CPT g9873, g9874, G9875, G9880- G9891 - DIABETES PREVENTION

Medicare Diabetes Prevention Program: New Covered Service

Medicare Diabetes Prevention Program (MDPP)

"HCPCS G-Code"    Description    "VM Allowed* "    Payment 


CORE SESSIONS  
      
G9873     MDPP beneficiary attended the first MDPP core session.    No    $25
G9874     MDPP beneficiary attended a total of 4 MDPP core sessions.    Yes    $50
G9875     MDPP beneficiary attended a total of 9 MDPP core sessions.    Yes    $90

CORE MAINTENANCE SESSIONS  
      
G9876    MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9.    Yes    $15

G9877    MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12    Yes    $15

G9878    "MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9, and
the 5% weight loss from his/her baseline weight. Use G9878 or G9876."    Yes    $60

G9879    "MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12, and
achieved the 5% weight loss from his/her baseline weight. Use G9879 or G9877"    Yes    $60


ONGOING MAINTENANCE SESSIONS          

G9882    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 13-15, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9883    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 16-18, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9884    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 19-21, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9885    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 22-24, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

ADDITIONAL CODES          

G9880    "MDPP beneficiary achieved at least 5% weight loss from his/her baseline weight in months 1–
12. This is a one-time payment available when a beneficiary first achieves at least 5% weight
loss from baseline as measured by an in-person weight measurement at a core session or
core maintenance session.
"    No    $160

G9881    "MDPP beneficiary achieved at least 9% weight loss from his/her baseline weight in months 1–
24. This is a one-time payment available when a beneficiary first achieves at least 9% weight
loss from baseline as measured by an in-person weight measurement at a core session, core
maintenance session, or ongoing maintenance session"    No    $25

G9890    "Bridge Payment: A one-time payment for the first MDPP core session, core maintenance
session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP
beneficiary during months 1–24. This occurs when a beneficiary has previously received
his/her first core session from a different MDPP supplier. A supplier may only receive one
bridge payment per MDPP beneficiary."    Yes    $25

G9891    "MDPP session reported as a line item on a claim for MDPP services. This is a non-payable
code for reporting services of sessions furnished to MDPP beneficiaries (i.e. core sessions 2-3,
5-8, 10-16, and maintenance sessions before achievement of a performance goal)"    Yes    $0




This reference guide provides a snapshot of the MDPP payment structure and corresponding Healthcare Common Procedure Coding System (HCPCS) G-codes. This guide only applies to services furnished to beneficiaries receiving Medicare Part B coverage via Medicare Fee-for-Service (FFS).

A Glance at What is Covered

The first year of MDPP core services includes six months of weekly core sessions followed by six months of monthly maintenance sessions; the second year is contingent upon beneficiary performance and consists of monthly maintenance sessions

Follows a CDC-approved curriculum

• No beneficiary copay
• No referral required
• Beneficiaries are eligible for MDPP once-per-lifetime
* The ongoing maintenance sessions are unique to the MDPP services and not required for CDC recognition.

Beneficiary Eligibility Criteria

Specific criteria determine Medicare beneficiary eligibility throughout the MDPP services period Beneficiary Eligibility Requirements to Start Services:


Medicare beneficiaries are eligible for MDPP services if they meet the following criteria:

• Enrolled in Original Medicare (Part B) or Medicare Advantage (Part C)

• Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session

• Meet 1 of 3 blood test requirements within the 12 months prior to attending the first core session:

1. A hemoglobin A1c test with a value between 5.7% and 6.4%, or
2. A fasting plasma glucose of 110-125 mg/dL, or
3. A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)

• No previous diagnosis of diabetes prior to the date of the first core session (with exception of gestational diabetes)

• Do not have End-Stage Renal Disease (ESRD)

• Have not previously received MDPP services

Important Details on Eligibility Criteria

See the Beneficiary Eligibility Fact Sheet for more information
• Beneficiaries are only required to provide results from one of the 3 blood tests by the first core session
• The test must be completed in the 12 months before the first core session
• Beneficiaries may work with their health care provider to obtain the blood tests
• CMS does not designate specific types or forms of documentation that should be used as evidence of blood test results
• Beneficiaries’ weight and height must be measured in-person at the first core session and should be used to calculate BMI




Important Details on Eligibility Criteria

History of Diabetes
•Beneficiaries may self-report their history of type 1 or 2 diabetes
• If a beneficiary develops diabetes while receiving MDPP services, they can continue with the program
• History of gestational diabetes, which develops during pregnancy, does not disqualify a beneficiary from receiving MDPP services

MDPP Services
 • Beneficiaries are only eligible for services once-per-lifetime
• Beneficiaries who participated in any DPP services before April 1, 2018, or before they had Medicare coverage, are still eligible because these are not considered MDPP services
• Up to 2 years of services are covered for eligible beneficiaries at no copay
• No provider referral required

Using MDPP HCPCS G-Codes

• HCPCS G-codes are used when submitting claims to bill Medicare for payment. MDPP HCPCS G-codes may be used only one time per eligible beneficiary (except for G9890 and G9891)

• The initial session (G9873) or bridge payment (G9890) claim must be submitted before any other claims will be paid

• MDPP suppliers should submit claims when a performance goal is met

• Use the non-payable G-code (G9891) to report attendance at sessions that are not associated with a performance goal. These codes should be listed on the same claim as the payable code with which they are associated (e.g., report G9891 for sessions 2 and 3 if you are reporting G9874 for session 4 attendance)

• Each HCPCS G-code should be listed with the corresponding session date of service and rendering coach National Provider Identifier (NPI)

• If a beneficiary switches suppliers, the new supplier may receive a bridge payment (G9890) for the first MDPP session furnished to that beneficiary. More than one supplier may claim a bridge payment for the same beneficiary

• The Virtual Modifier, “VM”, should be appended to the end of any G-code that is associated with a session that was furnished as a virtual make-up session (e.g., G9891VM)


Skilled Nursing Facility Value-Based Purchasing Program

 The Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)

What is the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)?


The SNF VBP Program focuses on better outcomes and rewards skilled nursing facilities with incentive payments for the quality of care they give to people with Medicare, in particular reducing hospital readmissions. The SNF VBP Program moves CMS toward paying providers based on the quality, rather than the quantity, of care they give patients.

When will SNFs receive SNF VBP incentive payments?

SNFs will receive incentive payments, on an annual basis, at the start of each new fiscal year. The first time SNFs will receive incentive payments is on October 1, 2018, which is the start of fiscal year (FY) 2019. These incentive payment amounts are based on SNFs’ performance on the Program’s hospital readmissions measure during performance period, January 1, 2017, through December 31, 2017, and the baseline period, January 1, 2015 through December 31, 2015.

How will the program work?


A healthcare law called the 2014 Protecting Access to Medicare Act (PAMA) started the SNF VBP Program. Every year, CMS publishes a regulation that outlines what is required for the SNF VBP program. The most recent regulation can be found here. Under the SNF VBP Program:

SNFs will be evaluated on a hospital readmissions measure after a patient is discharged and has a hospital admission within 30 days.

SNFs will receive a performance score based on their individual performance and a performance score based on their comparison to other SNFs in the country.
SNFs will receive confidential quarterly and annual reports about their performance on the program’s measure.
SNFs will receive payment incentives based on their performance.
Since October 2016, CMS has been providing SNFs with quarterly confidential feedback reports containing information regarding their performance on the readmission measure specified for the SNF VBP Program. These quarterly reports are disseminated to SNFs via the Quality Improvement and Evaluation System (QIES)/Certification and Survey Provider Enhanced Reports (CASPER) system.

Public reporting of SNF performance will occur on the Nursing Home Compare website. In October 2017, performance data from the baseline year of the SNF VBP program was made available here. This includes SNFs’ performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015. Performance period data from CY 2017 will also be available on the Nursing Home Compare website. As a result of Phase Two review and corrections, an updated ranking file can be found here.

Performance data from the baseline year of the SNF VBP program are now available here. This includes SNFs’ performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015.

What types of SNFs are included in the SNF VBP Program?

All SNFs paid under the SNF Prospective Payment System (PPS) are included in the SNF VBP Program and are eligible for payment incentives based on their performance on the program’s measure. The types of SNFs in the Program include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities.

What measures will be used in the SNF VBP Program?
Skilled Nursing Facility 30-Day All-Cause Readmission Measure

The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) is used in the SNF VBP Program. The SNFRM estimates the risk-standardized rate of unplanned readmissions within 30 days for:

People with fee-for-service Medicare who were inpatients at PPS, critical access, or psychiatric hospitals.
Any cause or condition.
We finalized the SNFRM in the SNF PPS Final Rule for FY 2016. This fact sheet contains important information you should know about SNFRM.

This technical report and technical report supplement provide additional detail on the SNFRM.

Additional reliability testing for the SNFRM can be found in this memo.

What are the baseline and performance periods affecting FY 2019 payment for the SNF VBP Program?

For each year that the SNF VBP Program affects payment determination, SNFs are scored based on their performance during the applicable baseline period and performance period.

The baseline period affecting payment determination in FY 2019 is calendar year (CY) 2015 (January 1, 2015 through December 31, 2015).

The performance period affecting payment determination in FY 2019 is CY 2017 (January 1, 2017 through December 31, 2017).

How will SNFs' performance be scored under the SNF VBP Program?

SNFs will earn a SNF VBP Performance score (0 to 100) and ranking which is calculated based on that SNF’s performance on the measure specified for the Program during the performance period and the baseline period. The SNF VBP performance score is equal to the higher of the achievement score and improvement score.

SNFs will be awarded points for achievement on a 0-100-point scale and improvement on a 0-90-point scale, based on how their performance compares to national benchmarks and thresholds.
For more in-depth information on SNF VBP performance scoring, we refer you to the FY 2018 SNF PPS final rule and the FY 2019 SNF PPS final rule.

This report provides the analyses that were performed when proposing and finalizing the Program’s exchange function used to translate SNF performance scores into incentive payments.




**Please note that this mailbox is not secured to receive protected health information or patient-level data with direct identifiers.**


Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program: Frequently Asked Questions

What is the Skilled Nursing Facility Value-Based Purchasing Program?


The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program awards incentive payments to SNFs based on their performance on the Program’s measure of readmissions. SNF VBP payment incentives will be included on Medicare Part A claims paid under the SNF Prospective Payment System (PPS) as a single line item on each claim paid durinf the Fiscal Year (FY); no separate payment will be made. SNF VBP incentive payments do not any other type of claims (such as Medicare Advantage claims, Medicaid claims, or Medicaid managed claims). Beginning on October 1, 2018, which is the start of FY 2019, the Program will begin awarding incentive payments to SNFs based on performance on the SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510).

What SNFs are included in the SNF VBP Program?
All SNFs paid under the SNF PPS will receive incentive payments under the SNF VBP Program as directed by the Social Security Act. The types of SNFs that are paid under the SNF PPS include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities. The SNF VBP Program is not optional and does not require any action by SNFs to participate.

What measure is currently being used in the SNF VBP Program?


The SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510) is the messure currently used in the Program. The SNFRM evaluates the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions of Medicare beneficiaries. This measure assesses SNF patients hospital readmissions within 30 days of being discharged from a prior hospital stay.


What is the difference between a planned readmission and an unplanned readmission?
The SNFRM uses a readmission algorithm to identify planned readmisions. When the SNFRM measure was developed, a specific list of procedures or admitting diagnoses were identfied as being a planned readmission, based on input from technical experts. If a readmission does not meet the established criteria for a planned readmission according to this algorithm, it wil be considered an unplanned readmission. In addition, if a planned procedure occurs in combination with a diagnosis that disqualifies a readmission from being considered planned, the readmission with be considered unplanned.

When does the SNFRM 30-day readmissions period begin and end?
The SNFRM's 30-day readmission perion during which an unplanned readmission may be counted, referred to as the risk window, begins when a patient is discharged from an inpatient hospitalization and is subsequently admitted to a SNF within one day. The risk window ends 30 days from its start or when a patient is readmitted to a hospital, whichenve occurs first. For example, if a patient is discharged from a hospital to a SNF on 9/1/17, then readmitted to the hospital on 9/10/17, the 30-days risk window started on 9/1/17 and ended on 9/10/17 when the patient is readmitted to the hospital. A new 30-day risk window begin if the patient is subsequently discharged from the hospital and admitted back to the SNF.

Does the SNFRM count multiple hospital readmissions during a single 30-day readmission risk
window?


No. The SNFRM only assesses whether there is an unplanned readmission during a single 30-day readmission risk window. In the case of multiple readmissions, the 30-day risk window ends after the first readmission.

Are the measures in the SNF VBP Program the same as the measures in the SNF Quality Reporting Program (QRP) and on the Nursing Home Compare website?

No. The SNF VBP Program uses the SNFRM, which calculates the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions within 30-days of a SNF patient’s discharge from a prior hospital stay. Congress directed CMS in statute to use the SNFRM in the SNF VBP program.

How are performance scores calculated?
SNF VBP performance scores are calculated by first inverting the risk-standardized readmission rate (RSRR), so that higher rates are equal to better performance. Next, the SNF’s RSRR is compared to the performance standards published in each final rule and awarded between 0 and 100 points. SNFs are scored on improvement, compared to their baseline performance
rate, and achievement, compared to the national performance rate during the baseline period. The higher of the improvement and achievement scores will be a SNF’s performance score.

Will SNFs be able to calculate their achievement and improvement points?
A SNF can calculate its achievement and improvement points using the formulas provided in
the FY 2017 final rule with the following data:
• The SNF’s performance period rate on the SNFRM
• The SNF’s baseline period rate on the SNFRM
• The applicable achievement threshold and benchmark for the Program year
The higher of a SNF’s achievement and improvement scores will equal their performance score.

How are incentive payments determined?


Each SNF’s incentive payment will depend on its performance score, which will be placed in the logistic exchange function to determine the corresponding incentive multiplier. The highest scoring facilities will receive the highest payment incentives, and the lowest scoring facilities will receive the lowest payment incentives, as required by statute. In 2017, CMS notified SNFs and stakeholders in the Federal Register via rulemaking that we would redistribute 60 percent of withheld funds to SNFs based on their performance score. After calculation of performance scores for all SNFs, the following steps will be used to calculate incentive payments:

1. Estimate the 60 percent of Medicare fee-for-service payments to SNFs to be redistributed to SNFs (the “incentive pool”).

2. Assign payment incentive multipliers to each SNF VBP Performance Score using the logistic exchange function so that the total amount of incentive payments matches the 60 percent incentive pool.

How will SNFs be notified of their performance in the Program?


CMS provides confidential feedback reports to SNFs on a quarterly and annual basis. Quarterly supplemental workbooks containing patient-level data are provided for quality improvement purposes. SNFs will also receive two annual reports; one report containing a full performance period and their measure score, and the second report containing the SNF performance score, rank, and payment incentive to be applied to Medicare claims in the upcoming fiscal year. SNFs can access all reports through Quality Improvement Evaluation System (QIES) Certification and Survey Provider Enhanced Reporting (CASPER) system.

What is Phase One of the Review and Corrections process?

Phase One is an opportunity for SNFs to review and submit corrections to the facility-level information that will be made publicly available. Requests will only be accepted until March 31 following delivery of the confidential report containing facility-level information and must be submitted to the SNFVBPinquiries@cms.hhs.gov mailbox. CMS will review the request and notify the SNF of any changes that may result.

SNFs will need the following information to submit a Phase One Review and Corrections request to the SNFVBPinquiries@cms.hhs.gov mailbox:

1. The SNF’s CMS Certification Number (CCN)
2. The SNF’s Name
3. The correction requested and the reason for requesting the correction. SNFs must also submit evidence, if available, supporting the request.

CMS advises SNFs not to send protected health information (PHI) or patient-level data with direct identifiers with review and corrections requests; the SNF VBP mailbox is not secured to receive this information. For specific questions, SNFs may use the identification number in their workbook as this is a randomly assigned number and not considered PHI.

How can I correct an error in my patient-level data?

If a SNF identifies an error in information not covered under Phase One or Phase Two of the SNF VBP Review and Corrections process, CMS advises SNFs to follow the established claims process to update the information or contact the readmitting hospital to make corrections.

CMS encourages SNFs to work with hospitals as a part of its care coordination efforts to make any corrections to claims information and submit to their Medicare Administrative Contractor (MAC) in a timely manner. If an error is identified that may result in a correction to SNF VBP measure rates, the SNF must demonstrate that claims have been corrected and reprocessed by the MAC in relevant fields impacting SNF VBP performance, prior to CMS considering recalculation of SNF VBP measure data before the Phase One Review and Corrections deadline.

What is Phase Two of the Review and Corrections process?

Phase Two is an opportunity for SNFs to review and submit correction requests to their performance scores and rank only, found in the annual performance score report. CMS will not consider any patient level information or RSRR measure rate correction requests during Phase Two of the Review and Corrections process, since these correction requests are classified as being out of scope for review. Phase Two requests will only be accepted for 30 calendar days following the annual performance score reports being made available. A SNF must submit correction requests to the SNFVBPinquiries@cms.hhs.gov mailbox. CMS will review the request and notify the SNF of any changes that may result.

SNFs will need the following information to submit a Phase Two Review and Corrections request to the SNFVBPinquiries@cms.hhs.gov mailbox:
1. The SNF’s CMS Certification Number (CCN)
2. The SNF’s Name
3. The correction requested and the reason for requesting the correction. SNFs must also submit evidence, if available, supporting the request.

CMS advises SNFs not to send protected health information or patient-level data with direct identifiers with review and corrections requests since the SNF VBP mailbox is not secured to receive this information.

Immunization CPT full list - Medicare covered

CPT code and description

90630 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use

90653 – Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use

90654 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use

90655 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage,for intramuscular use

90656 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use

90657 – Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use

90658 – Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use

90660 – Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use

90661 – Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

90662 – Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

90672 – Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use

90673 – Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use

90674 – Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit,preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

90682 – Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA,hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use

90685 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use

90686 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use

90687 – Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use

90688 – Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use

90689* – Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25mL dosage, for intramuscular use

90756 – Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use

Q2034 – Influenza virus vaccine, split virus, for intramuscular use (agriflu)

Q2035 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria)

Q2036 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (flulaval)

Q2037 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluvirin)

90670 – Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use

90732 – Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

90739 – Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use

90740 – Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use

90743 – Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use

90744 – Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use

90746 – Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use

90747 – Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use



Recommend Influenza Vaccination: Each Office Visit is an Opportunity


People 65 years and older are at greater risk for serious influenza-related complications. The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. Your strong vaccine recommendation is a critical factor that affects whether your patients get an influenza vaccine. Take time to recommend and vaccinate your patients, your staff, and yourself.

Medicare Part B covers the influenza virus vaccine once per influenza season. Medicare covers additional influenza vaccines if medically necessary.

You may also want to recommend the pneumococcal vaccine during the same visit. Medicare covers:

An initial pneumococcal vaccine for Medicare beneficiaries who never received the vaccine under Medicare Part B

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




Does the Medicare Part B deductible, coinsurance, or copayment apply for Part B-covered immunizations?

When physicians or suppliers agree to accept assignment, the Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus, pneumococcal, and Hepatitis B vaccines or their administration.

If a beneficiary gets a seasonal influenza virus vaccine twice in a 12-month period, will Medicare still pay for it?
Yes, Medicare pays for one seasonal influenza virus vaccination per influenza season; however, a beneficiary could get the seasonal influenza virus vaccine twice in a calendar year for two different influenza seasons, and Medicare would pay the provider for each. For example, a beneficiary who received a seasonal influenza virus vaccination in January 2018 for the 2017–2018 influenza season could receive another seasonal influenza virus vaccination in November 2018 for the 2018–2019 influenza season, and Medicare would pay for both vaccinations.

Should providers administer the pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history?
Yes, if a beneficiary is uncertain about his or her vaccination history, and the provider cannot obtain verification from the beneficiary’s medical records, provide the vaccine. Medicare beneficiaries are eligible for the initial pneumococcal vaccine and a different pneumococcal vaccine one year after the first vaccine (at least 11 months have passed following the month when the last pneumococcal vaccine was administered).

Beneficiaries may be liable for the costs of the revaccination if they exceed the benefit maximum or if the timing of these services is sooner than the required 11 full months following the month of the last pneumococcal vaccine. We encourage providers to closely track vaccination history.

Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries?
No, Medicare covers the hepatitis B vaccine for certain beneficiaries at intermediate to high risk for the hepatitis B virus (HBV). These individuals include health care professionals who have frequent contact with blood or blood-derived body fluids during routine work, individuals with End-Stage Renal Disease (ESRD), individuals living with an HBV carrier, and individuals diagnosed with diabetes mellitus. Other situations could qualify a beneficiary as being at intermediate or high risk of contracting HBV. Medicare beneficiaries not eligible for this benefit are those currently positive for hepatitis B antibodies.

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

Yes, use separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines. Medicare pays both administration fees if a beneficiary gets both vaccines on the same day.

Can I roster bill the seasonal influenza virus, pneumococcal, and hepatitis B vaccines?
You may roster bill the seasonal influenza virus and pneumococcal vaccines. You cannot roster bill the hepatitis B vaccine.

What is a mass immunizer?

A mass immunizer offers seasonal influenza virus vaccination, pneumococcal vaccination, or both to many individuals. A mass immunizer may be a traditional Medicare provider or supplier or a nontraditional provider or supplier (such as a senior citizens’ center, a public health clinic, or a community pharmacy). Mass immunizers must submit claims for immunizations on roster bills and must accept assignment on the vaccine and its administration. A mass immunizer should enroll with the Medicare Administrative Contractor (MAC) prior to each influenza season. Please see the next question for more enrollment information.

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

Yes, providers must enroll in the Medicare Program even if immunizations are the only service they provide to beneficiaries. They should enroll as provider specialty type 73, Mass Immunization Roster Biller, by completing Form CMS-855I for individuals or Form CMS-855B for a group. New providers must receive an NPI prior to enrollment. To obtain an NPI if you do not already have one, register through the Identity & Access Management System, then go to the National Plan & Provider Enumeration System.

May I submit a single roster claim for the seasonal influenza virus and pneumococcal vaccines when the vaccines are administered on the same visit?
No, you must prepare a separate roster claim for the seasonal influenza virus vaccine and the pneumococcal vaccine. However, you may file an individual claim for both vaccines.

CPT for Sublingual Immunotherapy as a Technique of Allergen- Specific Therapy 95199


Code Description CPT

95199 Unlisted allergy/clinical immunologic service or procedure


Sublingual Immunotherapy as a Technique of Allergen- Specific Therapy

Introduction

Treating allergies often involves giving the person small doses of what they are allergic to. This tends to increase a person’s immunity, or tolerance, to the substance. These substances are often given by injections (shots). But a newer method is to put the substance in drops and give them under the tongue. This is called sublingual (which means under the tongue) immunotherapy. This treatment is also sometimes called allergy drops. This policy explains when sublingual immunotherapy is medically necessary.

Policy Coverage Criteria

Sublingual Immunotherapy Medical Necessity

* Oralair®
* Grastek®
* Ragwitek®

Sublingual immunotherapy using Oralair®, Grastek®, or Ragwitek® may be considered medically necessary, when used according to U. S. Food and Drug Administration labeling, for the treatment of pollen-induced allergic rhinitis when the following conditions are met:

* Patient has a history of rhinitis or rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure

* Patient has a documented positive pollen-specific skin test or pollen-specific immunoglobulin E test.

o Allergy must be confirmed by positive skin test or in vitro testing for pollen-specific immunoglobulin E antibodies to the species contained in the product or, for Grastek®, Timothy grass pollen extract, to cross-reactive species.

* Patient’s symptoms are not adequately controlled by appropriate pharmacotherapy (see Related Information). Sublingual immunotherapy as a technique of allergy immunotherapy is considered investigational for all other uses.




Use of Oralair®, Grastek®, and Ragwitek®

Contraindications


Contraindications include severe, unstable or uncontrolled asthma; history of any severe reactions (local or systemic) to sublingual or other immunotherapy; or a history of eosinophilic esophagitis.

Administration and Dose

* Prescribing information includes a black box warning for severe allergic reactions including anaphylaxis and severe laryngopharyngeal edema. Patients must be prescribed an epinephrine auto-injector and be trained on how to use it.

* Oralair® is approved by the Food and Drug Administration (FDA) for patients 10 to 65 years of age. Grastek® has been FDA-approved for patients 5 to 65 years of age. Ragwitek® has been FDA-approved for patients 18 to 65 years of age.

* Treatment should begin 12 weeks (16 weeks for Oralair®) before the expected onset of the allergy-inducing pollen season. Each product is dosed once daily and continued throughout the pollen season (precoseasonal dosing).

* The first dose is administered under the supervision of a physician experienced in diagnosing and treating severe allergic reactions. Subsequent doses may be taken at home.

* For Oralair®, dose titration is required in patients 10 to 17 years of age. Titration can be completed over 3 days at home, 100 IR [index of reactivity] on day 1, 2 times 100 IR on day 2, and 3 times 100 IR on day 3. In patients between 18 and 65 years, no dose titration is needed; treatment is initiated at the maintenance dose of 300 IR.

* Grastek® and Ragwitek® both are initiated at the maintenance dose (2800 bioequivalent allergy unit and 12 Amb a 1 unit, respectively). Pharmacotherapy of Pollen-Induced Allergic Rhinitis

There is general agreement from clinical practice guidelines on the pharmacologic treatment of pollen-induced allergic rhinitis or rhinoconjunctivitis:

* Treatment should be individualized based on symptom severity and duration, comorbidities, patient age, preference (eg, route of administration, tolerance for adverse effects), and previous treatment history

* Measures to increase treatment adherence (eg, shared decision making, consideration of the patient’s school or work schedule, use of a medication calendar or check-off list) are encouraged

* Goals of treatment are symptom reduction and improvements in functional capacity and quality of life

* A “step-up” (if treatment is inadequate) or “step-down” (if symptom relief is achieved with other interventions, eg, avoidance) approach to treatment is recommended

* Allergen avoidance is the first step of treatment but may be unrealistic for some patients Six medication classes are used to treat allergic rhinitis:
1. H1-antihistamines (oral and intranasal)
2. Corticosteroids (oral [short-course for severe disease] and intranasal)
3. Leukotriene receptor antagonists (oral)
4. Sympathomimetic decongestants (oral and intranasal)
5. Chromones (intranasal)
6. Anticholinergic, ipratropium bromide (intranasal)

o Treatment should be symptom-specific, eg, oral antihistamines may be less effective for prominent congestion than other treatments; prominent rhinorrhea may respond to intranasal ipratropium; rhinitis-only symptoms may be treated with local (intranasal) rather than systemic (oral) therapy
o For mild or intermittent symptoms, oral or nasal antihistamine may be considered firstline treatment
o Newer generation (selective) oral antihistamines generally are recommended over older (nonselective) antihistamines. Patients with insomnia and pregnant women may prefer older antihistamines because of their sedating effects and longer safety history, respectively
o Intranasal corticosteroids may be effective for more severe or persistent symptoms
o Combination treatment (eg, oral antihistamine plus intranasal corticosteroid, intranasal antihistamine and corticosteroid, antihistamine [oral or intranasal] plus sympathomimetic [oral or short-course (=5 days to avoid rebound congestion) intranasal]) may be effective for symptoms nonresponsive to single medications
o Oral sympathomimetics may cause insomnia; their use is limited in patients with certain comorbidities (eg, diabetes mellitus, unstable hypertension)
o Oral leukotriene receptor antagonists may reduce asthma exacerbations in patients with comorbid asthma

Consideration of Age

The ages stated in this policy for which Grastek®, Ragwitek®, and Oralair®, are considered medically necessary is based on the ages approved in the FDA labeling.

Benefit Application

Sublingual immunotherapy may be offered by specialized clinics.

Evidence Review Background


Sublingual immunotherapy (SLIT) is a potential alternative to subcutaneous immunotherapy (SCIT) for providing allergen-specific therapy. SLIT is proposed as a more convenient alternative delivery route for treating a variety of allergic disorders.

Allergen-specific immunotherapy involves administering well-characterized allergen extracts, the potencies of which are measured and compared with a reference standard. An initial induction or build-up phase progressively increases the allergen dose; this is followed by multiple years of maintenance injections at the highest dose. Allergen-specific immunotherapy has been used to treat a variety of conditions including insect allergy, allergic rhinitis, and asthma. Subcutaneous immunotherapy is the standard of care. Due to the inconvenience of multiple injections, particularly in children, alternative delivery routes have been investigated; of these, sublingual immunotherapy is the most prominent. Sublingual immunotherapy targets absorption to the sublingual and buccal mucosa. Allergen preparations used for sublingual immunotherapy are held under the tongue for one to several minutes and then swallowed or spit out.

CPT 0278t, 97014, E7045,E7062, E1399, G0283, L8679 - Electrical Stimulation Devices

Coding Code Description CPT

0278T Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)

97014 Application of modality to one or more areas; electrical stimulation, unattended HCPCS

E0745 Neuromuscular stimulator, electronic shock unit

E0762 Transcutaneous electrical joint stimulation device system, includes all accessories

E1399 Durable medical equipment, miscellaneous (Determine if an alternative HCPCS Level II or a CPT code better describes the service being reported. This code should be used only if a more specific code is unavailable.)

G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

L8679 Implantable neurostimulator, pulse generator, any type




Introduction

When muscles can’t be used after an injury or surgery, there’s a risk that the tissue will deteriorate or waste away. This is known as disuse atrophy. Neuromuscular electrical stimulation (NMES) is a way to keep muscles active so they won’t atrophy. In NMES, an electrode — a patch attached to skin that can transmit electrical signals into the body — is placed over the muscles to be stimulated. A device then sends an electrical signal to the electrode and through the skin. The electrical signal is the same type that a nerve would send to a muscle. The muscle contracts. This contraction keeps the muscles active when they otherwise wouldn’t be. This policy describes when NMES may be considered medically necessary.


Policy Coverage Criteria

Service Medical Necessity Services eligible for reimbursement


Use of a neuromuscular electrical stimulator (NMES) via an open loop system, including but not limited to the RS 4m and RS 2m, may be considered medically necessary for disuse atrophy when the nerve supply to the muscle is intact and the patient has any of the following non-neurological causes for disuse atrophy:
* Previous casting or splinting of a limb
* Contractures due to soft tissue scarring (eg, from burn)
* Previous major knee surgery (eg, total knee replacement), when there is a failure to respond to physical therapy
* Hip replacement surgery (up until the time physical therapy begins)
A conductive garment may be needed when a member meets criteria for treatment with a neuromuscular electrical stimulation device (NMES) and has one of the following medical indications:
* The treatment site is large and using a large number of standard electrodes is impractical
* There are multiple large treatment sites on the body that make using standard electrodes impractical
* The treatment site is hard to reach using standard electrodes and lead wires
* The member has a skin sensitivity that precludes use of standard electrodes, adhesive tape or lead wires

Note: Functional neuromuscular electrical stimulators (closed loop systems) are addressed in a separate policy (see Related Medical Policies).

Service Investigational

Services not eligible for reimbursement

Neuromuscular electrical stimulators (NMES) are considered investigational for ANY other unproven indication (eg, when used for general muscle strengthening in healthy individuals, for cardiac conditioning, for the treat.


Service Investigational

Electrical sympathetic stimulation therapy devices are considered investigational.

Galvanic or high-voltage galvanic stimulation is considered investigational in the treatment of chronic pain.

Microcurrent electrical nerve stimulation (MENS) devices are considered investigational.

Pulsed electrical stimulation and pulsed electromagnetic therapy are considered investigational for any indication including, but not limited to the treatment of osteoarthritis, rheumatoid arthritis, neuropathic pain (diabetic peripheral neuropathy), post-operative or non-post-operative pain, or to treat wounds. (HCPCS E0762).

Transcutaneous electrical modulation pain reprocessing (TEMPR) (also called Scrambler therapy or Calmare® pain therapy) is considered investigational (CPT 0278T).

Documentation Requirements

The patient’s medical records submitted for review should document that medical necessity criteria are met. The record should include the following:
* For neuromuscular electrical stimulator (NMES):
o Clinical documentation showing that member has disuse atrophy (loss/decrease of muscle mass due to lack of use) where the nerve supply to the muscle is intact and the member has any of the following non-neurological reasons for disuse atrophy:
* Previous casting or splinting of a limb
* Contractures due to burn scarring or recent hip replacement surgery (up until the time physical therapy begins)
* Previous major knee surgery when there is a failure to respond to physical therapy
* For a conductive garment clinical documentation of all of the above plus documentation of one of the following medical reasons:
o The treatment site is large and using a large number of standard electrodes is impractical
o There are multiple large treatment sites on the body that make using standard electrodes impractical


Documentation Requirements

o The treatment site is hard to reach using standard electrodes and lead wires
o The member has a skin sensitivity that precludes use of standard electrodes, adhesive tape, or lead wires



Related Information Definition of Terms

Conductive garment: A form-fitted garment with integrated conductive fibers that are separated from the patient’s skin by a layer of fabric. Disuse atrophy: Gradual wasting or deterioration of a muscle when not used or subjected to prolonged inactivity, such as when an arm is in a cast for a long time (see muscle atrophy).

Muscle atrophy: Muscle wasting or tissue loss that occurs when a muscle is no longer as active as usual. When muscles are no longer used movement and strength decline causing weakness. Neurogenic atrophy: This most severe type of muscle atrophy occurs when a nerve that connects to the muscle is injured or has a disease. This type of muscle atrophy tends to occur suddenly when compared to disuse atrophy that is more gradual.

Evidence Review

Background Pulsed electrical and electromagnetic stimulation are being investigated to improve functional status and relieve pain related to osteoarthritis (OA) and rheumatoid arthritis that is unresponsive to other standard therapies. Electrical stimulation is provided using a device that noninvasively delivers a subsensory low-voltage, monophasic electrical field to the target site of pain. Pulsed electromagnetic fields are delivered using coils placed over the skin.

Neuromuscular Electrical Stimulation Devices (NMES)


These devices, through multiple channels, attempt to stimulate motor nerves and alternately causes contraction and relaxation of muscles, unlike a TENS device which is intended to alter the perception of pain. NMES are used to prevent or retard disuse atrophy, relax muscle spasm, increase blood circulation, maintain or increase range of motion, and re-educate muscles.

This policy address the use of open loop neuromuscular systems which are used for simple tasks such as muscle strengthening alone, and typically in healthy individuals with intact neural control.

Functional neuromuscular stimulators are closed loop systems, which provide feedback information on muscle force and joint position, thus allowing constant modification of stimulation parameters which are required for complex activities such as walking. (These are addressed in a separate policy, see Related Medical Policies.) The RS 4m and RS 2m muscle stimulator are examples of devices that delivers neuromuscular electric stimulation.

Galvanic Stimulation Devices


Galvanic stimulation is characterized by high voltage, pulsed stimulation and is used primarily for local edema reduction through muscle pumping and polarity effect. Edema is comprised of negatively charged plasma proteins, which leak into the interstitial space. The theory of galvanic stimulation is that by placing a negative electrode over the edematous site and a positive electrode at a distant site, the monophasic high voltage stimulus applies an electrical potential which disperses the negatively charged proteins away from the edematous site, thereby helping to reduce edema.

Microcurrent Stimulation Devices (MENS)


MENS is characterized by subsensory current that acts on the body’s naturally occurring electrical impulses in an effort to decrease pain and facilitate the healing process. MENS differs from TENs in that it uses a significantly reduced level of electrical stimulation. TENS blocks pain, while MENS acts on the naturally occurring electrical impulses to decrease pain by stimulating the healing process.

Pulsed Electrical and Electromagnetic Stimulation Devices

Pulsed electrical and electromagnetic stimulation are being investigated to improve functional status and relieve pain related to osteoarthritis (OA) and rheumatoid arthritis (RA) unresponsive to other standard therapies. Noninvasive electrical stimulators generate a weak electrical current within the target site using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads or electrodes are placed on either side of the knee or wrist. Electrical stimulation is provided by an electronic device that noninvasively delivers a subsensory low-voltage, monophasic electrical field to the target site of pain. Pulsed electromagnetic fields are delivered via treatment coils that are placed over the skin. Combined  magnetic fields deliver a time-varying magnetic field by superimposing the time-varying magnetic field onto an additional static magnetic field.

In basic research studies, pulsed electrical stimulation has been shown to alter chondrocyterelated gene expression in vitro and to have regenerative effects in animal models of cartilage injury. It is proposed that the device treats the underlying cause of the disease by stimulating the joint tissue and improving the overall health of the joint and that it provides a slow-acting, but longer-lasting improvement in symptoms.

Sympathetic Stimulation Devices


Sympathetic therapy describes a type of electrical stimulation of the peripheral nerves that is designed to stimulate the sympathetic nervous system in an effort to “normalize” the autonomic nervous system and alleviate chronic pain. Unlike TENS or interferential electrical stimulation, sympathetic therapy is not designed to treat local pain, but is designed to induce a systemic effect on sympathetically induced pain.

Sympathetic therapy uses four intersecting channels of various frequencies with bilateral electrode placement on the feet, legs, arms, and hands. Based on the location of the patient’s pain and treatment protocols supplied by the manufacturers, electrodes are placed in various locations on the lower legs and feet or the hands and arms. Electrical current is then induced with beat frequencies between 0 and 1000Hz. Treatment may include daily one-hour treatments in the physician’s office, followed by home treatments if the initial treatment is effective. Transcutaneous Electrical Modulation Pain Reprocessing (TEMPR) (CPT 0278T)

Scrambler Therapy/Calmare® device is also known as transcutaneous electrical modulation pain reprocessing (TEMPR). It is an electrocutaneous nerve stimulation device. It uses a biophysical rather than a biochemical approach. A “no-pain” message is transmitted to the nerve via disposable surface electrodes applied to the skin in the region of the patient’s pain. The perception of pain is cancelled when the no-pain message replaces that of pain, by using the same pathway through the surface electrodes in a non-invasive way. Regardless of pain intensity, a patient’s pain can be completely removed for immediate relief. Maximum benefit is achieved through follow-up treatments. The patient may be able to go for extended periods of time between subsequent treatments while experiencing significant pain control and relief. The period of time between treatments depends on the underlying cause and severity of the pain in addition to other factors. Treatment utilizing the Calmare® medical device may only be done under the direct supervision of allopathic physicians and other qualified licensed healthcare professionals who are certified in its use and application and are familiar with the principles, clinical applications, side effects and hazards associated with transdermal pain modulation.

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