HYSTERECTOMY

Federal regulations governing payment of a hysterectomy under Medicaid (Title XIX) prohibit payment for a hysterectomy under the following circumstances:

• If the hysterectomy is performed solely for the purpose of terminating reproductive capability

OR

• If there was more than one purpose for performing the hysterectomy, but the procedure would not have been performed except for the purpose of rendering the individual permanently incapable of reproducing.

According to Louisiana Medicaid Program guidelines, if a hysterectomy is performed, reimbursement can be made if:

1. The person who secured authorization to perform the hysterectomy has informed the individual and her representative* (see sample consent), if any, orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing; and


2. The individual or her representative, if any, has signed a written acknowledgement of receipt of that information.

These regulations apply to all hysterectomy procedures, regardless of the woman's age, fertility, or reason for the surgery.



Consent for Hysterectomy

Providers may use BHSF Form 96-A for the hysterectomy consent form. A sample follows this section and may be copied for use.

The hysterectomy consent form must be signed and dated by the recipient on or before the date of the hysterectomy. The consent must include signed acknowledgement from the recipient stating they have been informed orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing.

The physician who obtains the consent should share the consent form with all providers involved in that patient’s care, (such as attending physician, hospital, anesthesiologist, and assistant surgeon) as each of these claims must have the valid consent form attached. To avoid a “system denial”, the consent must be attached to any claim submission related to a  hysterectomy.

When billing for services that require a hysterectomy consent form, the name on the Medicaid file for the date of service in which the form was signed should be the same as the name signed at the time consent was obtained. If the patient name changes before the claim is processed for payment, the provider must attach a letter from the physician’s office from which the consent was obtained. The letter should be signed by the physician and should state that the patient’s name has changed and should include the patient’s social security number and date of birth. This letter should be attached to all claims requiring consent upon submission for claims processing A witness signature is needed on the hysterectomy consent when the recipient meets one of the following criteria:

• Recipient is unable to sign her name and must indicate “x” on signature line;

• There is a diagnosis on the claim that indicates mental incapacity. If a witness does sign the consent form, the signature date must match the date of the recipient signature. The witness must both sign and date the form; if the dates do not match or the witness does not sign and date the form, all claims related to the hysterectomy will deny.



Exceptions

Obtaining a hysterectomy consent is unnecessary in the following circumstances:

• The individual was already sterile before the hysterectomy, and the physician who performed the hysterectomy certifies in his own writing that the individual was already sterile at the time of the hysterectomy and states the cause of sterility.

• The individual required a hysterectomy because of a life-threatening emergency situation in which the physician determined that prior acknowledgment was not possible, and the physician certifies in his own writing that the hysterectomy was performed under these conditions and includes in his narrative a description of the nature of the emergency.


• The individual was retroactively certified for Medicaid benefits, and the physician who performed the hysterectomy certifies in his own writing that the individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing. In addition, if the individual was certified retroactively for benefits, and the hysterectomy was performed under one of the two other conditions listed above, the physician must certify in writing that the hysterectomy was performed under one of those conditions and that the patient was informed, in advance, of the reproductive consequences of having a hysterectomy.

In any of the above events, the written certification from the physician must be attached to the hard copy of the claim in order for the claim to be considered for payment.

Filing Adjustments for a Medicare/Medicaid Claim 

When a provider has filed a claim with Medicare, Medicare reimburses the claim, then the claim becomes a “crossover” to Medicaid for consideration of payment of the Medicare deductible and/or co-insurance/co-payment.

If, at a later date, it is determined that Medicare has overpaid or underpaid, the provider should rebill Medicare for a corrected payment. These claims may “crossover” from Medicare to Medicaid, but cannot be automatically processed by Medicaid (as the electronic crossover claim appears to be a duplicate claim, and therefore must be denied by Medicaid).

In order for the provider to receive an adjustment, it is necessary for the provider to file a hard copy adjustment claim (Unisys Form 213) with Medicaid. These should be sent to Unisys, Attention: Crossover Adjustments, P.O. Box 91023, Baton Rouge, LA 70821, and should have a copy of the most recent Medicare explanation of benefits and the original explanation of benefits attached. In addition, the provider should write “2X7” at the top of the adjustment/void form to indicate the adjustment is for a Medicare/Medicaid claim.


Instructions for Completing the 213 Adjustment/Void form

1. REQUIRED ADJ/VOID—Check the appropriate block

2. REQUIRED Patient’s Name

a. Adjust—Print the name exactly as it appears on the original claim if not adjusting this information

b. Void—Print the name exactly as it appears on the original claim

3. Patient’s Date of Birth

a. Adjust—Print the date exactly as it appears on the original claim if not adjusting this information

b. Void—Print the name exactly as it appears on the original claim

4. REQUIRED Medicaid ID Number—Enter the 13 digit recipient ID number

5. Patient’s Address and Telephone Number

a. Adjust—Print the address exactly as it appears on the original claim

b. Void—Print the address exactly as it appears on the original claim

6. Patient’s Sex

a. Adjust—Print this information exactly as it appears on the original claim if not adjusting this information

b. Void—Print this information exactly as it appears on the original claim

7. Insured’s Name— Leave blank

8. Patient’s Relationship to Insured—Leave blank

9. Insured’s Group No.—Complete if appropriate or blank

10. Other Health Insurance Coverage—Complete with 6-digit TPL carrier code if appropriate or leave blank

11. Was Condition Related to—Leave blank

12. Insured’s Address—Leave blank

13. Date of—Leave blank

14. Date First Consulted You for This Condition—Leave blank

15. Has Patient Ever had Same or Similar Symptoms—Leave blank

16. Date Patient Able to Return to Work—Leave blank

17. Dates of Total Disability-Dates of Partial Disability—Leave blank 2007 Louisiana Medicaid Professional Services Provider
Training 123

18. Name of Referring Physician or Other Source—Leave this space blank

18a. Referring ID Number—Enter The CommunityCARE authorization number if applicable

or leave blank.

19. For Services Related to Hospitalization Give Hospitalization Dates—Leave blank

20. Name and Address of Facility Where Services Rendered (if other than home or office)—

Leave blank

21. Was Laboratory Work Performed Outside of Office—Leave blank

22. REQUIRED Diagnosis of Nature of Illness

a. Adjust—Print the information exactly as it appears on the original claim if not

adjusting the information

b. Void—Print the information exactly as it appears on the original claim

23. Attending Number—Enter the attending number submitted on original claim, if any, or

leave this space blank

24. Prior Authorization #—Enter the PA number if applicable or leave blank

25. REQUIRED A through F

a. Adjust—Print the information exactly as it appears on the original claim if not

adjusting the information

b. Void—Print the information exactly as it appears on the original claim

26. REQUIRED Control Number—Print the correct Control Number as shown on the

remittance advice

27. REQUIRED Date of remittance advice that Listed Claim was Paid—Enter MM DD YY

from RA form

28. REQUIRED Reasons for Adjustment—Check the appropriate box if applicable, and

write a brief narrative that describes why this adjustment is necessary

29. REQUIRED Reasons for Void—Check the appropriate box if applicable, and write a

brief narrative that describes why this void is necessary

30. REQUIRED Signature of Physician or Supplier—All Adjustment/Void forms must be

signed

31. REQUIRED Physician’s or Supplier’s Name, Address, Zip Code and Telephone Number—Enter the requested information appropriately plus the seven (7) digit Medicaid provider number. The form will be returned if this information is not entered.

32. Patient’s Account Number—Enter the patient’s provider-assigned account number. REQUIRED items must be completed or form will be returned.

Background

Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive treatment that uses magnetic resonance pulsed fields to induce an electric current in the brain. Repetitive TMS can either decrease or increase the excitability of the targeted structures.

In 2008 the U.S. Food and Drug Administration (FDA) granted 510(k) marketing clearance as a de novo device for NeuroStar ® TMS to be utilized as a Class II rTMS device for the treatment of major depressive disorder in patients who had not responded to one adequate trial of antidepressant medication. A September 2011 AHRQ report “Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults. Comparative Effectiveness Review” found that rTMS was beneficial relative to controls receiving a sham procedure for all three outcomes (severity of depressive symptoms, response rate, remission rate), with high strength of evidence for severity of depressive symptoms and response rate, and moderate strength of evidence for remission rate. The AHRQ report cites that relative to sham control, rTMS averaged a decrease in depressive severity measured by the Hamilton Rating Scale for Depression (HAM-D) of more than 5 points (a 3 point difference is considered clinically meaningful).

TMS offers a well-tolerated, non-pharmacologic alternative that does not require attendant anesthesia services. When used as an antidepressant therapy, rTMS has no adverse effects on cognition, and unlike electroconvulsant therapy (ECT) does not induce amnesia or seizures. Comparative outcomes for ECT and rTMS are similar.

Indications

Left prefrontal rTMS is considered reasonable and necessary for patients diagnosed with resistant depression who also have at least one of the following:

Resistance to treatment with psychopharmacologic agents as evidenced by a lack of clinically significant response to four trials of such agents, in the current depressive episode, from at least two different agent classes. At least one of the treatment trials must have been administered at an adequate course of mono- or poly–drug therapy; or

Inability to tolerate psychopharmacologic agents as evidenced by trials of four such agents, from at least two different agent classes, with distinct side effects; or

History of good response to rTMS in a previous episode; or

If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable and necessary as a less invasive treatment option.


Limitations

TMS is considered not reasonable and necessary when used as a treatment modality for patients with psychotic symptoms.

Use of rTMS is not indicated in patients with:

Seizure disorder, or
A vagus nerve stimulator, or
An implanted medical device or metal in close proximity to the brain.



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.



CPT/HCPCS Codes


90867Tcranial magn stim tx plan
90868Tcranial magn stim tx deli
90869Tcran magn stim redetemine




ICD-10 CODEDESCRIPTION

F32.2Major depressive disorder, single episode, severe without psychotic features
F33.2Major depressive disorder, recurrent severe without psychotic features

Coverage Indications, Limitations, and/or Medical Necessity

Background

A major limitation of external beam radiation therapy (EBRT) is a curative dose cannot be used because normal tissues cannot be completely protected from the radiation.

Conventional x-ray beams give off the most energy a short distance below the skin surface (entrance dose) and continue to deposit some dose throughout the path of the beam even beyond the target (exit dose). In contrast, proton particles deposit a smaller amount of radiation energy as they enter the body (lower entrance dose), culminating in an intensity dose peak, also called the Bragg Peak. There is no further energy deposition beyond the Bragg peak (no exit dose).

Stereotactic techniques are sometimes used with proton beam therapy.


Indications

Proton beam therapy is considered medically reasonable and necessary for the following conditions:

Group 1

Unresectable benign or malignant central nervous system tumors to include, but not limited to, primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations.

Intraocular melanomas.

Pituitary neoplasms.

Chordomas and chondrosarcomas.

Advanced staged and unresectable malignant lesions of the head and neck.

Malignant lesions of the paranasal sinuses.

Unresectable retroperitoneal sarcoma.

Pediatric CNS malignancies under 19 years of age.
Group 2

This section defines conditions that are still under investigation and may be covered when the patient is:

enrolled in an IRB-approved clinical trial which meets the ‘standards of scientific integrity and relevance to the Medicare population’ described in the CMS Internet Only Manual (IOM): Medicare National Coverage Determinations (NCD) Manual (Pub. 100-03), Chapter 1, Section 20.32 B.3.a-k;

or,

enrolled in a national or regional clinical registry compliant with the principles established in AHRQ’s ‘Registries for Evaluating Patient Outcomes: A User’s Guide’, such as the Registry for Prostate Cancer Radiosurgery (RPCR). Additionally, the claim must contain the Q0 (zero) modifier.


Whether in a clinical trial or in a national or regional registry, the information about the trial or registry must be included in the clinical record / progress notes.

Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers.

Advanced stage, unresectable pelvic tumors including those with peri-aortic nodes or malignant lesions of the cervix.

Unresectable breast tumors in proximity to the heart.

Unresectable pancreatic and adrenal tumors.

Skin cancer with macroscopic perineural/cranial nerve invasion of skull base.

Unresectable malignant lesions of the liver, biliary tract, anal canal and rectum

Prostate cancer, non-metastatic.

Limitations

For the treatment of primary lesions, the intent of treatment must be curative.

For the treatment of metastatic lesions, there must be the expectation of a long-term benefit (greater than 2 years of life expectancy).

Conditions not listed under the above Indications for Group 1 or Group 2 will remain noncovered.




CPT/HCPCS Codes


Group 1 Codes:
77520Proton trmt simple w/o comp
77522Proton trmt simple w/comp
77523Proton trmt intermediate
77525Proton treatment complex





ICD-10 CODEDESCRIPTION

C00.0 - C14.8 - Opens in a new windowMalignant neoplasm of external upper lip - Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx
C30.0 - C32.9 - Opens in a new windowMalignant neoplasm of nasal cavity - Malignant neoplasm of larynx, unspecified
C41.0 - C41.2 - Opens in a new windowMalignant neoplasm of bones of skull and face - Malignant neoplasm of vertebral column
C44.00 - C44.49 - Opens in a new windowUnspecified malignant neoplasm of skin of lip - Other specified malignant neoplasm of skin of scalp and neck
C45.1Mesothelioma of peritoneum
C47.0Malignant neoplasm of peripheral nerves of head, face and neck
C48.0 - C49.0 - Opens in a new windowMalignant neoplasm of retroperitoneum - Malignant neoplasm of connective and soft tissue of head, face and neck
C69.00 - C72.9 - Opens in a new windowMalignant neoplasm of unspecified conjunctiva - Malignant neoplasm of central nervous system, unspecified
C75.1 - C75.3 - Opens in a new windowMalignant neoplasm of pituitary gland - Malignant neoplasm of pineal gland
C76.0Malignant neoplasm of head, face and neck
C79.31Secondary malignant neoplasm of brain
D16.4 - D16.5 - Opens in a new windowBenign neoplasm of bones of skull and face - Benign neoplasm of lower jaw bone
D32.0 - D33.9 - Opens in a new windowBenign neoplasm of cerebral meninges - Benign neoplasm of central nervous system, unspecified
D35.2 - D35.4 - Opens in a new windowBenign neoplasm of pituitary gland - Benign neoplasm of pineal gland
D42.0 - D43.2 - Opens in a new windowNeoplasm of uncertain behavior of cerebral meninges - Neoplasm of uncertain behavior of brain, unspecified
D43.4Neoplasm of uncertain behavior of spinal cord
D44.3 - D44.5 - Opens in a new windowNeoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal gland
D49.6 - D49.7 - Opens in a new windowNeoplasm of unspecified behavior of brain - Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
G95.9Disease of spinal cord, unspecified
Q28.2 - Q28.3 - Opens in a new windowArteriovenous malformation of cerebral vessels - Other malformations of cerebral vessels
Showing 1 to 20 of 20 entries in Group 1
FirstPrevCurrently Selected1NextLast

Group 2 Paragraph: Group 2



ICD-10 CODEDESCRIPTION

C19 - C25.9 - Opens in a new windowMalignant neoplasm of rectosigmoid junction - Malignant neoplasm of pancreas, unspecified
C33 - C34.92 - Opens in a new windowMalignant neoplasm of trachea - Malignant neoplasm of unspecified part of left bronchus or lung
C38.4Malignant neoplasm of pleura
C39.0 - C39.9 - Opens in a new windowMalignant neoplasm of upper respiratory tract, part unspecified - Malignant neoplasm of lower respiratory tract, part unspecified
C45.0Mesothelioma of pleura
C50.011 - C58 - Opens in a new windowMalignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of placenta
C61Malignant neoplasm of prostate
C64.1 - C64.9 - Opens in a new windowMalignant neoplasm of right kidney, except renal pelvis - Malignant neoplasm of unspecified kidney, except renal pelvis
C74.00 - C75.0 - Opens in a new windowMalignant neoplasm of cortex of unspecified adrenal gland - Malignant neoplasm of parathyroid gland
C75.4 - C75.9 - Opens in a new windowMalignant neoplasm of carotid body - Malignant neoplasm of endocrine gland, unspecified
C76.3Malignant neoplasm of pelvis
C78.7Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.32Secondary malignant neoplasm of cerebral meninges
D44.10 - D44.12 - Opens in a new windowNeoplasm of uncertain behavior of unspecified adrenal gland - Neoplasm of uncertain behavior of left adrenal gland
Showing 1 to 14 of 14 entries in Group 2
FirstPrevCurrently Selected1NextLast

Hyposmolality and/or hyponatremia

E87.0 Hyperosmolality and hypernatremia
E87.1 Hypo-osmolality and hyponatremia
E87.2 Acidosis
E87.4 Mixed disorder of acid balance
E87.3 Alkalosis

Nephrology ICD-10 Codes

E87.0 Hyperosmolality and hypernatremia
E87.1 Hypo-osmolality and hyponatremia
E87.2 Acidosis
E87.4 Mixed disorder of acid balance
E87.3 Alkalosis

Endocrine, Nutritional and Metabolic Disease (E00-E89)

Disorders of Fluid, Electrolyte & Acid-base Balance

• E86.0 – Dehydration
• E86.1 – Hypovolemia
• E87.0 – Hyperosmolality and hypernatremia
• E87.1 – Hypo-osmolality and hyponatremia
• E87.2 – Acidosis
• E87.3 – Alkalosis
• E87.4 – Mixed disorder of acid-base balance
• E87.5 – Hyperkalemia
• E87.6 – Hypokalemia
• E87.70 – Fluid overload, unspecified
• E87.71 – Transfusion associated circulatory overload
• E87.8 – Other disorders of electrolyte and fluid balance, not elsewhere classified

what is copay?

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Definition of terms: Copayment (copay): A predetermined fee for physician office visits, prescriptions or hospital services that the member pays at the time of service.

Medicare Definition

• A copayment amount for each service you get in an outpatient visit. For each service, this amount generally can’t be more than the Part A inpatient hospital deductible. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.

• All charges for items or services that Medicare doesn’t cover.

Example: Mr. Davis needs to have his cast removed. He goes to his local hospital outpatient department. The hospital charges $150 for this procedure. His copayment amount for this procedure, under the outpatient prospective payment system, is $20. Mr. Davis has paid $85 of his $155 Part B deductible. To have his cast removed, Mr. Davis must pay $90 ($70 remaining deductible amount + $20 copayment amount). The amount you pay may change each year. The amount you pay may also be different for different hospitals. Note: If you have a Medigap (Medicare Supplement Insurance) policy, other supplemental coverage, or employer or union coverage, it may pay the Part B deductible and copayment amounts


Medicaid Co-pay Guide


Provider Responsibilities

• Check Medicaid eligibility and co-pay status each time they see participant

• Reimburse the participant if they charged a co-pay for exempt services or exempt participant

• Direct participants to Molina call center at (208) 373- 1432 or toll free at (866) 686-4752 if they feel they have met their max out- of-pocket for the month (CAP)


Which Providers can charge a Co-pay?

• Chiropractors

• Podiatrists

• Optometrists

• Physical, Occupational & Speech Therapists

• Hospitals (outpatient services except ER)

• Physicians & mid-levels (NP or PA)

• FQHCs & RHCs


How do I know to collect a Co-pay?

• First check eligibility on the participant to see if they are Medicaid eligible and co-pay exempt or not

– PORTAL
– EDI
– MACS

• Then determine whether or not the services you are about to render are subject to Co-pay by using this guide.


Who is exempt from Co-pay?

• A child with family income less than 133% FPG

• An adult with family income less than 100% FPG

• A pregnant or post-partum woman

• Children in foster care

• Those women who are eligible due to breast or cervical cancer

• Those on Hospice

• Those in Long Term care facilities

• Those on A&D or DD waiver

• Those who have primary insurance other than Medicaid

• Native Americans/Alaskan Natives

• Members who have reached a 5% CAP (a member who has paid out 5% or more of their monthly income is exempt for the remainder of the month)

• Workers with Disabilities Providers do not need to remember all these exemptions – the eligibility information provided by the system will reflect them.


What services can a provider charge a Co-pay for?

• Chiropractic services-services performed by a chiropractor.

• Podiatrist services-services performed by a podiatrist.

• Optometrist services- General Ophthalmological services billed by an Optometrist

• Physical, Occupational & Speech Therapy Services rendered in the therapist’s office or as an Outpatient hospital service


What services are subject to Co-pay? 

• Outpatient Hospital –any of the services on this list performed in an outpatient hospital setting, except the emergency department

• Physician office visit-services provided at a doctor’s office unless preventive, family planning, or pregnancy-related.

• FQHC & RHC medical encounters, unless preventive, family planning, pregnancy-related or mental health.


Which Services are Co-pay exempt?

• Services performed in an Emergency room

• Services performed by an Urgent care clinic billing as an Urgent Care Facility

• Preventive services

• Family Planning

• Pregnancy related services

• Mental Health Services

• Services rendered that are $36.49 or less for the total claim.


What can I do if a participant doesn’t make their Co-pay?

• You can refuse to render services

• You can waive the Co-pay but you must have a written policy documenting under what circumstances you will waive it

• You can bill the patient

• Whether or not you choose to charge a Co-pay, when both the participant and the visit is subject to Co-pay provisions, the Co-pay amount will be deducted from your reimbursement.


What about the 5% cost-sharing cap?

• The copay will be tracked against the CAP. It is possible the exempt status may not be triggered due to the timing of providers submitting claims. DHW will handle reimbursements to participants should this happen.

• How long will reimbursement to the participant take?

– The length of reimbursement time will vary depending on the situation. I.e. provider billing, number of visits.


How do I know if I have met my 5% 

CAP for Co-pay?

• You must calculate your CAP using the income information you provided Medicaid to determine your eligibility.

• EXAMPLE ONLY: If your family income is $1,635.00 a month you would need to go to 22 qualifying appointments in a month to reach your CAP. (Use this guide to determine “qualifying” appointments)

(Calculation for example: $1635 x 5% = $81.75 (Max out-of-pocket (CAP)) $81.75 divided by $3.65 = 22 visits)


Copayment for commercial insurance

Its differ patient to patient and plan to plan. For example see the different type of plan or treatment and the copayment.

• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12)

DIAGNOSIS– ICD Indicator Enter 9 for ICD-9 diagnosis codes and 0 for ICD-10 diagnosis codes. The correct code set is determined by date of service.




Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties(i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All  arrative diagnoses for nonphysician specialties shall be submitted on an attachment.

Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to implementation of ICD-10-CM, on either the old or revised version of the CMS-1500 claim form. For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes. For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).

• The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

Indicator Code Set

9 ICD-9-CM diagnosis

0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)

• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.

• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

• Do not insert a period in the ICD-9-CM or ICD-10-CM code.

Coding and Reporting Principles 

Claims-Based Reporting Principles Reporting DX for PQRS

• The 2014 Physician Quality Reporting System (PQRS) Measure Specifications contain ICD-9-CM coding and ICD-10-CM coding. Beginning 10/01/2015, the PQRS system will only accept ICD-10-CM codes for analysis.

• A new CMS-1500 claim form (02/12) is available for use to accommodate the new ICD-10-CM coding. CMS will continue to accept the old CMS-1500 claim form (08/05) through March 31, 2014. However, on April 1, 2014, CMS will receive claims on only the revised CMS-1500 claim form (02/12). Claims sent on the old CMS-1500 claim form (08/05) will not be accepted.

• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12) (see the 2014 PQRS Implementation Guide) and up to twelve diagnoses can be reported in the header on the electronic claim.

o Only one diagnosis can be linked to each line item.

o PQRS analyzes claims data using ALL diagnoses from the base claim (item 21 of the CMS-1500 or electronic equivalent) and service codes for each individual EP (identified by individual NPI).

o EPs should review ALL diagnosis and encounter codes listed on the claim to make sure they are capturing ALL measures chosen to report and that are applicable to patient’s care.

• All diagnoses reported on the base claim will be included in PQRS analysis, as some measures require reporting more than one diagnosis on a claim.

o For line items containing QDC, only one diagnosis from the base claim should be referenced in the diagnosis pointer field.

o To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, all diagnoses on the claim(s) are considered in PQRS analysis.

• If your billing software limits the number of line items available on a claim, you must add a $0.01 nominal amount to one of the line items on that second claim for a total charge of one penny.

o PQRS analysis will subsequently join claims based on the same beneficiary for the same dateof-service, for the same Taxpayer Identification Number/National Provider Identifier (TIN/NPI) and analyze as one claim.

o Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses, QDCs, or nominal charge amounts are not dropped.

o In an effort to streamline reporting of QDCs across multiple CMS quality reporting programs, CMS strongly encourages all EPs and practices to begin billing 2014 QDCs with a $0.01 charge. EPs should pursue updating their billing software to accept the $0.01 charge prior to implementing 2014 PQRS. EPs and practices will need to work with their billing software or EHR vendor to ensure this capability is activated.

Procedure Codes and Description

Group 1 Paragraph: 36299* is used for sclerotherapy with mechanical agitation (e.g. Clarivein® device).

37799* should be used to report "Trivex Procedure"

36299UNLISTED PROCEDURE, VASCULAR INJECTION

36470INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN

36471INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG

36473ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED

36474ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

36475ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED

36476ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

36478ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED

36479ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

37700LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS

37718LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN

37722LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW

37735LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA

37760LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), INCLUDING SKIN GRAFT, WHEN PERFORMED, OPEN,1 LEG

37761LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN, INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG

37765STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS

37766STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS

37780LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)

37785LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG

37799UNLISTED PROCEDURE, VASCULAR SURGERY

93970DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY

93971DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY


Coverage Indications, Limitations, and/or Medical Necessity

Varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes. Treatment of telangiectases (36468) is not covered by Medicare.

Historically, varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and avoidance of prolonged immobility. When conservative measures are unsuccessful, and symptoms persist, the next step has been sclerotherapy or surgical ligation with or without stripping. Sclerotherapy involves the injection of a sclerosing solution into the varicose vein(s).

Compressive sclerotherapy is the injection of the sclerosant into an empty vein (elevated limb) followed by application of a compressive bandage or dressing. This is the most commonly performed sclerotherapy procedure for varicose veins of the lower extremity. Compressive sclerotherapy is indicated for local small to medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after adequate surgical removal of varices. It is not considered an appropriate option for large, extensive or truncal varicosities. Foam sclerotherapy is FDA indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein (GSV) system above and below the knee. It is usually given with ultrasound guidance. Non-Compressive sclerotherapy is not covered by Medicare.

More recently, endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been developed as alternatives to sclerotherapy and surgical intervention. These procedures are designed to damage the intimal wall of the vein resulting in fibrosis and subsequent ablation of the lumen of a segment of the vessel. Both procedures utilize specially designed catheters inserted through a small incision in the distal thigh and advanced, often under ultrasound guidance, nearly to the saphenofemoral junction. The catheter is then slowly withdrawn while controlled radiofrequency or laser energy is applied. This is followed by external compression of the treated segment.

Doppler ultrasound or duplex studies are often used to map the anatomy of the venous system prior to the procedure. There is adequate evidence that pre-procedural ultrasound is helpful, and Medicare will cover one ultrasound or duplex scan prior to the procedure to determine the extent and configuration of the varicosities.

Evidence and clinical experience supports the use of ultrasound guidance during the procedure (ERFA and laser ablation only) and shows that the outcomes may be improved and complication rates may be minimized when ultrasound guidance is used. The CPT codes for radiofrequency and laser include the intraoperative ultrasound service in the valuation and ultrasound may not be billed separately with these procedures.

In contrast to ERFA and laser procedures, intra-operative ultrasound guidance techniques have not been shown to increase the effectiveness or safety of sclerotherapy for varicose veins, therefore, intra-operative ultrasound guidance will not be separately covered for sclerotherapy.

A. Indications for surgical treatment (CPT codes: 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785) and sclerotherapy (CPT codes: 36470, 36471):

1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND

2. The patient is symptomatic and has one, or more, of the following:
a. Pain or burning in the extremity severe enough to impair mobility
b. Recurrent episodes of superficial phlebitis
c. Non-healing skin ulceration
d. Bleeding from a varicosity
e. Stasis dermatitis
f. Refractory dependent edema

B. Indications for ERFA or laser ablation (CPT codes 36475, 36476, 36478, 36479):

In addition to the above (see A), the patient's anatomy and clinical condition are amenable to the proposed treatment including ALL of the following:

1. Absence of aneurysm in the target segment.
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. –4. The absence of significant peripheral arterial diseases.

C. Limitations for ERFA and laser ablation:
1. ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy.
2. Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation, and sclerotherapy.
3. The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3-month trial of conservative measures, by any technique will be considered cosmetic and therefore not covered.
4. The treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic, and therefore not covered.
5. Coverage is only for devices specifically FDA-approved for these procedures.
6. One pre-operative Doppler ultrasound study or duplex scan will be covered.

Noridian notes that stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this LCD are met.

Noridian notes that if sclerotherapy is used with endovenous radiofrequency ablation, it may be covered if the criteria for reasonable and necessary as described in this LCD are met.

Noridian will not consider the treatment of asymptomatic veins with endoluminal ablation or sclerotherapy medically reasonable and necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure.

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


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.
011xHospital Inpatient (Including Medicare Part A)
012xHospital Inpatient (Medicare Part B only)
013xHospital Outpatient
071xClinic - Rural Health
077xClinic - Federally Qualified Health Center (FQHC)
085xCritical Access Hospital
999xNot Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to Part A.
0330Radiology - Therapeutic and/or Chemotherapy Administration - General Classification
0360Operating Room Services - General Classification
0490Ambulatory Surgical Care - General Classification
0510Clinic - General Classification
0520Freestanding Clinic - General Classification







ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

I80.01Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
I80.02Phlebitis and thrombophlebitis of superficial vessels of left lower extremity
I80.03Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral
I83.011Varicose veins of right lower extremity with ulcer of thigh
I83.012Varicose veins of right lower extremity with ulcer of calf
I83.013Varicose veins of right lower extremity with ulcer of ankle
I83.014Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015Varicose veins of right lower extremity with ulcer other part of foot
I83.018Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021Varicose veins of left lower extremity with ulcer of thigh
I83.022Varicose veins of left lower extremity with ulcer of calf
I83.023Varicose veins of left lower extremity with ulcer of ankle
I83.024Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025Varicose veins of left lower extremity with ulcer other part of foot
I83.028Varicose veins of left lower extremity with ulcer other part of lower leg
I83.11Varicose veins of right lower extremity with inflammation
I83.12Varicose veins of left lower extremity with inflammation
I83.211Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.811Varicose veins of right lower extremities with pain
I83.812Varicose veins of left lower extremities with pain
I83.813Varicose veins of bilateral lower extremities with pain
I83.891Varicose veins of right lower extremities with other complications
I83.892Varicose veins of left lower extremities with other complications
I83.893Varicose veins of bilateral lower extremities with other complications
I87.001Postthrombotic syndrome without complications of right lower extremity
I87.002Postthrombotic syndrome without complications of left lower extremity
I87.003Postthrombotic syndrome without complications of bilateral lower extremity
I87.011Postthrombotic syndrome with ulcer of right lower extremity
I87.012Postthrombotic syndrome with ulcer of left lower extremity
I87.013Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.021Postthrombotic syndrome with inflammation of right lower extremity
I87.022Postthrombotic syndrome with inflammation of left lower extremity
I87.023Postthrombotic syndrome with inflammation of bilateral lower extremity
I87.031Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.091Postthrombotic syndrome with other complications of right lower extremity
I87.092Postthrombotic syndrome with other complications of left lower extremity
I87.093Postthrombotic syndrome with other complications of bilateral lower extremity
I87.311Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.321Chronic venous hypertension (idiopathic) with inflammation of right lower extremity
I87.322Chronic venous hypertension (idiopathic) with inflammation of left lower extremity
I87.323Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity
I87.331Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity

Coverage Indications, Limitations, and/or Medical Necessity

Note: Providers should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor's discretionary coverage related to this service.

This policy addresses standard CT and MR imaging. Magnetic Resonance Angiography (MRA) is not addressed in this policy.

Computerized Tomography (CT)

Computerized tomography (CT scanning) uses the attenuation of an x-ray beam by an object in its path to create cross-sectional images. As x-rays pass through planes of the body, the photons are detected and recorded as they exit from different angles. Computers process the signals to produce a cross-sectional view of the body. The signal data may be subjected to a variety of post-acquisitional processing algorithms to obtain a multiplanar view of the anatomy.

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic scanning technique that employs a powerful and highly uniform static magnetic field, rather than ionizing radiation, to produce images. Fluctuations in the strength of the magnetic field alter the motion and relaxation times of hydrogen molecules, which are related to the density of molecules and reflect the physicochemical properties of the tissues. Reconstructed images can be displayed in multiple planes to facilitate analysis. See national non-coverage in CMS section above.

Coverage is limited to those CT and MRI machines that have received pre-market approval by the FDA. Such units must be operated within the parameters specified by the approval.

Medicare coverage for CT scans is allowed provided the service is medically reasonable and necessary.

Inconclusive findings on a CT scan may warrant a MRI study and, conversely, findings of a MRI study may be further clarified (under certain circumstances) with a subsequent CT scan. The information provided by the two modalities may be complementary.

Cancer Staging. Clinicians commonly use CT and MRI of the brain when metastatic involvement is suspected.

Non-covered indications: esophagus, oropharynx, and prostate, and non-melanoma skin cancer in the absence of symptoms of brain involvement. “Certain tumors almost never metastasize to the brain parenchyma. These include carcinomas of the esophagus, oropharynx, and prostate, and non-melanoma skin cancers.” (DeVita, Chapter 52.1) Accordingly, the related diagnoses found in the following diagnosis code list do not justify brain scans for “staging” purposes unless a patient has signs or symptoms suggesting brain involvement. Covered: In contrast, for those malignancies that commonly metastasize to the brain, staging in the absence of neurological findings may be appropriate.

Payment will be allowed for reasonable and necessary scans of different areas of the body that are performed on the same day.



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.

012xHospital Inpatient (Medicare Part B only)
013xHospital Outpatient
022xSkilled Nursing - Inpatient (Medicare Part B only)
023xSkilled Nursing - Outpatient
085xCritical Access Hospital

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.

032XRadiology - Diagnostic - General Classification
035XCT Scan - General Classification
040XOther Imaging Services - General Classification
061XMagnetic Resonance Technology (MRT) - General Classification

Procedure Codes and Description

Group 1 Paragraph: CT Scans

Group 1 Codes:
70450Ct head/brain w/o dye
70460Ct head/brain w/dye
70470Ct head/brain w/o & w/dye
70480Ct orbit/ear/fossa w/o dye
70481Ct orbit/ear/fossa w/dye
70482Ct orbit/ear/fossa w/o&w/dye
70486Ct maxillofacial w/o dye
70487Ct maxillofacial w/dye
70488Ct maxillofacial w/o & w/dye
70490Ct soft tissue neck w/o dye
70491Ct soft tissue neck w/dye
70492Ct sft tsue nck w/o & w/dye
72125Ct neck spine w/o dye
72126Ct neck spine w/dye
72127Ct neck spine w/o & w/dye

Group 2 Paragraph: MRI Scans

Group 2 Codes:
70336Magnetic image jaw joint
70540Mri orbit/face/neck w/o dye
70542Mri orbit/face/neck w/dye
70543Mri orbt/fac/nck w/o &w/dye
70551Mri brain stem w/o dye
70552Mri brain stem w/dye
70553Mri brain stem w/o & w/dye
70557Mri brain w/o dye
70558Mri brain w/dye
70559Mri brain w/o & w/dye
72141Mri neck spine w/o dye
72142Mri neck spine w/dye
72156Mri neck spine w/o & w/dye



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: The following list of ICD-10-CM codes represents diagnoses that, alone or together, support the medical necessity of either MRIs or CTs. These diagnoses must be supported by appropriate documentation of medical necessity in the medical record. These are the only covered diagnoses:


ICD-10 CODEDESCRIPTION

A02.21Salmonella meningitis
A06.6Amebic brain abscess
A17.0Tuberculous meningitis
A17.1Meningeal tuberculoma
A17.81Tuberculoma of brain and spinal cord
A17.82Tuberculous meningoencephalitis
A17.83Tuberculous neuritis
A17.89Other tuberculosis of nervous system
A17.9Tuberculosis of nervous system, unspecified
A18.01Tuberculosis of spine
A18.03Tuberculosis of other bones
A18.2Tuberculous peripheral lymphadenopathy
A18.50Tuberculosis of eye, unspecified
A18.51Tuberculous episcleritis
A18.52Tuberculous keratitis
A18.53Tuberculous chorioretinitis
A18.54Tuberculous iridocyclitis
A18.59Other tuberculosis of eye
A18.6Tuberculosis of (inner) (middle) ear
A27.81Aseptic meningitis in leptospirosis
A32.0Cutaneous listeriosis
A32.11Listerial meningitis
A32.12Listerial meningoencephalitis
A32.7Listerial sepsis
A32.81Oculoglandular listeriosis
A32.82Listerial endocarditis
A32.89Other forms of listeriosis
A32.9Listeriosis, unspecified
A39.0Meningococcal meningitis
A39.1Waterhouse-Friderichsen syndrome
A39.2Acute meningococcemia
A39.3Chronic meningococcemia
A39.4Meningococcemia, unspecified
A39.50Meningococcal carditis, unspecified
A39.51Meningococcal endocarditis
A39.52Meningococcal myocarditis
A39.53Meningococcal pericarditis
A39.81Meningococcal encephalitis
A39.82Meningococcal retrobulbar neuritis
A39.83Meningococcal arthritis
A39.84Postmeningococcal arthritis
A39.89Other meningococcal infections
A39.9Meningococcal infection, unspecified
A41.9Sepsis, unspecified organism
A50.30Late congenital syphilitic oculopathy, unspecified
A50.32Late congenital syphilitic chorioretinitis
A50.39Other late congenital syphilitic oculopathy
A50.40Late congenital neurosyphilis, unspecified
A50.41Late congenital syphilitic meningitis
A50.42Late congenital syphilitic encephalitis
A50.43Late congenital syphilitic polyneuropathy
A50.44Late congenital syphilitic optic nerve atrophy
A50.45Juvenile general paresis
A50.49Other late congenital neurosyphilis
A50.51Clutton's joints
A50.52Hutchinson's teeth
A50.53Hutchinson's triad
A50.54Late congenital cardiovascular syphilis
A50.55Late congenital syphilitic arthropathy
A50.56Late congenital syphilitic osteochondropathy
A50.57Syphilitic saddle nose
A50.59Other late congenital syphilis, symptomatic
A51.41Secondary syphilitic meningitis
A51.49Other secondary syphilitic conditions
A52.00Cardiovascular syphilis, unspecified
A52.10Symptomatic neurosyphilis, unspecified
A52.11Tabes dorsalis
A52.12Other cerebrospinal syphilis
A52.13Late syphilitic meningitis
A52.14Late syphilitic encephalitis
A52.15Late syphilitic neuropathy
A52.16Charcot's arthropathy (tabetic)
A52.17General paresis
A52.19Other symptomatic neurosyphilis
A52.2Asymptomatic neurosyphilis
A52.3Neurosyphilis, unspecified
A54.81Gonococcal meningitis
A80.0Acute paralytic poliomyelitis, vaccine-associated
A80.1Acute paralytic poliomyelitis, wild virus, imported
A80.2Acute paralytic poliomyelitis, wild virus, indigenous
A80.30Acute paralytic poliomyelitis, unspecified
A80.39Other acute paralytic poliomyelitis
A80.4Acute nonparalytic poliomyelitis
A80.9Acute poliomyelitis, unspecified
A81.00Creutzfeldt-Jakob disease, unspecified
A81.01Variant Creutzfeldt-Jakob disease
A81.09Other Creutzfeldt-Jakob disease
A81.1Subacute sclerosing panencephalitis
A81.2Progressive multifocal leukoencephalopathy
A81.81Kuru
A81.82Gerstmann-Straussler-Scheinker syndrome
A81.83Fatal familial insomnia
A81.89Other atypical virus infections of central nervous system
A81.9Atypical virus infection of central nervous system, unspecified
A82.0Sylvatic rabies
A82.1Urban rabies
A82.9Rabies, unspecified
A83.0Japanese encephalitis
A83.1Western equine encephalitis
A83.2Eastern equine encephalitis
Showing 1 to 100 of 6797 entries in Group 1
FirstPrevCurrently Selected12345NextLast





Group 2 Codes:


ICD-10 CODEDESCRIPTION
F19.180Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.181Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.188Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.220Other psychoactive substance dependence with intoxication, uncomplicated
F19.222Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.230Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231Other psychoactive substance dependence with withdrawal delirium
F19.232Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.250Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.280Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.288Other psychoactive substance dependence with other psychoactive substance-induced disorder
F32.81Premenstrual dysphoric disorder
F32.89Other specified depressive episodes
F53Puerperal psychosis
G83.5Locked-in state
G92Toxic encephalopathy
Showing 1 to 18 of 18 entries in Group 2
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Group 3 Paragraph: AND

ICD-10 CODEDESCRIPTION

S09.11XAStrain of muscle and tendon of head, initial encounter
S09.19XAOther specified injury of muscle and tendon of head, initial encounter
S09.8XXAOther specified injuries of head, initial encounter
S14.5XXAInjury of cervical sympathetic nerves, initial encounter
S16.8XXAOther specified injury of muscle, fascia and tendon at neck level, initial encounter
S19.81XAOther specified injuries of larynx, initial encounter
S19.82XAOther specified injuries of cervical trachea, initial encounter
S19.83XAOther specified injuries of vocal cord, initial encounter
S19.84XAOther specified injuries of thyroid gland, initial encounter
S19.85XAOther specified injuries of pharynx and cervical esophagus, initial encounter
S19.89XAOther specified injuries of other specified part of neck, initial encounter
Z91.410Personal history of adult physical and sexual abuse

Coverage Indications, Limitations, and/or Medical Necessity

For the purposes of this LCD and consistent with standard community understanding and the recommendations of specialty societies, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for three months or more.

Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local anesthetic solutions. Their utility in the diagnosis and treatment of non-neuropathic pain and specific syndromes mediated by sympathetic nervous system overactivity has been established.

• Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is central (within the brain and spinal cord) or peripheral (outside the brain and spinal cord) in origin; or to determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate the patient's response, as an initial diagnostic step so that other pain relief options may be considered.

• Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) and /or “inappropriate” sympathetic nervous system activity. An appropriate injection of local anesthetic induces a temporary interruption in the conduction of impulses by peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. When blockade has been of value in the relief of acute or chronic cancer related pain, somatic or epidural blockade may be maintained through the infusion of local anesthetics via indwelling catheter.

Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other collaborative comprehensive evaluation.

Imaging guidance with fluoroscopy, CT or ultrasound may be necessary to perform somatic nerve blockade. Only fluoroscopic or CT guidance will be covered for epidural injections.

Provider Qualifications

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

Patient safety and quality of care mandate that healthcare professionals who perform Nerve Blocks are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities.

PERIPHERAL NEUROPATHY

• Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain.

• The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-covered injections is also considered not medically necessary.

• The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Medical management using systemic medications is clinically indicated for the treatment of these conditions.


SOMATIC NERVE BLOCK

• Radiculopathy and other neurological deficits require further evaluation and management prior to performing the blocks.

EPIDURAL BLOCK (Cervical and Thoracic)

This policy does not cover lumbar epidural blocks, which are covered in another Noridian policy.

• Injections should not be repeated in less than five days.

• Injections are limited to a total of three in a three to six month period of time and should only be repeated if the injections produced significant and sustained relief documented by objective evidence, including improvements in the ability to perform activities of daily living (ADLs).

• Steroids should be used only in the presence of radiculopathy. Particulate steroids in the cervical region have been shown to be hazardous.



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.
999xNot Applicable

Revenue Codes:

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

CPT/HCPCS Codes

Group 1 Paragraph: CPT codes 64450 or 64640 may not be billed with diagnosis G57.61 and G57.62. The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma.



Group 1 Codes:

62281INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC
62320INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62321INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62324INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62325INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
64402INJECTION, ANESTHETIC AGENT; FACIAL NERVE
64405INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE
64408INJECTION, ANESTHETIC AGENT; VAGUS NERVE
64410INJECTION, ANESTHETIC AGENT; PHRENIC NERVE
64413INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS
64415INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE
64417INJECTION, ANESTHETIC AGENT; AXILLARY NERVE
64418INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR NERVE
64420INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE
64421INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, REGIONAL BLOCK
64425INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES
64430INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE
64435INJECTION, ANESTHETIC AGENT; PARACERVICAL (UTERINE) NERVE
64445INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE
64446INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64447INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE
64448INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64449INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64450INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
64455INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)
64461PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64462PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SECOND AND ANY ADDITIONAL INJECTION SITE(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64463PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; CONTINUOUS INFUSION BY CATHETER (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64479INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL
64480INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64505INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION
64508INJECTION, ANESTHETIC AGENT; CAROTID SINUS (SEPARATE PROCEDURE)
64510INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)
64517INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS
64520INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)
64530INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MONITORING
64620DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE
64632DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE
64640DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH

Group 2 Paragraph: CPT code 64450 is NOT medically necessary when billed with any other CPT code in the GROUP 2 Codes listed PLUS any one of the GROUP 1 diagnosis listed in the ICD-10 Codes the DO NOT Support Medical Necessity section below.

Group 2 Codes:

64450INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
76881ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE
76882ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC
76942ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION
76999UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)
97032APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES
97139UNLISTED THERAPEUTIC PROCEDURE (SPECIFY)
G0282ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0281
G0283ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE





ICD-10 Codes that Support Medical Necessity

ICD-10 CODEDESCRIPTION

B02.0Zoster encephalitis
B02.1Zoster meningitis
B02.21Postherpetic geniculate ganglionitis
B02.22Postherpetic trigeminal neuralgia
B02.23Postherpetic polyneuropathy
B02.24Postherpetic myelitis
B02.29Other postherpetic nervous system involvement
B02.7Disseminated zoster
B02.8Zoster with other complications
B02.9Zoster without complications
G50.0Trigeminal neuralgia
G54.0Brachial plexus disorders
G54.1Lumbosacral plexus disorders
G54.2Cervical root disorders, not elsewhere classified
G54.3Thoracic root disorders, not elsewhere classified
G54.4Lumbosacral root disorders, not elsewhere classified
G54.5Neuralgic amyotrophy
G54.6Phantom limb syndrome with pain
G54.8Other nerve root and plexus disorders
G55Nerve root and plexus compressions in diseases classified elsewhere
G56.01Carpal tunnel syndrome, right upper limb
G56.02Carpal tunnel syndrome, left upper limb
G56.03Carpal tunnel syndrome, bilateral upper limbs
G56.11Other lesions of median nerve, right upper limb
G56.12Other lesions of median nerve, left upper limb
G56.13Other lesions of median nerve, bilateral upper limbs
G56.21Lesion of ulnar nerve, right upper limb
G56.22Lesion of ulnar nerve, left upper limb
G56.23Lesion of ulnar nerve, bilateral upper limbs
G56.31Lesion of radial nerve, right upper limb
G56.32Lesion of radial nerve, left upper limb
G56.33Lesion of radial nerve, bilateral upper limbs
G56.41Causalgia of right upper limb
G56.42Causalgia of left upper limb
G56.43Causalgia of bilateral upper limbs
G56.81Other specified mononeuropathies of right upper limb
G56.82Other specified mononeuropathies of left upper limb
G56.91Unspecified mononeuropathy of right upper limb
G56.92Unspecified mononeuropathy of left upper limb
G57.01Lesion of sciatic nerve, right lower limb
G57.02Lesion of sciatic nerve, left lower limb
G57.03Lesion of sciatic nerve, bilateral lower limbs
G57.11Meralgia paresthetica, right lower limb
G57.12Meralgia paresthetica, left lower limb
G57.13Meralgia paresthetica, bilateral lower limbs
G57.21Lesion of femoral nerve, right lower limb
G57.22Lesion of femoral nerve, left lower limb
G57.23Lesion of femoral nerve, bilateral lower limbs
G57.31Lesion of lateral popliteal nerve, right lower limb
G57.32Lesion of lateral popliteal nerve, left lower limb
G57.33Lesion of lateral popliteal nerve, bilateral lower limbs
G57.41Lesion of medial popliteal nerve, right lower limb
G57.42Lesion of medial popliteal nerve, left lower limb
G57.43Lesion of medial popliteal nerve, bilateral lower limbs
G57.51Tarsal tunnel syndrome, right lower limb
G57.52Tarsal tunnel syndrome, left lower limb
G57.53Tarsal tunnel syndrome, bilateral lower limbs
G57.61*Lesion of plantar nerve, right lower limb
G57.62*Lesion of plantar nerve, left lower limb
G57.63*Lesion of plantar nerve, bilateral lower limbs
G57.71Causalgia of right lower limb
G57.72Causalgia of left lower limb
G57.73Causalgia of bilateral lower limbs
G57.81Other specified mononeuropathies of right lower limb
G57.82Other specified mononeuropathies of left lower limb
G57.91*Unspecified mononeuropathy of right lower limb
G57.92*Unspecified mononeuropathy of left lower limb
G58.0Intercostal neuropathy
G58.7*Mononeuritis multiplex
G58.8*Other specified mononeuropathies
G58.9*Mononeuropathy, unspecified
G59*Mononeuropathy in diseases classified elsewhere
G89.11Acute pain due to trauma
G89.12Acute post-thoracotomy pain
G89.18Other acute postprocedural pain
G89.21Chronic pain due to trauma
G89.22Chronic post-thoracotomy pain
G89.28Other chronic postprocedural pain
G89.3Neoplasm related pain (acute) (chronic)
G90.50Complex regional pain syndrome I, unspecified
G90.511Complex regional pain syndrome I of right upper limb
G90.512Complex regional pain syndrome I of left upper limb
G90.513Complex regional pain syndrome I of upper limb, bilateral
G90.521Complex regional pain syndrome I of right lower limb
G90.522Complex regional pain syndrome I of left lower limb
G90.523Complex regional pain syndrome I of lower limb, bilateral
G90.59Complex regional pain syndrome I of other specified site
I73.00Raynaud's syndrome without gangrene
I73.01Raynaud's syndrome with gangrene
L74.510Primary focal hyperhidrosis, axilla
L74.511Primary focal hyperhidrosis, face
L74.512Primary focal hyperhidrosis, palms
L74.513Primary focal hyperhidrosis, soles
M25.511Pain in right shoulder
M25.512Pain in left shoulder
M25.551Pain in right hip
M25.552Pain in left hip
M25.561Pain in right knee
M25.562Pain in left knee
M43.27Fusion of spine, lumbosacral region
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *R07.9 is used to describe rib pain
*G57.61, G57.62, G57.63 - The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma. CPT codes 64450 or 64640 may not be billed with diagnosis G57.61, G57.62 or G57.63.
*G57.91, G57.92, G58.7, G58.8, G58.9, G59, M54.10 and M79.2 - Is allowed when 64450 is billed WITHOUT CPT codes 76881, 76882, 76942, 76999, 97032, 97139, G0282 and/or G0283 on the same date of service (DOS). (Please see information in the ICD-10 Codes that DO NOT Support Medical Necessity section below).

G57.91Unspecified mononeuropathy of right lower limb
G57.92Unspecified mononeuropathy of left lower limb
G58.7Mononeuritis multiplex
G58.8Other specified mononeuropathies
G58.9Mononeuropathy, unspecified
G60.0Hereditary motor and sensory neuropathy
G60.1Refsum's disease
G60.2Neuropathy in association with hereditary ataxia
G60.3Idiopathic progressive neuropathy
G60.8Other hereditary and idiopathic neuropathies
G60.9Hereditary and idiopathic neuropathy, unspecified
G61.0Guillain-Barre syndrome
G61.1Serum neuropathy
G61.81Chronic inflammatory demyelinating polyneuritis
G61.89Other inflammatory polyneuropathies
G61.9Inflammatory polyneuropathy, unspecified
G62.0Drug-induced polyneuropathy
G62.2Polyneuropathy due to other toxic agents
G62.81Critical illness polyneuropathy
G62.82Radiation-induced polyneuropathy
G62.89Other specified polyneuropathies
G63Polyneuropathy in diseases classified elsewhere
M25.571Pain in right ankle and joints of right foot
M25.572Pain in left ankle and joints of left foot
M54.10Radiculopathy, site unspecified
M79.2Neuralgia and neuritis, unspecified
R20.0Anesthesia of skin
R20.1Hypoesthesia of skin
R20.2Paresthesia of skin
R20.3Hyperesthesia
R20.8Other disturbances of skin sensation
R20.9Unspecified disturbances of skin sensation

Procedure Codes and Description

Group 1 Paragraph: N/A

Group 1 Codes:

11920TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS

11921TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM

11922TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15775 - 15776PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS - PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS

15781DERMABRASION; SEGMENTAL, FACE

15788 - 15793CHEMICAL PEEL, FACIAL; EPIDERMAL - CHEMICAL PEEL, NONFACIAL; DERMAL

15828RHYTIDECTOMY; CHEEK, CHIN, AND NECK

15829RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP

15830EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY

19300MASTECTOMY FOR GYNECOMASTIA

19316MASTOPEXY

19318REDUCTION MAMMAPLASTY

19324MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT

19325MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT

19328REMOVAL OF INTACT MAMMARY IMPLANT

19330REMOVAL OF MAMMARY IMPLANT MATERIAL

19340IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

19342DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

19350NIPPLE/AREOLA RECONSTRUCTION

19355CORRECTION OF INVERTED NIPPLES

19357BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUBSEQUENT EXPANSION

19361BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITHOUT PROSTHETIC IMPLANT

19364BREAST RECONSTRUCTION WITH FREE FLAP

19366BREAST RECONSTRUCTION WITH OTHER TECHNIQUE

19367BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF
DONOR SITE;

19368BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR ANASTOMOSIS (SUPERCHARGING)

19369BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE

19370OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST

19371PERIPROSTHETIC CAPSULECTOMY, BREAST

19380REVISION OF RECONSTRUCTED BREAST

19396PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT

30400 - 30450RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP - RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES)

C9800DERMAL INJECTION PROCEDURE(S) FOR FACIAL LIPODYSTROPHY SYNDROME (LDS) AND PROVISION OF RADIESSE OR SCULPTRA DERMAL FILLER, INCLUDING ALL ITEMS AND SUPPLIES

G0429DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)

Q2026INJECTION, RADIESSE, 0.1 ML

Q2028INJECTION, SCULPTRA, 0.5 MG


Coverage Indications, Limitations, and/or Medical Necessity

According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures:

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Indications for specific surgical procedures:

Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered.

Removal or revision of a breast implant is considered medically necessary when it is removed for one of the following reasons:

Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion

Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.

Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement.

Reduction Mammoplasty is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.

Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.

Medical necessity for a reduction mammoplasty is limited to circumstances in which:

There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions, and To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:

Determining the macromastia is not due to an active endocrine or metabolic process.

Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.

Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.

A medically reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:

Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:

Conservative analgesia,

Supportive measures (garment, etc.),

Physical Therapy, or

Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or

Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.

Permanent shoulder grooving with skin irritation by supporting garment (bra strap).

The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.

Schnur Scale:

Body Surface

Area (m2)Average grams of tissue per breast to be removed

1.40-1.50218-260

1.51–1.60261-310

1.61-1.70311-370

1.71-1.80371-441

1.81-1.90442-527

1.91-2.00528-628

2.01-2.10629-750

2.11-2.20751-895

2.21-2.30896-1068

2.31-2.401069-1275

2.41-2.501276-1522

2.51-2.601523-1806

2.61-2.701807-2154

2.71-2.802155-2568

2.81-2.902569-3061

2.91-3.003062-3650


Mastectomy for gynecomastia 

Gynecomastia is the excessive growth of the male mammary glands. These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. Payment may be made for this procedure if it is documented that the tissue is primarily breast tissue and not just adipose (fatty tissue).

Tattooing to correct color defects of the skin may be considered reconstructive when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).

Punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal.

Rhinoplasty that is performed to improve nasal respiratory function due to airway obstruction or stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered.


Nasal fracture

Benign or malignant neoplasms

Nasal Obstruction

Chemical Peel

Is covered for the treatment of Actinic Keratosis.

Dermabrasion, segmental, face is covered for the treatment of rhinophyma.

Dermal injections for facial LDS using dermal fillers approved by the FDA for this purpose, and then only in HIV-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered. Effective for claims with dates of service on and after March 23, 2010.

See Pub. 100-03, Medicare National Coverage Determinations Chapter 1, Coverage Determinations Part 4, Section 250.5, for specific coverage criteria. See Pub. 100-04, Claims Processing Manual, Chapter 32, Section 260, for specific claims payment/coding instructions.

The following procedures will be considered on an individual basis.
Rhytidectomy is considered medically necessary to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.

Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision.

This procedure may also be considered to be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication.

These claims will be reviewed by the medical staff and considered on a case by case basis. Medical Records will be requested by the Contractor to determine medical necessity. See Documentation Requirements section of this LCD.

Procedure Codes and Description

Group 1 Codes:

G0477Drug test presump optical

G0478Drug test presump opt inst

G0479Drug test presump not opt

G0480Drug test def 1-7 classes

G0481Drug test def 8-14 classes

G0482Drug test def 15-21 classes

G0483Drug test def 22+ classes

Group 2 Paragraph: The following CPT codes are Non-Covered by Medicare

Group 2 Codes:

80300Drug screen non tlc devices

80301Drug screen class list a

80302Drug screen prsmptv 1 class

80303Drug screen one/mult class

80304Drug screen one/mult class

80320 - 80377Drug screen quantalcohols - Drug/substance nos 7/more

Coverage Indications, Limitations, and/or Medical Necessity

A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.
Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.

Analysis is comparative, matching the properties or behavior of a substance with that of a valid reference compound (a laboratory must possess a valid reference agent for every substance that it identifies). Drugs or classes of drugs are commonly assayed by qualitative/presumptive testing. A test may be followed by confirmation with a second method, only if there is a positive or negative inconsistent finding from the qualitative/presumptive test in the setting of a symptomatic patient, as described below.

Examples of drugs or classes of drugs that are commonly assayed by qualitative/presumptive tests, followed by confirmation with a second method, are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics, salicylates, cardiovascular drugs, antipsychotics, cyclic antidepressants, and others. Focused drug screens, most commonly for illicit drug use, may be more useful clinically.

Indications:

A. Although technology has provided the ability to measure many toxins, most toxicological diagnoses and therapeutic decisions are made based on historical or clinical considerations:
Laboratory turnaround time can often be longer than the critical intervention time course of an overdose.

The cost and support of maintaining the instruments, staff training, and specialized labor involved in some analyses are prohibitive.

For many toxins there are no established cutoff levels of .toxicity, making interpretation of the results difficult.

Although comprehensive screening is unlikely to affect emergency management, the results may assist the admitting physicians in evaluating the patient if the diagnosis remains unclear. Screening panels should be used when the results will alter patient management or disposition.

B. A qualitative/presumptive drug test may be indicated for a variety of reasons including the following:
1.A symptomatic patient when the history is unreliable, when there has been a suspected multiple-drug ingestion, to determine the cause of delirium or coma, or for the identification of specific drugs that may indicate when antagonists may be used.
2.For monitoring patient compliance during active treatment for substance abuse or dependence.
3. To monitor for compliance/adherence to the treatment plan or illicit drug use in patients under treatment or seeking treatment for a chronic pain condition. The clinical utility of drug tests in the emergency setting may be limited because patient management decisions are unaffected, since most therapy for drug poisonings is symptom directed and supportive.

C. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with suspected drug overdose and one or more of the following conditions:
Unexplained coma

Unexplained altered mental status in the absence of a clinically defined toxic syndrome or toxidrome

Severe or unexplained cardiovascular instability (cardiotoxicity)

Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome

Testing on neonates suspected of prenatal drug exposure

Seizures with an undetermined history

D. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with one or more of the following conditions:
For monitoring patient compliance during active treatment for substance abuse or dependence.

A drug screen is considered medically reasonable and necessary in patients on chronic opioid therapy:
-In whom illicit drug use, non-compliance or a significant pre-test probability of non-adherence to the prescribed drug regimen is suspected and documented in the medical record; and/or
-In those who are at high risk for medication abuse due to psychiatric issues, who have engaged in aberrant drug-related behaviors, or who have a history of substance abuse.

Medicare will consider performance of a drug test reasonable and necessary in patients with chronic pain to:
-determine the presence of other substances prior to initiating pharmacologic treatment
- detect the presence of illicit drugs
-monitor adherence to the plan of care

Drugs, or drug classes for which testing is performed, should reflect only those likely to be present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in common use. Drugs for which specimens are being tested must be indicated by the referring provider in a written order.

A drug test may be reasonable and necessary for patients with known substance abuse or dependence, only when the clinical presentation has changed unexpectedly and one of the above indications is met.

A drug test may be reasonable and necessary for patients with symptoms of schizophrenia suspected to be secondary to drug or substance intoxication.

Definitive drug testing is indicated when:
1. The results of the screen are presumptively positive.
2. Results of the screen are negative and this negative finding is inconsistent with the patient's medical history.
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids.

A positive screen often results in an inadequate result upon which to make a proper determination. A more specific method, such as gas or liquid chromatography coupled with mass spectrometry, may be needed in order to obtain a confirmed analytical result. In particular, screens are frequently inadequate for interpretation of opiate and benzodiazepine results and therefore; quantitative testing may be needed in these instances. Confirmation testing is usually not required for drugs like methadone, wherein false positive results are rare. However, factors such as cross-reactivity with other similar compounds or interfering substances in the specimen may affect test results. Confirmatory testing eliminates the risk of false positives. Also, eliminated by confirmation, is the risk of a “pill scraper” slipping through. Patients diverting their drug, attempt to cheat the test by scraping a bit of drug from a pill into their urine sample. It would screen positive, but there would be no metabolite upon confirmation. Frequent use of this code will be monitored for appropriateness.

Limitations:

It is considered not reasonable or necessary to test for the same drug with both a blood and a urine specimen simultaneously.

Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) are not covered.


Bill Type Codes:

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

Revenue Codes:

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

N/A

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: For monitoring of patient compliance in a drug treatment program, use diagnosis code Z03.89 as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis.

For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence use diagnosis code Z79.891, suspected of abusing other illicit drugs, use diagnosis code Z79.899.

G0477, G0478, G0479, G0480, G0481, G0482, G0483

Diagnosis codes must be coded to the highest level of specificity.

For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

ICD-10 CODEDESCRIPTION

E87.2Acidosis

F11.20Opioid dependence, uncomplicated

F18.10Inhalant abuse, uncomplicated

F18.120Inhalant abuse with intoxication, uncomplicated

F18.90Inhalant use, unspecified, uncomplicated

F19.20Other psychoactive substance dependence, uncomplicated

F20.0Paranoid schizophrenia

F20.1Disorganized schizophrenia

F20.2Catatonic schizophrenia

F20.89Other schizophrenia

F55.3Abuse of steroids or hormones

F55.8Abuse of other non-psychoactive substances

I45.81Long QT syndrome

I47.2Ventricular tachycardia

R40.0Somnolence

R40.1Stupor

R40.20Unspecified coma

R40.2110Coma scale, eyes open, never, unspecified time

R40.2111Coma scale, eyes open, never, in the field [EMT or ambulance]

R40.2112Coma scale, eyes open, never, at arrival to emergency department

R40.2113Coma scale, eyes open, never, at hospital admission

R40.2114Coma scale, eyes open, never, 24 hours or more after hospital admission

R40.2120Coma scale, eyes open, to pain, unspecified time

R40.2121Coma scale, eyes open, to pain, in the field [EMT or ambulance]

R40.2122Coma scale, eyes open, to pain, at arrival to emergency department

R40.2123Coma scale, eyes open, to pain, at hospital admission

R40.2124Coma scale, eyes open, to pain, 24 hours or more after hospital admission

R40.2210Coma scale, best verbal response, none, unspecified time

R40.2211Coma scale, best verbal response, none, in the field [EMT or ambulance]

R40.2212Coma scale, best verbal response, none, at arrival to emergency department

R40.2213Coma scale, best verbal response, none, at hospital admission

R40.2214Coma scale, best verbal response, none, 24 hours or more after hospital admission

R40.2220Coma scale, best verbal response, incomprehensible words, unspecified time

R40.2221Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance]

R40.2222Coma scale, best verbal response, incomprehensible words, at arrival to emergency department

R40.2223Coma scale, best verbal response, incomprehensible words, at hospital admission

R40.2224Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission

R40.2310Coma scale, best motor response, none, unspecified time

R40.2311Coma scale, best motor response, none, in the field [EMT or ambulance]

R40.2312Coma scale, best motor response, none, at arrival to emergency department

R40.2313Coma scale, best motor response, none, at hospital admission

R40.2314Coma scale, best motor response, none, 24 hours or more after hospital admission

R40.2320Coma scale, best motor response, extension, unspecified time

R40.2321Coma scale, best motor response, extension, in the field [EMT or ambulance]

R40.2322Coma scale, best motor response, extension, at arrival to emergency department

R40.2323Coma scale, best motor response, extension, at hospital admission

R40.2324Coma scale, best motor response, extension, 24 hours or more after hospital admission

R40.2340Coma scale, best motor response, flexion withdrawal, unspecified time

R40.2341Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]

R40.2342Coma scale, best motor response, flexion withdrawal, at arrival to emergency department

R40.2343Coma scale, best motor response, flexion withdrawal, at hospital admission

R40.2344Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission

R41.0Disorientation, unspecified

R41.82Altered mental status, unspecified

R44.0Auditory hallucinations

R44.2Other hallucinations

R56.9Unspecified convulsions

T39.011APoisoning by aspirin, accidental (unintentional), initial encounter

T39.012APoisoning by aspirin, intentional self-harm, initial encounter

T39.013APoisoning by aspirin, assault, initial encounter

T39.014APoisoning by aspirin, undetermined, initial encounter

T39.091APoisoning by salicylates, accidental (unintentional), initial encounter

T39.092APoisoning by salicylates, intentional self-harm, initial encounter

T39.093APoisoning by salicylates, assault, initial encounter

T39.094APoisoning by salicylates, undetermined, initial encounter

T39.1X1APoisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter

T39.1X2APoisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter

T39.1X3APoisoning by 4-Aminophenol derivatives, assault, initial encounter

T39.1X4APoisoning by 4-Aminophenol derivatives, undetermined, initial encounter

T39.2X1APoisoning by pyrazolone derivatives, accidental (unintentional), initial encounter

T39.2X2APoisoning by pyrazolone derivatives, intentional self-harm, initial encounter

T39.2X3APoisoning by pyrazolone derivatives, assault, initial encounter

T39.2X4APoisoning by pyrazolone derivatives, undetermined, initial encounter

T39.311APoisoning by propionic acid derivatives, accidental (unintentional), initial encounter

T39.312APoisoning by propionic acid derivatives, intentional self-harm, initial encounter

T39.313APoisoning by propionic acid derivatives, assault, initial encounter

T39.314APoisoning by propionic acid derivatives, undetermined, initial encounter

T39.391APoisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), initial
encounter

T39.392APoisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial encounter

T39.393APoisoning by other nonsteroidal anti-inflammatory drugs [NSAID], assault, initial encounter

T39.394APoisoning by other nonsteroidal anti-inflammatory drugs [NSAID], undetermined, initial encounter

T40.0X1APoisoning by opium, accidental (unintentional), initial encounter

T40.0X2APoisoning by opium, intentional self-harm, initial encounter

T40.0X3APoisoning by opium, assault, initial encounter

T40.0X4APoisoning by opium, undetermined, initial encounter

T40.1X1APoisoning by heroin, accidental (unintentional), initial encounter

T40.1X2APoisoning by heroin, intentional self-harm, initial encounter

T40.1X3APoisoning by heroin, assault, initial encounter

T40.1X4APoisoning by heroin, undetermined, initial encounter

T40.2X1APoisoning by other opioids, accidental (unintentional), initial encounter

T40.2X2APoisoning by other opioids, intentional self-harm, initial encounter

T40.2X3APoisoning by other opioids, assault, initial encounter

T40.2X4APoisoning by other opioids, undetermined, initial encounter

T40.3X1APoisoning by methadone, accidental (unintentional), initial encounter

T40.3X2APoisoning by methadone, intentional self-harm, initial encounter

T40.3X3APoisoning by methadone, assault, initial encounter

T40.3X4APoisoning by methadone, undetermined, initial encounter

T40.4X1APoisoning by other synthetic narcotics, accidental (unintentional), initial encounter

T40.4X2APoisoning by other synthetic narcotics, intentional self-harm, initial encounter

T40.4X3APoisoning by other synthetic narcotics, assault, initial encounter

Procedure codes and Description

Group 1 Codes:

11055PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION

11056PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS

11057PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS

11719TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER

11720DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5

11721DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE

G0127TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER


Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following, regardless of the provider rendering the service:
Cutting or removal of corns and calluses;

Trimming, cutting, clipping, or debridement of nails, including debridement of mycotic nails;

Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;

Other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients;

Any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

Routine foot care is usually performed by the beneficiary himself or herself, or by a caregiver.

However, the Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 describes exceptions to routine foot care exclusions. This LCD outlines such exceptions.


Indications

Routine foot care services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of routine foot care services.

Exceptions to the routine foot care exclusions include:
Necessary and integral part of otherwise covered services;

Treatment of warts on foot;

Presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;

Mycotic nails:
In the presence of systemic conditions as noted above in #3.

In the absence of systemic conditions:
Ambulatory patient must have marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

Non ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual.

Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *

Peripheral neuropathies involving the feet -
Associated with malnutrition and vitamin deficiency *
Malnutrition (general, pellagra)

Alcoholism

Malabsorption (celiac disease, tropical sprue)

Pernicious anemia

Associated with carcinoma *

Associated with diabetes mellitus *

Associated with drugs and toxins *

Associated with multiple sclerosis *

Associated with uremia (chronic renal disease) *

Associated with traumatic injury

Associated with leprosy or neurosyphilis

Associated with hereditary disorders

Hereditary sensory radicular neuropathy

Angiokeratoma corporis diffusum (Fabry’s)

Amyloid neuropathy

When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service.

Presumption of Coverage

In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of applying this presumption the following findings are pertinent:

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion thereof.

Class B Findings
Absent posterior tibial pulse;

Advanced trophic changes as: hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness) (Three required); and

Absent dorsalis pedis pulse.

Class C Findings
Claudication;

Temperature changes (e.g., cold feet);

Edema;

Paresthesias (abnormal spontaneous sensations in the feet); and

Burning.

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:
A Class A finding;

Two of the Class B findings; or

One Class B and two Class C findings.

In addition to a valid billing modifier, these services must include a systemic condition diagnosis listed above and in Group 1 of the diagnosis codes. All claims for routine foot care based on the presence of a systemic condition must have a billing modifier of Q7, Q8 or Q9 to be considered for payment.

Mycotic Nails

Mycotic nail debridement may be a covered service:
In the presence of a systemic disease with the class findings and appropriate Q modifier.

In the absence of systemic disease if the patient has mycotic nails and marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

In the absence of systemic disease when a non-ambulatory patient has mycotic nails and suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

For services without systemic disease and class findings, the diagnosis in Group 2 and Group 3 of the diagnosis codes below must be documented in the medical record and submitted on the claim.

The nail debridement procedure codes are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services.

Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.

The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.

Medicare allows payment for routine foot care only if the conditions under indications are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.

Services not meeting the criteria in this statement of national coverage will be denied as statutory non-covered services. For diagnosis codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy actively managing the patients systemic condition.

Nail debridement procedures are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.

Foot care services that do not require a professional would be considered routine and not a Medicare benefit. Professional in this situation is defined as an M.D., D.O., D.P.M., Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.

Loss of protective sensation (LOPS) is not the subject of this LCD. Please refer to NCD 70.2.1.



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: For codes 11055, 11056, 11057, 11719, 11720, 11721, G0127 billed with modifier Q7, Q8 or Q9. Diagnosis codes with an asterisk also need the date last seen and name and NPI of the attending physician.

For the codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.




Group 1Codes

ICD-10 CODEDESCRIPTION

A30.0Indeterminate leprosy

A30.1Tuberculoid leprosy

A30.2Borderline tuberculoid leprosy

A30.3Borderline leprosy

A30.4Borderline lepromatous leprosy

A30.5Lepromatous leprosy

A30.8Other forms of leprosy

A30.9Leprosy, unspecified

A52.10Symptomatic neurosyphilis, unspecified

A52.11Tabes dorsalis

A52.12Other cerebrospinal syphilis

A52.13Late syphilitic meningitis

A52.14Late syphilitic encephalitis

A52.15Late syphilitic neuropathy

A52.16Charcot's arthropathy (tabetic)

A52.17General paresis

A52.19Other symptomatic neurosyphilis

A52.2Asymptomatic neurosyphilis

A52.3Neurosyphilis, unspecified

D51.0*Vitamin B12 deficiency anemia due to intrinsic factor deficiency

E08.00 - E13.9* - Opens in a new windowDiabetes mellitus due to underlying condition with hyperosmolarity without nonketotic
hyperglycemic-hyperosmolar coma (NKHHC) - Other specified diabetes mellitus without complications

E46*Unspecified protein-calorie malnutrition

E52*Niacin deficiency [pellagra]

E56.9*Vitamin deficiency, unspecified

E64.0*Sequelae of protein-calorie malnutrition

E75.21Fabry (-Anderson) disease

E75.22Gaucher disease

E75.240Niemann-Pick disease type A

E75.241Niemann-Pick disease type B

E75.242Niemann-Pick disease type C

E75.243Niemann-Pick disease type D

E75.248Other Niemann-Pick disease

E75.249Niemann-Pick disease, unspecified

E75.3Sphingolipidosis, unspecified

E77.0Defects in post-translational modification of lysosomal enzymes

E77.1Defects in glycoprotein degradation

E77.8Other disorders of glycoprotein metabolism

E77.9Disorder of glycoprotein metabolism, unspecified

E85.0Non-neuropathic heredofamilial amyloidosis

E85.1Neuropathic heredofamilial amyloidosis


E85.2Heredofamilial amyloidosis, unspecified

E85.3Secondary systemic amyloidosis

E85.4Organ-limited amyloidosis

E85.8Other amyloidosis

E85.9Amyloidosis, unspecified
G13.0*Paraneoplastic neuromyopathy and neuropathy


G13.1Other systemic atrophy primarily affecting central nervous system in neoplastic disease

G35*Multiple sclerosis
G60.0*Hereditary motor and sensory neuropathy

G60.1Refsum's disease

G60.2*Neuropathy in association with hereditary ataxia

G60.3Idiopathic progressive neuropathy

G60.8Other hereditary and idiopathic neuropathies

G60.9Hereditary and idiopathic neuropathy, unspecified

G61.1Serum neuropathy

G62.0Drug-induced polyneuropathy

G62.1*Alcoholic polyneuropathy

G62.2Polyneuropathy due to other toxic agents

G62.82*Radiation-induced polyneuropathy

G63*Polyneuropathy in diseases classified elsewhere

G65.0Sequelae of Guillain-Barre syndrome

G65.1Sequelae of other inflammatory polyneuropathy

G65.2Sequelae of toxic polyneuropathy

I70.201Unspecified atherosclerosis of native arteries of extremities, right leg

I70.202Unspecified atherosclerosis of native arteries of extremities, left leg

I70.203Unspecified atherosclerosis of native arteries of extremities, bilateral legs

I70.211Atherosclerosis of native arteries of extremities with intermittent claudication, right leg

I70.212Atherosclerosis of native arteries of extremities with intermittent claudication, left leg

I70.213Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs

I70.221Atherosclerosis of native arteries of extremities with rest pain, right leg

I70.222Atherosclerosis of native arteries of extremities with rest pain, left leg

I70.223Atherosclerosis of native arteries of extremities with rest pain, bilateral legs

I70.231Atherosclerosis of native arteries of right leg with ulceration of thigh

I70.232Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233Atherosclerosis of native arteries of right leg with ulceration of ankle

I70.234Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot


I70.235Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg

I70.239Atherosclerosis of native arteries of right leg with ulceration of unspecified site

I70.241Atherosclerosis of native arteries of left leg with ulceration of thigh

I70.242Atherosclerosis of native arteries of left leg with ulceration of calf

I70.243Atherosclerosis of native arteries of left leg with ulceration of ankle

I70.244Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot

I70.245Atherosclerosis of native arteries of left leg with ulceration of other part of foot

I70.248Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg

I70.249Atherosclerosis of native arteries of left leg with ulceration of unspecified site

I70.261Atherosclerosis of native arteries of extremities with gangrene, right leg

I70.262Atherosclerosis of native arteries of extremities with gangrene, left leg

I70.263Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.291Other atherosclerosis of native arteries of extremities, right leg

I70.292Other atherosclerosis of native arteries of extremities, left leg

I70.293Other atherosclerosis of native arteries of extremities, bilateral legs

I70.301Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg

I70.302Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg

I70.303Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs

I70.311Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg

I70.312Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg

I70.313Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral
legs

I70.321Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg


I70.322Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg

Procedure code and Description


Group 1 Codes:

93975DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY

93976DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY

93978DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY

93979DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY

93980DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; COMPLETE STUDY


93981DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; FOLLOW-UP OR LIMITED STUDY

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity




Overview

Non-invasive abdominal/visceral vascular studies utilize ultrasonic Doppler and physiologic principles to assess the irregularities in blood flow in renal, iliac, and femoral artery systems. These tests are also used to diagnose aortic aneurysms. Noninvasive abdominal/ visceral vascular studies include the patient care required to perform the studies, supervision of the studies, and interpretation of study results, with copies for patient records of test results and analysis of all data, including bi-directional vascular flow or imaging when provided.

Diagnostic tests must be ordered by the physician who is treating the beneficiary and who will use the results in the management of the beneficiary’s specific medical problem. Services are deemed medically necessary when all of the following conditions are met:
Signs/symptoms of ischemia or altered blood flow are present;

The information is necessary for appropriate medical and/or surgical management;

The test is not redundant of other diagnostic procedures that must be performed. Although, in some circumstances, non-invasive vascular tests are complimentary, such as MRA and duplex, where the latter may confirm an indeterminate finding or demonstrate the physiologic significance of an anatomic stenosis such as in renal, iliac, and/or femoral arteries.




Definitions:

Duplex Scans: Duplex combines Doppler and conventional ultrasound, allowing the structure of blood vessels, how the blood is flowing through the vessels, and whether there is any obstruction in the vessels to be seen. Color Doppler produces a picture of the blood vessel, and a computer converts the Doppler sounds into colors overlaid on the image, representing information about the speed and direction of blood flow. Using spectral Doppler analysis, the duplex scan images provide anatomic and hemodynamic information, identifying the presence of any stenosis or plaque in the arteries. Duplex scans are in real-time.

Abdominal/Visceral Vascular Studies 

Abdominal/visceral non-invasive vascular studies are indicated in the evaluation and /or management of vascular disease along with, the narrowing or blockage of arteries that supply blood to the abdomen including intestines (mesenteric vascular disease), pelvic and scrotal contents, and/or retroperitoneal organs including the kidneys (renal vascular disease).
Abdominal, Retroperitoneal and Pelvic Organs (93975, 93976)
Indications:
Uncontrolled hypertension.

Stenosis of visceral artery (atherosclerotic, fibromuscular dysplasia, vasculitis, functional).

Aneurysm of visceral artery.

Portal hypertension, with or without ascites.

Cirrhosis of the liver.

Venous embolism, hemorrhage, infection, and/or thrombosis of visceral vein (renal, hepatic, mesenteric, portal or splenic).

Stenosis of visceral vein (renal, hepatic, mesenteric, portal or splenic).

Complications of internal (biological) (synthetic) prosthetic device implant and/or graft.

Complications in abdominal organ or tissue transplant.

Pain or swelling of scrotal contents which may be a result of suspected obstruction in arterial inflow or venous outflow to testicles or related structure.

Torsion of the spermatic cord; acute epididymitis or epididymoorchitis; or torsion of the testicular appendages.

Hypertension and normotensive renovascular disease with impaired renal function which could be acute kidney failure, chronic kidney disease, end stage renal disease, or other vascular disorders of the kidneys.

Pain or swelling of the female genital organs which may be the result of torsion of the ovaries, ovarian pedicle or fallopian tube.

Trauma to the abdominal, retroperitoneal and/or pelvic organs, arteries, and /or veins.


Aorta, Inferior vena cava, Iliac Vasculature and Bypass grafts (93978, 93979)
Indications:
Atherosclerosis of aorta.

Atherosclerosis of the extremities with intermittent claudication.

Atherosclerosis of other specified arteries.

Aortic aneurysm and dissection.

Aneurysm of iliac artery.

Thromboangiitis obliterans (Buerger’s disease).

Peripheral vascular disease unspecified.

Arterial embolism and thrombosis of abdominal aorta.

Arterial embolism and thrombosis of iliac artery.

Phlebitis and thrombophlebitis of iliac vein.

Venous embolism and thrombosis of vena cava.

Complications related to surgical procedures involving prosthetic device implant, graft, and/or shunts.

Complications of organ or tissue transplant.

Trauma to the chest wall and /or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.

Limitations:

Vascular studies are not the initial diagnostic modality for the evaluation of abdominal pain/tenderness. There must be a high index of suspicion that the pain is caused by a vascular disorder, such as mesentery ischemia.

Routine imaging of the iliac veins is not medically necessary. Exceptions will be made for specific medical indications of possible propagation of a known thrombus for consideration for placement of a vena cava filter device via the femoral approach. The medical necessity must be documented in the medical record.

Abdominal aortic aneurysms > four cm in diameter may be followed with abdominal ultrasound every six months. Documentation of medical necessity needs to be provided for studies performed more frequently.

The outcome must impact the clinical management of the patient. For example, if a patient is going to proceed on to other diagnostic and/or therapeutic procedures regardless of the outcome of the noninvasive studies, the non-invasive vascular studies are usually not medically necessary. That is, if it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then noninvasive vascular studies may not be medically necessary.

Penile Vascular Studies (93980, 93981)

Duplex scans of the arterial inflow and venous outflow of penile vessels, have no therapeutic implications. Therefore, they are considered not medically reasonable or necessary, except in a patient with treatment failure who has sustained a documented groin injury where a vascular etiology for impotence is suspected.

Credentialing and Accreditation Standards

The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience. A vascular diagnostic study may be personally performed by a physician, a certified technologist, or in a certified vascular testing lab.

Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

All non-invasive vascular diagnostic studies must be performed meeting at least one of the following:
performed by a licensed qualified physician, or

performed by a technician who is certified in vascular technology, or

performed in facilities with laboratories accredited in vascular technology.

A licensed qualified physician for these services is defined as:
Having trained and acquired expertise within the framework of an accredited residency or fellowship program in the applicable specialty/subspecialty in ultrasound (US) or must reflect equivalent education, training, and expertise endorsed by an academic institution in ultrasound or by applicable specialty/subspecialty society in ultrasound, or

Has the Registered Vascular Technologist (RVT), Registered Physician Vascular Interpretation (RPVI), or ASN: Neuroimaging Subspecialty Certification; and

Is able to provide evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed.

Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests and have training and proficiency as evidenced by licensure or certification by an appropriate State health or education department. In the absence of a State licensing board, non-physician personnel must be certified by an appropriate national credentialing body.

Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers (ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular Credentialing International’s Registered Vascular Specialist (RVS).

Laboratories accredited by the Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) Vascular Ultrasound Program, Joint Commission or DNV-GL must follow the accrediting body’s standards.






ICD-10 Codes that Support Medical Necessity



Group 1Codes

ICD-10 CODEDESCRIPTION

I10Essential (primary) hypertension

I11.0Hypertensive heart disease with heart failure

I11.9Hypertensive heart disease without heart failure

I12.0Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

I12.9Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.0Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.10Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.11Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.2Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

I15.0Renovascular hypertension

I15.1Hypertension secondary to other renal disorders

I15.2Hypertension secondary to endocrine disorders

I15.8Other secondary hypertension

I70.1Atherosclerosis of renal artery


I71.1Thoracic aortic aneurysm, ruptured

I71.2Thoracic aortic aneurysm, without rupture

I71.3Abdominal aortic aneurysm, ruptured

I71.4Abdominal aortic aneurysm, without rupture

I71.5Thoracoabdominal aortic aneurysm, ruptured

I71.6Thoracoabdominal aortic aneurysm, without rupture

I72.2Aneurysm of renal artery

I72.8Aneurysm of other specified arteries

I74.01Saddle embolus of abdominal aorta

I74.09Other arterial embolism and thrombosis of abdominal aorta

I74.10Embolism and thrombosis of unspecified parts of aorta

I74.19Embolism and thrombosis of other parts of aorta

I74.5Embolism and thrombosis of iliac artery

I74.8Embolism and thrombosis of other arteries

I75.81Atheroembolism of kidney

I75.89Atheroembolism of other site

I76Septic arterial embolism

I77.2Rupture of artery

I77.3Arterial fibromuscular dysplasia

I77.4Celiac artery compression syndrome

I77.73Dissection of renal artery

I77.79Dissection of other specified artery

I77.810Thoracic aortic ectasia

I77.811Abdominal aortic ectasia

I77.812Thoracoabdominal aortic ectasia

I77.819Aortic ectasia, unspecified site

I80.8Phlebitis and thrombophlebitis of other sites

I81Portal vein thrombosis

I82.0Budd-Chiari syndrome

I82.1Thrombophlebitis migrans

I82.210Acute embolism and thrombosis of superior vena cava

I82.211Chronic embolism and thrombosis of superior vena cava

I82.290Acute embolism and thrombosis of other thoracic veins

I82.291Chronic embolism and thrombosis of other thoracic veins

I82.3Embolism and thrombosis of renal vein

I86.1Scrotal varices

I86.2Pelvic varices

I86.3Vulval varices

I86.4Gastric varices

I86.8Varicose veins of other specified sites

K55.011Focal (segmental) acute (reversible) ischemia of small intestine

K55.012Diffuse acute (reversible) ischemia of small intestine

K55.019Acute (reversible) ischemia of small intestine, extent unspecified

K55.021Focal (segmental) acute infarction of small intestine

K55.022Diffuse acute infarction of small intestine

K55.029Acute infarction of small intestine, extent unspecified

K55.031Focal (segmental) acute (reversible) ischemia of large intestine

K55.032Diffuse acute (reversible) ischemia of large intestine

K55.039Acute (reversible) ischemia of large intestine, extent unspecified

K55.041Focal (segmental) acute infarction of large intestine

K55.042Diffuse acute infarction of large intestine

K55.049Acute infarction of large intestine, extent unspecified

K55.051Focal (segmental) acute (reversible) ischemia of intestine, part unspecified

K55.052Diffuse acute (reversible) ischemia of intestine, part unspecified

K55.059Acute (reversible) ischemia of intestine, part and extent unspecified

K55.061Focal (segmental) acute infarction of intestine, part unspecified

K55.062Diffuse acute infarction of intestine, part unspecified

K55.069Acute infarction of intestine, part and extent unspecified

K55.1Chronic vascular disorders of intestine

K55.30Necrotizing enterocolitis, unspecified

K55.31Stage 1 necrotizing enterocolitis

K55.32Stage 2 necrotizing enterocolitis

K55.33Stage 3 necrotizing enterocolitis

K55.8Other vascular disorders of intestine

K70.2Alcoholic fibrosis and sclerosis of liver

K70.30Alcoholic cirrhosis of liver without ascites

K70.31Alcoholic cirrhosis of liver with ascites

K74.0Hepatic fibrosis

K74.60Unspecified cirrhosis of liver

K74.69Other cirrhosis of liver

K76.6Portal hypertension

N17.0Acute kidney failure with tubular necrosis

N17.1Acute kidney failure with acute cortical necrosis

N17.2Acute kidney failure with medullary necrosis

N17.8Other acute kidney failure

N17.9Acute kidney failure, unspecified

N18.1Chronic kidney disease, stage 1

N18.2Chronic kidney disease, stage 2 (mild)

N18.3Chronic kidney disease, stage 3 (moderate)

N18.4Chronic kidney disease, stage 4 (severe)

N18.5Chronic kidney disease, stage 5

N26.1Atrophy of kidney (terminal)

N26.2Page kidney

N26.9Renal sclerosis, unspecified

N27.0Small kidney, unilateral

N27.1Small kidney, bilateral

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
82306VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED
82652VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED


Coverage Indications, Limitations, and/or Medical Necessity

Vitamin D is a hormone, synthesized by the skin, the liver, and then metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.

Vitamin D is called a "vitamin" because of its availability from an exogenous source, predominately from oily fish in the form of cholecalciferol, vitamin D3. Plant-based vitamin D is in the form of ergocalciferol, Vitamin D2. It is really a hormone, as it is synthesized by the skin, metabolized by the liver and converted by the kidney to an active hormone, calcitriol. Calcitriol in its classical action, absorbs calcium from the intestine, and promotes bone mineralization.

In the skin, 7-dehydrocholesterol is converted to vitamin D3 in response to sunlight, a process that is inhibited by sunscreen with a skin protection factor (SPF) of 8 or greater. Once in the blood, vitamin D2 or D3 from diet, or D3 from skin production are carried by an alpha-2-globulin, vitamin D binding protein, and are carried to the liver where they are hydroxylated to yield 25-hydroxyvitamin D (25OHD; calcidiol). 25OHD then is converted in the kidney to 1, 25(OH)2D (calcitriol) by the action of 25OHD-1-alpha hydroxylase (CYP27B1). The CYP27B1 in the kidney is regulated by nearly every hormone involved in calcium homeostasis, and its activity is stimulated by PTH, estrogen, calcitonin, prolactin, growth hormone, low calcium levels, and low phosphorus levels. Its activity is inhibited by calcitriol, thus providing the feedback loop that helps regulates its synthesis.

An excess of vitamin D is unusual, but may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders; the well-described is rickets in growing children or osteomalacia in adults. Evaluating the status of a patient’s vitamin D sufficiency is accomplished by measuring the level of 25-hydroxyvitamin D. Measurement of other metabolites is generally not necessary outside of several unusual metabolic bone disorders or in chronic kidney disease-mineral bone disorder (CKD-MBD).

Indications:

Measurement of vitamin D levels is indicated for patients with:
chronic kidney disease stage III or greater;

osteoporosis;

osteomalacia;

osteopenia;

osteogenesis imperfecta;

osteosclerosis;

hypocalcemia;

hypercalcemia;

hypoparathyroidism;

hyperparathyroidism;

rickets;

vitamin D deficiency to monitor the efficacy of replacement therapy;

fibromyalgia;

granuloma forming diseases;

hypovitaminosis D;

hypervitaminosis D;

long term use of anticonvulsants or glucocorticoids and other medications known to lower -vitamin D levels;

malabsorption states;

obstructive jaundice;

cirrhosis;

psoriasis;

Paget's disease of bone;

gastric bypass.


Limitations:

For Medicare beneficiaries, screening tests are governed by statute (Social Security Act 1861 {nn}). Vitamin D testing may not be used for routine screening.

Assays of calcitriol need not be performed for each of the above conditions. The most common type of vitamin D deficiency is that of 25 OH Vitamin D.

The 1,25-dihydroxy form of vitamin D is generally only required to assist in the diagnosis of certain cases of rare endocrine disorders (primary hyperparathyroidism, hypothyroidism, pseudohypoparathyroidism), or for diagnosing and treating renal osteodystrophy and vitamin D-dependent and vitamin D resistant rickets, or in cases of unknown causes of hypercalcemia, including sarcoidosis. Level of both 25OHD and calcitriol are not needed as a panel for determining a patient's vitamin D status or to monitor routine vitamin D replacement therapy for most diseases. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the Contractor upon request.

This Contractor does not expect to receive billing for the various component sources of 25 OH vitamin D separately (such as stored D or diet derived D). Only one total 25 OH vitamin D assay (comprising the sum of both 25OHD2 and 25OHD3) will be considered for reimbursement on any particular day, if medically necessary, for the patient's condition.

Once a beneficiary has been shown to be vitamin D deficient, further testing may be medically necessary only to ensure adequate replacement has been accomplished for this vitamin deficiency, although, generally, other parameters are measured. Annual testing of the vitamin D status may be appropriate depending upon the indication and other mitigating factors. Because there can be variability in individual 25OHD responses to supplemental vitamin D in high-risk individuals, the serum 25OHD levels could be retested after about 3 months of supplementation to confirm that the target 25OHD level has been reached. If the follow up test shows they have not yet reached the target level, the test can it be repeated in another 3 months until the target level is achieved.

Testing Methods
Several methods are available for measuring circulating concentrations of 25-OH-D. Medicare will cover laboratory tests that give practitioners accurate and reliable information. The method used to perform this testing should be validated.

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.
999xNot Applicable

Revenue Codes:

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

N/A



ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

A15.0Tuberculosis of lung

A15.4Tuberculosis of intrathoracic lymph nodes

A15.5Tuberculosis of larynx, trachea and bronchus

A15.6Tuberculous pleurisy

A15.7Primary respiratory tuberculosis

A15.8Other respiratory tuberculosis

A17.0Tuberculous meningitis

A17.1Meningeal tuberculoma

A17.81Tuberculoma of brain and spinal cord

A17.82Tuberculous meningoencephalitis

A17.83Tuberculous neuritis

A17.89Other tuberculosis of nervous system

A17.9Tuberculosis of nervous system, unspecified

A18.01Tuberculosis of spine

A18.02Tuberculous arthritis of other joints

A18.03Tuberculosis of other bones

A18.09Other musculoskeletal tuberculosis

A18.10Tuberculosis of genitourinary system, unspecified

A18.11Tuberculosis of kidney and ureter

A18.12Tuberculosis of bladder

A18.13Tuberculosis of other urinary organs

A18.14Tuberculosis of prostate

A18.15Tuberculosis of other male genital organs

A18.16Tuberculosis of cervix

A18.17Tuberculous female pelvic inflammatory disease

A18.18Tuberculosis of other female genital organs

A18.2Tuberculous peripheral lymphadenopathy

A18.31Tuberculous peritonitis

A18.32Tuberculous enteritis

A18.39Retroperitoneal tuberculosis

A18.4Tuberculosis of skin and subcutaneous tissue

A18.50Tuberculosis of eye, unspecified

A18.51Tuberculous episcleritis

A18.52Tuberculous keratitis

A18.53Tuberculous chorioretinitis

A18.54Tuberculous iridocyclitis

A18.59Other tuberculosis of eye

A18.6Tuberculosis of (inner) (middle) ear

A18.7Tuberculosis of adrenal glands

A18.81Tuberculosis of thyroid gland

A18.82Tuberculosis of other endocrine glands

A18.83Tuberculosis of digestive tract organs, not elsewhere classified

A18.84Tuberculosis of heart

A18.85Tuberculosis of spleen

A18.89Tuberculosis of other sites

A19.0Acute miliary tuberculosis of a single specified site

A19.1Acute miliary tuberculosis of multiple sites

A19.8Other miliary tuberculosis

C22.0Liver cell carcinoma

C22.1Intrahepatic bile duct carcinoma

C22.2Hepatoblastoma

C22.3Angiosarcoma of liver

C22.4Other sarcomas of liver

C22.7Other specified carcinomas of liver

C22.8Malignant neoplasm of liver, primary, unspecified as to type

C22.9Malignant neoplasm of liver, not specified as primary or secondary

C23Malignant neoplasm of gallbladder

C24.0Malignant neoplasm of extrahepatic bile duct

C24.1Malignant neoplasm of ampulla of Vater

C24.8Malignant neoplasm of overlapping sites of biliary tract

C24.9Malignant neoplasm of biliary tract, unspecified

C25.0Malignant neoplasm of head of pancreas

C25.1Malignant neoplasm of body of pancreas

C25.2Malignant neoplasm of tail of pancreas

C25.3Malignant neoplasm of pancreatic duct

C25.4Malignant neoplasm of endocrine pancreas

C25.7Malignant neoplasm of other parts of pancreas

C25.8Malignant neoplasm of overlapping sites of pancreas

C25.9Malignant neoplasm of pancreas, unspecified

C26.0Malignant neoplasm of intestinal tract, part unspecified

C26.1Malignant neoplasm of spleen

C26.9Malignant neoplasm of ill-defined sites within the digestive system

D13.0Benign neoplasm of esophagus

D13.1Benign neoplasm of stomach

D13.2Benign neoplasm of duodenum

D13.30Benign neoplasm of unspecified part of small intestine

D13.39Benign neoplasm of other parts of small intestine

D13.4Benign neoplasm of liver

D13.5Benign neoplasm of extrahepatic bile ducts

D13.6Benign neoplasm of pancreas

D13.7Benign neoplasm of endocrine pancreas

D13.9Benign neoplasm of ill-defined sites within the digestive system

D86.0Sarcoidosis of lung

D86.1Sarcoidosis of lymph nodes

D86.2Sarcoidosis of lung with sarcoidosis of lymph nodes

D86.3Sarcoidosis of skin

D86.81Sarcoid meningitis

D86.82Multiple cranial nerve palsies in sarcoidosis

D86.83Sarcoid iridocyclitis

D86.84Sarcoid pyelonephritis

D86.85Sarcoid myocarditis

D86.86Sarcoid arthropathy

D86.87Sarcoid myositis

D86.89Sarcoidosis of other sites

E20.0Idiopathic hypoparathyroidism

E20.8Other hypoparathyroidism

E21.0Primary hyperparathyroidism

E21.1Secondary hyperparathyroidism, not elsewhere classified

E21.2Other hyperparathyroidism

E21.4Other specified disorders of parathyroid gland

HCPCS CODES:

Group 1 Codes:

A9270NON-COVERED ITEM OR SERVICE
J8498ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED
J8597ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED
J8999PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
Q0511PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR THE FIRST PRESCRIPTION IN A 30-DAY PERIOD
Q0512PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR A SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIOD


Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for “reasonable and necessary”, based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Statutory coverage criteria for oral anticancer drugs are specified in the related Policy Article. In addition, the drug must be reasonable and necessary for the individual beneficiary.

If the statutory coverage criteria are met but the drug is not reasonable and necessary for the individual beneficiary it will be denied as not medically necessary.

Drugs may be covered only if dispensed and billed to Medicare by the entity that actually dispenses the drug to the Medicare beneficiary, and that entity must be permitted under all applicable federal, state, and local laws and regulations to dispense drugs. Only entities licensed in the state where they are physically located may bill the DME MAC for oral anticancer and oral antiemetic drugs. (CMS Benefit Policy Manual, Internet-Only Manual, CMS Pub. 100-02, Chapter 15, Section 110.3 [hereinafter bp102c15, §110.3]). Physicians may bill the DME MAC for drugs if all of the following conditions are met: the physician is 1) enrolled as a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier with the National Supplier Clearinghouse, and 2) dispensing the drug(s) to the Medicare beneficiary, and 3) authorized by the state to dispense drugs as part of the physician’s license. Claims submitted by entities not licensed to dispense drugs will be denied for lack of medical necessity.

If the drug on the claim is denied as not medically necessary, the related supply fee will also be denied as not medically necessary.

REFILL REQUIREMENTS

For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. (CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-8, Chapter 5, Section 5.2.8).

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the prescribing practitioner that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a one month quantity at a time.


Bill Type Codes:

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

Revenue Codes:

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

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIER:

EY - No physician or other licensed health care provider order for this item or service

NATIONAL DRUG CODES (NDC):

The National Drug Code (NDC) is a number which uniquely identifies a manufacturer's product in terms of the strength of each tablet/capsule, quantity of tablets/capsules in a package and other packaging details. Suppliers must use the NDC that matches the product dispensed.

The oral anticancer drugs that are addressed in this policy are:

Busulfan
Capecitabine
Cyclophosphamide
Etoposide
Fludarabine phosphate
Melphalan
Methotrexate
Temozolomide
Topotecan



Coverage Indications, Limitations, and/or Medical Necessity For Oral Antiemetic Drugs

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

Refer to the Non-Medical Necessity Coverage and Payment Rules section of the related Policy Article for information about the statutory coverage requirements for oral antiemetic drugs.

The use of the oral anti-emetic 3-drug combination of an FDA approved oral NK-1 antagonist in combination with an oral 5HT3 antagonist and dexamethasone (J8540) is covered if, in addition to meeting the statutory coverage criteria specified in the related Policy Article, they are administered to beneficiaries who are receiving one or more of the following anti-cancer chemotherapeutic agents:

Alemtuzumab

Azacitidine

Bendamustin

Carboplatin

Carmustine

Cisplatin

Clofarabine

Cyclophosphamide

Cytarabine

Dacarbazine

Daunorubicin

Doxorubicin

Epirubicin

Idarubicin

Ifosfamide

Irinotecan

Lomustine

Mechlorethamine

Oxaliplatin

Streptozocin

If the NK-1 antagonist, 5HT3 antagonist and dexamethasone 3-drug combination meet the statutory coverage criteria, but are not used with one of the preceding chemotherapeutic agents, they will be denied as not reasonable and necessary.

An NK-1 antagonist and/or dexamethasone are only covered as an oral antiemetic regimen when administered as the 3-drug regimen described above. The 3-drug regimen is available in differing preparations as single drugs or in multi-drug combinations. All drugs must be billed on the same claim. Refer to the POLICY SPECIFIC DOCUMMENTATION REQUIREMENTS in this LCD and the CODING GUIDELINES section of the related Policy Article for specific instructions. Billing for these drugs on separate claims will be denied as not reasonable and necessary, incorrect billing.

The supplier may dispense only a single course of oral antiemetic drugs at one time unless it is known there will be more than a single course of chemotherapy in the month, in which case the supplier may dispense no more than a single month’s supply.

Drugs may be covered only if dispensed and billed to Medicare by the entity that actually dispenses the drug to the Medicare beneficiary, and that entity must be permitted under all applicable federal, state, and local laws and regulations to dispense drugs. Only entities licensed in the state where they are physically located may bill for oral antiemetic drugs (CMS Benefit Policy Manual, Internet-Only Manual, CMS Pub. 100-02, Chapter 15, Section 110.3). Physicians may bill the DME MAC for drugs if all of the following conditions are met: the physician is 1) enrolled as a DMEPOS supplier with the National Supplier Clearinghouse, and 2) dispensing the drug(s) to the Medicare beneficiary, and 3) authorized by the State to dispense drugs as part of the physician’s license. Claims submitted by entities not licensed to dispense drugs will be denied for lack of medical necessity.

If the drug on the claim is denied as not reasonable and necessary, the supply fee will be denied as not reasonable and necessary.

Refer to the Oral Anticancer Drugs policy for information on coverage of antiemetic drugs used in conjunction with oral anticancer drugs.

REFILL REQUIREMENTS

For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. (CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-08, Chapter 5, Section 5.2.8).

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the prescribing practitioner that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a 1-month quantity at a time.


Bill Type Codes:

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




Revenue Codes:

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

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY - No physician or other licensed health care provider order for this item or service
GA – Waiver of liability statement issued as required by payer policy, individual case
GZ – Item or service expected to be denied as not reasonable and necessary
KX - Requirements specified in the medical policy have been met

HCPCS Codes

Q9981 ROLAPITANT, ORAL, 1 MG effective July 1, 2016


Group 1 Codes:

J8501APREPITANT, ORAL, 5 MG

J8540DEXAMETHASONE, ORAL, 0.25 MG

J8650NABILONE, ORAL, 1 MG

J8655NETUPITANT 300 MG AND PALONOSETRON 0.5 MG

Q0161CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0162ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0163DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0164PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0166GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR DOSAGE REGIMEN

Q0167DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0169PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0173TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0174THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0175PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0177HYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0180DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR DOSAGE REGIMEN

Q0181UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

Q0511PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR THE FIRST PRESCRIPTION IN A 30-DAY PERIOD

Q0512PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR A SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIOD

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

J0585INJECTION, ONABOTULINUMTOXINA, 1 UNIT

J0586INJECTION, ABOBOTULINUMTOXINA, 5 UNITS

J0587INJECTION, RIMABOTULINUMTOXINB, 100 UNITS

J0588INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT

Group 1 Codes:

J3489INJECTION, ZOLEDRONIC ACID, 1 MG

Coverage Indications, Limitations, and/or Medical Necessity


Indications

Zoledronic acid is indicated for the treatment of:

Acute Hypercalcemia of malignancy;

Multiple myeloma;

Bone metastases from solid tumors in conjunction with standard antineoplastic therapy, including bone metastases from multiple myeloma, breast carcinoma, prostate carcinoma, and other solid tumors. Note: Prostate cancer should have progressed after treatment with at least one hormonal therapy;

Drug-induced osteopenia, secondary to androgen-deprivation therapy in prostate cancer patients (prophylaxis);

Cancer treatment-induced bone loss in breast cancer;

Pagets disease;

Post-Menopausal (Senile) Osteoporosis;

Osteoporosis in men; and

Glucocorticoid - induced osteoporosis in patients expected to be on glucocorticoids for at least 12 months (Effective 3/13/2009).


Limitations

The safety and efficacy of zoledronic acid in the treatment of hypercalcemia associated with hyperparathyroidism or with other non-tumor-related conditions has not been established.

Osteonecrosis of the jaw has been reported. All patients should have a routine oral exam prior to treatment.



ICD-10 CODEDESCRIPTION

C00.0 - C43.9 - Opens in a new windowMalignant neoplasm of external upper lip - Malignant melanoma of skin, unspecified

C4A.0 - C4A.9 - Opens in a new windowMerkel cell carcinoma of lip - Merkel cell carcinoma, unspecified

C44.00 - C49.9 - Opens in a new windowUnspecified malignant neoplasm of skin of lip - Malignant neoplasm of connective and
soft tissue, unspecified

C50.011 - C75.9 - Opens in a new windowMalignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of
endocrine gland, unspecified

C7A.00 - C7B.8 - Opens in a new windowMalignant carcinoid tumor of unspecified site - Other secondary neuroendocrine tumors

C76.0 - C79.9 - Opens in a new windowMalignant neoplasm of head, face and neck - Secondary malignant neoplasm of
unspecified site
C80.0 - C84.79 - Opens in a new windowDisseminated malignant neoplasm, unspecified - Anaplastic large cell lymphoma, ALK-
negative, extranodal and solid organ sites

C84.A0 - C84.Z9 - Opens in a new windowCutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell
lymphomas, extranodal and solid organ sites

C84.90 - C84.99 - Opens in a new windowMature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell
lymphomas, unspecified, extranodal and solid organ sites

C85.10 - C86.6 - Opens in a new windowUnspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-
cell proliferations

C88.2 - C91.62 - Opens in a new windowHeavy chain disease - Prolymphocytic leukemia of T-cell type, in relapse

C91.A0 - C91.Z2 - Opens in a new windowMature B-cell leukemia Burkitt-type not having achieved remission - Other lymphoid
leukemia, in relapse

C91.90 - C91.92 - Opens in a new windowLymphoid leukemia, unspecified not having achieved remission - Lymphoid leukemia,
unspecified, in relapse

C92.00 - C92.62 - Opens in a new windowAcute myeloblastic leukemia, not having achieved remission - Acute myeloid leukemia
with 11q23-abnormality in relapse

C92.A0 - C92.Z2 - Opens in a new windowAcute myeloid leukemia with multilineage dysplasia, not having achieved remission -
Other myeloid leukemia, in relapse

C92.90 - C92.92 - Opens in a new windowMyeloid leukemia, unspecified, not having achieved remission - Myeloid leukemia,
unspecified in relapse

C93.00 - C93.32 - Opens in a new windowAcute monoblastic/monocytic leukemia, not having achieved remission - Juvenile
myelomonocytic leukemia, in relapse

C93.Z0 - C93.Z2 - Opens in a new windowOther monocytic leukemia, not having achieved remission - Other monocytic leukemia,
in relapse

C93.90 - C93.92 - Opens in a new windowMonocytic leukemia, unspecified, not having achieved remission - Monocytic leukemia,
unspecified in relapse

C94.00 - C94.32 - Opens in a new windowAcute erythroid leukemia, not having achieved remission - Mast cell leukemia, in
relapse

C94.80 - C96.4 - Opens in a new windowOther specified leukemias not having achieved remission - Sarcoma of dendritic cells
(accessory cells)

C96.A - C96.Z - Opens in a new windowHistiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic
and related tissue

C96.9Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D03.0 - D03.9 - Opens in a new windowMelanoma in situ of lip - Melanoma in situ, unspecified

D45Polycythemia vera

E83.52Hypercalcemia

M81.0 - M81.8 - Opens in a new windowAge-related osteoporosis without current pathological fracture - Other osteoporosis
without current pathological fracture

M85.9Disorder of bone density and structure, unspecified

M88.0 - M88.9 - Opens in a new windowOsteitis deformans of skull - Osteitis deformans of unspecified bone

M89.9Disorder of bone, unspecified



CPT/HCPCS Codes

J9310INJECTION, RITUXIMAB, 100 MG




Coverage Indications, Limitations, and/or Medical Necessity


Indications

FDA:

Non-Hodgkin's Lymphoma (NHL).
Chronic Lymphocytic Leukemia (CLL).
Rheumatoid Arthritis (RA) in combination with methotrexate in adult patients with moderately- to severely-active RA who have inadequate response to one or more TNF antagonist therapies.
Wegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA) in adult patients in combination with glucocorticoids.

Off Label Use:

Waldenstrom's macroglobulinemia - relapsed or refractory
Thrombocytopenic purpura, immune or idiopathic
Renal transplant
prophylaxis - reduction of renal transplant rejection (pre and post) by reducing HLA/ABO antibodies in highly sensitized patients
acute rejection - reducing HLA/ABO antibodies
Pemphigus
Autoimmune hemolytic anemias
Acute Lymphoblastic Leukemia (ALL)


ICD-10 CODEDESCRIPTION

C82.00 - C84.79 - Opens in a new windowFollicular lymphoma grade I, unspecified site - Anaplastic large cell lymphoma, ALK-
negative, extranodal and solid organ sites
C84.A0 - C84.Z9 - Opens in a new windowCutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell
lymphomas, extranodal and solid organ sites

C84.90 - C84.99 - Opens in a new windowMature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell
lymphomas, unspecified, extranodal and solid organ sites

C85.10 - C88.0 - Opens in a new windowUnspecified B-cell lymphoma, unspecified site - Waldenstrom macroglobulinemia

C88.4Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

C91.00 - C91.01 - Opens in a new windowAcute lymphoblastic leukemia not having achieved remission - Acute lymphoblastic
leukemia, in remission

C91.10 - C91.12 - Opens in a new windowChronic lymphocytic leukemia of B-cell type not having achieved remission - Chronic
lymphocytic leukemia of B-cell type in relapse

C91.40Hairy cell leukemia not having achieved remission

C91.42Hairy cell leukemia, in relapse
C96.0 - C96.4 - Opens in a new windowMultifocal and multisystemic (disseminated) Langerhans-cell histiocytosis - Sarcoma
of dendritic cells (accessory cells)

C96.A - C96.Z - Opens in a new windowHistiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic
and related tissue

C96.9Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D47.3Essential (hemorrhagic) thrombocythemia

D59.0 - D59.1 - Opens in a new windowDrug-induced autoimmune hemolytic anemia - Other autoimmune hemolytic anemias
D69.3 - D69.42 - Opens in a new windowImmune thrombocytopenic purpura - Congenital and hereditary thrombocytopenia purpura

E88.01Alpha-1-antitrypsin deficiency

G70.01Myasthenia gravis with (acute) exacerbation

L10.0 - L10.9 - Opens in a new windowPemphigus vulgaris - Pemphigus, unspecified

L12.0 - L12.1 - Opens in a new windowBullous pemphigoid - Cicatricial pemphigoid

L12.8 - L12.9 - Opens in a new windowOther pemphigoid - Pemphigoid, unspecified
M05.00 - M05.09 - Opens in a new windowFelty's syndrome, unspecified site - Felty's syndrome, multiple sites


Group 1 Codes:
J9201INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG


Coverage Indications, Limitations, and/or Medical Necessity

Indications

FDA:

Pancreatic cancer;
Non-small cell lung cancer;
Breast cancer;
Ovarian cancer
Off Label Use:

Bladder cancer - metastatic bladder (urothelial) cancer;
Uterine neoplasms, uterine sarcoma;
Head and neck cancers – cancer of the nasopharynx;
Hodgkins and non-Hodgkin’s lymphomas;
Germ cell tumors - ovarian;
Fallopian tube cancer;
Primary peritoneal cancer
Cancer of the thymus


ICD-10 CODEDESCRIPTION

C14.0 - C14.8 - Opens in a new windowMalignant neoplasm of pharynx, unspecified - Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C16.9Malignant neoplasm of stomach, unspecified

C22.1Intrahepatic bile duct carcinoma

C23 - C25.9 - Opens in a new windowMalignant neoplasm of gallbladder - Malignant neoplasm of pancreas, unspecified

C33 - C37 - Opens in a new windowMalignant neoplasm of trachea - Malignant neoplasm of thymus

C38.1 - C38.3 - Opens in a new windowMalignant neoplasm of anterior mediastinum - Malignant neoplasm of mediastinum, part unspecified

C38.8Malignant neoplasm of overlapping sites of heart, mediastinum and pleura

C45.1Mesothelioma of peritoneum

C45.9Mesothelioma, unspecified

C47.0 - C50.929 - Opens in a new windowMalignant neoplasm of peripheral nerves of head, face and neck - Malignant neoplasm of unspecified site of unspecified male breast

C53.0Malignant neoplasm of endocervix

C54.0 - C57.4 - Opens in a new windowMalignant neoplasm of isthmus uteri - Malignant neoplasm of uterine adnexa, unspecified

C58Malignant neoplasm of placenta

C62.00 - C62.92 - Opens in a new windowMalignant neoplasm of unspecified undescended testis - Malignant neoplasm of left testis, unspecified whether descended or undescended

C65.1 - C67.9 - Opens in a new windowMalignant neoplasm of right renal pelvis - Malignant neoplasm of bladder, unspecified

C68.9Malignant neoplasm of urinary organ, unspecified

C75.3Malignant neoplasm of pineal gland

CPT/HCPCS Codes

Group 1 Codes:

92507Speech/hearing therapy

92508Speech/hearing therapy

92521Evaluation of speech fluency

92522Evaluate speech production

92523Speech sound lang comprehen

92524Behavral qualit analys voice

92607Ex for speech device rx 1hr

92608Ex for speech device rx addl

92609Use of speech device service

92626Eval aud rehab status

92627Eval aud status rehab add-on

96105Assessment of aphasia

96110Developmental screen w/score

96111Developmental test extend

96125Cognitive test by hc pro

97532Cognitive skills development



Coverage Indications, Limitations, and/or Medical Necessity

Indications General Guidelines

Speech Language Pathology (SLP) services may be considered reasonable and necessary when the following criteria are met and supported by the documentation:
The conditions of coverage and payment must be met as outlined in the Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.1.
SLP services are either rehabilitative or maintenance related. The documentation must clearly indicate if skilled therapy services are being provided for rehabilitative purposes or maintenance. Rehabilitative therapy includes services designed to address recovery or improvement in function. Rehabilitative therapy services may be covered if the documentation indicates that the skills of the therapist are needed and are provided and if the documentation indicates by objective measurements that improvements are being made, or a decrease in severity is present, or rationalization for an optimistic outlook is present to justify continued treatment. For coverage requirements for maintenance related services, see number 7 below.

SLP services are covered, provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified Speech Language Pathologist. Services normally considered to be a routine part of nursing care are not covered.
For rehabilitative therapy, the goal for a patient is to return to the highest level of function realistically attainable and within the context of the disability. The skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc. then transferring their care to a caregiver and home program.

Covered SLP services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan of care must be certified/approved by the physician/NPP.

In order for the plan of care to be covered, it must address a condition for which SLP is an accepted method of treatment, as defined by standards of medical practice.
For rehabilitative therapy, there must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the physician’s assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified therapist. The documentation must clearly support this expectation. For maintenance therapy, the documentation must clearly indicate that:

the skills of the therapist must be necessary to establish a safe and effective maintenance program in connection with a specific disease state, or
the services required to maintain the patient’s current function or to prevent or to slow further deterioration are of such complexity and sophistication that the skills of a therapist are required, or
the particular patient’s special medical complications require the skills of a therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration.

The therapist must document the patient’s functional limitations in terms that are objective and measurable. The therapist must document the therapeutic short and long term goals in terms that are objective and measurable. SLP services are not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist.

Rehabilitative SLP services are not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate. Establishing or designing a maintenance program or instructing the patient or appropriate caregiver in a maintenance program is not covered if the specialized skill, knowledge and judgment of a therapist are not required. Performance of a maintenance program by the therapist is not covered if the maintenance procedures do not require the skills of a therapist or the patient’s medical complications are not complex to require the skills of a therapist to perform the maintenance procedures. The skills of a therapist are not generally required to maintain function. In addition, establishing, designing or performing a maintenance program is not covered if the patient would not benefit from it or refuses to participate.

Rehabilitative SLP services are not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected.

The design of a maintenance regimen/home speech program required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary if the skills of the therapist are required. Limited services may be considered reasonable and necessary to establish and assist the patient and/or caregiver with the implementation of a rehabilitation maintenance program/home program. No more than 2-4 visits for completion of the maintenance program and instruction of the patient and supportive personnel or family are considered medically necessary without significant documentation. Documentation must indicate that the maintenance program has been designed for the patient’s level of function and instructions to the patient and supportive personnel have been completed. The initiation of a maintenance program should occur early in a course of therapy.
SLP services are not covered to treat Skilled Nursing Facility patients whose care can safely and effectively be rendered by the Skilled Nursing Facility’s trained professional staff. .

SLP therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the Speech Language Pathologist. For example, the patient with a TIA with speech deficits that are resolving.
SLP services provided to identify patients who might need or benefit from SLP services (i.e. screening) intervention are not covered.
SLP services visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient’s condition improves.
SLP services which are duplicative of other concurrent rehabilitation services are not covered.
Services which are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.
The educational component of treatment is included in the service described by the specific CPT code; therefore there is no separate coverage for education.
Documentation of services is part of the coverage of the respective CPT. Therefore there is no separate coverage for time spent on documentation.
The service must be considered acceptable under state standards of practice to be a specific and effective treatment for the beneficiary's condition.
The amount, frequency and duration of the services must be reasonable under accepted standards of practice.
If a separate maintenance program is required, the documentation must demonstrate the need for development of a distinct and separate maintenance program which could only be completed safely by a Speech Language Pathologist.

EVALUATIONS/ASSESSMENTS

CPT 92522 - Evaluation of Speech Sound Production and CPT 92523 - Evaluation of Speech Sound Production with Evaluation of Language Comprehension and Expression

The Speech Language Pathologist employs a variety of formal and informal speech and language assessment tests to ascertain the type, causal factor(s), and severity of the speech and language disorders. Re-evaluation of patients for whom speech and language services were previously contraindicated would be covered only if the patient exhibited a significant change in medical condition. However, monthly re-evaluations for a patient undergoing a rehabilitative SLP program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.

The evaluation/re-evaluation should demonstrate that an actual hands-on assessment occurred to support coverage. Screening assessments are noncovered and should not be billed.

Additional Documentation Requirements

History and the onset or exacerbation date of the current disorder. The history in conjunction with the current symptoms must establish support for additional treatment.

Prior level of functioning; as well as current baseline abilities, to establish the basis for the therapeutic interventions.
The plan, goals (realistic, long-term, functional, measurable, communication goals) duration of therapy, frequency of therapy, and definition of the type of service – rehabilitative or maintenance.

Diagnostic and assessment services to ascertain the type, causal factor(s) and severity of speech, language and/or cognitive communication disorders, should be identified during the evaluation.

CPT 92607 - Evaluation For Prescription For Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; First Hour

CPT 92608 - Evaluation For Prescription For Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; Each Additional 30 Minutes (List Separately In Addition To Code For Primary Procedure)

The Speech-Generating Device (SGD) evaluation is conducted to determine the appropriateness and selection of devices that synthesize or digitize speech and enhance communication of patients with expressive and/or receptive communication disorders.
The SGD evaluation considers the needs, abilities, and preferences of the patient and of the patient’s communication partner(s).
This SGD evaluation is usually the result of a physician referral or by the failure of a speech and language evaluation (CPT 92522/92523). This assessment is covered once.

Additional Documentation Requirements

Basis for evaluation: referral or failed speech language evaluation.
Communication disorder: diagnosis, onset, duration, severity, anticipated course (i.e. progressive, stable, improving).
The cognitive and communication abilities of the individual based on the formal evaluation.
Previous level of communication; use of other AAC devices.
Results of device trials.
Rationale for devices and/or accessories related to daily functional needs.
Measurable short and long term goals relating to functional communication need.
Timeframe for completing these goals.
Participation of communication partner/caregiver when applicable.
Time spent performing each CPT code.

CPT 96105 - Assessment Of Aphasia (Includes Assessment Of Expressive And Receptive Speech And Language Function, Language Comprehension, Speech Production Ability, Reading, Spelling, Writing, Eg, By Boston Diagnostic Aphasia Examination) With Interpretation And Report, Per Hour

A comprehensive aphasia assessment that is covered once.
Other tests in this category include the Western Aphasia Battery, The Minnesota Differential Diagnosis Examination of Aphasia, etc.
Conducted when more detailed linguistic information is needed to plan the treatment program of patients with moderate to mild aphasia.
Documentation should reflect the comprehensive nature of the assessment.
Regular progress reports, at least every ten treatment visits, conducted to determine or document progress, e.g., Western Aphasia Battery, for a patient undergoing a rehabilitative SLP program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.
For patients with severe aphasia, comprehensive assessments such as those listed above would not be performed routinely without documentation explaining the need.

THERAPEUTIC SERVICES

CPT 92507 - Treatment Of Speech, Language, Voice, Communication, And/ Or Auditory Processing Disorder; Individual

Rehabilitative therapeutic services must improve the beneficiary's functional abilities. Medicare will cover those skilled procedures that are reasonable and necessary for rehabilitative purposes or, if the skills of the therapist are required, to establish and instruct in a maintenance program. Those services that are unskilled are not covered by Medicare.
Skilled procedures include:
Design of a treatment program relevant to the beneficiary's disorder. Continued assessment and analysis during the implementation of the services is expected at regular intervals.
Establishment of compensatory skills for communication (e.g., air injection techniques or word finding strategies).
Establishment of a hierarchy of speech-language cognitive communication tasks and cuing that directs a beneficiary toward communication goals.
Analysis related to actual progress toward goals.
Patient and family training to augment rehabilitative treatment or to establish a maintenance program which requires the skills of a therapist. Education of staff and family must begin after the initial evaluation and after the design of a maintenance program. Additional modalities for education of staff in maintenance or rehabilitative programs will not be considered a covered service.
Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction for rehabilitative therapy. Absence of this documentation will result in a denial of services. For establishment and instruction in a maintenance program which requires the skills of a therapist, there must be documentation of the training which is provided to the patient and/or caregiver. The unavailability of a caregiver to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make the performance of the non-skilled maintenance program a skilled service when the therapist furnishes the service.
Medicare does not recognize the SLP aide or anyone other than the licensed Speech Language Pathologist for re-imbursement purposes.
The following are examples of common medical disorders and resulting communication deficits which may necessitate active skilled therapy: This list should not be considered all inclusive.
Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria.
Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria, dysphagia, inadequate respiratory volume/control, or voice disorder.
Laryngeal carcinoma requiring laryngectomy, resulting in aphonia.
Unskilled Procedures include:
Nondiagnostic/nontherapeutic routine, repetitive and reinforced procedures (e.g., the practicing of work drills without skilled feedback).
Procedures which are repetitive and/or reinforcing of previously learned material which the patient or family is instructed to repeat.
Procedures which may be effectively carried out with the patient by any nonprofessional (e.g., family member, restorative nursing aide) after instruction and training is completed.
Provision of practice for use of augmentative or alternative assessment communication systems.
Supervision of the patient practicing the use of speech generating devices and non-speech generating devices.

Additional Documentation Requirements
Basic hearing evaluation; and audiogram.
Identification of type and extent of hearing loss.
Alertness of the beneficiary.
Adequate cognitive and memory skills.
Visual acuity (with glasses) of the beneficiary, to determine ability to participate with the therapy.
Motivation to undergo therapy in order to improve understanding of speech.

CPT 92508 - Treatment Of Speech, Language, Voice, Communication, And/Or Auditory Processing Disorder (Includes Aural Rehabilitation); Group, Two Or More Individuals

Group therapy may be covered when the following criteria are met:
Group therapy services are rendered under an individualized plan of treatment, and are integral to the achievement of the patient’s individualized goals.
The skills of a Speech Language Pathologist are required to safely and/or effectively carry out the group services.
The group consists of four or fewer group members.
The group therapy satisfies all of the “reasonable and necessary criteria” listed under Indications and Limitations of Coverage.
Group therapy sessions in social organizations such as the Stroke Club or Lost Cord Club are not covered.

Additional Documentation Requirements

Documentation of the specific skilled treatments used in the group and how they relate to the Plan of Care.
Documentation of the number of persons in the group.

CPT 92609 - Therapeutic Services For The Use Of Speech-Generating Device, Including Programming And Modification

These services should reflect a program instructing a patient how to use a device and acquire the necessary skills for functional communication with the device.
Practice use of the device is not considered a skilled service and therefore is noncovered.
When the service is provided on the same date of service as CPT 92508, the documentation should reflect separate and distinct services.


CPT 92626 - Evaluation Of Auditory Rehabilitation Status; First Hour

CPT 92627 - Evaluation Of Auditory Rehabilitation Status; Each Additional 15 Minutes (List Separately In Addition To Code For Primary Procedure)

Aural rehabilitation may be covered and medically necessary when it has been determined by a speech-language pathologist in collaboration with an audiologist that the beneficiary's current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patient's functional communication needs.

Assessment for the need for aural rehabilitation may be done by a speech language pathologist and includes evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family.

Aural rehabilitation consists of treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the beneficiary's performance in both clinical and natural environment should be considered.


CPT 97532 - Development Of Cognitive Skills To Improve Attention, Memory, Problem Solving, (Includes Compensatory Training), Direct (One-On-One) Patient Contact, Each 15 Minutes

Development of cognitive skills, as described by code 97532, seeks to improve attention, memory and problem solving, and includes compensatory training, which refers to training provided to make up for a deficiency or loss of cognitive skills. This is often indicated for adults with diagnoses of psychiatric disorders, brain injuries and cerebral vascular accidents (CVAs). Cognitive skill training may allow individuals with these types of impairments to live independently, return to work, and function safely in their environments. Cognitive impairments are broken down into three categories: Attentional Impairments, Short Term Memory Impairments and Problem Solving Impairments. As the definition of the goal is “to improve”, this service would not be expected to be used with maintenance therapy.

Plan of treatment should document specific short and long term measurable goals of treatment and that significant gains are reasonable and expected.
Documentation should indicate measurable progress toward goals and that the beneficiary is able to participate if compensatory training is part of the treatment.
Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction. Absence of this documentation will result in a denial of services.
Throughout the course of their disease, patients with cognitive disorders may benefit from speech-language pathology therapies. However, the use of diagnosis codes for cognitive deficits alone may not adequately define the extent of a beneficiary’s cognitive impairment and its relevance to a functional impairment. Documentation must support that these therapies are reasonable and necessary when reviewed in the context of the beneficiary’s overall functional impairment. Services for stable chronic illness are not expected to be reasonable and necessary.

CENTRAL NERVOUS SYSTEM ASSESSMENT/TESTS


CPT 96110 - Developmental Testing; Limited (Eg, Developmental Screening Test II, Early Language Milestone Screen), With Interpretation And Report

CPT 96111 - Developmental Testing; Extended (Includes Assessment Of Motor, Language, Social, Adaptive And/Or Cognitive Functioning By Standardized Developmental Instruments) With Interpretation And Report



CPT 96125 – Standard cognitive performance testing (eg., Ross Informational Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face with the patient and time interpreting test results and preparing the report.

These tests evaluate different aspects of neurocognitive ability in patients who have compromised functioning due to acute neurological events such as traumatic brain injury or cerebrovascular accident (CVA). The assessment includes memory, reasoning, sensory processing, visual perceptual status, orientation, right hemisphere processing for temporal and spatial organization, social pragmatics, and elements of decision-making and executive function.
A separate interpretation and report should be readily located in the medical record.
This assessment is considered specialized and not routine.

Limitations 

Nondiagnostic/nontherapeutic routine, repetitive and reinforced procedures (e.g., the practicing of word drills without skilled feedback).
Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat.
Procedures which may be effectively carried out with the beneficiary by any nonprofessional (family or restorative aide) after instruction is completed.
Provision of practice for use of augmentative or alternative assessment communication systems.
Contradictory documentation (as to the mental status and learning ability of the beneficiary) between nursing and therapists of any discipline will be subject to denial.
Statements such as “mildly impaired to moderately impaired” or “fair plus to good minus” do not offer sufficient objective and measurable information to support progress and may result in denial of services.
Memory aids such as memory books, memory boards, or communication books which by description mimic memory books will not be covered.
Metronome therapy
The following disorders are typically noncovered for the geriatric beneficiary:
Fluency disorder, dysprosody, stuttering and cluttering (except neurogenic stuttering caused by acquired brain damage)
Myofunctional Disorders (e.g., tongue thrust)
SLP services interventions for communication difficulties demonstrated by beneficiaries with primary language other than English will not be covered for SLP services interventions to instruct the beneficiary in English phrases. This type of intervention is not considered reasonable and necessary and is not reimbursable. However, when the primary language of the beneficiary is other than English, SLP services interventions in the patient's primary language will be covered in the context of this policy.


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.
999xNot Applicable

Revenue Codes:

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

N/A





ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

F80.1 - F80.2 - Opens in a new windowExpressive language disorder - Mixed receptive-expressive language disorder

F98.5Adult onset fluency disorder

G52.2 - G52.8 - Opens in a new windowDisorders of vagus nerve - Disorders of other specified cranial nerves

H90.0 - H90.12 - Opens in a new windowConductive hearing loss, bilateral - Conductive hearing loss, unilateral, left ear,
with unrestricted hearing on the contralateral side

H90.3 - H90.8 - Opens in a new windowSensorineural hearing loss, bilateral - Mixed conductive and sensorineural hearing
loss, unspecified

H93.241 - H93.243 - Opens in a new windowTemporary auditory threshold shift, right ear - Temporary auditory threshold
shift, bilateral

H93.25 - H93.293 - Opens in a new windowCentral auditory processing disorder - Other abnormal auditory perceptions,
bilateral

I69.01 - I69.028 - Opens in a new windowCognitive deficits following nontraumatic subarachnoid hemorrhage - Other
speech and language deficits following nontraumatic subarachnoid hemorrhage

I69.090Apraxia following nontraumatic subarachnoid hemorrhage

I69.092Facial weakness following nontraumatic subarachnoid hemorrhage

I69.11 - I69.128 - Opens in a new windowCognitive deficits following nontraumatic intracerebral hemorrhage - Other

speech and language deficits following nontraumatic intracerebral hemorrhage

I69.190Apraxia following nontraumatic intracerebral hemorrhage

I69.192Facial weakness following nontraumatic intracerebral hemorrhage

I69.21 - I69.228 - Opens in a new windowCognitive deficits following other nontraumatic intracranial hemorrhage -
Other speech and language deficits following other nontraumatic intracranial hemorrhage

I69.290Apraxia following other nontraumatic intracranial hemorrhage

I69.292Facial weakness following other nontraumatic intracranial hemorrhage

I69.31 - I69.328 - Opens in a new windowCognitive deficits following cerebral infarction - Other speech and language
deficits following cerebral infarction

I69.390Apraxia following cerebral infarction

I69.392Facial weakness following cerebral infarction

I69.81 - I69.828 - Opens in a new windowCognitive deficits following other cerebrovascular disease - Other speech and
language deficits following other cerebrovascular disease

I69.890Apraxia following other cerebrovascular disease

I69.892Facial weakness following other cerebrovascular disease

I69.91 - I69.928 - Opens in a new windowCognitive deficits following unspecified cerebrovascular disease - Other
speech and language deficits following unspecified cerebrovascular disease

I69.990Apraxia following unspecified cerebrovascular disease

I69.992Facial weakness following unspecified cerebrovascular disease

J38.00 - J38.02 - Opens in a new windowParalysis of vocal cords and larynx, unspecified - Paralysis of vocal cords and
larynx, bilateral

R41.840Attention and concentration deficit

R41.841Cognitive communication deficit

R41.842Visuospatial deficit

R41.843Psychomotor deficit

R41.844Frontal lobe and executive function deficit

R47.01 - R47.82 - Opens in a new windowAphasia - Fluency disorder in conditions classified elsewhere

R48.0 - R48.2 - Opens in a new windowDyslexia and alexia - Apraxia

R48.8Other symbolic dysfunctions

R49.0 - R49.1 - Opens in a new windowDysphonia - Aphonia

DESCRIPTION

Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.

CODING INFORMATION

ICD-10 Codes that may support medical necessity:

D69.0 Allergic purpura

H10.401 – H10.409 Unspecified chronic conjunctivitis
H10.421 – H10.429 Simple chronic conjunctivitis
H10.44 Vernal conjunctivitis
H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal
H10.411 – H10.419 Chronic giant papillary conjunctivitis
H10.45 Other chronic allergic conjunctivitis
H10.9 Unspecified conjunctivitis
J30.0 – J30.9 Vasomotor and allergic rhinitis
J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis
J32.0 – J32.9 Chronic sinusitis
J33.0 – J33.9 Nasal polyp
J45.20 – J45.998 Asthma
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
L20.0 – L20.9 Atopic dermatitis
L22 Diaper dermatitis
L23.0 – L23.9 Allergic contact dermatitis
L24.0 – L24.9 Irritant contact dermatitis
L25.0 – L25.9 Unspecified contact dermatitis
L27.0 – L27.9 Dermatitis due to substances taken internally
L29.8 Other pruritus
L29.9 Pruritus, unspecified
L30.0 – L30.9 Other and unspecified dermatitis
L50.0 Allergic urticaria
L50.1 Idiopathic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
L50.9 Urticaria, unspecified
L56.4 Polymorphous light eruption
T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances
T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances
T78.00xA-T78.1xxS Anaphylactic reaction due to food


ALLERGY TESTING / IMMUNOTHERAPY

POLICY/CRITERIA

A. The following allergy tests are covered benefits:

1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.

2. Skin tests (scratch, intradermal, pricks)

3. Patch application tests

4. Drug Provocation testing

5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.

B. The following services have not been proven to be effective in diagnosing and/or treating allergies, and are not covered benefits:

1. Cytotoxicity testing (Bryan's test)

2. Urine autoinjection (autogenous urine immunization)

3. Provocation testing and neutralization therapy for food allergy (intracutaneous, subcutaneous or sublingually). Also called Intracutaneous Progressive Dilution Food Test (IPDFT).

4. Antigen leukocyte cellular antibody test (ALCAT) for all indications including but not limited to testing for food allergies or intolerance (chemical sensitivities) and as a tool to establish elimination diets.

5. Electrodermal testing or electro-acupuncture*

6. Applied kinesiology or muscle strength testing of allergies

7. Reaginic pulse testing or pulse testing for allergies

8. Total serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM)

9. Testing of specific IgG antibody (e.g., by RAST or ELISA testing)

10. Lymphocyte subset counts

11. Lymphocyte function assay

12. Lymphocyte transformation test (LTT), also known as lymphocyte proliferation test and metal ion testing for metal-induced hypersensitivity response.

13. Cytokine, cytokine receptor assay and Th1/Th2 cytokine ratio

14. Natural Killer (NK) cell assay or activity

15. Food immune complex assay (FICA)

16. Leukocyte histamine release testing

17. Body chemical analysis

18. Sublingual immunotherapy (SLIT) as an alternative way to treat allergies without injections. SLIT is not FDA approved in the United States

*Note: Acupuncture may be covered with a rider for some commercial plans