Occurrence Code 32 , Condition Codes 20 and 21

Condition Codes 20 and 21, Occurrence Code 32

If an FI receives a completely non-covered claim with either a condition code 20 or a condition code 21, process the claim through all systems.

Beneficiaries are assumed to be liable on claims using condition code 21, since these claims, sometimes called “no-pay bills” and having all non-covered charges, are submitted to Medicare to obtain a denial that can be passed to subsequent payers. An advance beneficiary notice (ABN) is not required in these cases. If an ABN is given, condition code 21 cannot be used.

Claims with condition code 20 may be submitted with both covered and non-covered charges. An ABN, specifically Form CMS-R-131, should not be employed when condition code 20 is used. Note that condition code 20 may be used when: (1) a Home Health (HH) ABN, Form CMS-R-296, is used because payment will be made under the HH Prospective Payment System (PPS); or (2) a hospital or SNF inpatient notice of non-coverage is provided, since a Form CMS-R-131 will not be given in these cases.

Claims are billed with condition code 20 at a beneficiary’s request, where the provider has already advised the beneficiary that Medicare is not likely to cover the service(s) in question. Providers may directly collect payment from beneficiaries in such cases for non-covered charges, but if, upon review, Medicare decides a service in question is actually covered and pays, providers must return any payment collected from beneficiaries for these services. Medicare reviews all home health (HH)
and skilled nursing facility (SNF) services in question on these bills using condition code 20 to make a payment determination.

Occurrence code 32 on a claim signifies that an ABN, Form CMS-R-131, was given to a beneficiary on a specific date. This code must be employed if this specific ABN form is given, and condition code 20 will not be used on the subsequent claim (i.e., no charges will be submitted as non-covered). All services on such claims with occurrence code 32 must be covered charges, even if the result of full adjudication of these claims is expected to be that services will be found to be non-covered. If such services are non-covered after full adjudication, the beneficiary remains liable for the services.

If instead, as a result of medical review, Medicare finds services are covered, the Medicare Program becomes liable since the provider will receive payment direct from Medicare.



NOTE: The use of a provider ABN, Form CMS-R-131 and occurrence code 32 can apply to all outpatient or institutional Part B services, with three exceptions. One, only a HHABN, Form CMSR-296 and condition code 20, can apply to HH PPS services. Two, the provider ABN, Form R-131, and occurrence code 32 are to be used when needed for hospice services paid under either Trust Fund A or Trust Fund B. Three, a totally separate process will be used for ambulance claims containing non-covered miles; a new PM is currently in development for this ambulance situation.

Only services for which the ABN was given should be shown on the claim with occurrence code 32, since the code pertains to every service on the claim. Providers must give separate ABNs for different procedures if performed on different dates, and show the services and the dates ABNs were given on separate bills for each date involved. The one exception is that only one ABN is required for a series of services given under standing orders.

If a service not pertaining to the ABN was rendered in the same period as service(s) requiring an ABN, such services must be submitted on separate claims, and the statement dates of these claims cannot overlap. If the time periods cannot be separated (i.e., a service requiring an ABN is given on the same day a service not requiring an ABN), a single claim must be submitted, just for the overlapping period, using occurrence code 32, showing all services as covered, and placing modifier GA on the HCPCS code to identify the service (revenue code) line for which the ABN (Form CMS-R-131) was given. Since this is an exception process, providers are reminded to use this mechanism only when it is impossible to separate the billing periods.


The final instance in which beneficiaries are liable for non-covered charges is for services they request be billed to Medicare, but Medicare does not cover by statute. Examples of services not covered by statute include personal comfort items, hearing aides and hearing examinations, routine eye and dental care. Medicare claims processing edits are being refined to effectuate the processing of such claims. Providers should advise beneficiaries each time they are aware services not covered
by statute are being requested before Medicare is billed, but ABNs are not to be used in these cases.


If, in a situation in which giving an ABN, Form CMS-R-131 is not appropriate, a beneficiary demands a Medicare determination for any line(s) for other than HH PPS services, instruct the provider to put those line(s) on a separate bill showing the charges as non-covered and put condition code 20 on the bill. If a beneficiary wants an MSN for denial reasons on any line(s), instruct the provider to put those line(s) on a separate bill and show condition code 21 on that bill. If the provider gives the beneficiary an ABN under any other circumstances, the provider must show the charges as covered and also put occurrence code 32 on the claims to fix beneficiary liability. There are no provider billing requirements for billing services excluded by statute other than billing such items as non-covered. The SS will generate denial reasons for the lines containing non-covered charges. HH PPS services are addressed in a previous section of this instruction.

Billing With an ABN (Use of Occurrence Code 32) Comparable to Traditional Demand Bills

Now, using an ABN is frequently required, much more often than traditional demand billing, usually when medical necessity is in doubt, or when other issues captured in §1862(a)(1) and §1879 of the Act apply, or when previous covered treatment is to be reduced or terminated within a Medicare benefit. Previous ABN instructions brought about a large change in billing practices, because before these instructions, covered charges were never billed when medical necessity was in doubt.

Claims billed in association with an ABN, other than HHPPS and SNF PPS exceptions, never use condition code 20 or 21, and will be returned to providers if received, but instead:

Must use a claim-level occurrence code 32 to signify all services on the claim are associated with one particular ABN given on a specific date (unless the use of modifiers, discussed below, makes clear not every line on the claim is linked to the
ABN);

• Must provide the date the ABN was signed by the beneficiary in association with the occurrence code;

Occurrence code 32 and accompanying date must be used multiple times if more than one ABN is tied to a single claim for services that must be bundled/billed on the same claim (i.e., one date for one ABN lab
services tied to a R-131-L, another for services tied to a R-131-G, even if the date is the same for both ABNs);

Must submit all ABN-related services as covered charges (note –GA modifier exception, below); and •

• Must complete all basic required claim elements as for other comparable claims for covered services.

Again, if an ABN is given, these billing procedures must be used, rather than traditional demand billing. New with this instruction, providers should be aware CMS may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN. Citations for instructions on the ABN, which include information on when an ABN is
appropriate, are given above. If claims using occurrence code 32 remain covered, they will be paid, RTP'ed, rejected or denied in accordance with other instructions/edits applied in processing to completion. Denials made through automated medical review of service submitted as covered are still permitted after medical review, and the FI will determine if additional documentation requests or manual development of these services are warranted. For all denials of services associated with the ABN, the beneficiary will be liable.


Condition Codes 20 and 21

If FIs receive a completely non-covered claim without either a condition code 20 or a condition code 21, process the claim through your system. All non-covered claims must be processed as provider liable unless occurrence code 32 and date is present signifying that an advance beneficiary notice was given to the beneficiary on that date, or, unless the service is non-covered by statute.

If a beneficiary demands a Medicare determination for any line(s) for other than Home Health services, instruct the provider to put those line(s) on a separate bill showing the charges as noncovered and put condition code 20 on the bill. If a beneficiary wants an MSN for denial reasons on
4 any line(s) for other than Home Health services, put those line(s) on a separate bill and show condition code 21 on that bill. The SS will generate denial reasons for the lines containing noncovered charges. Home Health services are addressed in a previous section of this instruction.

Note: The use of occurrence code 32 should be made specific to all claim types except Home Health bills. Since there is only one occurrence code (32) to indicate the date the beneficiary received an ABN, only lines for which you notified the beneficiary on the same date may be submitted on the same bill for both demand bills and billing for denial bills (condition codes 20 and 21). If you gave ABNs on different dates for different procedures, show the services and the dates you gave ABNs on separate bills for each date involved

In summary, other general requirements for demand bills are:

• Condition Code 20 must be used;

• All charges associated with Condition Code 20 must be submitted as non-covered;

• All non-covered services on the demand bill must be in dispute;

• At least one non-covered line must appear on the claim related to the services in dispute;

• Unrelated covered charges are allowed on the same claim;

• Unrelated non-covered charges not in dispute, if any, would be billed on a no payment claim using Condition Code 21;

• Frequency code zero should be used if all services on the claim are non-covered;

• Occurrence code 32 (i.e., ABN) is NEVER submitted on a claim using condition code 20; and

• Basic required claim elements must be completed. Claims not meeting these requirements will be returned to providers.



In using the ABN, beneficiaries select only one option on the ABN notice prior to billing, after they have been told that the provider anticipates Medicare will not cover a service. Claims, other than HHPPS claims, billed in association with an ABN never use condition code 20 or 21, and will be returned to providers if received with those codes. Instead, the claims: • Must use occurrence code 32 to signify all services on the claim are associated with one particular ABN given on a specific date, unless the use of modifiers makes clear that not every line on the claim is linked to the ABN;

• Must provide the date the ABN was signed by the beneficiary in association with the occurrence code;

• Must use occurrence code 32 and the accompanying date multiple times if more than one ABN is tied to a single claim for services that must be bundled/billed on the same claim;

• Must submit all ABN-related services as covered charges (note –GA modifier exception, below); and

• Must complete all the same basic required claim elements as comparable claims for covered services.

Providers should be aware CMS may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN.

If claims using occurrence code 32 remain covered, they will be paid, RTP’ed, rejected or denied in accordance with other instructions/edits applied in processing. Denials made through automated medical review of service submitted as covered are still permitted after medical review, and the Medicare contractor will determine if additional documentation requests or
manual development of these services are warranted. For all denials of services associated with the ABN, the beneficiary will be liable.



Line level coding

The –GA modifier is used when provider must bill some services which are related and some which are not related to a ABN on the same claim. The –GA modifier is used when both covered and non-covered service appear on an ABN-related claim. Occurrence code 32 must still be used on claims using the –GA modifier, so that these services can be linked to specific ABN(s). In
such cases, only the line items using the –GA modifier are considered related to the ABN and must be covered charges, other  ine items on the same claims may appear as covered or noncovered charges.

CPT 96150, 96152 - Health and behavior assessment

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

96150 Assess hlth/behave init
96151 Assess hlth/behave subseq
96152 Intervene hlth/behave indiv
96153 Intervene hlth/behave group
96154 Interv hlth/behav fam w/pt

Group 2 Paragraph: The following CPT code is not covered by Medicare.


Group 2 Codes:

96155 Interv hlth/behav fam no pt


Coverage Indications, Limitations, and/or Medical Necessity

Indications

The Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes 96152-96153) may be considered reasonable and necessary for the patient who meets all of the following criteria:

The patient has an underlying physical illness or injury, and

There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and

The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and

The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, and

The assessment is not duplicative of other provider assessments

In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well being.

Health and Behavioral Intervention (with the family and patient present) (CPT code 96154) is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient.
Limitations

Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:

Does not have an underlying physical illness or injury, or
For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or
Does not have the capacity to understand and to respond meaningfully during the face to face encounter, because of:
Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.
Delirium
Severe and profound mental retardation
Persistent vegetative state/no discernible consciousness,
Impaired mental status, e.g.,

Disorientation to person, time, place, purpose, or
Inability to recall current season, location of own room, names and faces, or
Inability to recall that he or she is in a nursing home or skilled nursing facility, or
Does not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living, or
For whom the conditions noted under the indications portion of this section are not met.

Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT code 96155.

Examples of Health and Behavioral Intervention services not considered reasonable and necessary and not covered are:

Provide family psychotherapy or mediation
Maintain the patient's or family's existing health and overall well-being
Provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.
Individual social activities
Teaching social interaction skills
Socialization in a group setting
Vocational or religious advice
Tobacco or caffeine withdrawal support
Teaching the patient simple self-care
Weight loss management
Maintenance of behavioral logs

Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP-Specialty Code 68).

Biofeedback is coded as 90901 and will not be covered as a health and behavioral intervention.


Bill Type Codes:

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

Revenue Codes:

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

99999 Not Applicable



CPT code for SNF in home health or hospice setting

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

G0299 DIRECT SKILLED NURSING SERVICES OF A REGISTERED NURSE (RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0300 DIRECT SKILLED NURSING SERVICES OF A LICENSE PRACTICAL NURSE (LPN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Neurological conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s over-all health status. Health status includes environmental factors, such as the availability of palliative care services. The objective of this policy is to present a framework for identifying, documenting, and communicating the unique health care needs of individuals with neurological conditions and thus promote the over-all goal of the right care for every person, every time.

Neurological conditions may support a prognosis of six months or less under many clinical scenarios. Medicare rules and regulations addressing hospice services require the documentation of sufficient clinical information and other documentation to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning. Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with neurological conditions is suggested, but not required.

The health status changes associated with neurological conditions can be characterized using categories contained in the ICF. The ICF contains domains and categories (e.g., structures of the nervous system, mental functions, sensory functions and pain, neuromusculoskeletal and movement related functions, communication, mobility, and self-care) that allow for a comprehensive description of an individual’s health status and service needs. Information addressing relevant ICF categories, defined within each of these domains and categories, should form the core of the clinical record and be incorporated into the care plan, as appropriate.

Additionally, the care plan may be impacted by relevant secondary and/or comorbid conditions. Secondary conditions are directly related to a primary condition. In the case of neurological conditions, examples of secondary conditions could include dysphagia, pneumonia, and pressure ulcers. Comorbid conditions affecting beneficiaries with neurological conditions are, by definition, distinct from the primary condition itself, however, services aimed at the comorbid condition may indeed be related to the palliation and/or management of the terminal condition. An example of a comorbid condition would be Chronic Obstructive Pulmonary Disease (COPD).

The important roles of secondary and comorbid conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. The identification and documentation of relevant secondary and comorbid conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.




Secondary Conditions:

Neurological conditions may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments - together with any limitation in activity and restriction in participation - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with neurological conditions results from the presence of impairments in such body functions as consciousness, attention, sequencing complex movements, ingestion (which includes chewing, manipulation of food in the mouth, and swallowing), muscle power, tone, and endurance. These impairments contribute to the increased incidence of secondary conditions such as dysphagia, pneumonia, and pressure ulcers observed in Medicare beneficiaries with neurological conditions. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurological condition and any identified secondary condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.

Comorbid Conditions:

The significance of a given comorbid condition is best described by defining the structural/functional impairments - together with any limitation in activity and restriction in participation - related to the comorbid condition. For example, a beneficiary with a primary neurological condition such as Amyotrophic Lateral Sclerosis (ALS) and a comorbidity of COPD could have specific COPD-related structural and functional impairments of respiration (e.g., structural impairments of the bronchoalveolar tree resulting in increased respiratory rate, cough and impaired gas exchange) that contribute to the activity limitations and participation restrictions already present due to the respiratory muscle weakness often observed with ALS.

Such a combination could affect the palliative care plan by contributing to the individual’s dyspnea and impaired exercise tolerance. Further description/documentation using the activities and participation component of the ICF (e.g., mobility, self-care, and interpersonal interactions and relationships), would help complete the clinical picture. Palliative care aimed at relieving the dyspnea and improving the individual’s health status would be the goal.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurologic condition and any identified comorbid condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less. The documentation of structural/functional impairments, together with the observed activity limitations, facilitate the selection of the most appropriate intervention strategies (palliative/hospice vs. long-term disease management) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.




Bill Type Codes:

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



Revenue Codes:

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

N/A





CPT code 92133, 92134 - SCODI

Procedure code and Description

Group 1 Paragraph: N/A

Group 1 Codes:

92132 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL

92133 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE


92134 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA

Coverage Guidance


Coverage Indications, Limitations, and/or Medical Necessity

Medicare will consider scanning computerized ophthalmic diagnostic imaging (SCODI) medically reasonable and necessary in evaluating retinal disorders, glaucoma and anterior segment disorders as documented in this local coverage determination (LCD).

SCODI includes the following tests:

Confocal Laser Scanning Ophthalmoscopy (topography) uses stereoscopic videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina.

Scanning Laser Polarimetry (nerve fiber analyzer) measures change in the linear polarization of light (retardation). It uses both a polarimeter (an optical device to measure linear polarization change) and a scanning laser ophthalmoscope, to measure the thickness of the nerve fiber layer of the retina.

Optical Coherence Tomography (OCT) a non-invasive, non-contact imaging technique.

OCT, especially SCODI, produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of the optic nerve head, nerve fiber layer, and retina.
Scanning computerized ophthalmic diagnostic imaging allows earlier detection of glaucoma and more sophisticated analysis for ongoing management. These tests also provide more precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of time than visual fields and/or disc photos. This allows earlier and more efficient efforts of treatment toward the disease process.




Indications

Glaucoma

Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Glaucoma also is diagnostically challenging. Almost 50% of glaucoma cases remain undetected. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 30% of those suffering from the disease have pressures in the normal range. 

Glaucoma commonly causes a spectrum of related eye and vision changes, including erosion of the optic nerve and the associated retinal nerve fibers, and also loss of peripheral vision. A diagnosis of glaucoma seldom is made on the basis of a single clinical observation, but instead relies upon analysis of an assemblage of clinical data, including: optic nerve, retinal nerve fiber, and anterior chamber structures, as well as looking for hemorrhages of the optic nerve, pigment in the anterior chamber, and, especially visual field loss. Each of these methods has its own strengths and limitations, thus the dependence upon multiple observations. Careful reliance upon all available clinical data can allow early treatment and can prevent unnecessary end-stage therapies.

Scanning Computer Ophthalmic Diagnostic Imaging (SCODI) allows earlier detection of those patients with normal tension glaucoma and more sophisticated analysis for ongoing management. Because SCODI detects glaucomatous damage to the nerve fiber layer or optic nerve of the eye, it can distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure (IOP). It may separate patients with elevated IOP and early glaucoma damage from those without glaucoma.

Technological improvements have rendered SCODI as a valuable diagnostic tool in the diagnosis and treatment of glaucoma. These improvements enable discernment of changes of the optic nerve and nerve fiber layer, even in advanced cases of glaucoma. 

It is expected that only two (SCODI) exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma. 

Retinal Disorders

Retinal disorders are the most common causes of severe and permanent vision loss. Scanning computerized ophthalmic diagnostic imaging (SCODI) is a valuable tool for the evaluation and treatment of patients with retinal disease, especially macular abnormalities. SCODI is able to detail the microscopic anatomy of the retina and the vitreo-retinal interface. SCODI is useful to measure the effectiveness of therapy, and in determining the need for ongoing therapy, or the safety of cessation of that therapy.

Retinal thickness analysis is a non-invasive and non-contact imaging technique that takes direct cross-sectional images of the retina. These high resolution images capture ocular structures and provide data to create thickness maps of the retina. Retinal thickness is directly correlated to ocular disease, including retinal disorders and glaucoma. In contrast, Scanning Laser Polarimetry is not an appropriate diagnostic technique for the management of retinal disorders.

Long Term Use of Chlorquine (CQ) and or Hydroxychloroquine (HCQ)

Clinical evidence has shown that long-term use of chloroquine (CQ) and/or hydroxychloroquine (HCQ) can lead to irreversible retinal toxicity. Therefore, these two medications are deemed high risk, and scanning optical coherence tomography may be indicated to provide a baseline prior to starting the medication and as an annual follow-up. Clinical evidence shows that the resolution of time domain OCT instruments is not sufficient to detect early toxic retinal changes. Because of that, spectral domain-optical coherence tomography (SD-OCT) is expected to be used to detect retinal changes that are due to the use of CQ or HCQ. 

Anterior Segment Disorders

SCODI may be used to examine the structures in the anterior segment structures of the eye. However, it is still seen as experimental/investigational except in the following:
Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma

Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction

Iris tumor

Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber

Calculation of lens power for cataract patients who have undergone prior refractive surgery. Payment will only be made for the cataract codes as long as additional documentation is available in the patient record of their prior refractive procedure. Payment will not be made in addition to A-scan or IOL master.

Limitations

The following codes/ procedures would generally not be necessary with SCODI. When medically needed the same day, documentation must justify the procedures.
92250 - Fundus photography with interpretation and report

92225 - Opthalmoscopy extended with retinal drawing (e.g. For retinal detachment, melanoma) with interpretation and report initial

92226 - Subsequent ophthalmoscopy

76512 - B-scan (with or without superimposed non-quantitative A-scan)




ICD-10 Codes that Support Medical Necessity 

ICD-10 CODE DESCRIPTION

C69.01 Malignant neoplasm of right conjunctiva

C69.02 Malignant neoplasm of left conjunctiva

C69.11 Malignant neoplasm of right cornea

C69.12 Malignant neoplasm of left cornea

C69.21 Malignant neoplasm of right retina

C69.22 Malignant neoplasm of left retina

C69.31 Malignant neoplasm of right choroid

C69.32 Malignant neoplasm of left choroid

C69.41 Malignant neoplasm of right ciliary body

C69.42 Malignant neoplasm of left ciliary body

C69.51 Malignant neoplasm of right lacrimal gland and duct

C69.52 Malignant neoplasm of left lacrimal gland and duct

C69.61 Malignant neoplasm of right orbit

C69.62 Malignant neoplasm of left orbit

C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa

C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa

D31.01 Benign neoplasm of right conjunctiva

D31.02 Benign neoplasm of left conjunctiva

D31.11 Benign neoplasm of right cornea

D31.12 Benign neoplasm of left cornea

D31.21 Benign neoplasm of right retina

D31.22 Benign neoplasm of left retina

D31.31 Benign neoplasm of right choroid

D31.32 Benign neoplasm of left choroid

D31.41 Benign neoplasm of right ciliary body

D31.42 Benign neoplasm of left ciliary body

D31.51 Benign neoplasm of right lacrimal gland and duct

D31.52 Benign neoplasm of left lacrimal gland and duct

D31.61 Benign neoplasm of unspecified site of right orbit

D31.62 Benign neoplasm of unspecified site of left orbit

D31.91 Benign neoplasm of unspecified part of right eye

D31.92 Benign neoplasm of unspecified part of left eye

H16.001 Unspecified corneal ulcer, right eye

H16.002 Unspecified corneal ulcer, left eye

H16.003 Unspecified corneal ulcer, bilateral

H16.011 Central corneal ulcer, right eye

H16.012 Central corneal ulcer, left eye

H16.013 Central corneal ulcer, bilateral

H16.021 Ring corneal ulcer, right eye

H16.022 Ring corneal ulcer, left eye

H16.023 Ring corneal ulcer, bilateral

H16.031 Corneal ulcer with hypopyon, right eye

H16.032 Corneal ulcer with hypopyon, left eye

H16.033 Corneal ulcer with hypopyon, bilateral

H16.041 Marginal corneal ulcer, right eye

H16.042 Marginal corneal ulcer, left eye

H16.043 Marginal corneal ulcer, bilateral

H16.051 Mooren's corneal ulcer, right eye

H16.052 Mooren's corneal ulcer, left eye

H16.053 Mooren's corneal ulcer, bilateral

H16.061 Mycotic corneal ulcer, right eye

H16.062 Mycotic corneal ulcer, left eye

H16.063 Mycotic corneal ulcer, bilateral

H16.071 Perforated corneal ulcer, right eye

H16.072 Perforated corneal ulcer, left eye

H16.073 Perforated corneal ulcer, bilateral

H18.11 Bullous keratopathy, right eye

H18.12 Bullous keratopathy, left eye

H18.13 Bullous keratopathy, bilateral

H18.20 Unspecified corneal edema

H18.211 Corneal edema secondary to contact lens, right eye

H18.212 Corneal edema secondary to contact lens, left eye

H18.213 Corneal edema secondary to contact lens, bilateral

H18.221 Idiopathic corneal edema, right eye

H18.222 Idiopathic corneal edema, left eye

H18.223 Idiopathic corneal edema, bilateral

H18.231 Secondary corneal edema, right eye

H18.232 Secondary corneal edema, left eye

H18.233 Secondary corneal edema, bilateral

H18.50 Unspecified hereditary corneal dystrophies

H18.51 Endothelial corneal dystrophy

H18.711 Corneal ectasia, right eye

H18.712 Corneal ectasia, left eye

H18.713 Corneal ectasia, bilateral

H18.721 Corneal staphyloma, right eye

H18.722 Corneal staphyloma, left eye

H18.723 Corneal staphyloma, bilateral

H18.731 Descemetocele, right eye

H18.732 Descemetocele, left eye

H18.733 Descemetocele, bilateral

H40.021 Open angle with borderline findings, high risk, right eye

H40.022 Open angle with borderline findings, high risk, left eye

H40.023 Open angle with borderline findings, high risk, bilateral

H40.031 Anatomical narrow angle, right eye

H40.032 Anatomical narrow angle, left eye

H40.033 Anatomical narrow angle, bilateral

H40.061 Primary angle closure without glaucoma damage, right eye

H40.062 Primary angle closure without glaucoma damage, left eye

H40.063 Primary angle closure without glaucoma damage, bilateral

H40.1110 Primary open-angle glaucoma, right eye, stage unspecified

H40.1111 Primary open-angle glaucoma, right eye, mild stage

H40.1112 Primary open-angle glaucoma, right eye, moderate stage

H40.1113 Primary open-angle glaucoma, right eye, severe stage

H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage

H40.1120 Primary open-angle glaucoma, left eye, stage unspecified

H40.1121 Primary open-angle glaucoma, left eye, mild stage

H40.1122 Primary open-angle glaucoma, left eye, moderate stage

H40.1123 Primary open-angle glaucoma, left eye, severe stage

H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage

H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified

what is cost outlier - occurrence code OC 47, 70, 61

Definitions

Cost outlier -- an inpatient hospital discharge that is extraordinarily costly. Hospitals may be eligible to receive additional payment for the discharge. Section 1886(d)(5)(A) of the social security act provides for Medicare payments to Medicare-participating hospitals in addition to the basic prospective payments for cases incurring extraordinarily high costs.

• To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).

• Total covered charges for an inpatient admission are $100,000 (hospital costs)

• The prospective payment system (PPS) threshold amount for the DRG is $65,000 (fixed-loss threshold amount)

• The Centers for Medicare & Medicaid Services (CMS) publishes the outlier threshold amounts in the annual inpatient prospective payments system (IPPS) final rule. Providers may access CMS' website to download the IPPS pricer.

• Inlier -- a case where the cost of treatment falls within the established cost boundaries of the DRG payment. To determine if the inpatient hospital claim meets the criteria for cost outlier reimbursement, two pieces of information are needed: 1) total covered charges and 2) PPS threshold amount. If the total covered charges exceed the PPS threshold amount, follow the coding rules for inpatient cost outlier claims.

• DRG cutoff day -- the "To" date or "End" date of the inlier period. Once the PPS threshold amount is known add the daily covered charges incurred by the patient until determining the day that covered charges reach the cost outlier threshold amount. Exclude days and charges during noncovered spans (e.g., occurrence span code 74 [noncovered level of care], 76 [patient liability], 79 [payer code] dates).

Occurrence code (OC) 47 -- a code that indicates the first day the inpatient cost outlier threshold is reached or the date after the DRG cutoff date. For Medicare purposes, a beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. OC47 date cannot be equal to or during dates coded for occurrence span code 74, 76, or 79. Click here for an example. pdf file

Occurrence code A3 -- (Benefits Exhausted) the last date for which benefits are available and after which no payment can be made.

Occurrence span code 70 -- a code and span of time that indicates the from and through dates during the PPS inlier stay for which the beneficiary has exhausted all regular days and/or coinsurance days, but which is covered on the cost report. Click here for an example. pdf file

• Condition code 61 -- a code that indicates this bill is a cost outlier. Click here for an example. pdf file

• Condition code 67 -- a code that indicates the beneficiary has elected not to use lifetime reserve (LTR) days.

• Condition code 68 -- a code that indicates the beneficiary has elected to use lifetime reserve (LTR) days.


Q: When should occurrence span code (OSC) 70 be used?

A: OSC70 should be coded on the cost outlier claim when the beneficiary’s benefit days have exhausted and there are extra days within the inlier portion of the claim. The claim may be paid up to the diagnosis related group (DRG), as long as there are benefit days remaining for the claim.

Answering this question will assist in submitting the claim correctly. Did the beneficiary’s regular, coinsurance or life time reserve days exhaust during the inlier portion of the stay?

• If no -- submit claim as regular inpatient claim or follow guidelines for using occurrence code 47 and A3, if applicable.
• If yes --
• Did the regular benefit days exhaust during the inlier period?
• Indicate occurrence span code 70.
• Did life time reserve days exhaust during the inlier period? Note: Lifetime reserve days can be billed only in the inlier period when these are the only benefit days available at the time of admission.
• The from and through dates should represent the period of time during the prospective payment system (PPS) inlier stay for which the benefit days are exhausted.

If a beneficiary has at least one regular benefit day remaining in the benefit period available for use at the time of admission, the entire stay up to the DRG cutoff will be paid for by Medicare.

All charges for dates within the occurrence span code 70 should be billed as covered.

Definition

• OSC 70 -- Non-utilization dates (for payer use on hospital bills only). The from/through dates during a prospective payment system (PPS) inlier stay for which the beneficiary has exhausted all regular days and/or coinsurance days, but which is covered on the cost report.


Q: Should a claim be submitted as a cost outlier?

A: Yes, we encourage you to code the claim appropriately when submitting it the first time. You have access to the Centers for Medicare & Medicaid Services’ (CMS) PRICER software external link which helps you determine the prospective payment system (PPS) threshold. Once you determine the PPS threshold and confirm the claim can be submitted as a cost outlier, you should code the claim appropriately and forward to the fiscal intermediary standard system (FISS).

To determine if the inpatient hospital claim meets criteria for cost outlier reimbursement, you need two pieces of information:
• Total covered charges, and
• PPS threshold amount

If the total covered charges exceed the PPS threshold amount by CMS’ published standards for the current year, then you should follow the coding rules for inpatient cost outlier claims.


Occurrence code 47 -- indicates the first day the inpatient cost outlier threshold is reached or the date after the diagnostic related group (DRG) cutoff date. For Medicare purposes, a beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. Occurrence code 47 cannot be equal to or during the dates of occurrence span code 74 or 76.

Occurrence span code 74 -- the from/through dates for a period at a non-covered level of care in an otherwise covered stay, excluding any period reported with occurrence span codes 76, 77, or 79. Codes 76 and 77 apply to most non-covered care. Used for leave of absence, or for repetitive part B services to show a period of inpatient hospital care or outpatient surgery during the billing period. Also used for home health association (HHA) or hospice services billed under part A, but not valid for HHA under prospective payment system (PPS).

Occurrence span code 76 -- the from/through dates for a period of non-covered care for which the provider is permitted to charge the beneficiary. Codes should be used only where the Medicare administrative contractor (MAC) or fiscal intermediary (FI)of the quality improvement organization (QIO) has approved such charges in advance and the patient has been notified in writing three days prior to the ‘from’ date of this period.


Q: When is it appropriate to use occurrence code 47 when submitting an inpatient cost outlier claim?

A: Reference the Outlier Flowchart pdf file after asking this question: Does the cost for an inpatient stay exceed the cost outlier threshold amount?
• If no -- submit claim as regular inpatient claim.
• If yes -- are there enough benefit days (regular or life time reserve) to cover the medically necessary days?
• If yes -- submit claims as regular inpatient claim. Do not indicate occurrence code 47.
• If no -- indicate occurrence code 47 and date of the first full day of cost outlier status (the day after the day that covered charges reach the cost outlier threshold).
• For Medicare purposes, cost outlier payments are paid for each day during the outlier period that the beneficiary has an available benefit day (regular, coinsurance, and/or life time reserve).
• Diagnosis related group (DRG) claims without cost outlier payments can never have regular benefit days combined with life time reserve benefit days. When regular benefit and life time reserve days are billed on the same claim, life time reserve usage begins on the cost outlier date (should be equal to occurrence code 47 date).


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