Avoiding e-prescription fine payment from Medicare

Do you want to avoid the 1% Medicare Part B payment adjustment on claims in 2012?

*  Send at least 10 e-prescriptions for Medicare Part B patient visits which include one of the e-prescribing denominator codes*

AND

*  Send your 10 claims to Medicare Part B with the denominator code* and code G8553 before 6/30/2011
OR

* Send one (1) claim to Medicare Part B with the denominator code and one of the Hardship codes before 6/30/2011


G8642: The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act

G8643: The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act

G8644: the eligible professional does not have prescribing privileges

Hyaluronate Polymers CPT code J7231, J7323, J7324, J7325

Various hyaluronic acid polymers have been approved and marketed as implanted prosthetic devices. Clinical studies of sodium hyaluronate and hylan G-F-20 have demonstrated that injection of these agents into the joint space of osteoarthritic knees is sometimes marginally more effective than placebo procedures in reduction of pain and improvement in functional capacity in some patients. These marginal beneficial results are more pronounced with the larger molecular weight compound hylan G-F 20. There are no data indicating that these agents reverse or retard the osteoarthritic process in the injected joints. The long-term effects of repeated injections are unknown.

• Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria:
  • Knee pain associated with radiographic evidence of osteophytes in the knee joint, sclerosis in bone adjacent to knee or joint space narrowing.
  • Morning stiffness of less than 30 minutes in duration or crepitus on motion of the knee.
• The pain cannot be attributed to other forms of joint disease.
• The prosthetic device is approved by the FDA for intra-articular injection.
• Pain that interferes with functional activities (e.g., ambulation, prolonged standing, ability to sleep).
• Lack of functional improvement following a trial of at least three months of conservative therapy, or the patient is unable to tolerate Non-Steroidal Anti-Inflammatory Drug (NSAID) therapy because of adverse side effects.
• Bilateral injections may be allowed if both knees meet the criteria.

The frequency of injections is:

• An initial series of three to five weekly injections per knee. Note: Synvisc-ONE is administered through a single intra-articular injection.
• A repeat series of injections for patients who have responded to the first series may be given individual consideration by Medicare for coverage under the following circumstances:
  • The medical record objectively documents significant improvement in pain and functional capacity using a standardized assessment tool.

Or,

• The medical record documents significant reduction in the doses of non-steroidal anti-inflammatory medications taken or reduction in the number of intra-articular steroid injections to the knees during the six-month period following the injection.
• And,
• At least six months have elapsed since the prior series of injections.

A series is defined as a set of injections for each joint and each treatment. The EJ modifier must be used with the HCPCS code for the drug administered to indicate subsequent injections of a series. The modifier is not to be used with the first injection of each series.

The appropriate records documenting the improvement must be maintained in the medical record and made available to Medicare upon request.

If the series of injections using sodium hyaluronate did not prove to be beneficial to the patient, it would not be reasonable to repeat the therapy again using any of these products. Thus, a repeat series of injections would not be covered.

Topical application is not covered.

Drug Wastage

Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient’s condition. If the physician has made good faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored and used the drug and made good faith efforts to minimize the unused portion of the drug in how it is supplied, then the program will cover the amount of drug discarded along with the amount administered. Documentation requirements are given below. Coding and billing instructions can be referenced in the attached article. Reference to national policy:Medicare Claims Processing Manual – Pub. 100-04, Chapter 17, Section 40.

Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP). Reference to national policy: Medicare Claims Processing Manual, Pub. 100-04, Chapter 17, Section 100.2.9.

Note: This LCD and the related Article do NOT describe drug and biological coverage under the Medicare Part D benefit.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

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

13X, 18X, 21X, 71X, 73X, 74X, 77X, 83X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

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

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual for further guidance.

0250, 036X, 049X, 051X, 0636, 076X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
J7321	Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose
J7323	Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
J7324	Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
J7325	Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes J7321, J7323, J7324 and J7325:

Covered for:

715.16	Osteoarthrosis, localized, primary, lower leg
715.26	Osteoarthrosis, localized, secondary, lower leg
715.36	Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
715.96	Osteoarthrosis, unspecified whether generalized or localized, lower leg

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
• An appropriate diagnosis code must be submitted on the claim. The patient’s medical record should indicate the signs/symptoms supporting the diagnosis and functional impairment. The appropriate records documenting the improvement must be maintained in the medical record and made available to Medicare upon request.
• An X-ray report of the knees must be available in the event of a review.
• Medical records should reflect failure of conservative treatment defined as physical therapy and use of simple non-narcotic analgesics including acetaminophen.

Drug Wastage Documentation Requirements

Any amount wasted must be clearly documented in the medical record, regardless of whether the JW modifier will be used in billing for the drug/biological, with:

• Date and time.
• Amount of medication wasted.
• Reason for the wastage.

CPT code - 78267, 78268, 83013, 83014, 86677 , 87338 - Helicobacter Pylori Testing

The breath test for Helicobacter pylori (H. pylori) is a non-invasive diagnostic procedure utilizing analysis of breath samples to determine the presence of H. pylori in the stomach. The H. pylori breath test consists of analysis of breath samples before and after ingestion of labeled C-urea. There are two methods for labeling the urea used in the breath test. One is to use the stable heavy isotope 13C-urea and the other is to use the radioactive isotope 14C-urea. Labeled C-urea will decompose to form labeled CO2 and NH4 in the presence of urease that is produced by H. pylori in the stomach. The labeled CO2 is absorbed in the blood, and then exhaled in the breath. The exhaled breath sample is then analyzed and compared with the baseline breath sample, which was obtained before the ingestion of the labeled C-urea.

The breath test can detect H. pylori colonization with reported 95 percent accuracy. H. pylori is accepted as an etiologic factor in duodenal ulcers, peptic ulcer disease, gastric carcinoma and primary B cell gastric lymphoma.

The stool test (code 87338) describes an in vitro qualitative procedure for the detection of Helicobacter pylori antigens in human stool. A fresh or appropriately stored stool specimen is processed and tested by enzyme immunoassay technique.

Serological testing for antibodies to H. pylori is inexpensive, convenient and simple, but, because antibody levels persist some months after treatment, it is not useful for assessing therapeutic effectiveness.

Invasive tests for H. pylori detection involve endoscopic biopsies of stomach tissue and are not addressed in this policy.

The tests available for the diagnosis of Helicobacter pylori infection differ with respect to sensitivity, specificity, invasiveness, cost and the additional information that they provide.

The appropriate choice of test depends on the clinical situation. The following clinical scenarios are appropriate for use of the H. pylori breath test:

• Patient with classic relatively uncomplicated symptoms of peptic ulcer disease for whom antibiotic therapy is planned, if the H. pylori breath test is positive, and no endoscopy is planned.

• Patients who have had an upper gastrointestinal endoscopy and in whom no helicobacter testing was performed.
• Patients who have non-specific dyspeptic symptoms with a positive H. pylori serum antibody test, and no endoscopy is planned.
• An upper gastrointestinal contrast X-ray series has been done that shows a duodenal ulcer or significant gastritis and/or duodenitis, and no endoscopy is planned.
• There are persistent or recurrent symptoms six weeks after treatment for a documented H. pylori infection, and no endoscopy is planned.
• Anyone with complications from peptic ulcer disease (i.e., bleeding ulcers, perforated ulcers), after appropriate antibiotic/H3 antagonist treatment, to establish a bacterial cure.

The H. pylori breath test is not considered reasonable and necessary in the following situations:

• Patients who are being screened for H. pylori infection in the absence of documented upper gastrointestinal tract symptoms and/or pathology.
• Patients who have had an upper gastrointestinal endoscopy within the preceding six weeks and helicobacter testing was performed, or for whom an upper gastrointestinal endoscopy is planned who have not been treated for H. pylori.
• Patients who have non-specific dyspeptic symptoms with a negative H. pylori serum antibody test or a negative H. pylori stool antigen test.
• Patients who are asymptomatic after treatment of an H. pylori infection (either proven or suspected) except in the situation of a history of a major complication of ulcer disease such as bleeding, perforation, penetration or multiple recurrences in which case an H. pylori breath test may be used to document eradication of the infection in lieu of a follow-up endoscopy.

Based on cure rates for H. pylori infection with the currently accepted regimens utilizing antibiotics, repeat endoscopy or H. pylori breath test would be expected in less than 30 percent of patients with H. pylori infection associated with duodenal ulcer and/or gastritis/duodenitis.

The serological test for H. pylori antibody is appropriate for the patient with non-specific dyspeptic symptoms in order to rule in or out H. pylori infection. Because high levels of antibody persist for months after successful or unsuccessful treatment of H. pylori infection, this test is not appropriate to determine treatment outcome.

The stool test for H. pylori antigen is also appropriate for the patient with non-specific dyspeptic symptoms. In contrast to the serum antibody test, the stool antigen test returns to normal (negative) after successful treatment, and may be used to determine treatment outcome.

The serological test for H. pylori antigen (CPT code 87339) is not recommended.

Screening services are not covered under Medicare.

Procedure codes 83013 and 83014 should be used to describe the C-13 versions of the test, and 78267 and 78268 should be used to describe the C-14 versions of the breath tests. The payment for provision of the C-13 and C-14 isotopes is included in the payment for these CPT codes. The provider may not bill separately for providing these isotopes.

CPT code 83013 should be used to report the laboratory charge for the analysis of the breath sample obtained.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

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

12X, 13X, 14X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

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

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.

030X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
78267©	Breath tst attain/anal c-14
78268©	Breath test analysis, c-14
83013©	H pylori (c-13), breath
83014©	H pylori drug admin
86677©	Helicobacter pylori
87338©	Hpylori, stool, eia

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 78267, 78268 (the breath tests), 83013, 83014, 86677 and 87338 (stool test):

Covered for:

041.86	Helicobacter pylori [H. pylori]
530.81	Esophageal reflux
531.00-531.01	Gastric ulcer, acute with hemorrhage
531.10-531.11	Gastric ulcer, acute with perforation
531.20-531.21	Gastric ulcer, acute with hemorrhage and perforation
531.30-531.31	Gastric ulcer, acute without mention of hemorrhage or perforation
531.40-531.41	Gastric ulcer, chronic or unspecified with hemorrhage
531.50-531.51	Gastric ulcer, chronic or unspecified with perforation
531.60-531.61	Gastric ulcer, chronic or unspecified with hemorrhage and perforation
531.70-531.71	Gastric ulcer, chronic without mention of hemorrhage or perforation
531.90-531.91	Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation
532.00-532.01	Duodenal ulcer, acute with hemorrhage
532.10-532.11	Duodenal ulcer, acute with perforation
532.20-532.21	Duodenal ulcer, acute with hemorrhage and perforation
532.30-532.31	Duodenal ulcer, acute without mention of hemorrhage or perforation
532.40-532.41	Duodenal ulcer, chronic or unspecified with hemorrhage
532.50-532.51	Duodenal ulcer, chronic or unspecified with perforation
532.60-532.61	Duodenal ulcer, chronic or unspecified with hemorrhage and perforation
532.70-532.71	Duodenal ulcer, chronic without mention of hemorrhage or perforation
532.90-532.91	Duodenal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation
533.00-533.01	Peptic ulcer, site unspecified, acute with hemorrhage
533.10-533.11	Peptic ulcer, site unspecified, acute with perforation
533.20-533.21	Peptic ulcer, site unspecified, acute with hemorrhage and perforation
533.30-533.31	Peptic ulcer, site unspecified, acute without mention of hemorrhage and perforation
533.40-533.41	Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage
533.50-533.51	Peptic ulcer, site unspecified, chronic or unspecified with perforation
533.60-533.61	Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage and perforation
533.70-533.71	Peptic ulcer, site unspecified, chronic without mention of hemorrhage or perforation
533.90-533.91	Peptic ulcer, site unspecified, unspecified as acute or chronic, without mention of hemorrhage or perforation
534.00-534.01	Gastrojejunal ulcer, acute with hemorrhage
534.10-534.11	Gastrojejunal ulcer, acute with perforation
534.20-534.21	Gastrojejunal ulcer, acute with hemorrhage and perforation
534.30-534.31	Gastrojejunal ulcer, acute without mention of hemorrhage or perforation
534.40-534.41	Gastrojejunal ulcer, chronic or unspecified with hemorrhage
534.50-534.51	Gastrojejunal ulcer, chronic or unspecified with perforation
534.60-534.61	Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation
534.70-534.71	Gastrojejunal ulcer, chronic without mention of hemorrhage or perforation
534.90-534.91	Gastrojejunal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation
535.00-535.01	Gastritis and duodenitis, acute gastritis
535.10-535.11	Gastritis and duodenitis, atrophic gastritis
535.20-535.21	Gastritis and duodenitis, gastric mucosal hypertrophy
535.30-535.31	Gastritis and duodenitis, alcoholic gastritis
535.40-535.41	Gastritis and duodenitis, other specified gastritis
535.50-535.51	Gastritis and duodenitis, unspecified gastritis and gastroduodenitis
535.60-535.61	Gastritis and duodenitis, duodenitis
536.2	Persistent vomiting
536.8	Dyspepsia and other specified disorders of function of stomach
537.89	Other specified disorders of stomach and duodenum
538	Gastrointestinal mucositis (ulcerative)
787.01–787.03	Nausea with vomiting – vomiting alone
787.1	Heartburn
787.3	Flatulence eructation and gas pain
789.01–789.02	Abdominal pain right upper quadrant – abdominal pain left upper quadrant
789.06	Abdominal pain epigastric
793.4	Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

When requesting a written appeal, please send all relevant documentation with the appeal request.

Appendices

N/A

Utilization Guidelines

N/A

Sources of Information and Basis for Decision

J4 (CO, NM, OK, TX) MAC Integration

TrailBlazer adopted the Noridian Administrative Services, LLC LCD, “Helicobacter Pylori Testing,” for the Jurisdiction 4 (J4) MAC transition.

Full disclosure of information sources is found with original contractor LCDs.

Fundus Photography CPT code 92250, 92499 and Valid diagnosis code

Fundus photography requires a camera using film or digital media to photograph structures behind the lens of the eye. Near photo-quality images are also obtainable utilizing scanning laser equipment with specialized software. (See the “CPT/HCPCS” section of this LCD and the “Coding Guidelines” section of the LCD Article for coding instructions.)

In order to document a disease process, plan its treatment or follow the progress of a disease, fundus photographs may be necessary. Fundus photographs are not medically necessary simply to document the existence of a condition. However, photographs may be medically necessary to establish a baseline to judge later whether a disease is progressive. Examples are as follows:

• It does not add to the patient’s care to photograph dry age-related maculopathy to document its existence.
• Fundus photography may be necessary to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy. In four to six months, the baseline photograph can be compared to the clinical appearance of the current diabetic retinal edema to see if it is progressing to clinically significant diabetic macular edema. This information can be used to decide whether or not to advise the patient to undergo focal laser photocoagulation.

The intent of these examples is to point out how in the former there is not a therapeutic decision being made, while in the latter there is. The fundus photography should aid in making a clinical decision.

Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.

Fundus photography is not a covered service when used to document the absence of pathology (i.e., a normal or healthy fundus or screening) or when the physician elects to incorporate it as a routine procedure. Routine fundus photography for purposes other than documentation, monitoring and treatment of a pathological process falls outside the standard of care as a medical necessity and is thereby not a covered service.

Some organizations recommend that diabetics have an annual dilated eye examination to look for retinal disease; fundus photographs are not an acceptable substitute for the dilated eye exam.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

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

12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

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

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual – (IOM) Pub. 100-04, Claims Processing Manual, – forfurther guidance.

0920

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
92250©	Eye exam with photos
	Note: Use 92250 only to report photographs obtained with a camera on film or digital media.
92499©	Unlisted ophthalmological service or procedure
	Note: Use 92499 to identify fundus images obtained with scanning laser equipment.

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS code 92250 and 92499 (when used to identify fundus images obtained with scanning laser equipment):

Covered for:

017.30–017.36	Tuberculosis of eye
042	Human immunodeficiency virus (hiv) disease
078.5	Cytomegaloviral disease
091.51	Syphilitic chorioretinitis (secondary)
094.83	Syphilitic disseminated retinochoroiditis
115.02	Histoplasma capsulatum retinitis
115.92	Histoplasmosis, unspecified, retinitis
130.0	Meningoencephalitis due to toxoplasmosis
130.2	Chorioretinitis due to toxoplasmosis
130.9	Toxoplasmosis unspecified
190.5–190.6	Malignant neoplasm of eye
198.4	Secondary malignant neoplasm of other parts of nervous system
224.0	Benign neoplasm of eyeball except conjunctiva cornea retina and choroid
224.5–224.6	Benign neoplasm of eye
225.1	Benign neoplasm of cranial nerves
238.8–238.9	Neoplasm of uncertain behavior of other and unspecified sites and tissues
250.50–250.51	Diabetes with ophthalmic manifestations
264.7	Other ocular manifestations of vitamin a deficiency
270.2	Disorders of amino acid transport and metabolism; other disturbances of aromatic amino acid metabolism
340	Multiple sclerosis
348.2	Benign intracranial hypertension
360.00–360.04	Purulent endophthalmitis
360.11–360.14	Other endophthalmitis
360.19	Other endophthalmitis
360.20–360.24	Degenerative disorders of the globe
360.30–360.33	Hypotony of eye
360.43–360.44	Degenerated conditions of the globe
360.50	Disorders of the globe; foreign body, magnetic, intraocular, unspecified
360.54–360.55	Retained (old) intraocular foreign body, magnetic
360.59	Disorders of the globe; intraocular foreign body, magnetic, in other or multiple sites
360.64–360.65	Retained (old) intraocular foreign body, nonmagnetic
360.69	Disorders of the globe; non-magnetic, foreign body in other or multiple sites
361.00–361.07	Retinal detachment with retinal defect
361.10–361.14	Retinoschisis and retinal cysts
361.19	Other retinoschisis and retinal cysts
361.2	Retinal detachments and defects; serous retinal detachment
361.30–361.33	Retinal defects without detachment
361.81	Traction detachment of retina
361.89	Other forms of retinal detachment
361.9	Unspecified retinal detachment
362.01–362.07	Diabetic retinopathy
362.10–362.18	Other background retinopathy and retinal vascular changes
362.20–362.27	Other proliferative retinopathy
362.29	Other non-diabetic proliferative retinopathy
362.30–362.37	Retinal vascular occlusion
362.40–362.43	Separation of retinal layers
362.50–362.57	Degeneration of macula and posterior pole
362.60–362.66	Peripheral retinal degenerations
362.70–362.77	Hereditary retinal dystrophies
362.81–362.85	Other retinal disorders
362.89	Other retinal disorders
362.9	Other retinal disorders; unspecified retinal disorder
363.00–363.01	Focal chorioretinitis and focal retinochoroiditis
363.03–363.08	Focal chorioretinitis and focal retinochoroiditis
363.10–363.15	Disseminated chorioretinitis and disseminated retinochoroiditis
363.20–363.22	Other and unspecified forms of chorioretinitis and retinochoroiditis
363.30–363.35	Chorioretinal scars
363.40–363.43	Choroidal degenerations
363.50–363.57	Hereditary choroidal dystrophies
363.61–363.63	Choroidal hemorrhage and rupture
363.70–363.72	Choroidal detachment
363.8–363.9	Other disorders of choroid
365.00–365.04	Borderline glaucoma [glaucoma suspect]
365.10–365.15	Open angle glaucoma
365.20–365.24	Primary angle-closure glaucoma
365.31–365.32	Corticosteroid-induced glaucoma
365.41–365.44	Glaucoma associated with congenital anomalies, dystrophies and systemic syndromes
365.51–365.52	Glaucoma associated with disorders of the lens
365.59	Glaucoma associated with other lens disorders
365.60–365.65	Glaucoma associated with other ocular disorders
365.81–365.83	Other specified forms of glaucoma
365.89	Other specified forms of glaucoma
365.9	Glaucoma, unspecified
368.54	Achromatopsia
368.61	Congenital night blindness
377.00–377.04	Disorders of optic nerve and visual pathways; papilledema
377.10–377.16	Disorders of optic nerve and visual pathways; optic atrophy
377.21–377.24	Disorders of optic nerve and visual pathways; other disorders of optic disc
377.30–377.34	Disorders of optic nerve and visual pathways; optic neuritis
377.39	Disorders of optic nerve and visual pathways; other optic neuritis
377.41–377.43	Disorders of optic nerve and visual pathways; other disorders of optic nerve
377.49	Disorders of optic nerve and visual pathways; other disorders of optic nerve
379.00	Other disorders of eye; scleritis, unspecified
379.07	Other disorders of eye; posterior scleritis
379.09	Other disorders of eye; other scleritis and episcleritis
379.11	Scleral ectasia
379.21–379.26	Disorders of vitreous body
379.29	Other disorders of vitreous
379.60–379.63	Inflammation (infection) of postprocedural bleb
710.0	Systemic lupus erythematosus
743.51–743.59	Congenital cataract and lens anomalies
759.5–759.6	Other and unspecified congenital anomalies
759.82	Marfan syndrome
771.0	Congenital rubella
871.5–871.6	Open wound of eyeball
950.0–950.1	Injury to optic nerve and pathways
V10.84	Personal history of malignant neoplasm of eye
V58.63	Long-term (current) use of antiplatelets/antithrombotics
V58.64	Long-term (current) use of nonsteroidal anti-inflammatories
V58.65	Long-term (current) use of steroids
V58.69	Encounter for other and unspecified procedures and after care; long-term (current) use of other medications
V67.51	Follow-up examination; following completed treatment with high-risk medication, NEC

Note: Diabetic retinopathy must be coded using appropriate ICD-9-CM codes from 362.0X. Correct coding of 362.0X dictates primary coding with 250.50–250.51, but payment will not occur unless 362.0X is also reported.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

In order to determine medical necessity, a copy of the clinical records which must justify the diagnosis listed on the claim and the reason(s) that fundus photographs and the frequency with which they were repeated were necessary for planning therapy and monitoring the progress of the disease diagnosed may be requested.

Documentation must support the medical necessity of this service as outlined in the “Indications and

Limitations of Coverage and/or Medical Necessity” section of this policy.

Documentation in the patient’s medical record should include all of the following:

• A current pertinent history and physical examination, and progress notes describing and supporting the covered indication.
• Pertinent prior diagnostic testing and completed report(s). This would include, when appropriate, previous fundus photographs.
• The medical record must be made available to Medicare upon request.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.