Most used Anesthesia CPT codes and time units

Anesthesia CPT codes and Time units

00100 ANESTHESIA PROC SALIVARY GLANDS INCLUDING BIOPSY 5
00102 ANES-PROC INVOLVING PLASTIC REPAIR CLEFT LIP 6
00103 ANESTHESIA RECONSTRUCTIVE PROCEDURES OF EYELID 5
00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 4
00120 ANES-PROC EXTERNAL MIDDLE&INNER EAR INCL BX; NOS 5
00124 ANES-PROC EXT MID&INNR EAR INCL BX; OTOSCOPY 4
00126 ANES-PROC EXT MID&INNR EAR INCL BX; TYMPANOTOMY 4
00140 ANESTHESIA FOR PROCEDURES ON EYE; NOS 5
00142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY
00144 ANESTHESIA PROCEDURES ON EYE; CORNEAL TRANSPLANT 6
00145 ANESTHESIA PROCEDURES EYE; VITREORETINAL SURGERY 6
00147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY
00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY 4
00160 ANESTHESIA PROC NOSE&ACCESSORY SINUSES; NOS 5
00162 ANES-PROC NOSE&ACCESS SINUSES; RADICAL SURGERY 7
00164 ANES-PROC NOSE&ACCESS SINUSES; BX SOFT TISSUE 4
00170 ANES-INTRAORAL INCLUDING BIOPSY; NOS 5
00172 ANES-INTRAORAL INCLUDING BX; REPAIR CLEFT PALATE 6
00174 ANES-INTRAORL INCL BX; EXC RETROPHARYNG TUMR 6
00176 ANES-INTRAORAL INCLUDING BIOPSY; RADICAL SURGERY 7
00190 ANESTHESIA PROCEDURES FACIAL BONES OR SKULL; NOS 5
00192 ANES-PROC FACIAL BONES/SKULL; RADICAL SURGERY 7
00210 ANES-INTRACRAN; NOT OTHERWISE SPECIFIED 11
00212 ANES-INTRACRAN; SUBDURAL TAPS 5
00214 ANES-INTRACRAN; BURR HOLES INCL VENTRICULOGRAPHY 9
00215 ANES-INTRACRAN;PLASTY/ELEV SKULL FX-XTRADURL 9
00216 ANES-INTRACRAN; VASCULAR PROCEDURES 15
00218 ANES-INTRACRAN; PROCEDURES IN SITTING POSITION 13
00220 ANES-INTRACRAN; CEREBROSP FL SHUNTING PROCEDURES 10
00222 ANES-INTRACRAN; ELECTROCOAGULAT INTRACRAN NERVE 6
00300 ANES-INTEG SYST MUSC&NERV HEAD NECK TRUNK;NOS 5
00320 ANES-PROC ESOPH THYRD TRACHEA&LYMPH; NOS 1 YR/> 6
00322 ANES-PROC ESOPH THYROID TRACH LYMPH;BX THYROID 3
00326 ANES-ON THE LARYNX&TRACHEA CHILDREN < 1 YEAR AGE
00350 ANESTHESIA PROCEDURES MAJOR VESSELS OF NECK; NOS 10
00352 ANES-PROC MAJOR VESSELS NECK; SIMPLE LIGATION 5
00400 ANES-PROC INTEG SYS EXTREM ANT TRNK&PERIN; NOS 3
00402 ANES-INTEG SYST EXTREM TRUNK PERIN;BREAST RECON 5
00404 ANES-INTEG EXTREM TRUNK;RADL/MOD RAD BREAST PROC 5
00406 ANES-INTEG EXTREM TRUNK;RADL BRST W/NODE DISSECT 13
00410 ANES-INTEG EXTREM TRUNK PERINEM;CONVERT ARRYTH 4
00450 ANESTHESIA PROCEDURES CLAVICLE AND SCAPULA; NOS 5
00452 ANES-PROC CLAVICLE&SCAPULA; RADICAL SURGERY 6
00454 ANES-PROC CLAVICLE&SCAPULA; BIOPSY CLAVICLE 3
00470 ANESTHESIA FOR PARTIAL RIB RESECTION; NOS 6

Time  Units

In calculating units of time, use 10 minutes per unit. If a medical provider bills for a portion of 10 minutes, round the time up to the next 10 minutes and reimburse one unit for the portion of time. (See Subsection A, Payment Ground Rules for Anesthesia Services, for additional information on reporting of time units.)

Multiple Procedures

Anesthesia reimbursement for multiple procedures is based on the procedure with the highest base value, plus modifying units (if appropriate), plus total time units for all combined surgical procedures.

No additional base value shall be reimbursed for anesthesia rendered during additional surgical procedures (other than the primary procedure) performed on the same day during the same operative setting.

Reimbursement Guidelines

Anesthesia services must be submitted with an appropriate anesthesia payment modifier toindicate the number of providers and roles involved in the anesthesia service. Effective for claims processed on or after July 1, 2018, regardless of date of service, claims for anesthesia services submitted without an appropriate payment modifier will be denied as a billing error for lack of a required modifier. A corrected claim will need to be submitted with the appropriate modifier(s) added.

One anesthesia provider at a time shall be reimbursed per patient. The only exception is supervised anesthesia services by a CRNA under the medical direction of a physician.

If two anesthesia services claims are received for the same patient, same date of service, and the payment modifiers do not agree about the medical direction or supervision performed, the first claim processed will be allowed. The second claim processed is subject to denial as a billing error due to lack of consistent information about who performed the service. No adjustment for reimbursement to the second anesthesia provider can be made until a corrected claim is received from the first (allowed) anesthesia provider so that the payment modifiers on both claims agree about who performed which responsibilities in the anesthesia service. The billing office for the denied claim is responsible to contact the billing office for the other anesthesia provider involved (supervised CRNA or physician providing medical direction) and arrange for the submission of the needed corrected claim.


Finger Modifier Guidelines and usage examples




A. Policy

Aetna Better Health of Louisiana implements comprehensive and robust policies to ensure alignment with Louisiana Department of Health (LDH) and to warrant that regulatory standards are met. According to the AMA CPT Manual, the HCPCS Level II Manual and our policy, the anatomic specific modifiers, such as fingers, toes and coronary artery designate the area or part of the body on which the procedure is performed. It is correct coding to append modifiers to the greatest specificity at all times.

B. Overview

CPT and HCPCS Level II guidelines support the use of anatomic specific modifiers to develop policies which validate the area or part of the body on which a procedure is performed.

Procedure codes that do not specify right or left require an anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

C. Definitions

Modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims.

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.

D. Reimbursement Guidelines

When submitting claims, always append an anatomical modifier, when applicable. Louisiana Department of Health Medicaid policy for both the commercial and Medicaid Advantage lines of business is that a claim is incomplete without an anatomical modifier, when applicable

E. Codes/Condition of Coverage

These codes are not all inclusive and for more please refer AMA CPT Manual, the HCPCS Level II Manual. These modifiers can be used with diagnostic, as well as therapeutic services.

Anatomical Modifiers:

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.




LT, RT Modifiers LT and RT are only considered valid for procedure codes specific to body parts that exist only twice in the body, once on the left and once on the right (paired body parts). For example, eye procedures (e.g. cataract surgery) and knee procedures (e.g. total knee replacement).

Modifiers LT and RT should be used when a procedure was performed on only one side of the body, to identify which one of the paired organs was operated upon. LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)

If the code description is for a structure that occurs multiple times on one side ofthe body (e.g. fingers, tendons, nerves, etc.) and is not specific enough for you to be able to mark on a body diagram where the left or right procedure is performed without looking at the medical record (e.g. place an “x” on the left shoulder for  73030-LT), then LT and RT are not valid modifiers. (Modifier -59 may be needed to indicate a separate lesion, separate nerve, separate tendon, etc. for nonpaired procedure codes.)



** To report an unplanned, unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery.
** To explain surgery/procedure.

Note
** Carrier may deny if modifier 79 is not included on the submitted claim.
** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.
** The unrelated procedure starts a new global period.
** For repeat procedures on the same day, see modifier 76.
** Do not report modifier 79 with modifiers 58 or 78.
** Modifier 79 is an information modifier (not subject to payment reduction). Example
** January 22 – Patient is seen for an injury to the right index finger. The patient’s finger is amputated at the DIP joint.
** 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure.
** March 15 – Same patient has an amputation of the right leg at femur.
** 27590 – 79 Amputation, thigh, through femur, any level.


Blue Cross Requires use of Anatomical Modifiers

Effective February 1, 2019, Blue Cross and Blue Shield of Minnesota (Blue Cross) will change the Reimbursement Policy titled “General Coding-Modifier Policy”. Submission of anatomical modifiers to specify locations will be required when submitting claims.

Anatomical Modifiers

The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment, effective February 1, 2019 Blue Cross requires the anatomical modifier(s) be submitted in the first modifier position, if applicable.

E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
RC Right coronary artery
RT Right side (used to identify procedures performed on the right side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit





Modifier Guidelines

procedures have been inappropriately billed by a surgical assistant. If guidelines are not met, the claim will suspend.

• Modifier 95 is used to designate when a service is a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.

• Modifier AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross and Blue Shield of North Carolina uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife.

• Modifier AX – item furnished in conjunction with dialysis services. J0604 and J0606 are drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease.

They are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier.

• HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate sitespecific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”).
• Modifier GQ designates services performed via asynchronous telecommunications system and will not be allowed.
• Modifier GT designates services performed via interactive audio and video telecommunication systems and will be allowed with codes specified in the Corporate Reimbursement Policy titled, “Telehealth.”
• Modifier MS - six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
• For Modifiers PA (surgical or other invasive procedure on wrong body part), PB (surgical or other invasive procedure on wrong patient), and PC (wrong surgery or other invasive procedure on patient), refer to Corporate Reimbursement Policy titled “Nonpayment for Serious Adverse Events”
• Modifier RA – Replacement of a DME item
• Modifier SZ – Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. (See policy titled “Rehabilitative Therapies”)
• Modifier RB – Replacement of a part of DME furnished as part of a repair


7 HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”). Notification given 11/28/17 for effective date of 1/27/18.

CPT code 12001,12018 - Laceration repair


CPT Codes for Laceration Repair 

Laceration 

Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities : 2.5 cm or less - cpt 12001



Simple Repairs

CPT Codes 12001 – 12018

** Usually included in all minor and major Usually included in all minor and major surgical procedures

** Cannot be reported separately when performed in conjunction with minor/major procedure

** However, can be reported if that is the only service provided e.g. simple closure of laceration


Intermediate Repairs (12001 – 12057)

Use for repair of wounds or defects which:



**  Require layered closure, one/more deeper layers SC tissue & superficial (nonmuscle) fascia

**  Need prolonged support y g (sum of lengths)

Need obliteration of “dead” space

Need prolonged support



Guidelines:

**  Code by site and length

**  Report in addition to excision code

Note: Not appropriate to be

**  used with excision of benign to control tension

**  used with excision of benign lesions 0.5 cm or less (11400, 11420, 11440) for Medicare & Aetna




Surgical Team

Under some circumstances highly complex procedures are carried out under the “surgical team” concept. Each participating physician would report the basic procedure with the addition of modifier -66.

Starred Surgical (*) Procedures

Certain services listed in the schedule are marked with a star (*) after the CPT® code.

These are relatively small surgical procedures for which the usual global package does not apply. Payment for the starred (*) service includes anesthesia for infiltration, digital block, or topical application.

When the starred (*) service is performed at the time of the initial visit, and theservice is the major service rendered during the visit, an office visit will be paid when billed with CPT® code 99025. Example: procedure code 12001 (repair of laceration) and procedure code 99025 (initial new patient exam) would both be paid.

When the starred (*) service is performed at the time of an initial or other visit involving significant identifiable service(s), the appropriate E/M service is listed in addition to the starred (*) service. Example: when an initial consult is performed and a joint injection is also performed, it is appropriate to bill and be paid for both the consult and the injection.

When a starred (*) service is performed at the time of a follow-up visit and the surgical procedure constitutes the major service, the evaluation and management service is not paid in addition to the surgical procedure. When the starred (*) service requires hospitalization, an appropriate hospital visit is listed, in addition to the starred (*) surgical procedure and its follow-up care.

Note: When follow-up days are listed as "0" the follow-up services shall be billed as independent procedures.

Note: When billing starred (*) surgical procedures for injection codes into bursa, joints, etc., the Injectable medications may be billed separately using 99070 or the appropriate J code listed in Medicare’s Level II codes. The drug shall be reimbursed at AWP.



HELPFUL CODING HINTS

As part of Oxford’s ongoing effort to provide the best service possible to all providers, Oxford periodically reviews claims data to identify issues that can delay processing. This article is the second in a series of updates that will be featured in this publication on a regular basis. One of the areas frequently noted to cause difficulty is the inappropriate use of repair CPT codes in the ranges of 12001 through 13160 (Repair; simple, intermediate, complex). These codes cannot be billed for more than a quantity of one per each group of anatomic site and classification, and are frequently billed incorrectly with multiple quantities (e.g., 12001 quantity 2.) To ensure timely and correct reimbursement, physicians, when repairing multiple wounds, should total the sums of the lengths of the repairs performed in each anatomic site and bill with the appropriate corresponding repair code.

According to the AMA CPT 2001 description, “when multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor.” The following example illustrates this rule: The physician performs a simple repair 1 cm in length on the trunk and a simple repair 1.5 cm in length on the arm. The provider should bill CPT code 12001 with a quantity of one, since the total length of the repairs is equal to 2.5 cm. The AMA CPT 2001 description for code 12001 is “simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less.”

Providers should not add lengths of repairs from different groupings of anatomic sites (e.g., ears and legs) and should not add together lengths of different classifications (e.g., simple and complex repairs). Please remember to add the total lengths of repairs for each group of anatomic sites. The codes within the same classification and anatomic site cannot be billed in multiple quantities.




HCPC Code 12001


To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the data provided by CMS:


Step 1. Access the Medicare Physician Fee Schedule Look-up on the CMS website at www.cms.hhs.gov.

Step 2. To find the RVU for the procedure: Provide your search criteria selecting the year, “Single HCPCS Code” and “Relative

Value Units.” To find the GPCI: Provide your search criteria selecting the year, “Single HCPCS Code” and “Geographic Practice Cost Index (GPCI).”

Step 3. To find the RVU for the procedure: On the next page, select “Default Fields.” To find the GPCI: On the next page, select “Specific Locality” and “Default Fields.”

Step 4.

To find the RVU for the procedure:

Continue the process by providing the HCPCS (for this example we are using 12001  Repair superficial wounds in a non-facility setting), and select the appropriate modifier if applicable.

To find the GPCIs for the procedure: Continue the process by selecting the “Carrier Locality” (for this example we are selecting “Rest of Texas”).

Step 5.

To find the RVU for the procedure: Submit your search criteria to find the RVUs for the procedure.

To find the GPCIs for the procedure: Submit your search criteria to find the GPCIs for the locality.

 Step 6. Proceed with the calculations. [(Work RVU x Work GPCI)

+ (PE RVU x PE GPCI)
+ (MP RVU x MP GPCI)]
x Division Conversion Factor
= Division MAR


The MAR for CPT code 12001 (Repair superficial wounds) in a non-facility setting provided for the “Rest of Texas” in 2009 is $184.66.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a facility setting, follow the steps above using the Facility RVUs in place of the Non-facility RVUs.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the Trailblazer website:

Step 1. Go to the TrailBlazer Health Enterprises, LLC website at www.TrailBlazerhealth.com.

Step 2. If you have already registered on this site, sign in. If you have not, you must register to use the site. There is no cost to use this website.

Step 3. Use the Search function on the Homepage to search for ‘Fee Schedules’ and locate the Medicare Fee Schedule.

Step 4. Select the year of the fee schedule you want (2009), your state (Texas), and yourlocality (Rest of Texas) in the appropriate windows.

Step 5. Enter the procedure code (CPT) (and modifier if applicable) about which you seek information.

Step 6. Find the Medicare CF and divide it into the Division CF (2009 CF – $53.68) to derive the Division multiplier.

Step 7. Find the non-facility Participating Amount and multiply the amount by the Division ratio.




CPT U0001,U0002, 87635 - Coronavirus - ICD J12.89, A41.89, B34.2

CPT code and Description

U0001 - 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when specimens are sent to the CDC and CDC-approved local/state health department laboratories.

U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health department laboratories.

87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.  Use of code 87635 will help the labs to efficiently report and track testing services related to SARS-CoV-2 and will streamline the reporting and reimbursement for this test in the US.

There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) can be used by laboratories and healthcare facilities to bill Medicare as well as by other health insurers that choose to adopt this new code for such tests. HCPCS code (U0002) generally describes 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets). The Medicare claims processing system will be able to accept these codes on April 1, 2020 for dates of service on or after February 4, 2020.


CPT code and reimbursement rate


U0001 - $35.92

U0002 - $51.33

Modifiers:

The appropriate modifier should be assigned based on the below information,

GT - Via Interactive Audio and Video Telecommunications systems
GQ - Via Asynchronous Telecommunications systems.
95 - Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system (reported only with codes from Appendix P)
G0 -Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

POS:
​​Telemedicine service can be billed under POS 02.

Diagnosis:
The codes for classifying coronavirus (not associated with SARS) include,
Pneumonia due to coronavirus:  J12.89 (Other viral pneumonia) and B97.29 (Other coronavirus as the cause of diseases classified elsewhere)
Sepsis due to coronavirus:  A41.89 (Other specified sepsis) and B97.29
Other infection caused by coronavirus:  B34.2 (Coronavirus infection, unspecified)
If the provider documents “suspected”, “possible” or “probable” COVID-19, do not assign code B97.29. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828).


Medicaid will start to cover these services effective from March 16th, 2020 and the date of service would be February 4th, 2020.


FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19)

Q1. Do the Essential Health Benefits (EHB) currently include coverage for the diagnosis and treatment of COVID-19?

A1. Yes. EHB generally includes coverage for the diagnosis and treatment of COVID-19.
However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered. Nongrandfathered health insurance plans purchased by individuals and small employers, including qualified health plans purchased on the Exchanges, must provide coverage for ten categories of EHB.1 These ten categories of benefits include, among other things, hospitalization and laboratory services. Under current regulation, each state and the District of Columbia generally determines the specific benefits that plans in that state must cover within the ten EHB categories.

This standard set of benefits determined by the state is called the EHB-benchmark plan. All 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of COVID19.2 Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and will be waiving any cost-sharing that would otherwise apply to the test. Furthermore, many states are encouraging their issuers to cover a variety of COVID-19 related services, including testing and treatment, without cost-sharing, while several states have announced that health plans in the state must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing.

Q2. Is isolation and quarantine for the diagnosis of COVID-19 covered as EHB?

A2. All EHB-benchmark plans cover medically necessary hospitalizations. Medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission are generally covered as EHB. The cost-sharing and specific coverage limitations associated with these services may vary by plan. For example, some plans may require prior authorization before these services are covered or may apply other limitations. Quarantine outside of a hospital setting, such as a home, is not a medical benefit, nor is it required as EHB. However, other medical benefits that occur in the home that are required by and under the supervision of a medical provider, such as home health care or telemedicine, may be covered as EHB, but may require prior authorization or be subject to cost-sharing or other limitations.

Q3. When a COVID-19 vaccine is available, will it be covered as EHB, and will issuers be permitted to require cost-sharing?


A3. A COVID-19 vaccine does not currently exist. However, current law and regulations require specific vaccines to be covered as EHB without cost-sharing, and before meeting any applicable deductible, when the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, if ACIP recommends a new vaccine, plans are not required to cover the vaccine until the beginning of the plan year that is 12 months after ACIP issues the recommendation. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost-sharing, prior to that date.

In addition, as part of a plan’s responsibility to cover prescription drugs as EHB, as described above to cover ACIP-recommended vaccines, if a plan does not provide coverage of a vaccine (or other prescription drugs) on the plan’s formulary enrollees may use the plan’s drug exceptions process to request that the vaccine be covered under their plan, pursuant to 45 CFR 156.122(c)

Does Aetna cover the cost of COVID-19 testing for members?

CVS Health recently announced Aetna will waive co-pays and apply no cost-sharing for all diagnostic testing related to COVID-19 and there will be no member out of pocket cost. This policy will cover the cost of physician-ordered testing for patients who meet CDC guidelines, which can be done in any approved laboratory location. Aetna will waive the member costs associated with diagnostic testing at any authorized location for all Commercial, Medicare and Medicaid lines of business. Self-insured plan sponsors will be able to opt-out of this program at their discretion.

How will doctors and hospitals have access to COVID-19 lab testing?

 
Patients who have concerns that they may have been exposed to COVID-19 or may have symptoms of COVID-19 should contact their physician or local/state Department of Health for testing. The test specimens will be obtained and then sent to a laboratory. We are not currently able to do specimen collection or testing at MinuteClinic or CVS Retail pharmacies. The CDC states that coronavirus testing may be performed on patients with a doctor’s approval.

CPT G0104, G0105, G0106, G0120 - Colorectal cancer screening

Procedure code and Description

• CPT 82270 (HCPCS G0107) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneousdeterminations;

• HCPCS G0104 - Colorectal cancer screening; flexible sigmoidoscopy;

• HCPCS G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;

• HCPCS G0106 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy;

• HCPCS G0120 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy.

Medicare Billing Guidelines


G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.

HCPCS G0120 - Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0105, Screening Colonoscopy Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (HCPCS G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (HCPCS G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (HCPCS G0120) as an alternative to a screening colonoscopy (HCPCS G0105) in January 2000.

Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (HCPCS G0120) in January 2002.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening colonoscopy, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast bariumenema examination.

Screening Barium Enema Examinations (codes G0106 and G0120).--Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies (see §4180.2 B and C) above apply.

In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema in January 2002.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2000.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination.

Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.


Code G0106 (colorectal cancer screening; barium enema as an alternative to a screening flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280). Code G0120 (colorectal cancer screening; barium enema as an alternative to a screening colonoscopy; high risk individuals) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).

COLORECTAL CANCER SCREENING TESTS OVERVIEW

The following services are considered colorectal cancer screening services:

• Annual fecal occult blood tests (FOBTs);
• Flexible sigmoidoscopy;
• Screening colonoscopy for persons at average risk for colorectal cancer every 10 years,
• Screening colonoscopy for persons at high risk* for colorectal cancer every 2 years;
• Barium enema every 4 years as an alternative to flexible sigmoidoscopy, or
• Barium enema every 2 years as an alternative to colonoscopy for persons at high risk*;
• CologuardTM - Multitarget Stool DNA (sDNA) Test (effective October 9, 2014)

*Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of familial adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer; or
• A personal history of inflammatory bowel disease, C rohn’s Disease, and ulcerative colitis

It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.


Remittance Advice Notices.Denial codes

A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is under 50 years of age, use existing American National Standard Institute (ANSI) X12-835 claim adjustment reason code 6 “the procedure code is inconsistent with the patient’s age,” at the line level along with line level remark code M82 “Service is not covered when beneficiary is under age 50.”

B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the time period between the test/procedure has not passed, use existing ANSI X12-835 claim adjustment reason code 119 “Benefit maximum for this time period has been reached” at the line level.

C. If the claim is being denied for a screening colonoscopy (code G0105) or a screening barium enema (G0120) because the beneficiary is not at a high risk, use existing ANSI X12-835 claim adjustment reason code 46 “This procedure is not covered” at the line level along with line level remark code M83 “Service is not covered unless the beneficiary is classified as a high risk.”

D. If the service is being denied because payment has already been made for a similar procedure within the set time frame, use existing ANSI X12-835 claim adjustment reason code 18, “Duplicate claim/service” at the line level along with line level remark code M86 “This service is denied because payment has already been made for a similar procedure within a set timeframe.”

E. If the claim is being denied for a noncovered screening procedure such as G0122, use existing ANSI X12-835 claim adjustment reason code 49, “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.” 4180.10 Ambulatory Surgical Center Facility Fee.--CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center (ASC) facility fee under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) has been added to the ASC list effective for services furnished on or after January 1, 1998. Code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) was added to the ASC list effective for services furnished on or after July 1, 2001. Codes G0105 and G0121 are assigned to ASC payment group 2. The ASC facility service is the same whether the procedure is a screening or a diagnostic colonoscopy.3

Covered ICD codes

Routine screening examinations:
V76.41 SCREENING FOR MALIGNANT NEOPLASMS OF THE RECTUM
V76.51 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS COLON
Screening examinations for persons at high risk: (HCPCS Codes G0105 and G0120)
Personal or family history of gastrointestinal neoplasia:
211.3 BENIGN NEOPLASM OF COLON
211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL
235.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND
RECTUM
V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN
GASTROINTESTINAL TRACT
V10.05* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE
V10.06* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
V10.07 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER
V12.72 PERSONAL HISTORY OF COLONIC POLYPS
V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES
V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL
TRACT
V18.51 FAMILY HISTORY, COLONIC POLYPS
555.1* REGIONAL ENTERITIS OF LARGE INTESTINE
555.2* REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE
555.9* REGIONAL ENTERITIS OF UNSPECIFIED SITE
556.0* ULCERATIVE (CHRONIC) ENTEROCOLITIS
556.1* ULCERATIVE (CHRONIC) ILEOCOLITIS
556.2* ULCERATIVE (CHRONIC) PROCTITIS
556.3* ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS
556.4 PSEUDOPOLYPOSIS OF COLON
556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS
556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
556.8* OTHER ULCERATIVE COLITIS
556.9* ULCERATIVE COLITIS UNSPECIFIED



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