Medicare has retained the automated, multichannel fee schedule for reimbursement purposes. Last year's fees have been updated to yield the 1998 fee schedule (Table 2 )for automated, multichannel tests.
Reimbursement for the new automated, multichannel test panel codes is based on the number of automated tests in each panel.
Medicare carriers have been instructed by HCFA to pay for all combinations of new and existing automated, multichannel test panels and single automated tests starting January 1, 1998, according to the following rules.
Carriers are to:
Step 1: Unbundle each panel into automated and nonautomated tests; Step 2: Eliminate all duplicate tests resulting from overlapping panel test compositions; Step 3: Rebundle all remaining automated tests together and pay according to the updated automated, multichannel fee schedule (see above); and Step 4: Pay all nonautomated tests individually based on the applicable laboratory fee schedule.
Although carriers have been instructed to install edits to accomplish the proper rebundling and payment for unbundled claims, it remains to be seen how accurate their reimbursement will be. It would be wise to monitor payments and Explanation of Benefits summaries for all automated tests and panels to ensure that payments are correct. If a carrier does not reimburse correctly for the tests submitted and overpays and the provider does not refund an overpayment, Medicare at a later date may accuse the provider of making a False Claim. Likewise, if the carrier underpays, the provider needs to refile the claim to receive proper payment. Thus, it would be wise to monitor all payments and promptly refund or refile to make sure that no liability is incurred for overpayments and that no payments are less than they should be.
Sunday, September 26, 2010
Medical Necessity Rules for Automated Multichannel Tests
Payment will be made only for tests, including automated multichannel tests, that meet Medicare coverage rules. Tests are considered covered by Medicare if the beneficiary is eligible and presents with indications of a disease or other clinical problem. For example, screening or preventive care tests are not covered except in specific cases determined by Congress.
Starting January 1, 1998, annual mammograms (annually after age 40) and screening pelvic exams (every 3 years) will be covered, as well as annual fecal occult blood tests (beginning at age 50). As of July 1, 1998, coverage begins for expanded diabetes self-management training and bone mass measurement. Coverage for prostate cancer screening using prostate-specific antigen and a digital rectal examination begins January 1, 2000.
Medicare requires a diagnosis code (ICD-9) (2) for all laboratory tests as a means of verifying medical necessity.
Carriers have been instructed to review claims for patterns of high utilization of profiles with large numbers of tests and, if documentation (i.e., patient records and chart notes) does not support Medicare coverage, to recoup payments made in the past. Such actions can also put a provider at risk of prosecution by the Medicare Office of Inspector General under the False Claims Act for submission of medically unnecessary claims.
However, HCFA has stated that for automated, multichannel tests only: "When a physician orders automated tests on a test-by-test basis, that is, not as a part of a custom panel, each of the tests is to be considered medically necessary."
When more than one automated, multichannel test is ordered individually, documentation supporting the medical necessity for every individual test is not required. In other words, a single valid medically necessary diagnosis can be used for all automated, multichannel tests ordered and performed on the same date of service so long as the tests are ordered individually by the physician.
HCFA has also stated that the new automated, multichannel test panels as well as organ and disease panels are to be considered to be individual tests for medical necessity documentation purposes.
A special QP modifier is used to indicate that automated, multichannel tests were individually ordered and as such are not subject to individual documentation of medical necessity.
EXAMPLE
Carbon dioxide, chloride, potassium, sodium, BUN, and creatinine are ordered on the same date of service. If ordered as and billed as: Electrolyte Plus Profile 80059 Electrolyte Panel 84520 BUN 82565 Creatinine
Documentation of medical necessity is required for each of the six tests performed. If ordered as: and billed as:
Electrolyte Panel, 80059 BUN, 84520 Creatinine, 82565 80059QP Electrolyte Panel 84520QP BUN 82565QP CreatinineMedical necessity is assumed and only one diagnosis code is required for all of the tests (unless local medical review policy requires specific ICD-9 codes for these tests). If ordered as: and billed as:
Carbon dioxide Chloride Potassium Sodium BUN Creatinine 82374QP Carbon dioxide 82435QP Chloride 84132QP Potassium 84295QP Sodium 84520QP BUN 82565QP Creatinine Medical necessity is also assumed, and only one diagnosis code is required for all of the tests (unless local medical review policy requires specific ICD-9 codes for these tests). Note that this panel cannot be coded as a Liver panel, 80058, because it does not include direct bilirubin.
A number of tests commonly included in chemistry profiles or general health panels do not appear on the automated multichannel chemistry list in the CPT. For example: Amylase Magnesium Lipase Ferritin Iron TIBC HDL-cholesterol Apolipoproteins
These tests can be submitted to Medicare for individual payment. Because the average reimbursement level per test for automated tests is lower than the individual payment for each test, panel reimbursement increases dramatically when nonautomated tests are added to the panel and billed separately. Medical necessity is always required when such "add-on" tests are performed. If appropriate diagnosis codes are not submitted showing the necessity for performing such tests, payment may be denied by Medicare.
miscellaneous laboratory procedures and hepatitis tests
Changes in the 1998 CPT
The following new codes have been added to the laboratory section of the 1998 CPT.
miscellaneous laboratory procedures
hepatitis tests
An extensive new section covering the detection and quantification of infection agent antigens by various methods has been added under "Microbiology" in the Laboratory section of the CPT. These codes replace the following general method codes, which have been deleted.
INFECTIOUS AGENT ANTIGEN DETECTION BY DIRECT FLUORESCENT ANTIBODY TECHNIQUE: qualitative or semiquantitative, multistep method
The following new codes have been added to the laboratory section of the 1998 CPT.
miscellaneous laboratory procedures
- 80201 TOPIRAMATE
- 83019 H. PYLORI BREATH TEST: (including drug and breath sample collection kit)
- 84512 TROPONIN: qualitative
- 86148 ANTI-PHOSPHATIDYLSERINE: (Phospholipid)
- 86361 T CELLS: absolute CD4 count
- 80049 BASIC METABOLIC PANEL
- 80054 COMPREHENSIVE METABOLIC PANEL
- 80051 ELECTROLYTE PANEL
hepatitis tests
- 86704 HEPATITIS B CORE ANTIBODY: IgG and IgM
- 86705 HEPATITIS B CORE ANTIBODY: IgM
- 86706 HEPATITIS B SURFACE ANTIBODY
- 86707 HEPATITIS Be ANTIBODY
- 86708 HEPATITIS A ANTIBODY: IgG and IgM
- 86709 HEPATITIS A ANTIBODY: IgM
- 86803 HEPATITIS C ANTIBODY
- 86804 HEPATITIS C ANTIBODY: confirmatory test
An extensive new section covering the detection and quantification of infection agent antigens by various methods has been added under "Microbiology" in the Laboratory section of the CPT. These codes replace the following general method codes, which have been deleted.
- 86313 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIGEN: qualitative, multiple-step method
- 86315 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIGEN: qualitative, single-step method
- (a) detection by direct fluorescent antibody technique;
- (b) detection by enzyme immunoassay technique, qualitative or semiquantitative multistep method;
- (c) detection by enzyme immunoassay technique, qualitative or semiquantitative, single-step method;
- (d) detection by nucleic acid (DNA or RNA), direct probe technique;
- (e) detection by nucleic acid (DNA or RNA), amplified probe technique;
- (f) detection by nucleic acid (DNA or RNA), quantification; and
- (g) detection by immunoassay with direct optical observation.
INFECTIOUS AGENT ANTIGEN DETECTION BY DIRECT FLUORESCENT ANTIBODY TECHNIQUE: qualitative or semiquantitative, multistep method
- 87260 Adenovirus
- 87265 Bordetella pertussis or parapertussis
- 87270 Chlamydia trachomatis
- 87272 Cryptosporidum/giardia
- 87274 Herpes simplex virus
- 87276 Influenza A virus
- 87278 Legionella pneumophila
- 87280 Respiratory syncytial virus
- 87285 Treponema pallidum
- 87290 Varicella zoster
- 87299 Not otherwise specified
Medicare CLIA waived CPT code list
CLIA 1988 Waived Test Codes
CLIA 1988 waived test codes have been assigned to the following simple tests commonly performed in physician offices and other locations. These tests are not subject to many of the regulatory requirements of the Clinical Laboratory Improvement Act of 1988.
CLIA 1988 waived test codes have been assigned to the following simple tests commonly performed in physician offices and other locations. These tests are not subject to many of the regulatory requirements of the Clinical Laboratory Improvement Act of 1988.
- 81002 URINALYSIS, DIPSTICK OR TABLET: (selected analytes); without microscopy, nonautomated
- 81025 URINE PREGNANCY TEST: by visual color comparison methods
- 82270 FECAL OCCULT BLOOD
- 82962 BLOOD GLUCOSE: by glucose monitoring device(s) cleared by the Food and Drug Administration specifically for home use
- 83026 HEMOGLOBIN: by copper sulfate method, nonautomated
- 84830 OVULATION TESTS: by visual color comparison methods for human luteinizing hormone
- 85013 SPUN MICROHEMATOCRIT
- 8565 SEDIMENTATION RATE (ESR): nonautomated
- 80061QW LIPID PANEL
- 81001QW URINALYSIS: automated dipstick, with microscopy
- 81002QW URINALYSIS: automated dipstick without microscopy
- 82044QW MICROALBUMIN: urine, semiquantitative (reagent strip)
- 82273QW OCCULT BLOOD: other sources, qualitative
- 82465QW CHOLESTEROL: serum, total
- 82947QW GLUCOSE: quantitative
- 82950QW GLUCOSE, POST GLUCOSE DOSE: including glucose
- 82951QW GLUCOSE TOLERANCE TEST: 3 specimens including glucose
- 82952QW GLUCOSE TOLERANCE TEST: each additional specimen beyond 3
- 82985QW GLYCATED PROTEIN
- 83718QW LIPOPROTEIN, HDL CHOLESTEROL: direct measurement
- 83986QW pH BODY FLUID: except blood
- 84478QW TRIGLYCERIDES
- 85014QW BLOOD COUNT, HEMATOCRIT: other than spun
- 85018QW BLOOD COUNT, HEMOGLOBIN
- 85610QW PROTHROMBIN TIME
- 86318QW IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY: qualitative, one step
- 6588QW STREPTOCOCCUS: direct screen
- 87072QW CULTURE OR DIRECT BACTERIAL ID: each organism, by commercial kit, other than urine
Medicare cpt codes - antibody identification code - 86658, 86970 , 86671
Antibody Identification Codes
Antibody identification codes are organized together in the Immunology section of the CPT (codes 86602 through 86804). These procedures must be coded as precisely as possible. When multiple tests are performed to detect antibodies to a specific organism or class of immunoglobulin, each assay is to be coded separately.
For example, if antibodies to Coxsackie A and B viruses are determined using two separate assays, the following codes would be used:
Antibody identification codes are organized together in the Immunology section of the CPT (codes 86602 through 86804). These procedures must be coded as precisely as possible. When multiple tests are performed to detect antibodies to a specific organism or class of immunoglobulin, each assay is to be coded separately.
For example, if antibodies to Coxsackie A and B viruses are determined using two separate assays, the following codes would be used:
- 86658 ANTIBODY: Enterovirus (Coxsackie A)
- 86658 ANTIBODY: Enterovirus (Coxsackie B)
- 86658 ANTIBODY: Enterovirus (Coxsackie A, IgM)
- 86658 ANTIBODY: Enterovirus (Coxsackie B, IgM)
- 86790 ANTIBODY: virus, not listed elsewhere
- 86671 ANTIBODY: fungus, not listed elsewhere
- 86609 ANTIBODY: bacterium, not listed elsewhere
- 86256 FLUORESCENT ANTIBODY: titer, each antibody
Medicare allergy testing CPT codes
Allergy Testing
Allergen-specific IgE determinations are coded using the following two codes:
Other allergy testing is described under the Medicine section of the CPT using the following codes (954004-95078). These codes are not part of the laboratory fee schedule and are paid from the Physician Fee Schedule.
scratch, puncture, and prick tests
Allergen-specific IgE determinations are coded using the following two codes:
- 86003 ALLERGEN-SPECIFIC IgE: quantitative semiquantitative, each allergen
- 86005 ALLERGEN-SPECIFIC IgE: qualitative, multiallergen screen (dipstick or disk)
Other allergy testing is described under the Medicine section of the CPT using the following codes (954004-95078). These codes are not part of the laboratory fee schedule and are paid from the Physician Fee Schedule.
scratch, puncture, and prick tests
- 95004 PERCUTANEOUS TESTS: with allergenic extracts, immediate type reaction, specify number of tests
- 95010 PERCUTANEOUS TESTS: sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, specify number of tests
- 95015 INTRACUTANEOUS TESTS: sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, specify number of tests
- 95024 INTRACUTANEOUS TESTS: with allergenic extracts, immediate type reaction, specify number of tests
- 95028 INTRACUTANEOUS TESTS: with allergenic extracts, delayed type reaction, including reading, specify number of tests
- 95027 SKIN END POINT
- 95044 PATCH OR APPLICATION TEST(S): specify number of tests
- 95052 PHOTO PATCH TEST(S): specify number of tests
- 95056 PHOTO TESTS
- 95060 OPTHALMIC MUCOUS MEMBRANE TESTS
- 95065 DIRECT NASAL MUCOUS MEMBRANE TEST
- 95070 INHALATION BRONCHIAL CHALLENGE TESTING: with histamine, methacholine, or similar compounds
- 95071 INHALATION BRONCHIAL CHALLENGE TESTING: with antigens or gases, specify
- 95075 INGESTION CHALLENGE TEST
- 85078 PROVOCATIVE TESTING: (for example, Rinkel test)
Specimen Collection CPT Codes
Specimen collection codes are used to identify phlebotomy and other services required to obtain body fluids or tissue for laboratory analysis. Medicare and most other payers allow a separate specimen collection charge for drawing or collecting specimens by venipuncture or catheterization whether the specimen is processed on site or referred to another laboratory for analysis. Only one collection fee is allowed for each patient encounter, even when multiple specimens may be collected. When a series of specimens is collected for a single test (for example, glucose tolerance), the series is treated as a single encounter. For non-Medicare claims, the following CPT code is used:
- 36415 ROUTINE VENIPUNCTURE OR FINGER/HEEL/EAR STICK for collection of specimen(s)
- G0001 ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN
Physician laboratories may charge for specimen collection only when (a) it is accepted and prevailing practice among physicians in the locality to make a separate charge for drawing or collecting a specimen, and (b) it is the customary practice of the physician performing such a service to bill separately for specimen collection. In other words, physicians may collect the $3.00 Medicare venipuncture fee only if they also charge other payers for blood draws.
Specimen collection fees are also paid when it is medically necessary for a laboratory technician to draw a specimen from either a nursing home or homebound patient. The technician must personally draw the specimen. When a laboratory performs the specimen collection, it may receive payment both for the draw and the associated travel to obtain the specimen(s) for testing. Payment may be made to the laboratory even if the nursing facility has on-duty personnel qualified to perform the specimen collection. When the nursing home performs the specimen collection, it may receive payment only for the draw. Specimen collection performed by nursing home personnel for patients covered under Medicare Part A is paid for as part of the payment to the facility for its reasonable costs, not on the basis of the specimen collection fee.
The $3.00 Medicare specimen collection fee does not apply to non-routine venipuncture or arterial punctures. Arterial punctures for blood gas testing should be coded as CPT 36600 (arterial puncture, withdrawal of blood for diagnosis). Non-routine venipunctures, such as those common to pediatrics and those performed in atypical vein sites, should be coded using cardiovascular codes, 36400-36410 or 36420-36425. Medicare reimbursement for these procedures is paid from the Physicians' Medicare Fee Schedule rather than the Medicare Laboratory Fee Schedule.
A code for 24-h urine specimens (81050, volume measurement for timed collection, each) was added in 1993 and is used whenever a volumetric measure of urine is required to report a test result.
Enrollment Medicare EDI
How to Enroll in Medicare Electronic Data Interchange
The Centers for Medicare & Medicaid Services (CMS) Standard Electronic Data Interchange (EDI) Enrollment Form must be completed prior to submitting electronic media claims (EMC) or other EDI transactions to Medicare. The agreement must be executed by each provider of health care services, physician, or supplier that intends to submit EMC or use EDI, either directly with Medicare or through a billing service or clearinghouse.
Each new EMC biller must sign the form and submit it to their local Medicare carrier, durable medical equipment regional carrier (DMERC), or fiscal intermediary. For more information regarding the CMS Standard EDI Enrollment Form, please contact your local Carrier, DMERC or Intermediary.
An organization comprising of multiple components that have been assigned Medicare provider numbers, supplier numbers, or UPINs may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these numbers have been assigned. The organization as a whole is held responsible for the performance of its components.
Electronic Data Interchange (EDI) Support
Medicare Carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (MACs), and Durable Medical Equipment (DME) MACs as well as the DME MAC Common Electronic Data Interchange (CEDI) contractor furnish first line Electronic Data Interchange (EDI) support to physicians, suppliers and other providers that submit claims and conduct other Health Insurance Portability and Accountability Act (HIPPA) of 1996 named electronic business with the Medicare Part A and Part B program.
Providers, billing services, clearinghouses, or other entities that furnish services to providers, shall contact the following:• Carrier or A/B MAC – For professional claims, by geographic area in which the provider operates.
• FI or A/B MAC – For institutional claims, by FI that a provider chooses to process their claims. This only applies for Title XVIII FIs, as the A/B MACs will be handling institutional claims by geographic area in which the institution operates.
• DME MAC or CEDI – For durable medical equipment, claims are submitted by zip code of a beneficiary that receives services or supplies billed to.
Use of EDI transactions allows a provider to submit transactions faster and be paid for claims faster, and to accomplish this at a lower cost than is generally the case for paper or manual transactions.Medicare contractors can assist you to begin exchanging EDI transactions by furnishing you with enrollment and connectivity information, system access numbers and passwords, information on those transactions supported by Medicare Part A and Part B, and testing with you to assure correct transmission of the EDI formats. Although these contractors can supply limited EDI training, it is the responsibility of physicians, suppliers and other providers and other entities that will be using EDI to train their staff members on use of the hardware, software, and the security and privacy requirements that apply to HIPAA EDI transactions.
You can use the link(s) below to identify the contractor responsible for your EDI connectivity and for further information on the level of support available by the contractor to entities that exchange Medicare HIPAA EDI transactions.
Medicare information security help
Information Security - Overview
MS Information Security (IS) "Virtual Handbook"
The links to the left are the collection of all CMS policies, standards, procedures, and guidelines which implement the CMS Information Security Program.
"Holding Ourselves to a Higher Standard"
As CMS is a trusted custodian of individual health care data, we must protect its most valuable assets, its information and its information systems. At CMS, we believe that putting the government's credibility at risk is not acceptable.
Computer Based Training (CBT) is mandatory for most users of CMS Information Systems when an individual is initially issued their CMS User Id and then in conjunction with annual certification of their CMS User Id. Select the "CBT Instructions" menu item on the left or the "Information Security CBT" link below.
Access to CMS Systems - for more information about CMS User Ids in the EUA system, the annual User Id certification process, EUA Passport or EUA Workflow, select the the "EUA" link to the left or below. Select the "IACS" link below for User Ids related to Medicare Parts C and D.
Identity Theft - find out everything that you need to know about how to protect yourself or recovery from Identity Theft by visiting the Federal Trade Commission's web site by selecting the "Identity Theft" link below.
Information System Security Officers (ISSO) are the primary points of contact within each CMS Office/Center regarding information security issues and they are the component's liaison with the CMS Chief Information Security Officer (CISO). CMS contractors should contact their Project Officer in order to identify which ISSO supports their system. Select the "ISSO" link below. The CMS ISSO list access is restricted to authorized CMS users.
Security in the Systems Development Lifecycle (SDLC) - Are you involved in the design or maintenance of an information system for CMS ??? Select the links to the left to access the applicable information security laws, regulations, policies, procedures, standards and guidelines that affect all CMS information and information systems. The overall "Systems Lifecycle Framework" can be reached through the link below.
Security Incidents - Known or suspected security incidents involving CMS information or information systems should be reported immediately to the CMS IT Service Desk by calling 410-786-2580 begin_of_the_skype_highlighting 410-786-2580 end_of_the_skype_highlighting or 1-800-562-1963 begin_of_the_skype_highlighting 1-800-562-1963 end_of_the_skype_highlighting or via e-mail to CMS_IT_Service_Desk@cms.hhs.gov. Even if you are not positive but only suspect that it might be a security incident, you should still submit a report and allow the experts to determine whether or not it is a security incident. According the Computer Security Incident Response Team (www.CSIRT.org) a security incident is "An event which changes the security posture of an organization or circumvents security polices developed to prevent financial loss and/or the destruction, theft, or compromise of proprietary information. Also, an event investigated by an organization due to unusual activity, that cannot be explained as a consequence of normal operations.
Some possible classifications for security incidents are:
- Unauthorized Electronic Monitoring
- Misuse of Systems (internal or external)
- Website Defacement, Probes/Scans
- Denial of Service
- Intrusion/Hack
- Virus Attacks (Unable to clean, rename, or delete)
- IDS alert notifications
- External/Internal Threats (espionage)
- Unauthorized accesses to information systems
- Theft of intellectual property
- Extortion
Electronic Data Interchange System Access and Privacy
Medicare systems contain extensive personally identifiable information on beneficiaries. As established by the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA), beneficiaries have a right to expect that their data will not be seen by individuals or entities that do not have a need to know that information for billing or payment purposes. Acceptable uses of beneficiary data, such as for claims processing, are periodically published in the Federal Register.
Electronic Data Interchange (EDI) cannot occur unless providers and their agents such as billing services and clearinghouses are given some level of access to Medicare Systems, but the information which they submit to or obtain from Medicare systems, and the purposes for which they may use that data are limited to protect beneficiaries. Each provider must complete an EDI Enrollment form prior to starting to exchange any EDI transactions either directly with Medicare or through a billing service or clearinghouse. In that agreement, the provider agrees to accept responsibility for safeguarding of beneficiary data and to assure that billing services or clearinghouses whom they may engage to assist with transmission of beneficiary data in turn sign an agreement to also meet the same security and privacy requirements that are binding on the provider as required by CMS and HIPAA.
As part of their EDI Enrollment, each provider must also submit a written notice to their carrier, durable medical equipment regional carrier (DMERC) or fiscal intermediary (FI) specifying which transactions a billing service or clearinghouse is authorized to submit or receive on behalf of the provider, and must notify that same Medicare contractor whenever there is a change in that authorization or representation.
Medicare electronic billing
Electronic Billing & EDI Transactions
This section contains information on:
1. Our Electronic Data Interchange (EDI) transaction and corresponding paper claims requirements;
2. Links to those Chapters of the Medicare Claims Processing Manual (pub.100-04) that contain further information on these types of transactions;
3. Our Health Insurance Portability and Accountability Act (HIPAA) contingency plans;
4. The Administrative Simplification Compliance Act (ASCA) requirement that claims be sent to Medicare electronically as a condition for payment;
5. How you can obtain access to Medicare systems to submit or receive claim or beneficiary eligibility data electronically; and
6. EDI support furnished by Medicare contractors.
The information in this section is intended for the use of health care providers, clearinghouses and billing services that submit transactions to or receive transactions from Medicare fee-for-service contractors. EDI is the automated transfer of data in a specific format following specific data content rules between a health care provider and Medicare, or between Medicare and another health care plan. In some cases, that transfer may take place with the assistance of a clearinghouse or billing service that represents a provider of health care or another payer. EDI transactions are transferred via computer either to or from Medicare. Through use of EDI, both Medicare and health care providers can process transactions faster and at a lower cost.
Drug cpt coding - 80101
CPT Coding and Drugs of Abuse Testing Recommendations
It is our recommendation based on the currently available information that the appropriate CPT code
for on-site drugs of abuse test kits is;
80101* – Drug Screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay)
*add QW modifier if billing Medicare/Medicaid
For code 80101, each single drug class method tested and reported is to be counted as one drug
class. If a sample is analyzed by five separate class-specific immunoassays and reported separately,
code 80101 should be reported five times. Similarly, if a sample is run on a rapid assay kit composed
of five class-specific immunoassays in a single kit, and the five classes are reported separately, code
80101 should again be reported five times.
X the number of drug classes being tested
2009 National Limit: $20.11
It is our recommendation based on the currently available information that the appropriate CPT code
for on-site drugs of abuse test kits is;
80101* – Drug Screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay)
*add QW modifier if billing Medicare/Medicaid
For code 80101, each single drug class method tested and reported is to be counted as one drug
class. If a sample is analyzed by five separate class-specific immunoassays and reported separately,
code 80101 should be reported five times. Similarly, if a sample is run on a rapid assay kit composed
of five class-specific immunoassays in a single kit, and the five classes are reported separately, code
80101 should again be reported five times.
X the number of drug classes being tested
2009 National Limit: $20.11
| Drug Classes for Billing Purposes | ||
| Test | Calibrator | Cut-off |
| Amphetamine (AMP 1,000) | d-Amphetamine | 1,000 ng/mL |
| Barbiturates (BAR) | Secobarbital | 300 ng/mL |
| Benzodiazepines (BZO) | Oxazepam | 300 ng/mL |
| Buprenorphine (BUP) | Buprenorphine | 10 ng/mL |
| Cocaine (COC 300) | Benzoylecgonine | 300 ng/mL |
| Marijuana (THC) | 11-nor-Δ9-THC-9 COOH | 50 ng/mL |
| Methadone (MTD) | Methadone | 300 ng/mL |
| Methamphetamine (mAMP 1,000) Methylenedioxymethamphetamine (MDMA) Ecstasy | d,l Methylenedioxymethamphetamine | 500 ng/mL |
| Opiate (MOP 300) | Morphine | 300 ng/mL |
| Opiate (OPI 2,000) | Morphine | 2,000 ng/mL |
| Oxycodone (OXY) | Oxycodone | 100 ng/mL |
| Phencyclidine (PCP) | Phencyclidine | 25 ng/mL |
| Propoxyphene (PPX) | Propoxyphene | 300 ng/mL |
| Tricyclic Antidepressants (TCA) | Nortriptyline | 1,000 ng/mL |
Limiting Liability Relative to Medical Necessity Issues
The following actions should be useful in dealing with the new medical necessity rules:
- (a) Initiate educational programs for physicians and laboratory staff so that both understand what is required in terms of medical necessity documentation.
- (b) Note any local Medicare carrier policy regarding medical necessity published in Medicare bulletins and disseminate to both laboratory personnel and physicians.
- (c) Make sure that the source of ICD-9 codes can be documented and traced to the ordering physician.
- (d) Review all laboratory requisitions to make sure they comply with Medicare medical necessity rules. All automated tests should be ordered individually unless the selected tests constitute one of the new organ/disease-oriented panels listed in the 1998 CPT.
- (e) Make sure you have all current medical necessity policy from your carrier.
- (f) Create educational materials that help physicians select the correct ICD-9 codes. For example, lists of ICD-9 codes that relate to particular tests or CPT codes.
- (g) Institute a compliance program that ensures the education of all personnel involved in coding and billing Medicare tests, which includes education, periodic third party review, and punitive measures for individuals who do not follow the rules.
Noncovered BMMs
The following BMMs are noncovered under Medicare because they are not considered reasonable and necessary under section 1862(a)(1)(A) of the Act.
• Single photon absorptiometry (effective January 1, 2007).
• Dual photon absorptiometry (established in 1983).
cpt 77080 medicare payment update
CMS-1385-P Proposed Revisions to payment policies under the physician fee schedule and other Part B payment policies for CY 2008
Comments:
�� Practice Expense Inputs – CPT 77080
�� Work RVU – CPT 77080
�� Deficit Reduction Act
Comment: Practice Expense Inputs: CPT 77080 – Axial Bone Density Studies
We question the accuracy of the PE RVU formula after several attempts by various sources to include two CMS representatives to duplicate the .81 PE RVU for CPT 77080-Axial BMD, DXA as outlined in the CMS-1385-P PFS proposed rule it could not be duplicated. We contacted Rick Ensor who sent a detail worksheet with the calculation for determining the total PE RVU value. This worksheet showed the value of .85. ISCD received a similar worksheet from a different source with CMS that contained a few different line items within the calculation that showed a total value of .86. It was explained to us that there are rounding differences that would cause the variance. This would account only for a 1-point difference either way not a 5-point difference. When you take both worksheets and compare the direct and indirect cost, there were differences. After entering the same direct cost the variance is .15. It is important to note, that neither worksheet received from CMS matched the value listed in the proposed rule.
CMS has a responsibility to ensure the formula’s used to calculate the physician fee schedule is accurate and reproducible. We believe there is a significant flaw in the formula, therefore we request CMS to re-evaluate the formula.
We request CMS to revise the practice expense inputs for axial bone density studies to reflect differences in the factors: (1) type of equipment assigned to CPT 77080 & 77081, (2) the utilization rate assumption for these procedures; and (3) factors affecting the indirect cost assumptions. Discussion of each of these issues follows.
check Medicare for new update
Comments:
�� Practice Expense Inputs – CPT 77080
�� Work RVU – CPT 77080
�� Deficit Reduction Act
Comment: Practice Expense Inputs: CPT 77080 – Axial Bone Density Studies
We question the accuracy of the PE RVU formula after several attempts by various sources to include two CMS representatives to duplicate the .81 PE RVU for CPT 77080-Axial BMD, DXA as outlined in the CMS-1385-P PFS proposed rule it could not be duplicated. We contacted Rick Ensor who sent a detail worksheet with the calculation for determining the total PE RVU value. This worksheet showed the value of .85. ISCD received a similar worksheet from a different source with CMS that contained a few different line items within the calculation that showed a total value of .86. It was explained to us that there are rounding differences that would cause the variance. This would account only for a 1-point difference either way not a 5-point difference. When you take both worksheets and compare the direct and indirect cost, there were differences. After entering the same direct cost the variance is .15. It is important to note, that neither worksheet received from CMS matched the value listed in the proposed rule.
CMS has a responsibility to ensure the formula’s used to calculate the physician fee schedule is accurate and reproducible. We believe there is a significant flaw in the formula, therefore we request CMS to re-evaluate the formula.
We request CMS to revise the practice expense inputs for axial bone density studies to reflect differences in the factors: (1) type of equipment assigned to CPT 77080 & 77081, (2) the utilization rate assumption for these procedures; and (3) factors affecting the indirect cost assumptions. Discussion of each of these issues follows.
check Medicare for new update
Anti-Coagulation Management and E& M code
Highmark Medicare Services Position on the Necessity of E/M Services Submitted as a Component Service of Anti-Coagulation Management
Highmark Medicare Services continues to experience both questions and confusion regarding the billing of 99211, (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), in addition to the laboratory blood draws for warfarin management.
An evaluation and management (E/M) service (99211) would be allowable if it is determined that the patient's medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed.
The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or fingerstick) is not medically reasonable and necessary if the following conditions are met:
If the INR is within the therapeutic range, and
In this clinical setting, the medical necessity of a unique clinical service may be predicated upon the clinical circumstances of a previous visit, i.e., a significantly sub or supra-therapeutic INR necessitates quick follow-up. Use of a flow sheet and established protocol helps to provide both good patient care and documentation of medical necessity in these cases. Documentation of the services provided by the physician or nurse, discussion of symptoms, side effects, patient observations, etc. are considered supportive of the 99211 service.
The American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy suggests that the INR be checked daily until the therapeutic range has been reached and sustained for two consecutive days, then 2 or 3 times weekly for 1 to 2 weeks, and then less often based on stability of results. Once the INR becomes stable, the frequency of testing can be reduced to intervals as long as 4 weeks. Highmark Medicare Services expects to see the educational component of anticoagulation management reflected in the use of 99211 in the early post-initiation visits, and less frequently as the stable target of anti-coagulation is reached. Two cited European studies make a strong case for Patient Self-Testing and Management, in which case, the patient education would be documented within the appropriate level of an established E/M service, where time/counseling service guidelines would apply.
An evaluation and management (E/M) service (99211) would be allowable if it is determined that the patient's medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed.
The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or fingerstick) is not medically reasonable and necessary if the following conditions are met:
If the INR is within the therapeutic range, and
- the documentation does not support a need for adjustment of warfarin dosage, or
- the documentation does not support that the patient is symptomatic, or
- the documentation does not support the presence of a new medical co-morbidity or dietary change.
In this clinical setting, the medical necessity of a unique clinical service may be predicated upon the clinical circumstances of a previous visit, i.e., a significantly sub or supra-therapeutic INR necessitates quick follow-up. Use of a flow sheet and established protocol helps to provide both good patient care and documentation of medical necessity in these cases. Documentation of the services provided by the physician or nurse, discussion of symptoms, side effects, patient observations, etc. are considered supportive of the 99211 service.
The American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy suggests that the INR be checked daily until the therapeutic range has been reached and sustained for two consecutive days, then 2 or 3 times weekly for 1 to 2 weeks, and then less often based on stability of results. Once the INR becomes stable, the frequency of testing can be reduced to intervals as long as 4 weeks. Highmark Medicare Services expects to see the educational component of anticoagulation management reflected in the use of 99211 in the early post-initiation visits, and less frequently as the stable target of anti-coagulation is reached. Two cited European studies make a strong case for Patient Self-Testing and Management, in which case, the patient education would be documented within the appropriate level of an established E/M service, where time/counseling service guidelines would apply.
TOP ten ways to avoid appeal
Ways to AVOID an Appeal
1. 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.
2. Become familiar with Local Coverage Determinations (LCD).
3. Become familiar with National Coverage Determinations (NCD).
4. Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.
5. 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.
6. 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.
7. Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.
8. The supporting documentation must include the rendering physician’s signature. Failure to provide a valid signature will result in a denial.
9. 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.
10. 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.
1. 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.
2. Become familiar with Local Coverage Determinations (LCD).
3. Become familiar with National Coverage Determinations (NCD).
4. Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.
5. 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.
6. 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.
7. Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.
8. The supporting documentation must include the rendering physician’s signature. Failure to provide a valid signature will result in a denial.
9. 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.
10. 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.
Thursday, September 23, 2010
Billing FECAL-OCCULT BLOOD TEST-G0328
FECAL-OCCULT BLOOD TEST-G0328
Medicare will cover a new colorectal cancer screening for fecal-occult blood test, HCPCS G0328 effective for dates of service on/after January 1, 2004. This article provides coverage, coding, frequency and billing guidelines for this service.
Policy
Medicare will cover the new colorectal cancer screening FOBT G0328 beginning January 1, 2004. G0328 is payable under the clinical lab fee schedule. Medicare patients aged 50 and over can only receive one FOBT per year, either G0107 (gFOBT, or guaiac-based) or G0328 (iFOBT, or immunoassay-based).
A covered screening FOBT is allowed once every 12 months for beneficiaries who have attained age 50 (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). Medicare will allow either one covered G0107 gFOBT or one covered G0328 iFOBT, but not both during a 12-month period.
Screening FOBT means: (1) a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or, (2) a immunoassay (or immunochemical) test for antibody activity in which the beneficiary completes the test by taking the appropriate number of samples according to the specific manufacturer?s instructions.
This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes "other tests determined by the Secretary through a national coverage determination." This screening requires a written order from the beneficiary?s attending physician. (The term "attending physician" is defined to mean a doctor of medicine or osteopathy who is fully knowledgeable about the beneficiary?s medical condition and who would be responsible for using the results of any examination performed in the overall management of the beneficiary?s specific medical problem.)
This coverage revision is a National Coverage Determination (NCD). NCDs are binding on all Medicare carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on a Medicare Choice Organization. In addition, an administrative law judge may not review an NCD (See Section 1869(f)(1)(A)(i) of the Social Security Act).
Applies to the state of AK, AZ, CO, HI, IA, ND, NV, OR, SD, WA & WY.
Medicare will cover a new colorectal cancer screening for fecal-occult blood test, HCPCS G0328 effective for dates of service on/after January 1, 2004. This article provides coverage, coding, frequency and billing guidelines for this service.
Policy
Medicare will cover the new colorectal cancer screening FOBT G0328 beginning January 1, 2004. G0328 is payable under the clinical lab fee schedule. Medicare patients aged 50 and over can only receive one FOBT per year, either G0107 (gFOBT, or guaiac-based) or G0328 (iFOBT, or immunoassay-based).
A covered screening FOBT is allowed once every 12 months for beneficiaries who have attained age 50 (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). Medicare will allow either one covered G0107 gFOBT or one covered G0328 iFOBT, but not both during a 12-month period.
Screening FOBT means: (1) a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or, (2) a immunoassay (or immunochemical) test for antibody activity in which the beneficiary completes the test by taking the appropriate number of samples according to the specific manufacturer?s instructions.
This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes "other tests determined by the Secretary through a national coverage determination." This screening requires a written order from the beneficiary?s attending physician. (The term "attending physician" is defined to mean a doctor of medicine or osteopathy who is fully knowledgeable about the beneficiary?s medical condition and who would be responsible for using the results of any examination performed in the overall management of the beneficiary?s specific medical problem.)
This coverage revision is a National Coverage Determination (NCD). NCDs are binding on all Medicare carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on a Medicare Choice Organization. In addition, an administrative law judge may not review an NCD (See Section 1869(f)(1)(A)(i) of the Social Security Act).
Applies to the state of AK, AZ, CO, HI, IA, ND, NV, OR, SD, WA & WY.
which one is right ? CPT G0328 or 82274
G0328 or 82274? Choose Just 1 Fecal Blood Code
NCCI 10.2 bundles all FOBT code combinations
If you didn’t get the message from Medicare’s immunoassay fecal-occult blood test (iFOBT) coverage rules, you’ll get the message from the latest National Correct Coding Initiative (NCCI) edits — you must report either G0328 (Fecal blood screening immunoassay) or 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) for the iFOBT test.
NCCI 10.2, which took effect July 1, added a mutually exclusive edit pair that bundles G0328 and 82274 together. A”0″ modifier indicator means that you cannot under any circumstances override the edit pair for Medicare payment.
‘Reason for Test’ Drives Coding
Medicare recognizes the two iFOBT codes based on whether the physician orders the test for colorectal cancer screening (G0328) or for a diagnostic purpose (82274).
You should use the HCPCS Level II code if the ordering physician states that the FOBT is for colorectal cancer screening or requests the test with a screening code such as V76.51 (Special screening for malignant neoplasms; colon), according to Anne Pontius, MBA, CMPE, MT (ASCP), president of Laboratory Compliance Consultants Inc., in Raleigh, N.C.
Earlier NCCI Bundled Guaiac FOBT
Medicare also covers guaiac-based FOBT (gFOBT) for diagnostic purposes (82270, Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, 1-3 simultaneous determinations) or colorectal cancer screening G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations).
The latest NCCI edits’addition of the G0328/82274 code pair completes FOBT code bundling. NCCI continues to include the following code pairs added in previous NCCI versions: G0107/82270, 82274/82270, G0328/82270 and G0328/G0107.
Bottom line: You must select only one FOBT test code based on the lab method used and the reason for the test (screening or diagnostic).
NCCI 10.2 bundles all FOBT code combinations
If you didn’t get the message from Medicare’s immunoassay fecal-occult blood test (iFOBT) coverage rules, you’ll get the message from the latest National Correct Coding Initiative (NCCI) edits — you must report either G0328 (Fecal blood screening immunoassay) or 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) for the iFOBT test.
NCCI 10.2, which took effect July 1, added a mutually exclusive edit pair that bundles G0328 and 82274 together. A”0″ modifier indicator means that you cannot under any circumstances override the edit pair for Medicare payment.
‘Reason for Test’ Drives Coding
Medicare recognizes the two iFOBT codes based on whether the physician orders the test for colorectal cancer screening (G0328) or for a diagnostic purpose (82274).
You should use the HCPCS Level II code if the ordering physician states that the FOBT is for colorectal cancer screening or requests the test with a screening code such as V76.51 (Special screening for malignant neoplasms; colon), according to Anne Pontius, MBA, CMPE, MT (ASCP), president of Laboratory Compliance Consultants Inc., in Raleigh, N.C.
Earlier NCCI Bundled Guaiac FOBT
Medicare also covers guaiac-based FOBT (gFOBT) for diagnostic purposes (82270, Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, 1-3 simultaneous determinations) or colorectal cancer screening G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations).
The latest NCCI edits’addition of the G0328/82274 code pair completes FOBT code bundling. NCCI continues to include the following code pairs added in previous NCCI versions: G0107/82270, 82274/82270, G0328/82270 and G0328/G0107.
Bottom line: You must select only one FOBT test code based on the lab method used and the reason for the test (screening or diagnostic).
If patient seen another provider in the same group - whether consider as new patient
FAQ
Is it required by Medicare and Medicaid to have a referring physician in order to be able to bill for a new patient evaluation? If so, what should one do if the patient self refers himself/herself to you because of reputation/friend etc.?
Response: The CMS definition for a new patient states that, “such a patient would be regarded as a new patient, a patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient. Effective January 1, 2010, CMS has eliminated payment for the office or other outpatient consultation codes 99241- 99245. The office and other outpatient visit codes for new patients (99201- 99205) are still recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. As a result of these changes, there is no distinction between a patient who is referred by a physician or one who is self referred; for Medicare they are both considered a new patient. The E/M codes that can be used are CPT codes 99201 – 99205.
CPT code 99201: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.
CPT code 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.
CPT code 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
CPT code 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.
CPT code 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.
CPT code 99241: Office consultation for a new or established patient, which requires these 3 components: a problem focused history, a problem focused examination, and straightforward medical decision making.
CPT code 99242: Office consultation for a new or established patient, which requires these 3 components: an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision making.
CPT code 99243: Office consultation for a new or established patient, which requires these 3 components: a detailed history, a detailed examination, and medical decision making of low complexity.
CPT code 99244: Office consultation for a new or established patient, which requires these 3 components: a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.
CPT code 99245: Office consultation for a new or established patient, which requires these 3 components: a comprehensive history, a comprehensive examination, and medical decision making of high complexity.
Is it required by Medicare and Medicaid to have a referring physician in order to be able to bill for a new patient evaluation? If so, what should one do if the patient self refers himself/herself to you because of reputation/friend etc.?
Response: The CMS definition for a new patient states that, “such a patient would be regarded as a new patient, a patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient. Effective January 1, 2010, CMS has eliminated payment for the office or other outpatient consultation codes 99241- 99245. The office and other outpatient visit codes for new patients (99201- 99205) are still recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. As a result of these changes, there is no distinction between a patient who is referred by a physician or one who is self referred; for Medicare they are both considered a new patient. The E/M codes that can be used are CPT codes 99201 – 99205.
CPT code 99201: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.
CPT code 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.
CPT code 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
CPT code 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.
CPT code 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.
CPT code 99241: Office consultation for a new or established patient, which requires these 3 components: a problem focused history, a problem focused examination, and straightforward medical decision making.
CPT code 99242: Office consultation for a new or established patient, which requires these 3 components: an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision making.
CPT code 99243: Office consultation for a new or established patient, which requires these 3 components: a detailed history, a detailed examination, and medical decision making of low complexity.
CPT code 99244: Office consultation for a new or established patient, which requires these 3 components: a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.
CPT code 99245: Office consultation for a new or established patient, which requires these 3 components: a comprehensive history, a comprehensive examination, and medical decision making of high complexity.
radiation oncologist telephonce E & M service - CPT 99441,99442
FAQ
Question: If a radiation oncologist provides E/M services to his/her patients via telephone, can they bill 99441, 99442 and 99443? Also, can a Medicare Provider bill these CPT codes and, if so, where can the pricing be found on the Medicare Fee Schedule? Can this kind of phone service be billed under any other E/M billing code that is on the Medicare Fee Schedule?
Response: CPT codes 99441 - 99443 describe telephone evaluation and management services provided by a physician to an established patient. The patient or patient’s parent/guardian must initiate the contact as these codes may not be used for calls initiated by a provider. The codes are differentiated according to the length of the medical discussion with the patient. These codes are used only for services personally performed by a physician. CPT codes 98966-98968 describe telephone services performed by qualified non-physician health care professionals. Medicare has designated all telephone evaluation management codes with a status indicator “N” which indicates the service is not covered by Medicare. It should be noted that relative value units (RVUs) are listed for these codes in the Medicare Physician Fee Schedule. Therefore, while Medicare does not cover these services, some private payers could potentially cover these services and use the RVUs assigned by Medicare to set payment rates. ASTRO recommends you review the current policies of your major payers to determine their coverage policies regarding telephone evaluation management services. Phone calls during treatment are included in the work captured in CPT code 77427 which includes a 90-day global period after treatment is completed.
CPT® code 77427: Radiation treatment management, 5 treatments
CPT® code 98966: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
CPT® code 98967: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
CPT® code 98968: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
CPT® code 99441: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
CPT® code 99442: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
CPT® code 99443: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
Question: If a radiation oncologist provides E/M services to his/her patients via telephone, can they bill 99441, 99442 and 99443? Also, can a Medicare Provider bill these CPT codes and, if so, where can the pricing be found on the Medicare Fee Schedule? Can this kind of phone service be billed under any other E/M billing code that is on the Medicare Fee Schedule?
Response: CPT codes 99441 - 99443 describe telephone evaluation and management services provided by a physician to an established patient. The patient or patient’s parent/guardian must initiate the contact as these codes may not be used for calls initiated by a provider. The codes are differentiated according to the length of the medical discussion with the patient. These codes are used only for services personally performed by a physician. CPT codes 98966-98968 describe telephone services performed by qualified non-physician health care professionals. Medicare has designated all telephone evaluation management codes with a status indicator “N” which indicates the service is not covered by Medicare. It should be noted that relative value units (RVUs) are listed for these codes in the Medicare Physician Fee Schedule. Therefore, while Medicare does not cover these services, some private payers could potentially cover these services and use the RVUs assigned by Medicare to set payment rates. ASTRO recommends you review the current policies of your major payers to determine their coverage policies regarding telephone evaluation management services. Phone calls during treatment are included in the work captured in CPT code 77427 which includes a 90-day global period after treatment is completed.
CPT® code 77427: Radiation treatment management, 5 treatments
CPT® code 98966: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
CPT® code 98967: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
CPT® code 98968: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
CPT® code 99441: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
CPT® code 99442: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
CPT® code 99443: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
What is and A-Code ?
A-Codes: relate to emergent and non-emergent transportation services; miscellaneous medical and surgical supplies including dressings, ostomy and urinary supplies, some diabetic and DME supplies; also includes radiopharmaceutical diagnostic agents.
Please note:
ReimbursementCodes.com contains information for radiopharmaceuticals, ostomy, wound care and some diabetic medical supplies (needles, syringes, etc.) only.
Reimb Code | Description | Effective Date | Code Price | Code Price-5% |
A9516 | Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries (Code Price is per 100 microcuries) | 08/1/09 | $141.01 | $133.96 |
Related Links :
Massage Therapy billing - CPT 97010, 97124 97140
Billing Codes for Massage Therapists
CPT (Current Procedural Terminology) codes for massage therapy and related procedures - identifies the type of care or the procedure that is used in that care. The best way to know what codes the insurance company will accept is to call and ask them! You can not just bill whatever code that they accept. You have to bill what ever code you are trained in. Setting your fees for these codes are another issue. Just because you can get paid more for certain codes, you have to charge the same amount you charge cash clients (plus whatever additional billing fee there is) or else it is considered insurance fraud.
97010- modality; hot or cold packs- 15 minute increment
97124- massage treatment-15 minute increment
97140- myofascial release, manual therapy- 15 minute increment
97112- neuromuscular re-education- 15 minute increment
Diagnosis codes (ICD codes-International Classification of Disease)- Diagnosis codes are often needed when billing even though we are not able to diagnose. This information should come from the referring physician. If the physician does not write the code on the prescription, call them directly to get the code. I highly recommend that you do not try to select your own code from the online code finder or the information below as each physician may code things differently. I am providing this information because physicians often write the code but they don't say what it means.
Call the Physician to get the correct code.
CPT (Current Procedural Terminology) codes for massage therapy and related procedures - identifies the type of care or the procedure that is used in that care. The best way to know what codes the insurance company will accept is to call and ask them! You can not just bill whatever code that they accept. You have to bill what ever code you are trained in. Setting your fees for these codes are another issue. Just because you can get paid more for certain codes, you have to charge the same amount you charge cash clients (plus whatever additional billing fee there is) or else it is considered insurance fraud.
97010- modality; hot or cold packs- 15 minute increment
97124- massage treatment-15 minute increment
97140- myofascial release, manual therapy- 15 minute increment
97112- neuromuscular re-education- 15 minute increment
Diagnosis codes (ICD codes-International Classification of Disease)- Diagnosis codes are often needed when billing even though we are not able to diagnose. This information should come from the referring physician. If the physician does not write the code on the prescription, call them directly to get the code. I highly recommend that you do not try to select your own code from the online code finder or the information below as each physician may code things differently. I am providing this information because physicians often write the code but they don't say what it means.
Call the Physician to get the correct code.
Sunday, September 19, 2010
What locations can I get Medicare-covered ambulance transportation to and from?
Medicare may cover ambulance transport to and from certain locations that are within your service area and able to provide you with the care you need.
The service area is the geographical region around a facility that contains most of the patients whom the facility serves. For example, if you live in a town with a small community hospital and there is a larger urban hospital 20 miles away, the larger hospital would be part of your service area if it regularly serves people who live in your town.
The service area is the geographical region around a facility that contains most of the patients whom the facility serves. For example, if you live in a town with a small community hospital and there is a larger urban hospital 20 miles away, the larger hospital would be part of your service area if it regularly serves people who live in your town.
| From… | To… | |||
| Your home, or any other place where the need arose… | the closest appropriate hospital or skilled nursing facility (SNF). | |||
| A hospital or SNF… | your home if the facility is the closest appropriate one in relation to your home. | |||
| A SNF… | the nearest medical provider, if the SNF cannot provide you necessary treatment and the cost of transport is less then bringing the treatment to you, and back. | |||
| Your home… | the nearest appropriate renal dialysis facility, and back. | |||
Note: If your service area does not have a facility that is adequately equipped or capable of treating you, transport to the closest appropriate facility outside of your service area will be covered. However, Medicare will not pay for an ambulance transport to a hospital outside of your service area just so you can receive care from a particular doctor if the nearby hospital can treat you.
Medicare ambulance transportation coverage and guidelines
Does my doctor have to certify that I need ground ambulance transportation?
A doctor does not have to certify that your health requires ground ambulance transportation if it is an emergency. For non-emergency ground transportation, doctor certification may be needed, but it depends on your circumstances.
If you want to schedule regular ambulance trips, your doctor must send the supplier a written order ahead of time. The order can be dated no earlier than 60 days before the trip.
For irregular or unscheduled or trips, your doctor must send a written order to the supplier within 48 hours if you are in a SNF and are under the care of a doctor. If you are at home or in a facility where you are not under the direct care of a doctor, a doctor certification is not required.
A doctor does not have to certify that your health requires ground ambulance transportation if it is an emergency. For non-emergency ground transportation, doctor certification may be needed, but it depends on your circumstances.
If you want to schedule regular ambulance trips, your doctor must send the supplier a written order ahead of time. The order can be dated no earlier than 60 days before the trip.
For irregular or unscheduled or trips, your doctor must send a written order to the supplier within 48 hours if you are in a SNF and are under the care of a doctor. If you are at home or in a facility where you are not under the direct care of a doctor, a doctor certification is not required.
Will Medicare pay for air ambulance transportation?
Medicare will cover transportation in an air ambulance only in limited cases. It must be medically necessary for you to receive immediate and rapid ambulance transportation that could not be provided by a ground ambulance and either:
Note:In rural areas, medical necessity is automatically met if:
- A ground ambulance cannot get to where you are; or
- There is a great distance to travel or another obstacle involved in getting you to the nearest appropriate facility.
Note:In rural areas, medical necessity is automatically met if:
- A physician or other medical professional determines that air transport is necessary due to time or geographical factors and
- The air transport meets Medicare-approved air ambulance protocols.
What do I pay under Original Medicare when I go to the doctor?
For Medicare-covered services, you must first pay the Medicare Part B annual deductible, which is $155 in 2010.
After you have met your deductible, you pay a Part B coinsurance for Medicare-covered services. For doctors’ visits you generally pay 20 percent of the Medicare-approved amount. For mental health services you pay 45 percent of the Medicare-approved amount.
You may have to pay more depending on what your doctor charges and whether the doctor takes Medicare assignment:
- Most doctors who treat patients with Medicare accept assignment, which means they agree to accept the Medicare-approved amount as payment in full. Participating providers always take assignment. When you see a doctor who takes assignment, you are only responsible for the coinsurance amount.
- Non-participating doctors, or doctors who don’t routinely take assignment, can bill their Medicare patients up to 15 percent more than the Medicare-approved amount for most services and can request full payment up front for services. When you see a doctor that does not take assignment, you pay up to 15 percent of the Medicare-approved amount in addition to 20 percent of the Medicare-approved amount (45 percent for mental health services).
- Some states may have stricter limits on what doctors may charge you. See the MI Extra to find out what percent of the Medicare-approved cost for services a non-participating doctor may charge you in your state in addition to your coinsurance. You can also call your State Health Insurance Assistance Program (SHIP) to find out more.
- Providers who have opted out of Medicare can charge their Medicare patients whatever they want. They must officially opt out. These providers do not submit any claims to Medicare and are not subject to the Medicare law that limits the amount providers may charge patients. When you see a doctor who has opted out of Medicare, you pay the entire cost of your care (except in emergencies). The doctor should have you sign a private contract that states that you understand you are responsible for the full cost of the services. Medicare will not pay for any of the cost of services you receive.
Medicare reimbursement basic questions - provider accept assignment
When I see my doctor, must I pay first and then get Medicare to reimburse me?
It depends on your doctor and on whether your doctor accepts assignment.
If your doctor accepts assignment:
He or she can only ask you to pay the 20 percent coinsurance (45 percent for mental health services) up front (and your Part B deductible if you have not yet reached it—$155 in 2010). Your doctor files the claims, and Medicare pays the doctor directly.
If your doctor does NOT accept assignment:
Your doctor may ask you to pay the full amount for services in advance and charge you up to 15 percent more than Medicare’s approved amount under federal law. Some states have stricter limits on what your doctor can charge you. See the MI Extra to find out what percent of the Medicare-approved amount a non-participating provider may charge you in your state in addition to the Medicare coinsurance.
Medicare will reimburse you directly for its part of the bill (80 percent of Medicare's approved amount for most medical services; 55 percent for mental health services).
If your doctor accepts assignment:
He or she can only ask you to pay the 20 percent coinsurance (45 percent for mental health services) up front (and your Part B deductible if you have not yet reached it—$155 in 2010). Your doctor files the claims, and Medicare pays the doctor directly.
If your doctor does NOT accept assignment:
Your doctor may ask you to pay the full amount for services in advance and charge you up to 15 percent more than Medicare’s approved amount under federal law. Some states have stricter limits on what your doctor can charge you. See the MI Extra to find out what percent of the Medicare-approved amount a non-participating provider may charge you in your state in addition to the Medicare coinsurance.
Medicare will reimburse you directly for its part of the bill (80 percent of Medicare's approved amount for most medical services; 55 percent for mental health services).
Thursday, September 16, 2010
Billing CPT 77080, 77081, 77082 with covered dx
REIMBURSEMENT CODES FOR BONE DENSITOMETRY
The new Balanced Budget Amendment, signed into law, mandates preventative care for high risk individuals, and guarantees Bone Density Reimbursement even if the test is negative and also requires all states to pay for the codes below starting July 1998.
CPT Code 77080 - Hip, spine or central DEXA (Dual Energy X-Ray Absorptiometry) studies.
CPT Code 77081 - Peripheral DEXA Bone Mineral Density
CPT Code 77082 - Peripheral Ultrasound Bone Mineral Density
Osteopenias
* Osteoporosis
* Crush fractures of the spine
Thyroid Disease
Cushing's Disease
* Long-term corticosteriod use
Osteomalacia
* Hyperparathyroidism
* To monitor course of therapy
* Recent fracture of hip, spine, etc.
*252.0 Hyperparathyroidism
255.0 Cushing Syndrome
*256.2 Post Oblative Ovarian Failure - Age 40 and below
*256.3 Primary Ovarian Failure - Age 40 and below
256.30 Premature Osteoporosis
+256.8 Ovarian Dysfunction
257.2 Testicular Dysfunction
268.2 Osteomalacia/Osteoporosis Syndrome
269.1 Mineral Deficiency
307.1 Anorexia Nervosa/Bulimia
579.8 Malabsorption of Calcium
585.0 Chronic Renal Failure
588.0 Renal Osteodystrophy
588.8 Secondary Hyperparathyroidism
+627.20 Menopausal Syndrome
714.0 Rheumatoid Arthritis
715.0 Osteoarthritis
716.0 Arthritis
*733.00 General Osteoporosis
*733.01 Postmenopausal or Senile Osteoporosis
*733.02 Idiopathic Osteoporosis
733.03 Disuse Osteoporosis
*733.09 Drug Induced Osteoporosis
*733.8 Diabetic Bone Changes
+733.90 Osteopenia
*733.09 Use with Patients on Following Drugs: Corticosteroids, Heparin, Phenytoin, Thyroid Replacements (only if TSH Level is Subnormal)
*805.2 Fracture of Thoracic Spine,Closed
*806.4 Fracture of Lumbar Spine, Closed
*807.01 Fracture of Rib, Closed, One Rib
*807.02 Fracture of Rib, Closed,Two Ribs
*808.0-808.9 Fracture of Pelvis
*820.0-820.9 Fracture of Neck Femur
*808.00 Pelvic Fracture
*813.41 Colles Fracture
*814.00 Wrist Fracture
*V58.69 Long Term (current) use of high risk medication. (Generally used with 733.09)
• Excess Alcohol Consumption
• Low Body Weight
• Advanced Age
• Early Menopause
• Smoking History
• Family History of Osteoporosis
• Inadequate Calcium Intake
• Inactive Lifestyle
• Previous Fracture
The new Balanced Budget Amendment, signed into law, mandates preventative care for high risk individuals, and guarantees Bone Density Reimbursement even if the test is negative and also requires all states to pay for the codes below starting July 1998.
CPT Code 77080 - Hip, spine or central DEXA (Dual Energy X-Ray Absorptiometry) studies.
CPT Code 77081 - Peripheral DEXA Bone Mineral Density
CPT Code 77082 - Peripheral Ultrasound Bone Mineral Density
Indications for DEXA
Estrogen deficiencyOsteopenias
* Osteoporosis
* Crush fractures of the spine
Thyroid Disease
Cushing's Disease
* Long-term corticosteriod use
Osteomalacia
* Hyperparathyroidism
* To monitor course of therapy
* Recent fracture of hip, spine, etc.
Commonly Used ICD-9 Codes
ICD-9 Diagnosis*252.0 Hyperparathyroidism
255.0 Cushing Syndrome
*256.2 Post Oblative Ovarian Failure - Age 40 and below
*256.3 Primary Ovarian Failure - Age 40 and below
256.30 Premature Osteoporosis
+256.8 Ovarian Dysfunction
257.2 Testicular Dysfunction
268.2 Osteomalacia/Osteoporosis Syndrome
269.1 Mineral Deficiency
307.1 Anorexia Nervosa/Bulimia
579.8 Malabsorption of Calcium
585.0 Chronic Renal Failure
588.0 Renal Osteodystrophy
588.8 Secondary Hyperparathyroidism
+627.20 Menopausal Syndrome
714.0 Rheumatoid Arthritis
715.0 Osteoarthritis
716.0 Arthritis
*733.00 General Osteoporosis
*733.01 Postmenopausal or Senile Osteoporosis
*733.02 Idiopathic Osteoporosis
733.03 Disuse Osteoporosis
*733.09 Drug Induced Osteoporosis
*733.8 Diabetic Bone Changes
+733.90 Osteopenia
*733.09 Use with Patients on Following Drugs: Corticosteroids, Heparin, Phenytoin, Thyroid Replacements (only if TSH Level is Subnormal)
*805.2 Fracture of Thoracic Spine,Closed
*806.4 Fracture of Lumbar Spine, Closed
*807.01 Fracture of Rib, Closed, One Rib
*807.02 Fracture of Rib, Closed,Two Ribs
*808.0-808.9 Fracture of Pelvis
*820.0-820.9 Fracture of Neck Femur
*808.00 Pelvic Fracture
*813.41 Colles Fracture
*814.00 Wrist Fracture
*V58.69 Long Term (current) use of high risk medication. (Generally used with 733.09)
(+) Can be used in some states now (Not in Tennessee). Can be used after July 1, 1998 in all states along with all other codes listed.
(*) To get paid on negative or osteopenic studies one must use a code with (*) by it until July 1, 1998. Then all codes listed are acceptable for high risk (perimenopausal) individuals with two or more of the following risk factors:
• White or Asian Ancestry• Excess Alcohol Consumption
• Low Body Weight
• Advanced Age
• Early Menopause
• Smoking History
• Family History of Osteoporosis
• Inadequate Calcium Intake
• Inactive Lifestyle
• Previous Fracture
Billing BMM test - Medicare CPT list
BMM Test
• Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.
o Contractors will pay claims for screening tests when coded as follows:
• Contains CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130, and
• Contains a valid ICD-9-CM diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Contractors are to maintain local lists of valid codes for the benefit’s screening categories.
o Contractors will deny claims for screening tests when coded as follows:
• Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, but
• Does not contain a valid ICD-9-CM diagnosis code from the local lists of valid ICD-9-CM diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
• Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.
o Contractors will pay claims for monitoring tests when coded as follows:
•
Contains CPT procedure code 77080, and
•
Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code.
o Contractors will deny claims for monitoring tests when coded as follows:
• Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and
• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code, but
• Does not contain a valid ICD-9-CM diagnosis code from the local lists of valid ICD-9-CM diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
• Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350.
• Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.
o Contractors will pay claims for screening tests when coded as follows:
• Contains CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130, and
• Contains a valid ICD-9-CM diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Contractors are to maintain local lists of valid codes for the benefit’s screening categories.
o Contractors will deny claims for screening tests when coded as follows:
• Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, but
• Does not contain a valid ICD-9-CM diagnosis code from the local lists of valid ICD-9-CM diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
• Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.
o Contractors will pay claims for monitoring tests when coded as follows:
•
Contains CPT procedure code 77080, and
•
Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code.
o Contractors will deny claims for monitoring tests when coded as follows:
• Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and
• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code, but
• Does not contain a valid ICD-9-CM diagnosis code from the local lists of valid ICD-9-CM diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
• Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350.
BMM new updated CPTS
Effective for dates of services on and after January 1, 2007, the following changes apply to BMM:
• New 2007 CPT bone mass procedure codes have been assigned for BMM. The following codes will replace current codes, however the CPT descriptors for the services remain the same:
77078 replaces 76070
77079 replaces 76071
77080 replaces 76075
77081 replaces 76076
77083 replaces 76078
• New 2007 CPT bone mass procedure codes have been assigned for BMM. The following codes will replace current codes, however the CPT descriptors for the services remain the same:
77078 replaces 76070
77079 replaces 76071
77080 replaces 76075
77081 replaces 76076
77083 replaces 76078
WHO is eligible for BMM (Bone Mass measurements)
Beneficiaries Who May be Covered BMM
To be covered, a beneficiary must meet at least one of the five conditions listed below:
1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.
NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.
2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
4. An individual with primary hyperparathyroidism.
5. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.
To be covered, a beneficiary must meet at least one of the five conditions listed below:
1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.
NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.
2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
4. An individual with primary hyperparathyroidism.
5. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.
Medicare covereage of Bone Masss measurements CPT 77080
Conditions for Coverage for Bone Mass Measurements CPT 77080
Medicare covers BMM under the following conditions:
1. Is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary following an evaluation of the need for a BMM and determination of the appropriate BMM to be used.
A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision is one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the patient. For the purposes of the BMM benefit, qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.
2. Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
3. Is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the conditions described in §80.5.6.
4. In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry system (axial skeleton).
5. In the case of any individual who meets the conditions of 80.5.6 and who has a confirmatory BMM, is performed by a dual-energy x-ray absorptiometry system (axial skeleton) if the initial BMM was not performed by a dual-energy x-ray absorptiometry system (axial skeleton). A confirmatory baseline BMM is not covered if the initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton).
Medicare covers BMM under the following conditions:
1. Is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary following an evaluation of the need for a BMM and determination of the appropriate BMM to be used.
A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision is one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the patient. For the purposes of the BMM benefit, qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.
2. Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
3. Is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the conditions described in §80.5.6.
4. In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry system (axial skeleton).
5. In the case of any individual who meets the conditions of 80.5.6 and who has a confirmatory BMM, is performed by a dual-energy x-ray absorptiometry system (axial skeleton) if the initial BMM was not performed by a dual-energy x-ray absorptiometry system (axial skeleton). A confirmatory baseline BMM is not covered if the initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton).
Billing CPT 77080
Bone Mass Measurements CPT 77080
BMM means a radiologic, radioisotopic, or other procedure that meets all of the following conditions:
• Is performed to identify bone mass, detect bone loss, or determine bone quality.
• Is performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814.
• Includes a physician’s interpretation of the results.
BMM means a radiologic, radioisotopic, or other procedure that meets all of the following conditions:
• Is performed to identify bone mass, detect bone loss, or determine bone quality.
• Is performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814.
• Includes a physician’s interpretation of the results.
Wednesday, September 15, 2010
NCPDP 5.1 ERROR CODES
NCPDP 5.1 ERROR CODES
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Medicare physician fee schedule - Quick overview
