what are the important field to check before claim submission

Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.

• NPI of Billing Physician
• Assignment or Non-assignment of claim
• Health Insurance Number (HIC) of the beneficiary
• Zip Code of the place of service
• All related diagnosis reported with the highest degree of specificity
• NPI of Referring Physician
• Date of service
• Place of service
• Procedure code
• Modifiers when applicable
• Number of service(s)
• Billed amount for each service
• NPI of Rendering Physician
• Clinical Laboratory Improvement Amendment Number (CLIA) for laboratory services
• The date last seen/X-ray date, initial treatment date for Podiatry, Physical Therapy and Chiropractic services
• Primary payer data

what is LCD and NCD - How to use in billing

Way to avoid Appeal


 Become familiar with Local Coverage Determinations (LCD).

    * An LCD is a decision by a Medicare contractor whether to cover a particular item or service.  LCDs contain “reasonable and necessary” information and are administrative and educational tools to assist you in submitting correct claims for payment.
    * LCDs are located in the Medical Policy Center on the Highmark Medicare Services website.


 Become familiar with National Coverage Determinations (NCD).

    * The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on §1862(a)(1) of the Act (the “not reasonable and necessary” exclusion) unless otherwise specifically noted.
    * NCDs are located on the CMS website.

 Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.

    * Modifiers provide the means to indicate a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.
    * Appropriate modifier scenarios include:
          o  a service or procedure has both a professional (26) and technical (TC) component
          o a service or procedure was performed by more than one physician (77)
          o a service or procedure has been increased (22) or reduced (52)
          o only part of a service was performed (54 or 55)
          o an adjunctive service was performed (59)
          o a bilateral procedure was performed (50)
          o a service or procedure was provided more than once unusual events occurred (76)

Medicare billing - How to avoid denial

To avoid appeal

  Document a repeat or duplicate service to reflect it is as a distinct and separate service. Failure to document a repeat or duplicate service will result in a denial.

    * Report modifier 76 to indicate a procedure or service was repeated subsequent to the original procedure or service.
    * Report body site modifiers to indicate more than one of the same service is performed but on different body parts sites, e.g. LT, RT, TA – T9
    * Report modifier 59 modifier to indicate a distinct procedural service.  This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury (or area of injury in extensive injuries).
    * Report clarifying information pertaining to repeat or duplicate services using block 19 of the CMS-1500 (08-05) claim form or in the Extra Narrative Data segment (Loop 2300/2400) of the ANSI ASC X12 837 Versions of an electronic claim.  Utilize this field to report the time of each subsequent or repeat service or the number of times this service needed to be performed.



 Submit supporting documentation with the claim when certain modifiers e.g. 52 or 22 are appended to the service or when a LCD or NCD indicates documentation is required. Failure to submit the documentation will result in a denial.

    * Modifier 22 represents increased procedural services and when the work required to provide a service is substantially is greater than typically required. Documentation must support the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required)..

    * Modifier 52 represents reduced services and when under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion.  The explanation can be submitted by entering the information block 19 of the CMS-1500 (08-05) claim form or in the Extra Narrative Data segment (Loop 2300/2400) of the ANSI ASC X12 837 Versions of an electronic claim or submitting the supporting documentation.

    * Documentation can be submitted when a CMS-1500 claim is filed or if the claim is submitted electronically a  “Cover Sheet for Submitting Medical Documentation for Electronic Claims” form, must be completed.

How to avoiding denial and appeal of supporting documentation

To avoid appeal

 Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.

    * The process whereby a contractor requests additional documentation after claim receipt is known as “development”. When a coverage or coding determination cannot be made based upon the information on the claim and its attachments (e.g., due to a medical review of the service/claim), contractors may solicit for more information from the provider by issuing an Additional Documentation Request (ADR). Highmark Medicare Services will specify in the development letter or ADR the piece(s) of documentation needed to make the coverage or coding determination.

    * For responses to development that are received within the 45-day timeframe, Highmark Medicare Services will complete the review and notify the provider and beneficiary, if indicated, of the claim determination within 60 days of receiving all the requested documentation. For record or documentation requests where no timely response was received, Highmark Medicare Services will indicate that the denial was made without reviewing the medical record because the requested records were not received or were not received timely.



 The supporting documentation must include the rendering physician’s signature. Failure to provide a valid signature will result in a denial.

    * Medicare contractors require a legible identifier for services provided or ordered.
    * The only acceptable method of documenting the provider signature is by written or an electronic signature.
    * Stamp signatures are not acceptable to sign an order or other medical record documentation for medical review purposes.

Medicare NOC AND MSP CODE - AVOIDING DENIAL AND APPEAL

Way to avoid appeal

Enter the concise description of an unlisted procedure code (an NOC code) or a “not otherwise classified” code. Failure to describe the NOC or other scenarios listed below will result in a denial.

    * The description must be entered into block 19 of the CMS-1500 (08-05) claim form or in the Extra Narrative Data segment (Loop 2300/2400) of the ANSI ASC X12 837 Versions of an electronic claim.  This block/segment is also used to describe other billing scenarios listed below.

    * Enter the drug’s name and dosage.
    * Enter all applicable modifiers when modifier –99(multiple modifiers) is entered.
    * Enter the statement, “Testing for hearing aid,” when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.
    * When dental examinations are billed, enter the specific surgery for which the exam is being performed.
    * Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.
    * Enter the date for a global surgery claim when providers share post-operative care.




 When Medicare is the secondary payer (MSP) the claim must include information from the primary insurer. Failure to include this information will result in a denial.

   
    * To submit MSP claims electronically, please refer to the MSP loop and other inforamtion (ANSI) Implementation Guide.

    * Please note it is the provider's responsibility to obtain primary insurance information from the beneficiary and bill Medicare appropriately. Claim filing extensions will not be granted because of incorrect insurance information

Immunization/Vaccine CPT CODE LIST

All Service Codes for Immunization/Vaccine

• 86615 (CPT) - Antibody; Bordetella
• 86619 (CPT) - Antibody; Borrelia (relapsing fever)
• 86622 (CPT) - Antibody; Brucella
• 86625 (CPT) - Antibody; Campylobacter
• 86628 (CPT) - Antibody; Candida
• 90281 (CPT) - Immune globulin (Ig), human, for intramuscular use
• 90283 (CPT) - Immune globulin (IgIV), human, for intravenous use
• 90284 (CPT) - Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each
• 90287 (CPT) - Botulinum antitoxin, equine, any route
• 90288 (CPT) - Botulism immune globulin, human, for intravenous use
• 90291 (CPT) - Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use
• 90296 (CPT) - Diphtheria antitoxin, equine, any route
• 90371 (CPT) - Hepatitis B immune globulin (HBIg), human, for intramuscular use
• 90375 (CPT) - Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use
• 90376 (CPT) - Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use
• 90378 (CPT) - Respiratory syncytial virus immune globulin (RSV-IgIM), for intramuscular use, 50 mg, each
• 90379 (CPT) - Respiratory syncytial virus immune globulin (RSV-IgIV), human, for intravenous use
• 90384 (CPT) - Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use
• 90385 (CPT) - Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use
• 90386 (CPT) - Rho(D) immune globulin (RhIgIV), human, for intravenous use
• 90389 (CPT) - Tetanus immune globulin (TIg), human, for intramuscular use
• 90393 (CPT) - Vaccinia immune globulin, human, for intramuscular use
• 90396 (CPT) - Varicella-zoster immune globulin, human, for intramuscular use
• 90465 (CPT) - Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day
• 90466 (CPT) - Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
• 90467 (CPT) - Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day
• 90468 (CPT) - Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
• 90471 (CPT) - Immunization administration; one vaccine (single or combination vaccine/toxoid)
• 90472 (CPT) - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
• 90473 (CPT) - Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
• 90474 (CPT) - Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
• 90476 (CPT) - Adenovirus vaccine, type 4, live, for oral use
• 90477 (CPT) - Adenovirus vaccine, type 7, live, for oral use
• 90581 (CPT) - Anthrax vaccine, for subcutaneous use
• 90585 (CPT) - Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use
• 90586 (CPT) - Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use
• 90632 (CPT) - Hepatitis A vaccine, adult dosage, for intramuscular use
• 90633 (CPT) - Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use
• 90634 (CPT) - Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use
• 90636 (CPT) - Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
• 90645 (CPT) - Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use
• 90646 (CPT) - Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use
• 90647 (CPT) - Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
• 90648 (CPT) - Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
• 90649 (CPT) - Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
• 90655 (CPT) - Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
• 90656 (CPT) - Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
• 90657 (CPT) - Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
• 90658 (CPT) - Influenza virus vaccine, for 3 years of age and older, intramuscular use
• 90660 (CPT) - Influenza virus vaccine, live, for intranasal use
• 90661 (CPT) - Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
• 90662 (CPT) - Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
• 90663 (CPT) - Influenza virus vaccine, pandemic formulation
• 90665 (CPT) - Lyme disease vaccine, adult dosage, for intramuscular use
• 90669 (CPT) - Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use
• 90675 (CPT) - Rabies vaccine, for intramuscular use
• 90676 (CPT) - Rabies vaccine, for intradermal use
• 90680 (CPT) - Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use
• 90690 (CPT) - Typhoid vaccine, live, oral
• 90691 (CPT) - Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use
• 90692 (CPT) - Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use
• 90693 (CPT) - Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military)
• 90698 (CPT) - Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intramuscular use
• 90700 (CPT) - Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use
• 90701 (CPT) - Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use
• 90702 (CPT) - Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use
• 90703 (CPT) - Tetanus toxoid adsorbed, for intramuscular use
• 90704 (CPT) - Mumps virus vaccine, live, for subcutaneous use
• 90705 (CPT) - Measles virus vaccine, live, for subcutaneous use
• 90706 (CPT) - Rubella virus vaccine, live, for subcutaneous use
• 90707 (CPT) - Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
• 90708 (CPT) - Measles and rubella virus vaccine, live, for subcutaneous use
• 90710 (CPT) - Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
• 90712 (CPT) - Poliovirus vaccine, (any type[s]) (OPV), live, for oral use
• 90713 (CPT) - Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use
• 90714 (CPT) - Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use
• 90715 (CPT) - Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use
• 90716 (CPT) - Varicella virus vaccine, live, for subcutaneous use
• 90717 (CPT) - Yellow fever vaccine, live, for subcutaneous use
• 90718 (CPT) - Tetanus and diphtheria toxoids (Td) adsorbed when administered to individuals 7 years or older, for intramuscular use
• 90719 (CPT) - Diphtheria toxoid, for intramuscular use
• 90720 (CPT) - Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
• 90721 (CPT) - Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use
• 90723 (CPT) - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use
• 90725 (CPT) - Cholera vaccine for injectable use
• 90727 (CPT) - Plague vaccine, for intramuscular use
• 90732 (CPT) - Pneumococcal polysaccharide vaccine (PPV23), adult dose
• 90733 (CPT) - Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use
• 90734 (CPT) - Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use
• 90735 (CPT) - Japanese encephalitis virus vaccine, for subcutaneous use
• 90736 (CPT) - Zoster (shingles) vaccine, live, for subcutaneous injection
• 90740 (CPT) - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
• 90743 (CPT) - Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
• 90744 (CPT) - Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
• 90746 (CPT) - Hepatitis B vaccine, adult dosage, for intramuscular use
• 90747 (CPT) - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage
• 90748 (CPT) - Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use
• 90749 (CPT) - Unlisted vaccine/toxoid
• G0008 (CPT) - Flu Vaccine
• G0009 (CPT) - Pneumonia Vaccine
• G0010 (CPT) - Hepatitis Vaccine
• S0195 (CPT) - PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, INTRAMUSCULAR, FOR CHILDREN FROM; FIVE YEARS TO NINE YEARS OF AGE WHO HAVE NOT PREVIOUSLY RECEIVED THE VACCINE

What are the payable diagnoses for CPT 93306?

Below are the ICD-9 Codes that Support Medical Necessity 
 
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted. 

Please see revision history for ICD-9-CM code :
  
032.82  DIPHTHERITIC MYOCARDITIS 
     
074.21  COXSACKIE PERICARDITIS 
   
074.22  COXSACKIE ENDOCARDITIS 
   
074.23  COXSACKIE MYOCARDITIS 
   
086.0   CHAGAS' DISEASE WITH HEART INVOLVEMENT 
   
088.81  LYME DISEASE 
   
093.0  ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC 
   
093.1  SYPHILITIC AORTITIS 
   
093.21  SYPHILITIC ENDOCARDITIS OF MITRAL VALVE 
   
093.22  SYPHILITIC ENDOCARDITIS OF AORTIC VALVE 
   
093.23  SYPHILITIC ENDOCARDITIS OF TRICUSPID VALVE 
   
093.24  SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE 
   
093.81  SYPHILITIC PERICARDITIS 
   
093.82  SYPHILITIC MYOCARDITIS 
   
098.83  GONOCOCCAL PERICARDITIS 
 
098.84  GONOCOCCAL ENDOCARDITIS 
   
112.81  CANDIDAL ENDOCARDITIS 
   
115.03  HISTOPLASMA CAPSULATUM PERICARDITIS 
   
115.04  HISTOPLASMA CAPSULATUM ENDOCARDITIS 
   
115.13  HISTOPLASMA DUBOISII PERICARDITIS 
   
115.14  HISTOPLASMA DUBOISII ENDOCARDITIS 
   
130.3  MYOCARDITIS DUE TO TOXOPLASMOSIS 
   
135    SARCOIDOSIS 
   
164.1   MALIGNANT NEOPLASM OF HEART 
   
198.89  SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 
   
212.7   BENIGN NEOPLASM OF HEART 
 
238.8   NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES 
 
239.81  NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID 
   
239.89   NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES 
   
275.0  DISORDERS OF IRON METABOLISM 
   
276.50 - 276.52  VOLUME DEPLETION, UNSPECIFIED - HYPOVOLEMIA 
   
277.30  AMYLOIDOSIS, UNSPECIFIED 
   
277.31  FAMILIAL MEDITERRANEAN FEVER 
   
277.39  OTHER AMYLOIDOSIS 
   
391.0  ACUTE RHEUMATIC PERICARDITIS 
   
391.1  ACUTE RHEUMATIC ENDOCARDITIS 
 
391.2  ACUTE RHEUMATIC MYOCARDITIS 
   
391.8  OTHER ACUTE RHEUMATIC HEART DISEASE 
   
391.9  ACUTE RHEUMATIC HEART DISEASE UNSPECIFIED 
   
392.0  RHEUMATIC CHOREA WITH HEART INVOLVEMENT 
   
393  CHRONIC RHEUMATIC PERICARDITIS 
   
394.0 - 394.2  MITRAL STENOSIS - MITRAL STENOSIS WITH INSUFFICIENCY 
   
394.9  OTHER AND UNSPECIFIED MITRAL VALVE DISEASES 
   
395.0  RHEUMATIC AORTIC STENOSIS 
   
395.1  RHEUMATIC AORTIC INSUFFICIENCY 
   
395.2  RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY 
   
396.0 - 396.3  MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE INSUFFICIENCY 
   
396.8 - 396.9  MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES - MITRAL AND AORTIC VALVE DISEASES UNSPECIFIED 
 
397.0 - 397.1  DISEASES OF TRICUSPID VALVE - RHEUMATIC DISEASES OF PULMONARY VALVE 
   
397.9  RHEUMATIC DISEASES OF ENDOCARDIUM VALVE UNSPECIFIED 
   
398.0  RHEUMATIC MYOCARDITIS 
 
398.91  RHEUMATIC HEART FAILURE (CONGESTIVE) 
   
398.99  OTHER RHEUMATIC HEART DISEASES 
   
401.0  MALIGNANT ESSENTIAL HYPERTENSION 
   
402.00  MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 
   
402.10  BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 
   
402.90  UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 
   
404.00 - 404.03  HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 
   
404.10  HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 
   
404.90 - 404.93  HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 
   
405.11  BENIGN RENOVASCULAR HYPERTENSION 
   
405.19  OTHER BENIGN SECONDARY HYPERTENSION 
   
410.00 - 410.02  ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE 
   
410.10 - 410.12  ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE 
   
410.20 - 410.22  ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE 
   
410.30 - 410.32  ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE   
410.40 - 410.42  ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE 
   
410.50 - 410.52  ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE 
   
410.60 - 410.62  TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE 
   
410.70 - 410.72  SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE 
   
410.80 - 410.82  ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE 
   
411.0 - 411.1  POSTMYOCARDIAL INFARCTION SYNDROME - INTERMEDIATE CORONARY SYNDROME 
   
411.81  ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION 
   
411.89  OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER 
   
412  OLD MYOCARDIAL INFARCTION 
   
413.0 - 413.1  ANGINA DECUBITUS - PRINZMETAL ANGINA 
   
413.9  OTHER AND UNSPECIFIED ANGINA PECTORIS 
   
414.00 - 414.07  CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART 
   
414.10 - 414.12  ANEURYSM OF HEART (WALL) - DISSECTION OF CORONARY ARTERY 
   
414.19  OTHER ANEURYSM OF HEART 
  
414.2  CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY 
   
414.8  OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE 
   
415.0  ACUTE COR PULMONALE 
   
415.11  IATROGENIC PULMONARY EMBOLISM AND INFARCTION 
  
416.0  PRIMARY PULMONARY HYPERTENSION 
   
416.2  CHRONIC PULMONARY EMBOLISM 
  
416.8  OTHER CHRONIC PULMONARY HEART DISEASES 
   
416.9  CHRONIC PULMONARY HEART DISEASE UNSPECIFIED 
   
420.0  ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE 
   
420.90 - 420.91  ACUTE PERICARDITIS UNSPECIFIED - ACUTE IDIOPATHIC PERICARDITIS 
   
420.99  OTHER ACUTE PERICARDITIS 
   
421.0 - 421.1  ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS - ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 
   
421.9  ACUTE ENDOCARDITIS UNSPECIFIED 
   
422.0  ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 
   
422.91  IDIOPATHIC MYOCARDITIS 
   
422.92  SEPTIC MYOCARDITIS 
   
422.93  TOXIC MYOCARDITIS 
   
423.0 - 423.2  HEMOPERICARDIUM - CONSTRICTIVE PERICARDITIS 
   
423.8 - 423.9  OTHER SPECIFIED DISEASES OF PERICARDIUM - UNSPECIFIED DISEASE OF PERICARDIUM 
   
424.0 - 424.3  MITRAL VALVE DISORDERS - PULMONARY VALVE DISORDERS 
   
424.90 - 424.99  ENDOCARDITIS VALVE UNSPECIFIED UNSPECIFIED CAUSE - OTHER ENDOCARDITIS VALVE UNSPECIFIED 
     
425.0 - 425.9  ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED 
   
426.0  ATRIOVENTRICULAR BLOCK COMPLETE 
   
426.12  MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK 
   
426.3  OTHER LEFT BUNDLE BRANCH BLOCK 
   
426.50 - 426.54  BUNDLE BRANCH BLOCK UNSPECIFIED - TRIFASCICULAR BLOCK 
   
426.6  OTHER HEART BLOCK 
   
426.7  ANOMALOUS ATRIOVENTRICULAR EXCITATION 
   
426.9  CONDUCTION DISORDER UNSPECIFIED 
   
427.0  PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA 
   
427.1  PAROXYSMAL VENTRICULAR TACHYCARDIA 
   
427.31  ATRIAL FIBRILLATION 
   
427.32  ATRIAL FLUTTER 
   
427.41  VENTRICULAR FIBRILLATION 
   
427.42  VENTRICULAR FLUTTER 
   
427.5  CARDIAC ARREST 
   
427.60 - 427.61  PREMATURE BEATS UNSPECIFIED - SUPRAVENTRICULAR PREMATURE BEATS 
   
427.69  OTHER PREMATURE BEATS 
   
427.81  SINOATRIAL NODE DYSFUNCTION 
   
427.89  OTHER SPECIFIED CARDIAC DYSRHYTHMIAS 
   
428.0  CONGESTIVE HEART FAILURE UNSPECIFIED 
   
428.1  LEFT HEART FAILURE 
   
428.20 - 428.23  UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE 
 
428.30 - 428.33  UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC DIASTOLIC HEART FAILURE 
   
428.40 - 428.43  UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 
   
429.0  MYOCARDITIS UNSPECIFIED 
   
429.1  MYOCARDIAL DEGENERATION 
 
429.2  CARDIOVASCULAR DISEASE UNSPECIFIED 
  
429.3  CARDIOMEGALY 
 
429.4  FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY 
   
429.5  RUPTURE OF CHORDAE TENDINEAE 
   
429.6  RUPTURE OF PAPILLARY MUSCLE 
   
429.71  CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED ACQUIRED CARDIAC SEPTAL DEFECT 
   
429.79  CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED OTHER 
 
429.81  OTHER DISORDERS OF PAPILLARY MUSCLE 
   
434.10 - 434.11  CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION - CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION 
 
435.0  BASILAR ARTERY SYNDROME 
  
435.8  OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS 
   
435.9  UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 
 
436  ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 
   
440.20  ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED 
   
440.4  CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES 
   
441.00  DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE 
   
44.01  DISSECTION OF AORTA THORACIC 

441.03  DISSECTION OF AORTA THORACOABDOMINAL 
   
441.1  THORACIC ANEURYSM RUPTURED 
 
441.2  THORACIC ANEURYSM WITHOUT RUPTURE 
 
441.6  THORACOABDOMINAL ANEURYSM RUPTURED 
 
441.7  THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE 
 
441.9  AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE 
 
444.21 - 444.22  ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY - ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY 
 
446.1  ACUTE FEBRILE MUCOCUTANEOUS LYMPH NODE SYNDROME (MCLS) 
 
446.7  TAKAYASU'S DISEASE 
 
449  SEPTIC ARTERIAL EMBOLISM 
 
458.0  ORTHOSTATIC HYPOTENSION 
 
518.4  ACUTE EDEMA OF LUNG UNSPECIFIED 
 
518.5  PULMONARY INSUFFICIENCY FOLLOWING TRAUMA AND SURGERY 
 
518.7  TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) 
 
518.82  OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED 
 
674.50 - 674.54  PERIPART CARDIOMYOPATHY UNSPECIFIED - PERIPARTUM CARDIOMYOPATHY WITH POSTPARTUM CONDITION OR COMPLICATION 
 
674.82  OTHER COMPLICATIONS OF PUERPERIUM WITH DELIVERY WITH POSTPARTUM COMPLICATION 
 
674.84  OTHER COMPLICATIONS OF PUERPERIUM 
 
710.0  SYSTEMIC LUPUS ERYTHEMATOSUS 
 
745.0  COMMON TRUNCUS 
 
745.10 - 745.12  COMPLETE TRANSPOSITION OF GREAT VESSELS - CORRECTED TRANSPOSITION OF GREAT VESSELS 
 
745.19  OTHER TRANSPOSITION OF GREAT VESSELS 
 
745.2 - 745.5  TETRALOGY OF FALLOT - OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFECT 
 
745.60 - 745.61  ENDOCARDIAL CUSHION DEFECT UNSPECIFIED TYPE - OSTIUM PRIMUM DEFECT 
 
745.69  OTHER ENDOCARDIAL CUSHION DEFECTS 
 
745.7 - 745.9  COR BILOCULARE - UNSPECIFIED DEFECT OF SEPTAL CLOSURE 
 
746.00 - 746.02  CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - STENOSIS OF PULMONARY VALVE CONGENITAL 
 
746.09  OTHER CONGENITAL ANOMALIES OF PULMONARY VALVE 
 
746.1 - 746.7  TRICUSPID ATRESIA AND STENOSIS CONGENITAL - HYPOPLASTIC LEFT HEART SYNDROME 
 
746.81 - 746.9  SUBAORTIC STENOSIS CONGENITAL - UNSPECIFIED CONGENITAL ANOMALY OF HEART 
 
747.0  PATENT DUCTUS ARTERIOSUS 
 
747.10 - 747.11  COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) - INTERRUPTION OF AORTIC ARCH 
 
747.20 - 747.22  CONGENITAL ANOMALY OF AORTA UNSPECIFIED - CONGENITAL ATRESIA AND STENOSIS OF AORTA 
 
747.29  OTHER CONGENITAL ANOMALIES OF AORTA 
 
747.3  CONGENITAL ANOMALIES OF PULMONARY ARTERY 
 
747.40 - 747.42  CONGENITAL ANOMALY OF GREAT VEINS UNSPECIFIED - PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION 
 
747.49  OTHER ANOMALIES OF GREAT VEINS 
 
759.3  SITUS INVERSUS 
 
759.82  MARFAN SYNDROME 
 
780.01 - 780.03  COMA - PERSISTENT VEGETATIVE STATE 
 
780.09  ALTERATION OF CONSCIOUSNESS OTHER 
 
780.2  SYNCOPE AND COLLAPSE 
 
780.60 - 780.61  FEVER, UNSPECIFIED - FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE 
 
782.3  EDEMA 
 
782.5  CYANOSIS 
  ]
784.3  APHASIA 
 
785.1  PALPITATIONS 
 
785.2  UNDIAGNOSED CARDIAC MURMURS 
 
785.3  OTHER ABNORMAL HEART SOUNDS 
 
785.50  SHOCK UNSPECIFIED 
 
785.51  CARDIOGENIC SHOCK 
 
785.52  SEPTIC SHOCK 
 
785.59  OTHER SHOCK WITHOUT TRAUMA 
   
786.05  SHORTNESS OF BREATH 
 
786.09  RESPIRATORY ABNORMALITY OTHER 
 
786.50  UNSPECIFIED CHEST PAIN 
 
786.51  PRECORDIAL PAIN 
 
786.59  OTHER CHEST PAIN 
 
790.7   BACTEREMIA 
 
794.31  NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) 
 
799.01  ASPHYXIA 
 
799.02  HYPOXEMIA 
 
807.4   FLAIL CHEST 
 
861.01 - 861.03  CONTUSION OF HEART WITHOUT OPEN WOUND INTO THORAX - LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS WITHOUT OPEN WOUND INTO THORAX 
 
861.10 - 861.13  UNSPECIFIED INJURY OF HEART WITH OPEN WOUND INTO THORAX - LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS AND OPEN WOUND INTO THORAX 
 
901.0  INJURY TO THORACIC AORTA 
 
901.2  INJURY TO SUPERIOR VENA CAVA 
 
901.41  INJURY TO PULMONARY ARTERY 
 
901.42  INJURY TO PULMONARY VEIN 
 
958.0  AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA 
 
958.1  FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA 
 
958.4  TRAUMATIC SHOCK 
 
960.7  POISONING BY ANTINEOPLASTIC ANTIBIOTICS 
 
962.0  POISONING BY ADRENAL CORTICAL STEROIDS 
 
963.1  POISONING BY ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS 
 
965.09  POISONING BY OTHER OPIATES AND RELATED NARCOTICS 
 
972.0  POISONING BY CARDIAC RHYTHM REGULATORS 
 
972.1  POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION 
 
980.3  TOXIC EFFECT OF FUSEL OIL 
 
986  TOXIC EFFECT OF CARBON MONOXIDE 
 
990  EFFECTS OF RADIATION UNSPECIFIED 
 
994.0  EFFECTS OF LIGHTNING 
 
994.8  ELECTROCUTION AND NONFATAL EFFECTS OF ELECTRIC CURRENT 
 
995.1  ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED 
 
995.20  UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE 
 
995.22  UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA 
 
995.29  UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE 
 
996.01  MECHANICAL COMPLICATION DUE TO CARDIAC PACEMAKER (ELECTRODE) 
 
996.02  MECHANICAL COMPLICATION DUE TO HEART VALVE PROSTHESIS 
 
996.04  MECHANICAL COMPLICATION OF AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR 
 
996.61  INFECTION AND INFLAMMATORY REACTION DUE TO CARDIAC DEVICE IMPLANT AND GRAFT 
 
996.71  OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS 
 
996.83  COMPLICATIONS OF TRANSPLANTED HEART 
 
997.1  CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED 
 
998.0  POSTOPERATIVE SHOCK NOT ELSEWHERE CLASSIFIED 
 
998.51 - 998.59  INFECTED POSTOPERATIVE SEROMA - OTHER POSTOPERATIVE INFECTION 
 
999.31  INFECTION DUET CENTRAL VENOUS CATHETER 
 
999.39  INFECTION FOLLOWING OTHER INFUSION, INJECTION, TRANSFUSION, OR VACCINATION 
 
999.4   ANAPHYLACTIC SHOCK DUE TO SERUM NOT ELSEWHERE CLASSIFIED 
 
V12.53  PERSONAL HISTORY OF SUDDEN CARDIAC ARREST 
 
V12.54  PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS 
 
V42.1   HEART REPLACED BY TRANSPLANT 
 
V42.2   HEART VALVE REPLACED BY TRANSPLANT 
 
V43.3   HEART VALVE REPLACED BY OTHER MEANS 
 
V58.11  ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY 
 
V58.44  AFTERCARE FOLLOWING ORGAN TRANSPLANT 
 
V58.64  LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES 
 
V58.65  LONG-TERM (CURRENT) USE OF STEROIDS 
 
V58.69  LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS 
   
V59.8   DONORS OF OTHER SPECIFIED ORGAN OR TISSUE 
   
V67.51  FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED 
 
V72.83  OTHER SPECIFIED PRE-OPERATIVE EXAMINATION 
 
V81.2  SCREENING FOR OTHER AND UNSPECIFIED CARDIOVASCULAR CONDITIONS 

BILLING CPT 90662 - Influenza virus vaccine

CPT 90662

Short Description : Flu vacc prsv free inc antig
Long Descriptor: Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

(1) These codes will be denied when submitted for payment on the same date of service as 90662.

(2) Modifiers applied : "Yes" indicates that the use of a modifier with the denied code will overcome the edit and allow payment.
"No" indicates that the second code will always be denied.

BILLING 82948 Blood Glucose Testing

CPT Code: 82948 Blood Glucose Testing


Frequency Limitations: In stable, non-hospitalized patients who are unable or unwilling to do home glucose monitoring, it may be reasonable and necessary to measure quantitative blood glucose up to 4 times annually. 

Depending on the age and condition of the patient, the type of diabetes, degree of control, and other co-morbid conditions, more frequent testing may be reasonable and necessary.

ICD-9 Codes are associated with CPT code 82948 in this policy.

011.00	Tuberculosis of lung, infiltrative, unspecified
011.01	Tuberculosis of lung, infiltrative, bacteriological or histological examination not done
011.02	Tuberculosis of lung, infiltrative, bacteriological or histological examination unknown (at present)
011.03	Tuberculosis of lung, infiltrative, tubercle bacilli found (in sputum) by microscopy
011.04	Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture
011.05	Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
011.06	Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods
011.10	Tuberculosis of lung, nodular, unspecified
011.11	Tuberculosis of lung, nodular, bacteriological or histological examination not done
011.12	Tuberculosis of lung, nodular, bacteriological or histological examination unknown (at present)

.... and many more.

Medicare CPT 82947 and covered ICD 9

CPT Code: 82947 Blood Glucose Testing 

Frequency Limitations: In stable, non-hospitalized patients who are unable or unwilling to do home glucose monitoring, it may be reasonable and necessary to measure quantitative blood glucose up to 4 times annually. 

Depending on the age and condition of the patient, the type of diabetes, degree of control, and other co-morbid conditions, more frequent testing may be reasonable and necessary.

ICD-9 Codes are associated with CPT code 82947 in this policy.

011.00	Tuberculosis of lung, infiltrative, unspecified
011.01	Tuberculosis of lung, infiltrative, bacteriological or histological examination not done
011.02	Tuberculosis of lung, infiltrative, bacteriological or histological examination unknown (at present)
011.03	Tuberculosis of lung, infiltrative, tubercle bacilli found (in sputum) by microscopy
011.04	Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture
011.05	Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
011.06	Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods
011.10	Tuberculosis of lung, nodular, unspecified
011.11	Tuberculosis of lung, nodular, bacteriological or histological examination not done
011.12	Tuberculosis of lung, nodular, bacteriological or histological examination unknown (at present)

.... and many more.

billing CPT 82728 & covered DX

CPT Code: 82728 Serum Iron Studies 

Frequency Limitations: If a normal serum ferritin level is documented, repeat testing would not ordinarily be medically necessary unless there is a change in the patient's condition, and ferritin assessment is needed for the ongoing management of the patient. 

When an End Stage Renal Disease (ESRD) patient is tested for ferritin, testing more frequently than every three months (the frequency authorized by 3167.3, Fiscal Intermediary manual) requires documentation of medical necessity [e.g., other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)].


ICD-9 Codes are associated with CPT code 82728 in this policy.

002.0	Typhoid fever
002.1	Paratyphoid fever A
002.2	Paratyphoid fever B
002.3	Paratyphoid fever C
002.9	Paratyphoid fever, unspecified
003.0	Salmonella gastroenteritis
003.1	Salmonella septicemia
003.20	Localized salmonella infection, unspecified
003.21	Salmonella meningitis
003.22	Salmonella pneumonia

.... and many more.

Drugs, Biologicals: Provenge BILLING

Drugs & Biologicals: Provenge

Provenge(r) (sipuleucel-T) is an autologous cellular immunotherapy indicated for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer. Provenge is administered as three infusions, generally two weeks apart. Provenge should be administered via intravenous infusion over a period of approximately 60 minutes.

Patients receiving sipuleucel-T infusions will have been to a pheresis center for leukapheresis. The individual patient lymphocytes will be used to manufacture a patient-specific medication (autologous cellular therapy), which when infused back into the patient (usually three days after leukapheresis) will stimulate a positive immunogenic response against his prostate cancer.

For purposes of reimbursement, we will require the following:

• A diagnosis of prostate cancer (ICD-9-CM) 185 – Malignant neoplasm, prostate. Documentation in the chart would demonstrate the patient was asymptomatic or minimally symptomatic and had metastatic castrate resistant (hormone refractory) disease.
• Documentation must be submitted with the first infusion including:
  
  • Evidence of metastases to soft tissue or bone
  • Testosterone levels < 50ug or below lowest level of normal
  • Two sequential rising PSA levels obtained 2–3 weeks apart or other evidence of disease progression
• Patient cannot be getting simultaneous chemotherapy and should not be getting immunosuppressive therapy
• Intravenous infusion codes 96365 (initial hour) or 96366 (each additional hour if needed to complete the dose)
• Use code J3490 (unclassified drug) for the sipuleucel-T and supply the NDC number 30237890006 and description ‘sipuleucel-T’ in the information loop of electronic claims (box 19 of paper claims)

Since the drug is administered by infusion three times, we would expect a claim filed for each administration. Only the first infusion requires the accompanying documentation. However, each claim must be accompanied with the name of the drug, an invoice, the NCD number and the dose given on that date of service. Medicare will allow a maximum of three infusions per lifetime. This article is effective for dates of service on or after April 29, 2010.

Does consult code accepted by Medicare HMO

Consults codes and Medicare HMOs

     Medicare HMO plan does not cover the consultation service.

Insurance name
1 Medicare
2 Humana (HMO)
3 Freedom Health
4 AVMED
5 Advantra Gold plus ( Coventry )
6 Universal Health
7 Wellcare
8 AARP Medicare completed
9 UHC (HMO)
10 Polk County
11 PUP
12 QHP
13 Amerigroup
14 Citruscare

Billing consult code and preventive code together

Consult and Preventive codes

A consultation is an evaluation of a patient provided by a physician at the request of another physician or appropriate source. The consulting physician may order tests or therapeutic services at the time of the visit, and these would be reported separately. The request for the consultation as well as the consultant's opinion must be documented in the patient's chart. A written report must be sent back to the physician requesting the consult. A consultation requested by the patient or family member and not by a physician or appropriate source should not be reported with consultation codes. Report the appropriate evaluation and management (E/M) code for this service.

If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

A problem/abnormality encountered in the process of performing the preventive medicine evaluation and management service that does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.

where to enter NDC codes and required procedures

National Drug Code Required for Drug/Radiopharmaceutical Not Otherwise Classified Codes

The National Drug Code (NDC) number, name and dosage are required for all 'not otherwise classified' or 'unlisted' HCPCS procedure codes for drugs and radiopharmaceuticals (J3490, J3590, J9999, A4641, A9699 and A9700).

• For electronic claims: submit this information in the electronic documentation record (2400-NTE, 02)
• For paper claims: submit this information in Item 19 or an attachment to the CMS-1500 claim form
  
  • Note: The FDA standard is a 10 digit number, but to be compliant with the HIPAA standard of an 11 digit code, you may use a leading '0' to pad the number
• Claims for unlisted drugs or radiopharmaceuticals that are submitted without this information will be returned as unprocessable and must be submitted as new claims

billing CPT 82523 and covered DX

CPT Code: 82523 Collagen Crosslinks, Any Method

Frequency Limitations: Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.

ICD-9 Codes are associated with CPT code 82523 in this policy.

242.00	Toxic diffuse goiter without thyrotoxic crisis or storm
242.01	Toxic diffuse goiter with thyrotoxic crisis or storm
242.10	Toxic uninodular goiter without thyrotoxic crisis or storm
242.11	Toxic uninodular goiter with thyrotoxic crisis or storm
242.20	Toxic multinodular goiter without thyrotoxic crisis or storm
242.21	Toxic multinodular goiter with thyrotoxic crisis or storm
242.30	Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31	Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40	Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41	Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm

.... and many more.  

CPT Code: 82465 Lipids Testing and covered DX

CPT Code: 82465 Lipids Testing


Frequency Limitations: When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice for interim visits if the patient does not have hypertriglyceridemia (for example, ICD-9-CM code 272.1, Pure hyperglyceridemia). 

Any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharma-cologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. If no dietary or pharmacological therapy is advised, monitoring is not necessary. 

When evaluating non-specific chronic abnormalities of the liver (for example, elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.), a lipid panel would generally not be indicated more than twice per year.


ICD-9 Codes are associated with CPT code 82465 in this policy.

242.00	Toxic diffuse goiter without thyrotoxic crisis or storm
242.01	Toxic diffuse goiter with thyrotoxic crisis or storm
242.10	Toxic uninodular goiter without thyrotoxic crisis or storm
242.11	Toxic uninodular goiter with thyrotoxic crisis or storm
242.20	Toxic multinodular goiter without thyrotoxic crisis or storm
242.21	Toxic multinodular goiter with thyrotoxic crisis or storm
242.30	Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31	Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40	Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41	Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm

.... and many more.

Medicare CPT 82378 Carcinoembryonic Antigen and valid DX

CPT Code: 82378 Carcinoembryonic Antigen 


Frequency Limitations: 

Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. It may be proper to order the test more frequently when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence. Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.

ICD-9 Codes are associated with CPT code 82378 in this policy.

150.0	Malignant neoplasm of cervical esophagus
150.1	Malignant neoplasm of thoracic esophagus
150.2	Malignant neoplasm of abdominal esophagus
150.3	Malignant neoplasm of uUpper third of esophagus
150.4	Malignant neoplasm of middle third of esophagus
150.5	Malignant neoplasm of lower third of esophagus
150.8	Malignant neoplasm of other specified part of esophagus
150.9	Malignant neoplasm of esophagus, unspecified
151.0	Malignant neoplasm of cardia
151.1	Malignant neoplasm of pylorus

.... and many more.

CPT Code: 82272 with payaple DX CODE

CPT Code: 82272 Fecal Occult Blood Test 


Frequency Limitations: Patients who are taking non-steroidal anti-inflammatory drugs and have a history of GI bleeding but no other signs, symptoms, or complaints associated with GI blood loss: once every 3 months

ICD-9 Codes are associated with CPT code 82272 in this policy.

003.0	Salmonella gastroenteritis
003.1	Salmonella septicemia
004.0	Shigella dysenteriae, infection by group A Shigella
004.1	Shigella flexneri, infection by group B Shigella
004.2	Shigella boydii, infection by group C Shigella
004.3	Shigella sonnei, infection by group D Shigella
004.8	Other specified shigella infections
004.9	Shigellosis, unspecified
005.0	Staphylococcal food poisoning
005.1	Botulism food poisoning

.... and many more.  

Allergy cpt and office visit billing together

Allergy Shots and Visit Services on the Same Day

At the outset of the physician fee schedule, the question was posed as to whether visits should be billed on the same day as an allergy injection (CPT codes 95115-95117), since these codes have status indicators of A rather than T. Visits should not be billed with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service. This language parallels CPT editorial language that accompanies the allergen immunotherapy codes, which include codes 9515 and 95117. Prior to January 1, 1995, you appeared to be enforcing this policy through three (3) different means:

• Advising physician to use modifier 25 with the visit service;
• Denying payment for the visit unless documentation has been provided; and
• Paying for both the visit and the allergy shot if both are billed for.

For services rendered on or after January 1, 1995, you are to enforce the requirement that visits not be billed and paid for on the same day as an allergy injection through the following means. Effective for services rendered on or after that date, the global surgery policies will apply to all codes in the allergen immunotherapy series, including the allergy shot codes 95115 and 95117. To accomplish this, CMS changed the global surgery indicator for allergen immunotherapy codes from XXX, which meant that the global surgery concept did not apply to those codes, to 000, which means that the global surgery concept applies, but that there are no days in the postoperative global period. Now that the global surgery policies apply to these services, you are to rely on the use of modifier 25 as the only means through which you can make payment for visit services provided on the same day as allergen immunotherapy services. In order for a physician to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), the physician is to bill a modifier 25 with the visit code, indicating that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.

Examples for Allergy Immunotherapy billing

(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.

(2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.

(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.


(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.

(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.

(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.

Allergy Immunotherapy testing CPT 95004, 95117,95115

Allergy Testing and Immunotherapy

A - Allergy Testing

The MPFSDB fee amounts for allergy testing services billed under codes 95004-95078 are established for single tests. Therefore, the number of tests must be shown on the claim.

EXAMPLE
If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004 and specify 25 in the units field of Form CMS-1500 (paper claims or electronic format). To compute payment, the Medicare carrier multiplies the payment for one test (i.e., the payment listed in the fee schedule) by the quantity listed in the units field.

B - Allergy Immunotherapy

For services rendered on or after January 1, 1995, all antigen/allergy immunotherapy services are paid for under the Medicare physician fee schedule. Prior to that date, only the antigen injection services, i.e., only codes 95115 and 95117, were paid for under the fee schedule. Codes representing antigens and their preparation and single codes representing both the antigens and their injection were paid for under the Medicare reasonable charge system. A legislative change brought all of these services under the fee schedule at the beginning of 1995 and the following policies are effective as of January 1, 1995:

1 - CPT codes 95120 through 95134 are not valid for Medicare. Codes 95120 through 95134 represent complete services, i.e., services that include both the injection service as well as the antigen and its preparation.

2 - Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.
If both services are provided both codes are billed.
This includes allergists who provide both services through the use of treatment boards.

3 - If a physician bills both an injection code plus either codes 95165 or 95144, carriers pay the appropriate injection code (i.e., code 95115 or code 95117) plus the code 95165 rate. When a provider bills for codes 95115 or 95117 plus code 95144, carriers change 95144 to 95165 and pay accordingly. Code 95144 (single dose vials of antigen) should be billed only if the physician providing the antigen is providing it to be injected by some other entity. Single dose vials, which should be used only as a means of insuring proper dosage amounts for injections, are more costly than multiple dose vials (i.e., code 95165) and therefore their payment rate is higher. Allergists who prepare antigens are assumed to be able to administer proper doses from the less costly multiple dose vials. Thus, regardless
of whether they use or bill for single or multiple dose vials at the same time that they are billing for an injection service, they are paid at the multiple dose vial rate.

4 - The fee schedule amounts for the antigen codes (95144 through 95170) are for a single dose. When billing those codes, physicians are to specify the number of doses provided. When making payment, carriers multiply the fee schedule amount by the number of doses specified in the units field.

5 - If a patient’s doses are adjusted, e.g., because of patient reaction, and the antigen provided is actually more or fewer doses than originally anticipated, the physician is to make no change in the number of doses for which he or she bills. The number of doses anticipated at the time of the antigen preparation is the number of doses to be billed. This is consistent with the notes on page 30 of the Spring 1994 issue of the American Medical Association’s CPT Assistant. Those notes indicate that the antigen codes mean that the physician is to identify the number of doses “prospectively planned to be provided.” The physician is to “identify the number of doses scheduled when the vial is provided.” This means that in cases where the patient actually gets more doses than originally anticipated (because dose amounts were decreased during treatment) and in cases where the patient gets fewer doses (because dose amounts were increased), no change is to be made in the billing. In the first case, carriers are not to pay more because the number of doses provided in the original vial(s) increased. In the second case, carriers are not to seek recoupment (if carriers have already made payment) because the number of doses is less than originally planned. This is the case for both venom and nonvenom antigen codes.

6 - Venom Doses and Catch-Up Billing - Venom doses are prepared in separate vials and not mixed together - except in the case of the three vespid mix (white and yellow hornets and yellow jackets). A dose of code 95146 (the two-venom code) means getting some of two venoms. Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms. Some amount of each of the venoms must be provided. Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction. For example, a physician prepares ten doses of code 95148 (the four venom code) in two vials - one containing 10 doses of three vespid mix and another containing 10 doses of wasp venom. Because of dose adjustment, the three vespid mix doses last longer, i.e., they last for 15 doses. Consequently, questions arise regarding the amount of “replacement” wasp venom antigen that should be prepared and how it should be billed. Medicare pricing amounts have savings built into the use of the higher venom codes. Therefore, if a patient is in two venom, three venom, four venom or five venom therapy, the carrier objective is to pay at the highest venom level possible. This means that, to the greatest extent possible, code 95146 is to be billed for a patient in two venom therapy, code 95147 is to be billed for a patient in three venom therapy, code 95148 is to be billed for a patient in four venom therapy, and code 95149 is to be billed for a patient in five venom therapy. Thus, physicians are to be instructed that the venom antigen preparation, after dose adjustment, must be done in a manner that, as soon as possible, synchronizes the preparation back to the highest venom code possible. In the above example, the physician should prepare and bill for only 5 doses of “replacement” wasp venom - billing five doses of code 95145 (the one venom code). This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the “cheaper” four venom code. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up.”

7 - Code 95165 Doses. - Code 95165 represents preparation of vials of non-venom antigens. As in the case of venoms, some non-venom antigens cannot be mixed together, i.e., they must be prepared in separate vials. An example of this is mold and pollen. Therefore, some patients will be injected at one time from one vial – containing in one mixture all of the appropriate antigens – while other patients will be injected at one time from more than one vial. In establishing the practice expense component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc. Our PE computations were based on those facts. Therefore, a physician’s removing 10 1cc aliquot doses captures the entire PE component for the service.

This does not mean that the physician must remove 1 cc aliquot doses from a multidose vial. It means that the practice expenses payable for the preparation of a 10cc vial remain the same irrespective of the size or number of aliquots removed from the vial. Therefore, a physician may not bill this vial preparation code for more than 10 doses per vial; paying more than 10 doses per multidose vial would significantly overpay the practice expense component attributable to this service. (Note that this code does not include the injection of antigen(s); injection of antigen(s) is separately billable.)

When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial. That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medicare for fewer than 10 doses per vial when there is less than 10cc in the vial.

If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.

What is Vitro allergy testing

In Vitro Allergy Testing

Total serum IgE testing in patients with allergic disease has no established clinical role. Substantial proportions of individuals with IgE-mediated allergic disease have normal serum IgE levels, and many nonallergic diseases are associated with elevated serum IgE. Measurement of serum IgE may be indicated in adults with conditions such as suspected allergic bronchopulmonary aspergillosis and hyper- IgE syndromes (dermatitis and recurrent pyogenic infections), certain stages of HIV infection, IgE myeloma, drug-induced interstitial nephritis, graft-versus-host disease, several parasitic diseases and specific immune deficiency diseases. In children, serum concentrations of IgE increase slowly with development, with highest levels typically found in late adolescence. High concentrations of serum IgE measured in the first year of life have been shown to correlate with future development of atopic disease. However, in clinical situations when presenting signs of allergic disease are evident, total IgE levels do not provide additional diagnostic information. Furthermore, normal IgE levels do not exclude the diagnosis of allergic disease in infants or children.

Total serum IgG, IgA and IgM testing is not typically clinically useful, since their levels are not altered by allergic diseases. Based on a review of the literature, the role of routine quantitative measurement of serum IgG, IgA and IgM in the diagnosis and management of allergic disease has not been established.

Serum IgG antibodies are not involved in the pathogenesis of atopic disease. Although it has been suggested that IgG antibodies may be responsible for delayed symptoms or vague intolerance to foods, there is no evidence available that validates this contention. RAST and similar technologies are capable of detecting minute quantities of such antibodies, and it is known that low-level IgG antibodies to foods circulate normally but have no known pathogenic significance. The measurement of specific IgG antibodies is of no diagnostic value in the management of patients with atopic (allergic) disease. There is insufficient evidence in the published, peer-reviewed scientific literature to support the use of specific IgG antibody testing by RAST or ELISA in the diagnosis or treatment of allergic disease without suspected immunodeficiency.

The cytotoxic test, also known as the "leukocytotoxic test" or Bryan’s Test, has been proposed for food allergies but has no scientific support as a procedure for the diagnosis of food allergies or inhalant allergies. The rationale for this test is based on a claim that morphological changes in peripheral-blood leukocytes in contact with allergens in vitro indicate that the patient is allergic to the particular allergen. There is insufficient evidence in the published, peer-reviewed scientific literature to support the use of this testing in the diagnosis or management of allergic disease. The role of this testing in the diagnosis or management of allergic disease has not been established.
Lymphocyte subset counts may be useful in the diagnosis of lymphocyte cellular immunodeficiencies and lymphocytic leukemias. Quantifying lymphocyte subsets, however, has not been proven to be of any value in the diagnosis or management of allergic disease.
Lymphocyte function assays may be appropriate in the diagnosis of some immunodeficiency diseases; however, they are not abnormal in allergic diseases. The use of this testing in the diagnosis or management of allergic disease is unproven.

Cytokine and cytokine receptor assays have not been shown to be useful in the diagnosis or management of any allergic disease and are therefore considered unproven.

The food immune complex assay (FICA) is based on the solid-phase radioimmunoassay methodology. It has not been shown in well-designed clinical trials that any well-defined clinical disease involves pathogenic circulating immune complexes to foods. Furthermore, it has not been shown that the assay for such complexes is diagnostic of any disease. The clinical value of food immune complex assays in the diagnosis and management of allergic disease has not been established. The technique is therefore considered unproven.

Leukocyte histamine release testing is an in vitro test that evaluates the presence of specific IgE antibodies. The test has been proposed for the diagnosis of various allergic conditions, including atopic disorders and stinging insect allergies. Leukocyte histamine release testing detects the release of histamine from basophils in a sample of whole blood exposed to allergens in vitro. It is a cumbersome test typically conducted in research laboratories, and has not been studied fully for its predictive value in determining specificity and sensitivity. Its role in the diagnosis and management of allergic disease outside of the investigative setting has not been established.

Body chemical analysis is typically seen in the diagnosis of a condition known as "idiopathic environmental intolerances" (IEIs) or "multiple food and chemical sensitivities." Samples of whole blood, serum, erythrocytes, urine, fat and hair are tested for the presence of environmental chemicals. The most common chemicals measured are organic solvents, other hydrocarbons, pesticides and metals. Some proponents of this testing also recommend measurements of the quantity of vitamins, minerals and amino acids in blood and urine in a search for "environmental sensitivities." The concept of multiple food and chemical sensitivities manifested by numerous symptoms in the absence of objective physical findings lacks scientific foundation. There is no evidence to suggest that these patients suffer from an immunological abnormality. The existence of such an illness is based on anecdotal reports with no verification using well-designed clinical trials. There is no scientific evidence to support the value of diagnostic testing associated with IEIs or multiple food and chemical sensitivities, including body chemical analysis. Body chemical analysis is therefore considered unproven.

Antigen leukocyte cellular antibody testing (ALCAT) is an automated method of testing for food allergies that is purported to identify food sensitivity by using a modified Coulter counter linked to a computer program to measure the change in white blood cells incubated with purified food and mold extract. There is insufficient evidence in the published peer-reviewed scientific literature to support the use of this testing in the diagnosis or management of allergic disease.

Medicare payment for LAB cpt service codes

Medicare Payment for Clinical Laboratory Services 

Medicare consists of two parts: Medicare Part A covers inpatient hospitalization costs, once the annual deductible has been met, for almost everyone age 65 and older plus the permanently disabled and those with chronic renal disease. Coverage under Part A is automatic. Payment for inpatient care in most hospitals is based on a fixed fee determined for each diagnosis (diagnosis-related groups, DRGs).¹ DRGs are not applied to physician services. Laboratory tests performed for Medicare inpatients are considered a part of the DRG payment. Medicare Part B covers physician services, outpatient clinical laboratory, and x-ray tests for eligible persons along with other medical services and supplies not covered under Part A. Part B is voluntary; however, most who are eligible sign up. There is an annual deductible and a 20% co-payment for all Part B services except outpatient clinical laboratory services.


Most clinical laboratory procedures are paid from laboratory fee schedules issued by individual Medicare carriers. Medicare carriers are contractors, usually large insurance companies, who administer Part B Medicare services in each state. There are 57 carriers, including one for each state and territory plus two in California and three in New York. All physician services, including pathology services not included in the laboratory fee schedule, are paid according to the Physician Fee Schedule. Unlike the laboratory fee schedule, under this schedule co-payments of 20% are collected from the beneficiary so that the actual payment received from Medicare for a given procedure is 80% of the Physician Fee Schedule amount.


Before Medicare pays for any test or diagnostic service, two basic criteria must be met: (a) the service must be covered by Medicare, and (b) the service must be medically necessary and indicated. Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the applicable Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and adjusts payment levels as determined by Congress during the annual budget process. Updates, when granted, are effective January 1st.


national fee limitations
National caps apply to most laboratory tests. These caps define the maximum amount a carrier may pay for a given test. The 1998 National Limitation amounts for any given test are based on 74% of the median amount listed on all carriers' fee schedules for a particular laboratory test. National caps were reduced from 76% to 74% effective January 1, 1998, resulting in a reduction of 2.63% for most clinical laboratory tests.


Fee schedules may be adjusted only by statutory changes approved by Congress. When the fee schedule is adjusted by a given percentage, national caps are adjusted up or down by the same amount. Medicare payment for clinical laboratory tests is always the lowest of the fee schedule, the national cap, or the actual amount billed. 

CPT Code: 82270 Fecal Occult Blood Test

CPT Code: 82270 Fecal Occult Blood Test 

Frequency Limitations: 
Screening fecal occult blood tests are covered at a frequency of once every 12 months for beneficiaries who have attained age 50. A written order from the beneficiary's attending physician is required. Attending physician means a doctor or medicine or osteopathy who is fully knowledgeable about the beneficiary's medical condition, and who would be responsible for using the test results in the overall management of the beneficiary's specific medical problem.


1 ICD-9 Codes are associated with CPT code 82270 in this policy.

Contact local Medicare Contractor for guidance

.... and many more.  

Alpha-fetoprotein - CPT CODE 82105 WITH valid DX code

CPT Code: 82105 Alpha-fetoprotein 

ICD-9 Codes are associated with CPT code 82105 in this policy.

070.22	Viral hepatitis B with hepatic coma, chronic, without hepatitis delta
070.23	Viral hepatitis B with hepatic coma, chronic, with hepatitis delta
070.32	Viral hepatitis B without hepatic coma, chronic, without hepatitis delta
070.33	Viral hepatitis B without hepatic coma, chronic, with hepatitis delta
070.44	Chronic hepatitis C with hepatic coma
070.54	Chronic hepatitis C without hepatic coma
095.3	Syphilis of liver
121.1	Clonorchiasis
121.3	Fascioliasis
155.0	Malignant neoplasm, liver, primary

.... and many more. 

CPT Code: 80162 and covered ICD codes

CPT Code: 80162 Digoxin Therapeutic Drug Assay

ICD-9 Codes are associated with CPT code 80162 in this policy.

242.00	Toxic diffuse goiter without thyrotoxic crisis or storm
242.01	Toxic diffuse goiter with thyrotoxic crisis or storm
242.10	Toxic uninodular goiter without thyrotoxic crisis or storm
242.11	Toxic uninodular goiter with thyrotoxic crisis or storm
242.20	Toxic multinodular goiter without thyrotoxic crisis or storm
242.21	Toxic multinodular goiter with thyrotoxic crisis or storm
242.30	Toxic nodular goiter, unspecified, without thyrotoxic crisis or storm
242.31	Toxic nodular goiter, unspecified, with thyrotoxic crisis or storm
242.40	Thyrotoxicosis from ectopic thyroid nodule without thyrotoxic crisis or storm
242.41	Thyrotoxicosis from ectopic thyroid nodule with thyrotoxic crisis or storm

.... and many more.

Example Medicare redetermination form

Redetermination Reopening Request -Form

Improving Mesothelioma Life Expectancies

Improving Mesothelioma Life Expectancies

Those dedicated to researching mesothelioma are constantly testing new ways to improve the life expectancy of patients with the disease. This is accomplished largely through clinical trials , which test new drugs and treatments. Many promising alternatives to traditional treatments have materialized from clinical trials and patients often benefit from participating. Tests to detect mesothelioma in its earliest stages are also being developed, which may result in more effective treatment of the disease.


The life expectancy of mesothelioma patients can also be affected by treatment. Mesothelioma patients may elect to undergo treatment to combat the disease, remove the cancer and kill cancerous cells. A doctor will make treatment recommendations based on a myriad of factors. Surgery, chemotherapy and radiation are the most common mesothelioma treatment options for patients.



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