Both fi ndings can be associated with viral or Chlamydia infection.

Other cases where laboratory diagnostic testing may be of higher value include suspected MRSA or MRSE infection, chronic conjunctivitis unresponsive to treatment, conjunctivitis potentially secondary to canaliculitis or dacryocystitis, and hyperacute conjunctivitis if Gonococcus is the suspected organism. Minitipped bacterial culturettes are very useful for collecting sample material for laboratory evaluation in these cases.

Most patients report hyperemia, which may be localized, with irritation and stickiness of one eye followed by bilateral involvement in two to three days. Bacterial conjunctivitis frequently presents nasally initially, and then involves the remaining conjunctival surface. A mucopurulent or purulent discharge usually appears within the fi rst 24 hours, which may lead to some patients reporting that the eyelids are matted shut upon awakening in the morning. The sensation of eyelid stickiness or matting is more common in chronic or severe cases. 

• Treatment. Topical antibiotics are the mainstay of bacterial conjunctivitis treatment. Many recent and older antibiotic agents are effective for the treatment of bacterial conjunctivitis. This is important to understand in today’s world of managed care, where formulary restrictions may make it diffi cult or limit the ability to treat with many of the later generation fl uoroquinolone or macrolide agents.

Proper adjunctive treatment of the eyelids is also important in chronic bacterial or lid diseaserelated conjunctivitis. Daily lid hygiene/scrubs should be part of the management plan in these cases and continue on a maintenance basis long term. Lid scrubs with a commercially prepared eyelid cleansing foam or pad product are preferred over baby shampoo for this procedure. Adjunctive treatment with a broad-spectrum oral penicillin or cephalosporin antibiotic, such as amoxicillin/ clavulanate potassium, may be indicated in hyperacute conjunctivitis, chronic conjunctivitis related to lid disease or if associated preseptal cellulitis is suspected. For Neisseria gonorrhoeae-related hyperacute conjunctivitis, one gram of ceftriaxone by IM injection is required.

Proper adjunctive treatment of the eyelids is also important in chronic bacterial or lid diseaserelated conjunctivitis. Daily lid hygiene/scrubs should be part of the management plan in these cases and continue on a maintenance basis long term. Lid scrubs with a commercially prepared eyelid cleansing foam or pad product are preferred over baby shampoo for this procedure. Adjunctive treatment with a broad-spectrum oral penicillin or cephalosporin antibiotic, such as amoxicillin/ clavulanate potassium, may be indicated in hyperacute conjunctivitis, chronic conjunctivitis related to lid disease or if associated preseptal cellulitis is suspected. For Neisseria gonorrhoeae-related hyperacute conjunctivitis, one gram of ceftriaxone by IM injection is required.

EYE

H10.30 Acute Conjunctivitis, Unspecified
H10.429 Chronic Conjunctivitis, Simple
H10.44 Vernal Conjunctivitis
H10.45 Other Chronic Allergic Conjunctivitis
H10.501 Blepharoconjunctivitis, Unspecified, Right Eye
H10.502 Blepharoconjunctivitis, Unspecified, Left Eye
H10.503 Blepharoconjunctivitis, Unspecified, Bilateral
H10.509 Blepharoconjunctivitis, Unspecified

EAR
H60.391 Infective Otitis Externa, Right Ear
H60.392 Infective Otitis Externa, Left Ear
H60.393 Infective Otitis Externa, Unspecified Ear
H60.399 Infective Otitis Externa, Unspecified Ear
H65.00 Acute Serous Otitis Media, Unspecified Ear
H65.01 Acute Serous Otitis Media, Right Ear
H65.02 Acute Serous Otitis Media, Left Ear
H65.03 Acute Serous Otitis Media, Bilateral
H65.119 Acute Allergic Serous Otitis Media
H65.20 Chronic Serous Otitis Media
H65.21 Chronic Serous Otitis Media, Right Ear
H65.22 Chronic Serous Otitis Media, Left Ear
H65.23 Chronic Serous Otitis Media, Bilateral
H65.90 Other and Unspecified Chronic Nonsuppurative Otitis Media.

Unspecified Ear
H65.91 Nonsuppurative Otitis Media, Right Ear
H65.92 Nonsuppurative Otitis Media, Left Ear
H65.93 Nonsuppurative Otitis Media, Bilateral
H66.90 Otitis Media, Unspecified
H66.91 Otitis Media, Right Ear
H66.92 Otitis Media, Left Ear
H66.93 Otitis Media, Bilateral
H69.80 Dysfunction of Eustachian Tube, Unspecified Ear
H69.81 Dysfunction of Eustachian Tube, Left Ear
H69.82 Dysfunction of Eustachian Tube, Right Ear
H69.83 Dysfunction of Eustachian Tube, Bilateral
H83.01 Labyrinthitis, right Ear
H83.02 Labyrinthitis, Left Ear
H83.03 Labyrinthitis, Bilateral
H83.09 Labyrinthitis, Unspecified

Friday, January 6, 2017

CPT code Q4101, Q4106, Q4121, Q4132, q9363

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The provisions of this LCD apply to payment for bioengineered skin substitutes (BSS) for chronic ulcers of the lower extremities secondary to diabetes and venous stasis. This LCD does not address human skin autografts, cadaveric human skin allografts, or dermal xenografts (porcine). Additionally, the provisions of this LCD do not apply to treatment of acute wounds, tendon and/or ligament augmentation/repair, postoperative wounds, burns or pressure ulcers.



Indications


Applied to partial- or full-thickness ulcers of the lower extremities (see individual product information for labeled indications) as adjunctive therapy only after failing treatment with standard wound therapy. Failure to respond to standard wound therapy occurs when there are no documented measurable signs of healing for at least 30 consecutive days. Standard wound therapy includes:

assessment of a patient’s vascular status (e.g. presence of acceptable: lower extremity pulses, Doppler toe signals, Ankle-Brachial Index; evaluation of venous insufficiency; evaluation of edema) and correction of any vascular problems in the affected limb if possible;
optimization of nutritional status;
optimization of glucose control (when applicable);
debridement by any means to remove devitalized tissue;
maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings;
appropriate off-loading; and
necessary treatment to resolve any infection that might be present.



Limitations

During an initial course of treatment, repeat applications of skin substitutes/replacements are not indicated when applications were unsuccessful.

Initiation of retreatment of healed ulcers that have recurred is not indicated.

Coverage will not be provided under this LCD for any ulcer treatment of the lower extremities that does not meet the definition of Q4101, Q4102, Q4106, Q4107, Q4121, Q4127, Q4131, Q4132, Q4133 or Q4158 . Other products of the skin substitute series (Q4100-Q4111, Q4115-Q4120, Q4122-Q4126, Q4128-Q4130, Q4134-Q4138, Q4140-Q4143, Q4146-Q4148, Q4151- Q4161, Q4163-Q4165 and C9363) will be considered to be "biologic wound dressings" which are part of the relevant service provided and not separately payable.

The following modifiers were effective for dates of service on or after 01/01/2009:

JC – Skin substitute used as a graft
JD – Skin substitute not used as a graft

Providers should use the above modifiers in compliance with CPT ® and CMS instructions.

The following indications and limitations to Medicare coverage and payment apply to the specified BSS and their related skin substitute application physician services.

Apligraf ® (Q4101) is approved for diabetic foot ulcer and venous stasis ulcer. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for Apligraf ® is limited to five applications per ulcer.

Oasis ® (Q4102) is approved for diabetic foot ulcer and venous stasis ulcer. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for Oasis ® is limited to 12 weeks of therapy per ulcer.

Dermagraft ® (Q4106) is approved for treatment of full-thickness diabetic foot ulcers. Additionally, diabetic ulcers of the ankle and calf are covered. Frequency is limited to eight applications per ulcer. Medicare does not cover continued reapplication of Dermagraft ® for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.

GraftJacket ® (Q4107) is approved for full-thickness diabetic foot ulcers. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for GraftJacket ® is limited to 1 application per ulcer.

TheraSkin® (Q4121) is approved for diabetic foot ulcer and venous stasis ulcer. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for TheraSkin® is limited to five applications per ulcer.

Talymed ® (Q4127) is approved for diabetic foot ulcer and venous stasis ulcer. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for Talymed ® is limited to five applications per ulcer.

Epifix ® (Q4131) is approved for diabetic foot ulcer and venous stasis ulcer. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for Epifix ® is limited to five applications per ulcer.

Grafix® (Q4132 and Q4133) is a covered therapeutic option for the treatment of diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs) (but not limited to these). Medicare payment for Grafix® is limited to five applications per ulcer.

Kerecis Omega3 Wound® (Q4158) is approved for diabetic foot ulcer and venous stasis ulcer. Additionally, diabetic ulcers of the ankle and calf are covered. Medicare payment for Kerecis Omega3 Wound® is limited to twelve applications per ulcer.

Surgical Wound Preparation (CPT ® codes 15002–15005)
Medicare does not expect to be billed for CPT ® codes 15002–15005 in conjunction with routine, simple and/or repeat application of skin substitutes/replacements.

Skin Substitute Application Procedures (CPT ® codes 1527X)
BSS application codes should meet the definition of the CPT ®/HCPCS code descriptor.

Product Wastage

Medicare provides payment for the amount of the BSS product that is reasonable and necessary to treat the patient’s ulcer. If the physician has made good faith efforts to minimize the unused portion of the BSS product in how patients are scheduled and how he/she ordered, accepted, stored and used the product, and made good faith efforts to minimize the unused portion of the product in how it is supplied, the program will cover the amount of product discarded along with the amount used to treat the ulcer. Documentation requirements for unused/discarded materials are provided in coverage in interpretive manuals: Internet Only Manual (IOM): Medicare Claims Processing Manual – Pub. 100-04, Chapter 17, Section 40.


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.


CPT/HCPCS Codes



Group 1 Codes:
Q4101 Apligraf
Q4102 Oasis wound matrix
Q4121 Theraskin
Q4127 Talymed
Q4131 Epifix or epicord
Q4132 Grafix core
Q4133 Grafix prime
Q4106 Dermagraft
Q4107 Graftjacket

Group 3 Paragraph: Not Separately Payable

Group 3 Codes:

C9363 Integra meshed bil wound mat

Q4100 Skin substitute, nos

Q4103 - Q4105 Oasis burn matrix - Integra drt or omnigraft

Q4108 - Q4111 Integra matrix - Gammagraft

Q4115 - Q4118 Alloskin - Matristem micromatrix

Q4122 - Q4126 Dermacell - Memoderm/derma/tranz/integup

Q4128 - Q4130 Flexhd/allopatchhd/matrixhd - Strattice tm

Q4134 - Q4138 Hmatrix - Biodfence dryflex, 1cm

Q4140 - Q4143 Biodfence 1cm - Repriza, 1cm

Q4146 - Q4148 Tensix, 1cm - Neox 1k, 1cm

Q4151 - Q4161 Amnioband, guardian 1 sq cm - Bio-connekt per square cm

Q4163 - Q4165 Amnio bio and woundex sq cm - Keramatrix, per square cm



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: The correct use of an ICD-10-CM code listed in the "ICD-10 Codes that Support Medical Necessity" section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD.

ICD-10 codes must be coded to the highest level of specificity. Consult the ‘Official ICD-10-CM Guidelines for Coding and Reporting’ in the current ICD-10-CM book for correct coding guidelines. This LCD does not take precedence over the Correct Coding Initiative (CCI).

The recommended ICD-10 codes applicable to the indications in the LCD are as follows:

Q4101 used to report Apligraf®, Q4102 used to report Oasis®, Q4121 used to report Theraskin, Q4127 used to report Talymed®, Q4131 used to report Epifix® and Q4132 and Q4133 used to report Grafix®:





ICD-10 CODE DESCRIPTION

E10.621 - E10.622 - Opens in a new window Type 1 diabetes mellitus with foot ulcer - Type 1 diabetes mellitus with other skin ulcer

E11.621 - E11.622 - Opens in a new window Type 2 diabetes mellitus with foot ulcer - Type 2 diabetes mellitus with other skin ulcer

E13.621 - E13.622 - Opens in a new window Other specified diabetes mellitus with foot ulcer - Other specified diabetes mellitus with other skin ulcer

I83.002 - I83.008 - Opens in a new window Varicose veins of unspecified lower extremity with ulcer of calf - Varicose veins of unspecified lower extremity with ulcer other part of lower leg

I83.012 - I83.018 - Opens in a new window Varicose veins of right lower extremity with ulcer of calf - Varicose veins of right lower extremity with ulcer other part of lower leg

I83.022 - I83.028 - Opens in a new window Varicose veins of left lower extremity with ulcer of calf - Varicose veins of left lower extremity with ulcer other part of lower leg

I83.202 - I83.208 - Opens in a new window Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation - Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation

I83.212 - I83.218 - Opens in a new window Varicose veins of right lower extremity with both ulcer of calf and inflammation - Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation

I83.222 - I83.228 - Opens in a new window Varicose veins of left lower extremity with both ulcer of calf and inflammation - Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation

I87.311 - I87.313 - Opens in a new window Chronic venous hypertension (idiopathic) with ulcer of right lower extremity - Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity

I87.331 - I87.333 - Opens in a new window Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity - Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity


ICD-10 CODE DESCRIPTION

E10.621 - E10.622 - Opens in a new window Type 1 diabetes mellitus with foot ulcer - Type 1 diabetes mellitus with other skin ulcer
E11.621 - E11.622 - Opens in a new window Type 2 diabetes mellitus with foot ulcer - Type 2 diabetes mellitus with other skin ulcer
E13.621 - E13.622 - Opens in a new window Other specified diabetes mellitus with foot ulcer - Other specified diabetes mellitus with other skin ulcer
Showing 1 to 3 of 3 entries in Group 2
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Wednesday, June 22, 2016

CPT CODE G0839 and who is covered benefit

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)


HCPCS/CPT Codes
G0389 – Ultrasound exam for AAA screening


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


Who Is Covered

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


Frequency
Once in a lifetime


Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Tuesday, May 31, 2016

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

Screening Pap Tests

HCPCS/CPT Codes

G0123, G0124, G0141, G0143, G0144,

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

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

P3000 – Screening Pap smear by technician under physician supervision

P3001 – Screening Pap smear requiring interpretation by physician

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



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

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

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

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

ICD-10-CM Codes

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


Who Is Covered

All female Medicare beneficiaries


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


Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived


Indications and Limitations of Coverage and/or Medical Necessity

Screening Pap Smears, Pelvic and Breast Examinations 

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

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

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

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

High risk factors for cervical and vaginal cancer are:

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

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

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

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

Prenatal exposure to diethylstilbestrol - Exposed daughters of women who took

DES during pregnancy.


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



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

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

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

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

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

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

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

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

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

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

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

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

Anus and perineum.


D. Screening Services Coverage and Reimbursement

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

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

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

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

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

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

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

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

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

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

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

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



Diagnostic Pap Smears 

Diagnostic Pap Smears may be covered for the following conditions:

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

Previous abnormal Pap smear;

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

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

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

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

Limitations:

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

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

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

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


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

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

* Screening Pelvic Examinations (G0101)

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

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

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

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

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


Reimbursement Guidelines

A. For Moda Health Medicare Advantage plans:

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

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

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

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

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

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

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

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

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

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

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

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

The following procedure codes are payable for gynecological cytopathology services:

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

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


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


POLICY 

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

For the purpose of this policy, screening services include:

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

• G0102 Prostate cancer screening; digital rectal examination

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



CODE                 RULE        CODE

G0123

Incidental

88141


Raionale for Edit:

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


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

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


Well woman Exam POLICY

Well Woman Exams do not require prior authorization.

Advantage

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

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

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

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

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

* Screening Pelvic Examinations (G0101)



CODING/BILLING INFORMATION

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

HCPCS CODES

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

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

Sunday, May 22, 2016

CPT 87491, 87591 - sexually transmitted infection - STI screening

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

HCPCS/CPT Codes

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


ICD-10-CM Codes

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


Who Is Covered

Certain Medicare beneficiaries who are:

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

primary care provider in a primary care setting

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

Frequency

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

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

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

STI screening CODES

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


STIs and continued increased risk for the second screening

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


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

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

• Deductible waived


Chlamydia Infection Screening

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

Diagnosis Code(s):

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

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

Thursday, May 5, 2016

CPT CODE 90669, 90670, 90732 & G0009, G0008 ICD 10 CODE Z23

Pneumococcal Vaccine and Administration


HCPCS/CPT Codes

90669
– Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use

90670 – Pneumococcal conjugate vaccine, 13-valent, for intramuscular use

90732 – – Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

G0009 – Administration

G0008 Administration of influenza virus vaccine

Pneumococcal Vaccine 90669 Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for  intramuscular use B WAIVED 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use. WAIVED

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use WAIVED

G0009 Administration of pneumococcal vaccine WAIVED


ICD-10-CM Codes
Z23


Who Is Covered

All Medicare beneficiaries


Frequency

• An initial pneumococcal vaccine to Medicare beneficiaries who never received the vaccine under Medicare Part B; and

• A different, second pneumococcal vaccine 1 year after the first vaccine was administered

Once in a lifetime/ Medicare may cover additional vaccinations based on risk


Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived


For more information, refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243321.html on the Centers for Medicare & Medicaid Services (CMS) website.

Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit Administration Codes: G0008: Influenza Virus G0009: Pneumococcal  Diagnosis Code: V06.6

Use seasonal influenza virus and pneumococcal vaccine codes

Follow administration  guidelines for seasonal influenza virus and pneumococcal vaccines


Pneumoccal Vaccine cpt codes 90669, 90670, 90732, G0009




Hybrid Review Childhood Immunization and Lead Screenings

– The health plan is looking for all childhood immunizations and lead screenings to be completed on or before the child’s second birthday

• – in other words, 12-23 months (plus the number of days in that 23rd month just prior to the date of birth)

– Complete immunizations on or before the child’s second birthday:

• 4 – DTaP/DT (CPT – 90700; ICD-9-CM V20.2)

• 3 – IPV (90713; v04.0)

• 3 – Hep B (90743; 90744; V05.3)

• 3 – Hib (90647; v03.81)

• 4 – PCV (90670; v03.82)

• 1 – MMR (90707; v06.4)

• 1 – VZV (90716; 90660; v05.4)


When a beneficiary receives both the seasonal influenza virus and  pneumococcal vaccines on the same visit, would a provider continue to report separate administration codes for each type of vaccine?

Yes. Although the provider would use diagnosis code V06.6 when an individual receives both vaccines, separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines should be reported. Medicare will pay both administration fees if a beneficiary receives both the seasonal influenza virus and the pneumococcal vaccines on the same day


Immunization Guidelines

Applicable Codes: 90460-90749, G0008, G0009, G0010, Q2034-Q2039

Codes 90460 and 90461 must be reported in addition to the vaccine and toxoid codes 90476-90749.

Report codes 90460-90461 only when the physician or qualified health care professional provides faceto-face counseling of the patient and family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

Codes 90476-90748 identify the vaccine product only. To report the administration of a vaccine/toxoid, the vaccine product code must be used in addition to the administration code 90460-90474. Modifier 51 should not be reported for the vaccines/toxoids when performed with these administration procedures.

Each immunization given must be filed on a single line of the CMS 1500 claim form, with its specific CPT code.

The -25 modifier must be used with all evaluation and management services except preventive services CPT 99381-99397, when reporting a significant, separately identifiable service in addition to the immunization services.

It is inappropriate to use the unlisted vaccine code CPT 90749 to report immunization administration services.

The invoice from the laboratory or pharmacy the vaccine has been purchased from may be requested for claim review.

ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older.



CMS has data indicating the resource costs of vaccine administrations, yet continues to link payments to CPT 90782 (Therapeutic, prophylactic, or diagnostic injection). It is inappropriate for the agency to continue to link vaccine administration payments to 90782 when CPT maintains a code that describes administration of an immunization and when CMS has data on the resource costs associated with the service. ACP-ASIM has repeatedly asked CMS staff for an explanation for the linkage of Health Care Financing Administration Common Procedure Coding System (HCPCS) codes G0008, G0009, and G0010 to CPT 90782, but has not received a clear answer for this payment rationale.



Coding Policy

ACP-ASIM also strongly believes that CMS should revise the current coding requirements for vaccine administrations by replacing the HCPCS codes G0008, G0009, and G0010. Currently, each of these G codes for vaccine administration is linked to CPT code 90782, and reimbursed by Medicare Carriers at that rate. We believe that CPT codes 90471 and 90472 should replace HCPCS codes G0008, G0009, and G0010 because these codes were created to describe an immunization administration. Using CPT codes 90471 and 90472 to record vaccine administrations will also simplify the coding requirements placed on providers. The majority of private insurance plans require providers to bill for these services by using the codes 90471 and 90472. Medicare’s requirement to use G codes for vaccine administrations is an unnecessary  administrative hassle to providers that should be revised.


Does a deductible or coinsurance apply for adult immunizations covered by Medicare?

n Neither a deductible nor coinsurance applies to the influenza virus vaccine or Pneumococcal Polysaccharide Vaccine (PPV). However, a deductible plus 20 percent of the Medicare coinsurance amount applies to the Hepatitis B Virus (HBV) vaccine.

If a beneficiary receives a flu vaccination more than once in a 12-month period, will Medicare still pay for it?

n Yes. Medicare pays for one flu vaccination per flu season; however, a beneficiary could receive the flu vaccine twice in a calendar year for two different flu seasons and the provider would be reimbursed for each. For example, a beneficiary could receive a flu vaccination in January 2005 for the 2004-05 flu season and another flu vaccination in November 2005 for the 2005-06 flu season and Medicare would pay for both vaccinations.

Will Medicare pay for the PPV vaccination if a beneficiary is uncertain of his or her vaccination history?

n Yes. If a beneficiary is uncertain about his or her vaccination history in the past five years, the vaccine should be given and Medicare will cover the revaccination. If a beneficiary is certain that more than five years have passed, revaccination is not appropriate unless the beneficiary is at highest risk.

Does Medicare cover the HBV vaccine for all Medicare beneficiaries?

n No. Medicare provides coverage for certain beneficiaries at medium to high risk for HBV. These individuals include those with End Stage Renal Disease (ESRD), persons who live in the same household as an HBV carrier, and workers in healthcare professions who have frequent contact with blood or blood-derived body fluids during routine work.

When a beneficiary receives both the influenza and PPV vaccines on the same visit, would a provider continue to report separate administration codes for each type of vaccine?

n Yes. Although the provider would use diagnosis code V06.6 when an individual receives both vaccines, separate administration codes for influenza (G0008) and PPV (G0009) should be reported.

Can the influenza, PPV, and HBV vaccinations all be roster billed?

n No. Only the influenza and PPV vaccines are eligible for roster billing. Roster billing does not apply to the HBV vaccine.

What is a mass immunizer?

n A mass immunizer offers flu and/or PPV vaccinations to a large number of individuals and may be a traditional Medicare provider or supplier or a nontraditional provider or supplier (such as a senior citizen’s center, a public health clinic, or community pharmacy). Mass immunizers must submit claims for immunizations on roster bills and must accept assignment on both the vaccine and its administration. A mass immunizer should enroll with the Carrier prior to flu season. Please see the next question for more enrollment information.

Do providers that only provide immunizations need to enroll in the Medicare Program?

n Yes. Providers must enroll in the Medicare Program even if immunizations are the only service they will provide to beneficiaries. They should enroll as provider specialty type 73, Mass Immunization Roster Biller by completing Form CMS-855I for individuals or Form CMS-855B for a group.


CONTRAINDICATIONS

• Severe allergic reaction to any component of Prevnar 13, Prevnar, or any diphtheria toxoid-containing vaccine.
• Moderate or severe illness

PRECAUTIONS

Apnea following intramuscular vaccination has been observed in some infants born prematurely. Decisions about when to administer an intramuscular vaccine, including PCV13, to infants born prematurely should be based on consideration of the individual infant's medical status and potential benefits and possible risks of vaccination FURTHER POINTS

• May be administered simultaneously with influenza vaccine
• Local reactions (such as pain, swelling or redness) following PCV13 occur in up to half of recipients. Local reactions are generally more common with the fourth dose than with the first three doses.
• When elective splenectomy, immunocompromising therapy, or cochlear implant placement is being planned, PCV13 vaccination should be completed at least 2 weeks before surgery or initiation of therapy.
• CPT code:90670. ICD-9-CM code:V03.82

Pneumococcal Vaccine CPT Code 90669,G0009 and 90732

Pneumococcal illness is a disease created by the microscopic organisms Streptococcus pneumoniae, otherwise called pneumococcus. The most widely recognized sorts of contaminations brought on by this bacterium incorporate center ear diseases, pneumonia, circulation system contaminations (bacteremia), sinus diseases, and meningitis. Intrusive pneumococcal contamination executes a large number of individuals in the United States every year, the greater part of them 65 years old or more established. While flu infections for the most part strike amid the winter months, pneumococcal ailment happens year round. The pneumococcal immunization is great at ensuring grown-ups against intrusive pneumococcal infection and avoiding serious ailment, hospitalization, and demise. Medicare gives scope of the pneumococcal antibody and its organization for all Medicare recipients paying little mind to chance for the malady.

Scope Information

Scope of pneumococcal polysaccharide antibody (PPV) and its organization was included to the Medicare Program July 1, 1981. Scope of pneumococcal conjugate immunization and its organization was included to the Medicare Program January 1, 2008.

Medicare gives scope of pneumococcal inoculation rare for the most part for all Medicare recipients. (The recipient ought not have gotten the pneumococcal immunization inside of the most recent five years.) Medicare may give scope of extra inoculations taking into account danger or instability of recipient pneumococcal status.

Coding and Diagnosis Information

Medicare suppliers must utilize the accompanying Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes recorded

90669 - Pneumococcal conjugate antibody, polyvalent, when directed to youngsters more youthful than 5 years, for intramuscular use

90732 - Pneumococcal polysaccharide immunization, 23-valent, grown-up or immunosuppressed patient measurements, when managed to people 2 years or more established, for subcutaneous or intramuscular use

G0009 - Administration of pneumococcal immunization

Analysis Requirements


At the point when a Medicare supplier records a case, they must report the fitting finding code. On the off chance that the sole motivation behind the visit was to get the pneumococcal antibody, or if the pneumococcal immunization is the main administration charged on a case, the supplier must report determination code V03.82.

Be that as it may, if the motivation behind the visit was to get both the pneumococcal and flu infection immunization, suppliers must report analysis code V06.6.

V03.82 - Need for prophylactic immunization and immunization against bacterial ailments; other indicated inoculations against single bacterial infections; Streptococcus pneumoniae (pneumococcus)

V06.6 - Need for prophylactic immunization and vaccination against mixes of illnesses; Streptococcus pneumoniae (pneumococcus) and flu

Explanations behind Claim Denial

Medicare suppliers may discover particular installment choice data on the settlement guidance (RA). The RA will incorporate Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that give extra data on installment alterations.

Friday, April 15, 2016

Influenza Virus Vaccine and Administration and Glaucoma screening CPT codes

Glaucoma Screening

HCPCS/CPT Codes

G0117 – By an optometrist or ophthalmologist
G0118 – Under the direct supervision of an optometrist or ophthalmologist

ICD-10-CM Codes
Z13.5

Who Is Covered

Medicare beneficiaries who:
• Have diabetes mellitus;
• Have a family history of glaucoma;
• Are African-Americans aged 50 and older; or
• Are Hispanic-Americans aged 65 and older

Frequency
Annually for covered beneficiaries


Beneficiary Pays
• Copayment/coinsurance applies
• Deductible applies

Influenza Virus Vaccine and Administration

HCPCS/CPT Codes
90630, 90653, 90654, 90655, 90656, 90657,
90660, 90661, 90662, 90672, 90673, 90685,
90686, 90687, 90688, Q2035, Q2036, Q2037,
Q2038, Q2039 – Influenza Virus Vaccine
G0008 – Administration


ICD-10-CM Codes
Z23

Who Is Covered
All Medicare beneficiaries


Frequency
Once per influenza season Medicare covers additional flu shots if medically necessary


Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Tuesday, March 8, 2016

CPT 82947, 82950, 82951 ICD 10 Z13.1 -Diabetes screening

Diabetes Screening HCPCS/CPT Codes

82947 – Glucose; quantitative, blood (except reagent strip)
82950 – Glucose; post glucose dose (includes glucose)
82951 – Glucose; tolerance test (GTT), 3 specimens (includes glucose)

ICD-10-CM Codes

Z13.1

Who Is Covered

 Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes NOTE: Beneficiaries previously diagnosed
with diabetes are not eligible for this benefit


Frequency

• Two screening tests per year for beneficiaries diagnosed with pre-diabetes; or
• One screening per year if previously tested but not diagnosed with pre-diabetes or if never tested

Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived


*Medicare will only pay claims for DME if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service. Physicians and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If you are not enrolled on the date the prescription is filled or re-filled, Medicare will not pay the submitted claims. It is also important to tell the Medicare beneficiary if you are not participating in Medicare before you order DME. If you do not have an active record, please see the following fact sheet containing information on how to enroll, revalidate your enrollment, and/or make a change:  ttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243432.html on the CMS website.



Benefits for Treatment of Diabetes - BCBS

Benefits are available and will be determined on the same basis as any other sickness for those Medically Necessary items for Diabetes Equipment and Diabetes Supplies (for which a Physician or Professional Other Provider has written an order) and Diabetic Management Services/Diabetes Self-Management Training. Such items, when obtained for a Qualified Participant, shall include but not be limited to the following:

a. Diabetes Equipment

(1) Blood glucose monitors (including noninvasive glucose monitors and monitors for the blind);

(2) Insulin pumps (both external and implantable) and associated appurtenances, which include:

Insulin infusion devices,

Batteries,

Skin preparation items,

Adhesive supplies,

Infusion sets,

Insulin cartridges,

Durable and disposable devices to assist in the injection of insulin, and

Other required disposable supplies; and

(3) Podiatric appliances, including up to two pairs of therapeutic footwear per Calendar Year, for the prevention of complications associated with diabetes.

b. Diabetes Supplies

(1) Test strips specified for use with a corresponding blood glucose monitor

(2) Lancets and lancet devices

(3) Visual reading strips and urine testing strips and tablets which test for glucose, ketones, and protein

(4) Insulin and insulin analog preparations

(5) Injection aids, including devices used to assist with insulin injection and needleless systems

(6) Insulin syringes

(7) Biohazard disposable containers

(8) Prescriptive and non-prescriptive oral agents for controlling blood sugar levels, and

(9) Glucagon emergency kits.

c. Repairs and necessary maintenance of insulin pumps not otherwise provided for under the manufacturer's warranty or purchase agreement, rental fees for pumps during the repair and necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a similar replacement pump.


d. As new or improved treatment and monitoring equipment or supplies become available and are approved by the U. S. Food and Drug Administration (FDA), such equipment or supplies may be covered if determined to be Medically Necessary and appropriate by the treating Physician or Professional Other Provider who issues the written order for the supplies or equipment.

e. Medical-Surgical Expense provided for the nutritional, educational, and psychosocial treatment of the Qualified Participant. Such Diabetic Management Services/Diabetes Self-Management Training for which a Physician or Professional Other Provider has written an order to the Participant or caretaker of the Participant is limited to the following when rendered by or under the direction of a Physician.

Initial and follow-up instruction concerning:

(1) The physical cause and process of diabetes;

(2) Nutrition, exercise, medications, monitoring of laboratory values and the interaction of these in the effective self-management of diabetes;

(3) Prevention and treatment of special health problems for the diabetic patient;

(4) Adjustment to lifestyle modifications; and

(5) Family involvement in the care and treatment of the diabetic patient. The family will be included in certain sessions of instruction for the patient.

Diabetes Self-Management Training for the Qualified Participant will include the development of an individualized management plan that is created for and in collaboration with the Qualified Participant (and/or his or her family) to understand the care and management of diabetes, including nutritional counseling and proper use of Diabetes Equipment and Diabetes Supplies.

A Qualified Participant means an individual eligible for coverage under this Contract who has been diagnosed with (a) insulin dependent or non-insulin dependent diabetes, (b) elevated blood glucose levels induced by pregnancy, or (c) another medical condition associated with elevated blood glucose levels.


Wednesday, February 24, 2016

CPT CODE 80061, 82465 , 84478 AND G0472 - ICD 10 Z72.89, F19.20 AND Z13.6

Cardiovascular Disease Screening Tests

HCPCS/CPT Codes

80061 – Lipid panel, this panel must include the following:
82465 – Cholesterol, serum, total
83718 – Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
84478 – Triglycerides

ICD-10-CM Codes
Z13.6

Who Is Covered
All Medicare beneficiaries without apparent signs or symptoms of cardiovascular disease

Frequency
Once every 5 years

Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

New Service! Medicare began covering HCV screening effective June 2, 2014.

HCPCS/CPT Codes

G0472 – Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

ICD-10-CM Codes
Z72.89 and F19.20

Who Is Covered

Certain adult Medicare beneficiaries who:
• Are at high risk for HCV infection; or
• Were born between 1945 and 1965

Frequency
• Annually only for high risk beneficiaries with continued illicit injection drug use since the prior negative screening test; or
• Once in a lifetime for beneficiaries born between 1945 and 1965 who are not considered high risk.


Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Friday, February 20, 2015

ICD 10 BASIC information

The ICD-10 Transition - An Introduction

The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This fact sheet provides back ground on the ICD -10 transition, general guidance on how to prepare for it, and resources for more information.

About ICD-10

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:
•    ICD - 10 - CM for diagnosis coding
•    ICD - 10 - PCS for inpatient procedure coding

ICD - 10 - CM for diagnosis coding :
    ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead od the 3 to 5 digits used with ICD-9 CM, but the format of the code sets is similar.

ICD - 10 - PCS for inpatient procedure coding :
     ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digitis instead of the 3 or 4 numeric digits used under ICD-9 MC procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The transition to ICD-10 is occurring because ICD-9 produces limited data about patient's medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.

Who Needs to Transition


HEALTH CARE PROVIDERS, PAYERS, CLEARING HOUDE AND BILLING SERVICES MUST BE PREPARED TO COMPLY WITH THE TRANSITION TO ICD-10.

ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPPA). not just those who submit Medicare or Medicaid claims. THe change to ICD-10 does not affect CPT coding for outpatient procedures.

Health care providers, payers, clearinghouses, and billing services must be prepared to comply with the transition to ICD-10, which means:
All electronic transactions must use Version 5010 standards, which have the U.S., and ICD-10 procedure codes must be used for all hospital inpatient procedures. Claims with ICD-9 codes for services provided on or after the compliance deadline cannot be paid.

Transitioning to ICD-10
It is important to prepare now for the ICD-10 transition. The following are steps you can take to get started:

Providers : Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and budget. Check with your billing service, clearinghouse, or practice management software vendor about their compliance plans. Providers who handle billing and software development internally should plan for medical records/coding, clinical, IT, and finance staff to coordinate on ICD-10 transition efforts.

Payers : Review payment policies since the transition to ICD-10 will involve new coding rules. Ask your software vendors about their readiness plans and timelines for product development, testing, availability, and training for ICD-10. You should have an implementation plan and transition budget in place.

Software vendors, clearinghouses, and third-party billing services: Work with customers to install and test ICD-10 ready products. Take a proactive role in assisting with the transition so your customers can get their claims paid. Products and services will be obsolete if steps are not taken to prepare.

Friday, February 11, 2011

22 chapters in ICD 10 code

ICD 10 codes are organized in 22 chapters as listed below:
  • 1: A00-B99 - Certain infectious and parasitic diseases
  • 2: C00-D48 - Neoplasms
  • 3: D50-D89 - Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
  • 4: E00-E90 - Endocrine, nutritional and metabolic diseases
  • 5: F01-F99 - Mental and behavioral disorders
  • 6: G00-G99 - Diseases of the nervous system
  • 7: H00-H59 - Diseases of the eye and adnexa
  • 8: H60-H95 - Diseases of the ear and mastoid process
  • 9: I00-I99 - Diseases of the circulatory system
  • 10: J00-J99 - Diseases of the respiratory system
  • 11: K00-K93 - Diseases of the digestive system
  • 12: L00-L99 - Diseases of the skin and subcutaneous tissue
  • 13: M00-M99 - Diseases of the musculoskeletal system and connective tissue
  • 14: N00-N99 - Diseases of the genitourinary system
  • 15: O00-O99 - Congenital malformations, deformations and chromosomal abnormalities
  • 16: P00-P96 - Certain conditions originating in the perinatal period
  • 17: Q00-Q99 - Congenital malformations, deformations and chromosomal abnormalities
  • 18: R00-R99 - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
  • 19: S00-T98 - Injury, poisoning and certain other consequences of external causes
  • 20: V01-Y98 - External causes of morbidity and mortality
  • 21: Z00-Z99 - Factors influencing health status and contact with health services
  • 22: U00-U99 - Codes for special purposes

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