Showing posts with label Medical billing basics. Show all posts
Showing posts with label Medical billing basics. Show all posts

Saturday, December 8, 2018

CPT 0345T, 0483T, 0484T, 33418, 33419 - Transcatheter Mitral Valve Repair

Code Description CPT

0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus

0483T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed (new code effective 1/1/18)

0484T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) (new code effective 1/1/18)

33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis

33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
 

Transcatheter Mitral Valve Repair

Introduction


The heart has four chambers, two upper and two lower. The mitral valve is between the upper and lower left chambers. After blood has been pumped from the upper left chamber to the lower left chamber, the mitral valve closes. The mitral valve is made up of small pieces of tissue called leaflets. If the leaflets don’t close properly when the left lower chamber pumps blood out to the body some of the blood can leak back into the upper left chamber. This is known as mitral valve regurgitation. Medication can be used to help manage the symptoms of mitral valve regurgitation. Open heart surgery is a treatment option. If a person is too sick for surgery, a nonsurgical procedure may be used to place a clip to close the leaky mitral valve. In this procedure, a long, hollow tube (a catheter) is threaded through a specific vein into the heart. The catheter then becomes the pathway for getting the clip to the mitral valve. Imaging is used to make sure the device is correctly placed. This policy describes when transcatheter mitral valve repair is considered medically necessary.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage Criteria Service Medical Necessity Transcatheter mitral valve repair (eg, MitraClip® Clip Delivery System)

Transcatheter mitral valve repair using a device approved by the U.S. Food and Drug Administration for use in mitral valve repair may be considered medically necessary for patients with symptomatic, primary mitral regurgitation who are considered at prohibitive risk for open surgery. Prohibitive risk for open mitral valve repair surgery may be determined based on:


* The documented presence of a Society for Thoracic Surgeons predicted mortality risk of 12% or greater AND/OR

* The documented presence of a logistic EuroSCORE of 20% or greater

Transcatheter mitral valve repair is considered investigational in all other situations.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include the following:
* Name of the Food and Drug Administration (FDA) approved device to be used
* Documentation that patient has symptomatic primary mitral regurgitation AND
* Patient is at greater risk for open mitral valve repair surgery based on:
o The documented presence of a Society for Thoracic Surgeons predicted mortality risk of 12% or greater AND/OR
o The documented presence of a logistic EuroSCORE of 20% or greater


Related Information

Indications for Use


The FDA summary of safety and effectiveness data (SSED) from 2013 states the indications for use below: The MitraClip Clip Delivery System is indicated for the percutaneous reduction of significant symptomatic mitral regurgitation (MR of 3+ or greater) due to primary abnormality of the mitral apparatus [degenerative MR] in patients who have been determined to be at prohibitive risk for mitral valve surgery by a heart team that includes a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease, and in whom existing comorbidities would not preclude the expected benefit from reduction of the mitral regurgitation.12

Repair Device

MitraClip® Clip Delivery System has the U.S. Food and Drug Administration (FDA) approval for the treatment of severe symptomatic degenerative mitral regurgitation (see Regulatory Status).


Evidence Review Description

Transcatheter mitral valve repair (TMVR) is an alternative to surgical therapy for mitral regurgitation (MR). MR is a common valvular heart disease that can result from a primary structural abnormality of the mitral valve (MV) complex or a secondary dilatation of an anatomically normal MV due to a dilated left ventricle caused by ischemic or dilated cardiomyopathy. Surgical therapy may be underutilized, particularly in patients with multiple comorbidities, suggesting that there is an unmet need for less invasive procedures for MV repair. One device, MitraClip, has approval from the U.S. Food and Drug Administration for the treatment of severe symptomatic MR due to a primary abnormality of the MV (primary MR) in patients considered at prohibitive risk for surgery.

Background

Mitral Regurgitation

Epidemiology and Classification


Mitral regurgitation (MR) is the second most common valvular heart disease, occurring in 7% of  people older than age 75 years and accounting for 24% of all patients with valvular heart disease.1-2

Patients with MR generally fall into 2 categories — primary (also called degenerative) and secondary (also called functional) MR. Primary MR results from a primary structural abnormality in the valve, which causes it to leak. This leak may result from a floppy leaflet (called prolapse) or a ruptured cord that caused the leaflet to detach partially (called flail).3 Because the primary cause is a structural abnormality, most cases of primary MR are surgically corrected. In contrast, secondary MR results from left ventricular dilatation due to ischemic or dilated cardiomyopathy. This causes the mitral value (MV) leaflets not to coapt or meet in the center.4 Because the valves are structurally normal in secondary MR, correcting the dilated left ventricular using medical therapy is the primary treatment strategy used in the United States.

MR severity is classified as mild, moderate, or severe disease on the basis of echocardiographic and/or angiographic findings (1+, 2+, and 3-4+ angiographic grade, respectively). MR with accompanying valvular incompetence leads to left ventricular volume overload with secondary ventricular remodeling, myocardial dysfunction, and left heart failure. Clinical signs and symptoms of dyspnea and orthopnea may also present in patients with valvular dysfunction.4 Standard Management

Medical Management

Medical management has a primary role in secondary MR. Patients with chronic secondary MR  should receive standard therapy for heart failure with reduced ejection fraction; standardmanagement includes angiotensin converting enzyme inhibitor (or angiotensin II receptor blocker or angiotensin receptor-neprilysin inhibitor), *-blocker and mineralocorticoid receptor antagonist, and diuretic therapy as needed to treat volume overload.3,4

Surgical Management

In symptomatic patients with primary MR, surgery is the main therapy. In most cases, MV repair is preferred over replacement, as long as the valve is suitable for repair and personnel with appropriate surgical expertise are available. The American College of Cardiology and the American Heart Association have issued joint guidelines for the surgical management of MV, which are outlined in Table 1.3

Table 1. Guidelines on Mitral Value Surgery Recommendation COR LOE

MV surgery is recommended for the symptomatic patient with acute severe MR. I B
MV surgery is beneficial for patients with chronic severe MR and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 mm. I B
MV surgery is beneficial for asymptomatic patients with chronic severe MR and mild-tomoderate
LV dysfunction, ejection fraction 0.30 to 0.60, and/or end systolic dimension greater than or equal to 40 mm. I B
MV repair is recommended over MV replacement in the majority of patients with severe chronic
MR who require surgery, and patients should be referred to surgical centers experienced in MV I C

Tuesday, November 27, 2018

CPT 33340 - Percutaneous Left Atrial Appendage Closure Devices

Coding Code Description CPT

33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation


Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Introduction


The heart is divided into two upper and two lower chambers. Atrial fibrillation, also called a-fib, occurs when the heart’s upper chambers beat irregularly—and often rapidly. Because blood isn’t pumped out the way that it should be, blood tends to pool in these two upper chambers. Thepooling blood increases the risk of blood clots in the area of the heart called the left atrial appendage. If a blood clot comes loose, it may travel to the brain and cause a stroke. Blood thinners are the usual method of preventing blood clots in people with a-fib. If taking a blood thinner poses too much risk or a person can’t tolerate this medication, placing a device in the heart is a different way of helping to prevent stroke. This device seals off the left atrial appendage. Should a clot develop, the device blocks it from entering the bloodstream. This policy describes when a left atrial appendage closure device is considered medically necessary.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage Criteria Device Medical Necessity Percutaneous left atrial appendage closure device (eg, the Watchman)

The use of a device with U.S. Food and Drug Administration (FDA) approval for percutaneous left atrial appendage closure (eg, the Watchman) may be considered medically necessary for the prevention of stroke in patients with atrial fibrillation when the following criteria are met:

* There is an increased risk of stroke and systemic embolism based on CHADS2 or CHA2DS2-VASc score and systemic anticoagulation therapy is recommended AND

* The long-term risks of systemic anticoagulation outweigh the risks of the device implantation (see Related Information) The use of a device with FDA approval for percutaneous left atrial appendage closure (eg, the Watchman) for stroke prevention in patients who do not meet the above criteria is considered investigational.

Device InvestigationalOther percutaneous left atrial appendage closure devices

The use of other percutaneous left atrial appendage closure devices, including but not limited to the Lariat and Amplatzer devices, for stroke prevention in patients with atrial fibrillation is considered investigational.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include ALL of the following:
* Name of the Food and Drug Administration (FDA) device to be used
* CHADS2 or CHA2DS2-VASc score documenting patient’s increased risk of stroke and systemic embolism
* Documentation that systemic anticoagulation therapy is recommended AND the long-term risks of systemic anticoagulation outweigh the risks of the device implantation



Related Information

The balance of risks and benefits associated with implantation of the Watchman device for stroke prevention, as an alternative to systemic anticoagulation with warfarin, must be made on an individual basis.

Bleeding is the primary risk associated with systemic anticoagulation. A number of risk scores have been developed to estimate the risk of significant bleeding in patients treated with systemic anticoagulation. An example is the HAS-BLED score, which has been validated to assess the annual risk of significant bleeding in patients with atrial fibrillation treated with warfarin (Pisters et al, 2010). The score ranges from 0 to 9, based on a number of clinical characteristics (see Table 1).

Table 1: Clinical Components of the HAS-BLED Bleeding Risk Score Letter Clinical Characteristic Points Awarded

H Hypertension 1
A Abnormal renal and liver function (1 point each) 1 or 2
S Stroke 1
B Bleeding 1
L Labile international normalized ratios 1
E Elderly (>65 y) 1


Letter Clinical Characteristic Points Awarded D Drugs or alcohol (1 point each) 1 or 2 Adapted from Pisters et al (2010) Risk of major bleeding in patients with scores of 3, 4, and 5 has been reported at 3.74 per 100 patient-years, 8.70 per 100 patient-years, and 12.5 per 100 patient-years, respectively. Scores of 3 or greater are considered to be associated with a high risk of bleeding, potentially signaling the need for closer monitoring of patients for adverse risks, closer monitoring of international normalized ratio, or differential dose selections of oral anticoagulants or aspirin (January et al, 2014).

Evidence Review Description

Stroke prevention in atrial fibrillation (AF) is an important goal of treatment. Treatment with anticoagulant medications is the most common approach to stroke prevention. Most embolic strokes originate from the left atrial appendage; therefore, occlusion of the left atrial appendage may offer a nonpharmacologic alternative to anticoagulant medications for this purpose. Multiple percutaneously deployed devices are being investigated for left atrial appendage closure (LAAC). One left atrial appendage device (the Watchman device) has approval from the U.S. Food and Drug Administration for stroke prevention in patients with AF.


Background

Stroke


Stroke is the most serious complication of atrial fibrillation (AF). The estimated incidence of stroke in nontreated patients with AF is 5% per year. Stroke associated with AF is primarily embolic in nature, tends to be more severe than the typical ischemic stroke, and causes higher  rates of mortality and disability. As a result, stroke prevention is one of the main goals of AF treatment.

Stroke in AF occurs primarily as a result of thromboembolism from the left atrium. The lack of atrial contractions in AF leads to blood stasis in the left atrium, and this low flow state increases the risk for thrombosis. The area of the left atrium with the lowest blood flow in AF, and, therefore, the highest risk of thrombosis, is the left atrial appendage (LAA). It has been estimated that 90% of left atrial thrombi occur in the LAA.

Treatment Pharmacologic

The main treatment for stroke prevention in AF is anticoagulation, which has proven efficacy. The risk for stroke among patients with AF is evaluated using several factors. Two commonly used scores, the CHADS2 and the CHADS2-VASc score, are described below in Table 2. Warfarin is the predominant anticoagulation agent in clinical use. A number of newer anticoagulant medications, including dabigatran, rivaroxaban, and apixaban, have recently received U.S.

Food and Drug Administration (FDA) approval for stroke prevention in nonvalvular AF and have demonstrated noninferiority to warfarin in clinical trials. While anticoagulation is effective for stroke prevention, it carries an increased risk of bleeding. Also, warfarin requires frequent monitoring and adjustments, as well as lifestyle changes. Dabigatran does not require monitoring. However, unlike warfarin, the antithrombotic effects of dabigatran are not reversible with any currently available hemostatic drugs. Guidelines from the American College of Chest Physicians (2012) have recommended the use of oral anticoagulation for patients with AF who are at high risk of stroke (ie, CHADS2 score =2), with more individualized choice of antithrombotic therapy in patients with lower stroke risk.1

Table 2. CHADS2 and CHADS2-VASc Scores to Predict Ischemic Stroke Risk in Patients with Atrial Fibrillation

Letter Clinical Characteristics Points

Awarded


C Congestive heart failure (signs/symptoms of heart failure confirmed with objective evidence of cardiac dysfunction) 1
H Hypertension (resting blood pressure >140/90 mmHg on at least 2 occasions or current antihypertensive pharmacologic treatment)
1 A Age =75 y


Bleeding is the primary risk associated with systemic anticoagulation. Risk scores have been developed to estimate the risk of significant bleeding in patients treated with systemic anticoagulation, such as the HAS-BLED score, which has been validated to assess the annual risk of significant bleeding in patients with AF treated with warfarin.3 The score ranges from 0 to 9, based on a number of clinical characteristics, including the presence of hypertension, renal and liver function, history of stroke, bleeding, labile international normalized ratios, age, and drug/alcohol use. Scores of 3 or greater are considered to be associated with high risk of bleeding, potentially signaling the need for closer monitoring of patients for adverse risks, closer monitoring of international normalized ratios, or differential dose selections of oral anticoagulants or aspirin.2

Surgery

Surgical removal, or exclusion, of the LAA is often performed in patients with AF who are undergoing open heart surgery for other reasons. Percutaneous left atrial appendage closure (LAAC) closure devices have been developed as a nonpharmacologic alternative to anticoagulation for stroke prevention in AF. The devices may prevent stroke by occluding the LAA, thus preventing thrombus formation.

Several versions of LAA occlusion devices have been developed. The Watchman Left Atrial Appendage System (Boston Scientific) is a self-expanding nickel titanium device. It has a polyester covering and fixation barbs for attachment to the endocardium. Implantation is performed percutaneously through a catheter delivery system, using venous access and transseptal puncture to enter the left atrium. Following implantation, patients receive anticoagulation with warfarin or alternative agents for approximately 1 to 2 months. After this period, patients are maintained on antiplatelet agents (ie, aspirin  and/or clopidogrel)

indefinitely. The Lariat Loop Applicator is a suture delivery device that is intended to close a variety of surgical wounds in addition to LAAC. The Cardioblate® closure device (Medtronic) is currently being tested in clinical studies. The Amplatzer cardiac plug (St. Jude Medical), is FDAapproved for closure of atrial septal defects but not for LAAC. A second-generation device, the Amplatzer Amulet, has been developed. The Percutaneous LAA Transcatheter Occlusion device (ev3) has also been evaluated in research studies but has not received FDA approval. The Occlutech® (Occlutech) Left Atrial Appendage Occluder has received a CE mark for coverage in Europe.

Outcome Measures

The optimal study design for evaluating the efficacy of percutaneous LAAC for the prevention of stroke in AF is a randomized controlled trial that includes clinically relevant measures of health outcomes. The rate of ischemic stroke during follow-up is the primary outcome of interest, along with rates of systemic embolization, cardiac events, bleeding complications, and death. For the LAAC devices, the appropriate comparison group could be oral anticoagulation, no therapy (for patients who have a prohibitive risk for oral anticoagulation), or open surgical repair.

Although the Watchman device and other LAAC devices would ideally represent an alternative to oral anticoagulation for the prevention of stroke in patients with AF, during the postimplantation period, the device may be associated with increased thrombogenicity and, therefore, anticoagulation is used during the periprocedural period. Most studies evaluating the Watchman device have included patients who are eligible for anticoagulation. Summary of Evidence

For individuals who have AF who are at increased risk for embolic stroke who receive the Watchman percutaneous LAAC device, the evidence includes 2 RCTs and meta-analyses of these trials. Relevant outcomes are overall survival, morbid events, and treatment-related morbidity.

The most relevant evidence comes from 2 industry-sponsored RCTs that compared the Watchman device with anticoagulation alone. One trial reported noninferiority on a composite outcome of stroke, cardiovascular/unexplained death, or systemic embolism after 2 years o follow-up, with continued benefits with the Watchman device after 4 years of follow-up.

The second trial did not demonstrate noninferiority for the same composite outcome but did demonstrate noninferiority of the Watchman device to warfarin for late ischemic stroke and systemic embolization. Patient-level meta-analyses at 5-year follow-up for the 2 trials reported that the Watchman device is noninferior to warfarin on the composite outcome of stroke, systemic embolism, and cardiovascular death. Also, the Watchman was associated with lower rates in major bleeding, particularly hemorrhagic stroke, and mortality over the long term. The evidence also indicates that the Watchman device is efficacious in preventing stroke in the subset of patients with AF who are at increased risk for embolic stroke. When it is determined on an individualized basis that the long-term risk of systemic anticoagulation exceeds the procedural risk of device implantation, the net health outcome will be improved. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have AF who are at increased risk for embolic stroke who receive a percutaneous LAAC device other than the Watchman device (eg, the Lariat or Amplatzer), the evidence includes uncontrolled case series. Relevant outcomes are overall survival, morbid events, and treatment-related morbidity. Case series of these devices have reported high procedural success, but also numerous complications. Also, these devices do not have Food and Drug Administration approval for LAAC. The evidence is insufficient to determine the effects of the technology on health outcomes.

Ongoing and Unpublished Clinical Trials Some currently unpublished trials that might influence this policy are listed in Table 3

Thursday, November 8, 2018

CPT code Prolotherapy therapy (proliferative therapy) - 20999


Introduction

Prolotherapy therapy (proliferative therapy) is a method to try to heal joints and connective  tissue. A solution is injected in the area. The solution irritates the tissue, causing inflammation.  This inflammation is supposed to stimulate the body’s natural healing response. These injections  are repeated over time. The hope is to gradually build up new issue in the injured area and  restore strength. Prolotherapy is investigational (unproven). The studies that have been done are  small and don’t show substantial improvement. There’s not enough medical evidence to show if  this technique works.

Note: The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy  informs them about when a  service may be covered 

Coding Code Description

CPT 20999 Unlisted procedure,  musculoskeletal system, general

HCPCS  Description

Prolotherapy  describes a procedure  intended for healing and strengthening ligaments and  tendons by injecting an agent that induces inflammation and stimulates endogenous repair  mechanisms.  Prolotherapy may also be referred to as proliferant injection, prolo, joint  sclerotherapy, regenerative injection therapy, growth factor stimulation injection, or nonsurgical  tendon, ligament, and joint reconstruction M0076 Prolotherapy

Background

The goal of prolotherapy is to promote tissue repair or growth by prompting release of growth  factors, such as cytokines, or by increasing the effectiveness of existing circulating growth  factors due to injection of an irritant solution. The mechanism of action is not well - understood  but may involve local irritation and/or cell lysis. Agents used with prolotherapy have included  zinc sulfate, psyllium seed oil, combinations of dextrose , glycerin , and phenol, or dextrose alone, often combined with a local anesthetic. Polidocanol and  sodium morrhuate, vascular sclerosants,  have also been used to sclerose areas of high intratendinous blood flow associated with  tendinopathies.  Prolotherapy typically involves multiple injections per session conducted over a  series of treatment sessions.

A similar treatment approach involves the injection of autologous platelet - rich plasma, which  contains a high concentration of platelet - derived growth factors.Treatment of musculoskeletal  pain conditions (eg, tendinopathies) with PRP is discussed in a sepa rate policy (see  Related  Policies ).

Summary of Evidence

For  individuals who have musculoskeletal pain (eg, chronic neck, back pain),  osteoarthritic pain,  or  tendinopathies of the upper or lower limbs includes ,the evidence includessmall randomized trials with inconsistent results. Relevant outcomes are symptoms, functional outcomes, and quality of life. The strongest evidence evaluates the use of prolotherapy for the treatment of  osteoarthritis, but the clinical significance of  the  therapeutic  results is  uncertain. The evidence is  insufficient to determine the effects of the technology on health outcomes

Practice Guidelines and Position Statements

American Association of Orthopaedic Medicine


The American Association of Orthopedic Medicine currently has a recommendation posted  online for the use of prolotherapy for back pain. The Association has indicated that “...prolotherapy should be considered a valid treatment option in a selected group of chronic low back pain patients.”Medicare National Coverage The Coverage Issues Manual #35 - 13 states that prolotherapy, joint sclerother apy, and  ligamentous injections with sclerosing agents are not covered, noting that the medical effectiveness of these therapies has not been verified by scientifically controlled studies. In 1999,  on request for reconsideration of coverage of prolotherapy for treatment for chronic low back pain, Medicare retained its noncoverage decision for prolotherapy, citing a lack of scientific  eviden ce on which to base a decision.

Regulatory Status

Sclerosing agents have been approved by the U.S. Food and Drug Administration for use in  treating spider and varicose veins. These sclerosing agents include Asclera® (polidocanol),  Varithena® (an injectable polidocanol foam), Sotradecol® (sodium tetradecyl sulfate), Ethamolin® (ethanolamine oleate), and Scleromate® (sodium morrhuate). These agents are not  currently approved as joint and ligamentous sclerosing agents

Wednesday, October 24, 2018

CPT CODE 0398T, 0071T, 0072T - Magnetic resonance procedure

Introduction

Magnetic resonance - guided  high - intensity ultrasound uses two technologies: magnetic  resonance imaging (MRI) and ultrasound. It is a noninvasive procedure, which means  the skin is  not cut .  MRI uses a magnetic field, radio frequency, and a computer to create detailed images of  organs, tissues, and bones. Ultrasound uses sound waves  at a higher frequency  than a person  can hear.  Ultrasound is usually used to create images of  body  structures to help diagnose  illnesses.  But in this treatment, the ultrasound beams are at a different frequency and are  focused on one area.  Heat is created at the point where the high frequency beams meet , and  the heat ablates ( destroys )  unhealthy tissue . The MRI is used to both guide the location of the  ultrasound beams and  to  monitor treatment. This policy discusses when magnetic resonance - guided high - intensity ultrasound ablation may be considered medically necessary and covered  by the health plan.

Note:
The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider  also can be a place where medical care is given, like a hospital, clinic, or lab. This policy  informs them about when a  service may be covered.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should  include the following:
* Documentation that the requested service is for pain control  that has failed  for patient  with bone  metastases, or not a candidate for radiotherapy
OR
* Documentation that patient has essential tremors not responding to medication (such as beta - blockers or anticonvulsants)

Coding Code Description CPT

0398T Magnetic resonance image guided high intensity focused ultrasound (MRgFUS),  stereotactic ablation lesion, intracranial for movement disorder including stereotactic  navigation  and frame placement when performed
0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume of less than 200 cc of tissue
0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance;  total  leiomyomata volume greater or equal to 200 cc of tissue
53899 Unlisted procedure, urinary system
55899 Unlisted procedure, male genital system
76999 Unlisted ultrasound procedure (eg diagnostic, interventional

Note :  CPT codes, descriptions and  materials are copyrighted by the American Medical Association (AMA). HCPCS  codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Magnetic resonance - guided high - intensity ultrasound ablation of uterine fibroids is  specifically  identified by the following category III CPT codes:
* 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume of less than 200 cc of tissue
* 0072T As above, but with total leiomyomata volume great er or equal to 200 cc of tissue.

These CPT codes should not be used with 51702 (insertion of temporary indwelling bladder  catheter, simple) or 77022 (magnetic resonance imaging guidance for, and monitoring of,  visceral tissue ablation). Before the introduc tion of the specific category III CPT codes, the  procedure may have been coded using several codes describing the individual components of  the procedure. CPT codes 0071T - 0072T describe the comprehensive service.

The procedure may be performed in a magnetic resonance imaging suite with an open magnetic  resonance scanner, which might not be available at many institutions. The procedure is  performed in an outpatient setting, with the patient under conscious sedation. There are no specific CPT codes for the use of magnetic resonance - guided high - intensity  ultrasound ablation in metastatic bone cancer. An unlisted code would be used based on the  anatomic location of the metastasis being treated (eg, 23929 for the clavicle) or perhaps an  unlisted radiation oncology code (eg, 77299 or 77499)

Consideration of Age
Magnetic resonance*guided focused ultrasound (MRgFUS) is considered medically necessary for  bone metastases in adult patients, age 18 and older.
This is based on the randomized controlled  trial that studied the use of MRgFUS in  patients with  bone metatsase

Evidence Review Description
An integrated system providing magnetic resonance*guided focused ultrasound (MRgFUS) treatment is proposed as a noninvasive therapy for uterine fibroids and pain palliation of bone  metastases. MRgFUS is also being investigated as a treatment of other benign and malignant  tumors.

Background
Uterine Fibroids

Uterine fibroids are one of the most common conditions affecting women in the reproductive  years. Symptoms of uterine fibroids include menorrhagia, pelvic pressure, or pain.

Treatment
Several approaches currently available to treat symptomatic uterine fibroids include: hysterectomy, abdominal myomectomy, laparoscopic and  hysteroscopic myomectomy,  hormone therapy, uterine artery embolization, and watchful waiting. Hysterectomy and various  myomectomy procedures are considered the  criterion standard treatment.

Metastatic Bone Disease
Metastatic bone disease is one of the most common causes of cancer pain.  Treatment Existing treatments include conservative measures ( eg, massage,  exercise) and pharmacologic  agents ( eg, analgesics, bisphosphonates, corticosteroids). For patients who  do not respond to  these treatments, standard care is external - beam radiotherapy. However, a substantial  proportion of patients have residual pain after radiotherapy, and there is a need for alternative
treatments for these patients.   One option, radiofrequency a blation, is addressed in a  related policy.

Essential Tremors
Essential tremor (ET) is the most common movement disorder, with an estimated prevalence of 5% worldwide. ET most often affects the hands and arms, may affect the head and voice, and rarely includes the face, legs, and trunk. ET is heterogeneous among patients, varying in frequency, amplitude, causes of exacerbation, and association with other neurologic deficits

Treatment
The neuropathology of ET is uncertain, with some evidence suggesting that ET is localized in the  brainstem and cerebellum. If patients with ET experience intermittent or persistent disability due  to the tremors, initial therapy is with  drugs (*-blockersor anticonvulsants). For medicine-refractory patients, surgery (deep brain stimulation or thalamotomy) may be offered, though high rates of adverse events have been observed

Magnetic Resonance*Guided Focused Ultrasound
 
Magnetic resonance - guided focused ultrasound  ( MRgFUS ) is a noninvasive treatment that  combines  2  technologies : focused ultrasound and magnetic resonance imaging (MRI). The  ultrasound  beam penetrates through the soft tissues and, using MRI for guidance and monitoring, the beam can be focused on targeted sites. Ultrasound causes a local increase in temperature in the target tissue, resulting in coagulation necrosis while sparing the surrounding normal structures. Ultrasound waves from each sonication are  directed  at a focal point that has a  maximum focal volume of 20 nm in diameter and 15 nm in height/length. This causes a rapid  rise in temperature (ie , to 65°C - 85°C), which is sufficient to  ablate  tissue at the focal point. In  addition to providing guidance, the associated MRI can provide online thermometric imaging, a  temperature “map” , to confirm the ther apeutic effect of the ablation treatment and allow for real - time adjustment of the treatment parameters

The U.S. Food and Drug Administration (FDA) has approved the ExAblate MRgFUS system (InSightec) for two indications : treatment of uterine fibroids (leiomyomata) and palliation of pain associated with tumors metastatic to bone. The ultrasound equipment is specially designed to be compatible with magnetic resonance magnets and is integrated into standard clinical MRI  units; it also includes a patient table, which  has  a cradle  that houses  the focused  ultrasound transducer in  water or  a  light oil bath. Some models have a detachable cradle; only certain  cradle types can be used for palliation of pain associated with metastatic bone  cancer. For  treating pain associated with bone metastases, the aim of MRgFUS is to destroy nerves in the  bone surface surrounding the tumor. MRgFUS is also being investigated for treatment of other tumors, including breast, prostate,  brain , and desmoid tumors as well as nonspinal osteoid osteoma.(For prostate cancer see Related Policy8.01.61 Focal Treatments for Prostate Cancer)

Summary of Evidence


For individuals who have uterine fibroids who receive MRgFUS, the evidence includes  2  small RCT s , nonrandomized comparative studies, and case series. Relevant outcomes are symptoms,  quality of life, resource utilization, and treatment - related morbidity.  One RCT (N=20)  has  reported some health outcomes, but its primary purpose was to determine the feasibility of a  larger trial. It did not find statistically significant differences in quality of life outcomes between  active and sham treatment groups, but it did find lower fibroid volumes after active treatment.  This trial  did not have an  active comparator , the clinical significance of the primary outcome was  unclear, and there were no follow - up data beyond 1 year.  The second RCT (N=49) is ongoing;  preliminary results at 6 weeks posttreatment, comparing MRgFUS with uterine artery  embolization  have shown that the 2 groups  are comparable in medication use and symptom  improvement following treatments. Patients in the MRgFUS group reported recovering  significantly faster than patients in the
uterine artery embolization  group, as measured by  time  to return to work and time to normal activities. In  a separate  2013 comparative study, outcomes  appeared to be better with uterine artery embolization than with MRgFUS.  Long - term data on  the treatment effects, recurrence rates, and impact on future fertility and pregnancy are lacking .  The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals  with  metastatic bone cancer who failed or are not candidates for radiotherapy who receive MRgFUS, the evidence includes a sham- controlled randomized trial and several case  series . Relevant outcomes are symptoms, functional outcomes, health status measures, quality  of life, and treatment - related morbidity. The RCT found statistically significant improvements after MRg FUS in a composite outcome comprised of reduction in pain and morphine use, and in  pain reduction as a stand - alone outcome. A substantial proportion of patients in the treatment  group experienced adverse events, but most  events were  transient and not severe.  The case  series reported reductions in pain following MRgFUS treatment, consistent with the RCT.  The  evidence is sufficient to determine that the technology results in a meaningful improvement in  the net health outcome

Friday, August 24, 2018

Basics of Dental Billing and vision care billing in APG payments


DENTAL BILLING:

Dental services provided in the clinic setting (hospital or free-standing) are to be billed using the APG payment methodology. The only exception to this policy is orthodonture, which is to be billed to the dental practitioner fee schedule and not to APGs. Orthodontic procedures are identified as those D codes grouping to APG 371 – Orthodontics. Again, APG 371 is a non-payable APG. Providers will continue to be required to obtain prior approval for orthodontic procedures. E&M codes should not be billed for any dental services. All dental services should be billed using only D codes Effective January 1, 2010, medical visits will no longer package with dental procedures or exams. When a patient has a medical visit (i.e., with a practitioner other than a dentist) and a dental visit on the same day, both the medical visit and the dental exam will pay at the line level.

Effective February 1, 2010, dental professional services are included in the APG payment to the facility and may not be billed by dentists using the Medicaid dental fee schedule. Specifically, no D codes (other than those used for orthodonture) are billable against the practitioner fee schedule. Dentists and/or oral surgeons should not bill Medicaid fee-for-service for non orthodontic D codes but may submit a claim for their professional services to the facility (i.e., the APG biller). If a practitioner is enrolled in Medicaid as both a dentist and a physician he/she may submit a separate [non-APG] professional claim for services payable off the physician schedule. If a procedure requires three encounters to complete, a clinic should claim for the applicable procedure code for each distinct date of service. However, APGs 373 Level I Dental Film, 374 Level II Dental Film, and 375 Dental Anesthesia will not pay if there are no other procedures claimed for the applicable date of service. For dates of service beginning January 1, 2009, when multiple dental procedures are performed on the same date of service, the highest weighted procedure will pay at 100% and all other dental procedures will be discounted (at 50%). This will be the case even for procedures that group to the same APG. Multiple same APG consolidation has been eliminated for dental services.

The procedure code for dental sealants (D1351), should be coded once for each tooth that is sealed on a single date of service. If four teeth are sealed during a visit, the code D1351 should appear on each of four claim lines, each with the same date of service. Beginning on January 1, 2011, dental sealants will become a units-based procedure, to be coded on only a single claim line – with the number of teeth sealed shown in the units field. The following are the dental ancillary procedure APGs: 373 Dental Film, 374 Level II Dental Film, 375 Dental Anesthesia, 376 Diagnostic Dental Procedures, and 377 Preventive Dental Procedures. All dental ancillaries pay at the line level. Multiple ancillaries that group to the same APG will be discounted by 50%, whereas multiple ancillaries that group to different APGs will be paid at 100%.

For APG dental billing the 837i claim format must be used, not the 837d claim form.

Dental code D9920 -- behavior management (for patients with mental retardation or a developmental disability) groups to APG 999 and will not pay under the APG reimbursement methodology.

Reimbursable services provided to recipients with recipient exception codes 81 or 95 will receive a 20% higher operating payment. This rate enhancement will begin July 1, 2010 for hospital clinics (using rate code 1501 for visit billing or 1489 for episode billing). Immediately upon the D&TCs transition to the APGs, and retroactive to September 1, 2009, free-standing clinics will receive the 20% rate enhancement for MR/DD/TBI patients under rate code 1435 (the MR/DD/TBI episode rate code 1425 is pended due to the lack of CMS approval of the Dec. 2009 D&TC State Plan Amendment).

Effective April 1, 2010, oral sedation in dentistry (D9248- Sedation (non-iv)) will be paid based on a procedure based weight. This code is to be used only for MR/DD/TBI recipients (as defined by recipient exception codes 81 or 95). Since there are currently no edits in place relative to this code, it is possible to improperly bill for this code. As with any violations of Medicaid billing policy, improper claims are subject to take back accompanied by possible legal action. Please check for the recipient eligibility prior to billing D9248.

VISION CARE BILLING:

Most vision care services are covered in the APG payment methodology. However two vision care services; “the fitting of spectacles: monofocal, bifocal, or multifocal” , “the fitting of spectacles and the eyeglass materials” are carved out of APGs and are billed using rate codes 1226 and 1227 respectively.

4.4 ANCILLARY LABORATORY SERVICES AND RADIOLOGY PROCEDURES: Under the new APG payment methodology, payment for laboratory and radiology services ordered by practitioners in hospital-based outpatient clinics is made to the clinic. When the hospital or D&TC patient receives the ancillary service from someone other than the clinic, the clinic is responsible for paying the individual or entity providing the ancillary service, even in the absence of a contractual relationship between the two parties. The ancillary service provider may not bill Medicaid directly for lab or the technical component of radiology services related to an APG-reimbursed visit and therefore must bill the ordering clinic for the service provided to clinic patients. This ancillary billing policy will be implemented prospectively in DTCs, effective January 1, 2011.

For example, when a practitioner in Clinic A orders a lab test or radiology service that it is not able to provide and the patient goes to Provider B (separate hospital, lab or a radiology group) to receive the service, Clinic A will be responsible for billing eMedNY for the ancillary service and making arrangements to pay Provider B for the delivery of the service. Clinic providers may wish to develop or revisit existing contractual arrangements with laboratory and radiology providers to ensure the availability of ancillary services for their patients and to avoid payment issues upon the implementation of the new APG payment methodology. This payment policy also applies to hospital ED units in the event that the ED physician orders an ancillary laboratory or radiology service that is provided to the patient subsequent to the ED visit.

Hospitals are and effective January 1, 2011 D&TCs will be responsible for advising outside lab and radiology service providers on the order for the service when the payment for the ancillary service is subject to APG reimbursement and the APG ancillary billing policy. They must also advise radiology service providers if they want the provider to “read” the radiology results and bill Medicaid directly for these professional services. Alternatively, if the hospital provider plans to bill for “reading” the radiology result, the hospital should advise the radiology vendor not to bill for the professional component of the radiology service. Only one professional component per radiology procedure per recipient may be billed to Medicaid.

Friday, June 15, 2018

How to do the correction in Medical record after claim submission

Corrections in the Medical Record


If the original entry in the medical record is incomplete, contracting providers shall follow the guidelines below for making a correction, addendum, or amendment. Signature requirements as defined above apply to all corrections in the medical record.

a. Errors in paper-based records:

To add an addendum or amendment to paper-based records, draw a single line in ink through the incorrect entry, print the word "error" at the top of the entry, the reason for the change, the correct information, and authenticate the error by signing (including credentials) the notation with the date and time. Entries should not be antedated (assigned a date earlier than the current date). Errors must never be blocked out or erased.

b. Electronic medical records/Electronic health records:

i. Addendum

An addendum is new documentation used to add information to an original entry that has already been signed. Addenda should be timely with date and time of the addendum. Write “addendum” and state the reason for the addendum referring back to the original entry.

Complete the addendum as soon after the original note as possible. Identify any sources of information used to support the addendum. Entries should not be antedated (assigned a date earlier than the current date).

ii. Amendment

An amendment is documentation meant to clarify or provide additional information within the medical record in conjunction with a previous entry. An amendment is made after the original documentation has been completed and signed by the provider. All amendments should be timely with the date and time of the amended documentation. Write “amendment” and document the clarifying information referring back to the original entry.

Complete the amendment as soon after the original note as possible. Entries should not be antedated (assigned a date earlier than the current date).

5. Use of Medical Scribes

Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider. BCBSKS expects the signing and dating of all entries made by a scribe to be identifiable and distinguishable from that of a physician or licensed independent practitioner. All entries made by a scribe are ultimately the practitioner’s responsibility; therefore, review of the documentation and verification of its accuracy, including authentication by the practitioner, is required.

BCBSKS requests for medical records

1. BCBSKS staff members conduct medical review of claims and seek the advice of qualified and, typically, practicing professionals when necessary. Contracting providers agree to accept the decisions made as a result of those reviews and to follow the appeals procedures established by this Policy Memo.

2. The entire review process itself includes the development of guidelines that relate to specific provisions of members' contracts; the processing of claims based on guidelines and medical records when indicated; the retrospective review of claim determinations; and the appeal process. BCBSKS seeks the advice of clinical professionals at appropriate points throughout the entire review process.

3. Contracting providers must submit all pertinent and complete medical records to BCBSKS within the time frame specified by BCBSKS when records are needed for the initial review of a claim or when records are requested for an audit. In most instances, BCBSKS will allow 30 calendar days for the production of the requested records. In certain unusual circumstances as determined solely by BCBSKS, BCBSKS will require providers to submit medical records without advance notice. In such cases, a BCBSKS representative will visit the provider's office during business hours and secure the requested records immediately. The provider agrees to provide the requested records immediately. Members' contracts permit BCBSKS to obtain medical records without a signed patient release.


4. The ordering/referring provider shall also provide medical records to the performing provider when requested for the purpose of medical necessity review. Additional documentation that is not a part of the medical record and that was not provided at the time of the initial request will not be accepted. Only records created contemporaneous with treatment will be considered pertinent. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.

5. If BCBSKS determines that the patient services provided by the contracting provider are not medically necessary, the claim is denied and is a write-off to the provider. If the services are requested by the patient after being advised by the provider of the lack of medical necessity and the daily record or patient chart has been documented to that effect and a written waiver is obtained by the provider before the service being rendered, charges for the services will be the patient's responsibility.



Friday, May 18, 2018

Basics of Utilization review and medical necessity

UTILIZATION REVIEW AND MEDICAL NECESSITY


The contracting provider agreement requires providers to cooperate in utilization review and medical necessity determinations. Utilization review is the process of determining the appropriateness of services rendered to and payments made on behalf of members. Appropriateness of service and payment determinations consist of the following activities:


A. MEDICAL NEED FOR SERVICES RENDERED

Medical necessity policy applies to all services rendered to BCBSKS members and includes any services or supplies used to diagnose and/or treat illness or injury. The service should be widely accepted by a peer group of practicing providers, based on scientific criteria and determined to be reasonably safe. Health care professionals should discuss all appropriate treatment alternatives available to patients regardless of benefit coverage limitations. To be determined medically necessary, the service must be consistent with the diagnosis and treatment of the condition; be in accordance with standards of good health care practice; and not be for the convenience of the patient or provider. The following procedures/equipment would be subject to medical necessity and utilization review:


1. Established procedures/equipment of questionable current usefulness in the treatment of a specific condition(s).

2. Procedures/equipment which tend to be redundant when performed/supplied in combination with other procedures/equipment; or procedures/equipment which are unlikely to provide additional medical benefits, or are contradicting to one another.

3. Specific procedures/equipment or patterns of care which vary significantly from a peer group.

PRE-ADMISSION CERTIFICATION & CONCURRENT REVIEW


Before admitting a member to a hospital for elective (non-obstetrical, non-life threatening) inpatient care, medical information will need to be supplied to BCBSKS in order to certify medical necessity. A length of stay will be assigned at the time of pre-certification and will be subject to concurrent review. Concurrent review is the process of obtaining current medical information to review for the medical necessity of a requested extension to the length of stay or course of treatment. For the most accurate and complete information, all pre-admission certification should be validated through the BCBSKS provider portal (Availity®).

BCBSKS pre-admission certification and concurrent review activity are conducted in compliance with URAC guidelines. This includes the availability of either the expedited or standard appeal to services denied for medical necessity during the pre-admission certification and concurrent review processes. To initiate an appeal (phone or fax), you must have complete information since the time frame begins with the appeal request. These appeal options are only available prior to claim submission and are subject to time frames as established by BCBSKS, Department of Labor, and URAC. All pre-admission certification appeals for professional and hospital services will be reviewed concomitantly.

OUTPATIENT PRE-CERTIFICATION/PRIOR AUTHORIZATION


Under certain circumstances, pre-certification/prior authorization may be required for outpatient services/procedures. BCBSKS will notify contracting providers at least 30 days in advance of such requirement.

Pre-certification/prior authorization may also be required for other outpatient services such as home medical equipment and case management, including those services specified by employers, and outpatient procedures which necessitate a greater level of facility care than is usually needed.

Following provider notification, continued failure to complete pre-certification/prior authorization activities will result in a 50 percent Maximum Allowable Payment (MAP) reduction up to $200 with the member held harmless. Compliance audits will take place on a post-payment basis, which may result in refunds

CASE MANAGEMENT

Case management is a process that identifies and coordinates alternative treatment plans to enhance care through effective administration of available health care resources in the most cost-efficient manner. The process is accomplished through the development of a treatment plan by the patient or legal representative, the physician, other health care providers, and the BCBSKS case manager.

E. PREPAYMENT AND DATA ANALYSIS

BCBSKS will identify any trends or patterns of patient care, i.e., through data analysis, which appear inconsistent with overall patterns or trends. Prepayment review will be implemented if attempts to work with the provider have failed to resolve the issue. Specific utilization guidelines may be applied to individual prepay members. Prepayment review means all claims will be reviewed before payment and records will be required.

APPROPRIATE PLACE OF SERVICE

The provider agrees to use (to the extent possible) those inpatient, extended care, ancillary services and other health facilities and health professionals which have contracted with BCBSKS. Providers agree to render services to members in the most appropriate and economical setting consistent with the member’s diagnosis, treatment needs, and medical condition. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally requesting contract cancellation. In the event members request referrals to non-contracting providers, providers should have patients sign a statement acknowledging full understanding of the non-contracting referral and the patient’s financial responsibilities. The statement should be filed in the patient’s chart.

G. RESOLUTION OF PROBLEMS

Providers agree to work with BCBSKS and other providers of care in the resolution of any utilization or medical review problems that may be identified. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally contract cancellation.

H. MEDICAL NECESSITY/UTILIZATION REVIEW DENIALS

Occasionally BCBSKS does not consider an item or service to be medically necessary. In such situations the item or service becomes a provider write-off. In the few situations where services are known to be denied as not medically necessary (including deluxe items) and the patient insists on the services, the provider must obtain a patient waiver in advance of the services being rendered. (See Section X. WAIVER FORM)

Failure to discuss the above with the patient in advance, document this in the medical record, and obtain the waiver will result in a provider write-off.


Monday, November 13, 2017

What is Respite billing


RESPITE BENEFIT

Respite services provide limited and temporary relief for families caring for beneficiaries with complex health care needs when the care needs require nursing services in lieu of the trained caregivers. Services are provided in the family home by hourly skilled and licensed nursing services as appropriate. To be eligible and authorized for respite, MDHHS must determine the beneficiary to have:

* Health care needs that meet the following criteria:

* That skilled nursing judgments and interventions be provided by licensed nurses in the absence of trained and/or experienced parents/caregivers responsible for the beneficiary’s care;

* That the family situation requires respite; and

* That no other community resources are available for this service.

* No other publicly or privately funded hourly skilled nursing services in the home that would be duplicated by the CSHCS respite benefit.

* Service needs which can reasonably be met only by the CSHCS Respite benefit, not by another service benefit.

Respite is reimbursed when provided by a Medicaid enrolled home health agency, a Medicaid enrolled registered nurse (RN) who is licensed to practice in the state of Michigan, or a Medicaid enrolled licensed practical nurse (LPN) who is licensed to practice in the state of Michigan and working under supervision according to the Michigan Public Health Code. It is the responsibility of the LPN to secure the appropriate supervision and maintain documentation that identifies the supervising professional.

A maximum of 180 hours of CSHCS Respite services may be authorized per family during the 12-montheligibility period. When there is more than one respite-eligible beneficiary in a single home, the respite  service is provided by one nurse at an enhanced reimbursement rate for the services provided to multiple beneficiaries. Allotted respite hours may be used at the discretion of the family within the eligibility period. Unused hours from a particular eligibility period are forfeited at the end of that period and cannot be carried forward into the next eligibility period.

Beneficiaries receiving services through any of the following publicly funded programs and benefits are not eligible for the CSHCS Respite benefit:

* Private Duty Nursing Benefit

* Children’s Waiver

* Habilitation Supports Waiver

* MI Choice Waiver

Requests for respite must be made in writing to MDHHS (refer to the Directory Appendix for contact information) and include
the following information:

* The health care needs of the beneficiary;

* The family situation that influences the need for respite; and

* Other community resources or support systems that are available to the family (e.g., CMH services, MDHHS services, adoption subsidy, SSI, trust funds, etc.).

MDHHS responds to all requests for respite in writing.

Friday, October 6, 2017

INTERMITTENT NURSING VISITS/AIDE VISITS/THERAPIES Billing Guide

INTERMITTENT NURSING VISITS/AIDE VISITS/THERAPIES

Each visit must be reported on a separate claim line: Medicaid follows Medicare policy on the requirement that each home health agency visit (e.g., nursing, therapy) must be billed on an individual line. This policy includes two visits performed on the same day (i.e., two visits on the same day must be billed on individual lines of the same claim).

Report 15-minute time increments: Medicaid follows Medicare policy for reporting home health visits in 15-minute increments. When billing on the NUBC form, each home health visit revenue code that is reported must have a corresponding 15-minute increment HCPCS code along with the number of15-minute increments reported in the Service Units as follows:

Units Time Requirements

1 1 minute to < 23 minutes

2 23 minutes to < 38 minutes

3 38 minutes to < 53 minutes

4 53 minutes to < 68 minutes

5 68 minutes to < 83 minutes

6 83 minutes to < 98 minutes

7 98 minutes to < 113 minutes

8 113 minutes to < 128 minutes

If services continue for longer periods of time, the home health agency would follow the above pattern. Time of Service Visit: The timing of the visit begins at the beneficiary's home when services actively begin and ends when services are completed. The time counted must be the time spent actively treating the beneficiary. For example:

* If a beneficiary interrupts a treatment to talk on the telephone for other than a minimal amount of time (less than three minutes), then the time the beneficiary spends on the telephone and not engaged in treatment does not count in the amount of service.

* The home health aide completed bathing and transferring the beneficiary into a chair, and now begins to wash the kitchen dishes before leaving. Washing the dishes is considered incidental nd does not meet the definition of a home health aide service. Therefore, the time to perform  this activity would not be included in the 15-minute incremental reporting to Medicaid.


Other nontreatment-related interruptions would follow the same principle. If the beneficiary is late returning home from a doctor’s appointment, the waiting time of the home health agency personnel cannot be counted as treatment time.

However, if the professional spends time with family or other caretakers in the home teaching them to care for the beneficiary, this activity is counted as treatment time. Calls to the physician by the nurse while in the beneficiary’s home to report on the beneficiary’s condition can also be counted as treatment time.

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

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.



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