Tuesday, November 27, 2018

CPT 0301T,32998, 32999, 47382, 76940 -Microwave Tumor Ablation


CPT Code - Description

0301T Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under ultrasound thermotherapy guidance

19499 Unlisted procedure, breast

32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral

32999 Unlisted procedure, lungs and pleura

47382 Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency

47399 Unlisted procedure, liver

49999 Unlisted procedure, abdomen, peritoneum and omentum

50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency

53899 Unlisted procedure, urinary system (for renal tumors)

60699 Unlisted procedure, endocrine system (for adrenal or thyroid tumors)

76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation





Microwave Tumor Ablation

Introduction

Ablation refers to destroying tumors without removing them. Microwave ablation is a method of trying to treat tumors using microwave energy. A small probe is placed into the tumor. The probe sends out microwave energy. The microwaves cause enough heat to kill tumor cells. Medical studies show that while this technique can destroy tumors at a particular location, cancer recurrence at other sites is common, depending on the stage and type of cancer. More studies are needed to show which patients would benefit the most from this treatment, as well as explaining why this treatment should be used instead of other proven methods. For these reasons, microwave ablation of tumors is considered investigational (unproven).

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage Criteria Service Investigational Microwave ablation (MWA) Microwave ablation (MWA) of primary and metastatic tumors is considered investigational. Coding

According to an American Medical Association publication (Clinical Examples in Radiology, 2012, 8, [3}), “microwave is part of the radiofrequency spectrum, and simply uses a different part of the radiofrequency spectrum to develop heat energy to destroy abnormal tissue.” Therefore, AMA recommends that microwave ablation should be reported using the CPT codes for radiofrequency ablation as noted in the coding table below.

Related Information
This policy does not address MWA for the treatment of splenomegaly or ulcers or as a surgical coagulation tool. Evidence Review

Description

Microwave ablation (MWA) is a technique that is used to destroy tumors and soft tissue. It generates microwave energy to create thermal coagulation and localized tissue necrosis, and has been used to treat tumors not amendable to resection. It has also been used to treat patients ineligible for surgery due to age, comorbidities, or poor general health. MWA may be performed as an open procedure, laparoscopically, percutaneously, or thoracoscopically under image guidance (eg, ultrasound, computed tomography, magnetic resonance imaging) with sedation, or local or general anesthesia. This technique is also referred to as microwave coagulation therapy.

Background
MWA is a technique that uses microwave energy to induce an ultra-high speed, 915 MHz or 2.450 MHz (2.45 GHz), alternating electric field, which causes water molecules to rotate and create heat. This results in thermal coagulation and localized tissue necrosis. In MWA, a single microwave antenna or multiple antennas connected to a generator are inserted directly into the tumor or tissue to be ablated; energy from the antennas generates friction and heat. The local heat coagulates the tissue adjacent to the probe, resulting in a small, 2- to 3 -cm elliptical area  (5 x 3 cm) of tissue ablation. In tumors greater than 2 cm in diameter, 2 to 3 antennas may be used simultaneously to increase the targeted area of MWA and shorten operative time. Multiple antennas may also be used simultaneously to ablate multiple tumors. Tissue ablation occurs quickly, within 1 minute after a pulse of energy, and multiple pulses may be delivered within a treatment session, depending on tumor size. The cells killed by MWA are typically not removed but are gradually replaced by fibrosis and scar tissue. If there is local recurrence, it occurs at the margins. Treatment may be repeated as needed. MWA may be used to:

1. Control local tumor growth and prevent recurrence
2. Palliate symptoms
3. Extend survival duration

MWA is similar to radiofrequency (RFA) and cryosurgical ablation. However, MWA has potential advantages over RFA and cryosurgical ablation. In MWA, the heating process is active, which produces higher temperatures than the passive heating of RFA and should allow for more complete thermal ablation in less time. The higher temperatures reached with MWA (>100°C) can overcome the “heat sink” effect in which tissue cooling occurs from nearby blood flow in large vessels, potentially resulting in incomplete tumor ablation. MWA does not rely on the conduction of electricity for heating and, therefore, does not flow electrical current through patients and does not require grounding pads, because there is no risk of skin burns. Additionally, MWA does not produce electric noise, which allows ultrasound guidance during the procedure without interference, unlike RFA. Finally, MWA can take less time than RFA, because multiple antennas can be used simultaneously.

Adverse Events

Complications from MWA are usually considered mild and may include pain and fever. Other potential complications associated with MWA include those caused by heat damage to normal tissue adjacent to the tumor (eg, intestinal damage during MWA of the kidney or liver), structural damage along the probe track (eg, pneumothorax as a consequence of procedures on the lung), liver enzyme elevation, liver abscess, ascites, pleural effusion, diaphragm injury or secondary tumors if cells seed during probe removal. MWA should be avoided in pregnant women because potential risks to the patient and/or fetus have not been established. It should also be avoided in patients with implanted electronic devices such as implantable pacemakers that may be adversely affected by microwave power output.

Applications

MWA was first used percutaneously in 1986 as an adjunct to liver biopsy. Since then, MWA has been used to ablate tumors and other tissues in order to treat many conditions. These have included hepatocellular carcinoma, breast cancer, colorectal cancer metastatic to the liver, renal cell carcinoma, renal hamartoma, adrenal malignant carcinoma, non-small-cell lung cancer, intrahepatic primary cholangiocarcinoma, secondary splenomegaly and hypersplenism, abdominal tumors, and other tumors not amenable to resection. Well-established local or systemic treatment alternatives are available for each of these malignancies. The potential advantages of MWA for these cancers include improved local control and other advantages common to any minimally invasive procedure (eg, preserving normal organ tissue, decreasing morbidity, shortening length of hospitalization). MWA also has been investigated as primary and/or palliative treatment for unresectable hepatic tumors, and also as a bridge to liver transplantation. In the latter setting, MWA is being assessed to determine whether it can reduce the incidence of tumor progression while awaiting liver transplantation and thus maintain a patient’s candidacy for the transplant.

Summary of Evidence

For individuals who have an unresectable primary or metastatic tumor (eg, breast, hepatic [primary or metastatic], pulmonary, renal) who receive MWA, the evidence includes case series, observational studies, cohort studies, randomized controlled trials (RCTs), and systematic reviews. Relevant outcomes are overall survival, disease-specific survival, symptoms, quality of life, and treatment-related mortality and morbidity. Available studies have shown that MWA results in a wide range of complete tissue ablation (50%-100%) depending on tumor size, with complete ablation common and nearing 100% with smaller tumors (eg, less than or equal to 3 cm). Tumor recurrence rates at ablated sites are very low. However, tumor recurrence at nonablated sites is common and may correlate with disease state (eg, in hepatocellular carcinoma). Intraoperative and postoperative minor and major complications are low, especially when tumors are smaller and accessible. Patient selection criteria and rationale for using MWA over other established techniques (eg, surgical resection, radiofrequency ablation) are needed. The evidence is insufficient to determine the effects of the technology on health outcomes. Ongoing and Unpublished Clinical Trials

Thursday, November 1, 2018

Plastic Surgery, cosmetic, reconstructive CPT codes list


Introduction

There are generally two types of plastic surgery, cosmetic and reconstructive. Cosmetic surgery is performed to improve appearance, not to improve function or ability. The plan does not cover cosmetic surgery. Reconstructive surgery focuses on reconstructing defects of the body or face due to trauma, burns, disease, or birth disorders. Reconstructive surgery is designed to restore or improve function associated with the presence of a defect. This policy outlines when reconstructive surgery may be covered

Note:

The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers . A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered

Coding Code Description Medically Necessary Services  CPT
17106 Destruction of cutaneous vascular proliferative lesions (eg,laser technique; less than 10 sq cm
17107 Destruction of cutaneous vascular proliferative lesions (eg , laser technique; 10.0 to 50.0  sq cm
17108 Destruction of cutaneous vascular proliferative lesions (eg , laser technique); over 50.0 sq cm
21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle; with bone graft,  onlay or interpositional (includes obtaining autograft)
21137 Reduction forehead; contouring only
21138 Reduction forehead; contouring and application of prosthetic material or bone graft  (includes obtaining autograft)
21139 Reduction forehead;  contouring and setback of anterior frontal sinus wall
65760 Keratomileusis
65765 Keratophakia
65767 Epikeratoplasty

Cosmetic Services CPT
11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color  defects of skin, including micropigmentation; 6.0 sq cm or less
11921 Tattooing, intradermal introduction of insoluable opaque pigments to correct color  defects of skin, including micropigmentation; 6.1 sq cm to 20.0 sq cm
11922 Tattooing, intradermal introduction of insoluable 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)
11950 Subcutaneous injection of filling material (eg , collagen); 1cc or less
11951 Subcutaneous injection of filling material (eg , collagen); 1.1 to 5.0 cc
11952 Subcutaneous injection of filling material (eg , collagen); 5.1 to 10.0 cc
11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion
15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general  keratosis)
15781 Dermabrasion;  segmental, face
15782 Dermabrasion; regional, other than face
15783 Dermabrasion; superficial, any site, (eg, tattoo removal)
15786 Abrasion; single lesion (eg keratosis, scar)
15787 Abrasion; each additional four lesions or less (List separately in  addition to code for  primary procedure)
15819 Cervicoplasty
15824 Rhytidectomy; forehead
15825 Rhytidectomy; neck with platysmal tightening (platsymal flap, P - flap)
15826 Rhytidectomy; glabellar frown lines
15828 Rhytidectomy; cheek, chin, and neck
15829 Rhytidectomy; superficial musculoapneurotic system SMAS flap
15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837 Excision, excessive  skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839 Excision excessive skin and subcutaneous tissue (includes lipectomy); other areas
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg , abdominoplasty) (includes umbilical transposition and fascial plication) (List separately  in addition to code for primary procedure)
15876 Suction assisted lipectomy;  head and neck
15877 Suction assisted lipectomy; trunk
15878 Suction assisted lipectomy; upper extremity
15879 Suction assisted lipectomy; lower extremity
19355 Correction of inverted nipples
21120 Genioplasty; augmentation (autograft, allograft,  prosthetic material)
21121 Genioplasty; sliding osteotomy, single piece
21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg , wedge excision or bone  wedge reversal for asymmetrical chin)
21123 Genioplasty; sliding, augmentation with  interpositional bone grafts (includes obtaining  autografts)
40500 Vermilionectomy (lip shave), with mucosal advancement
54360 Plastic operation on penis to correct angulation
56620 Vulvectomy simple; partial
69300 Otoplasty, protruding ear, with or  without size reduction

HCPCS
Q2026 Injection, Radiesse, 0.1 ml
Q2028 Injection, sculptra, 0.5 mg

Cosmetic / Reconstructive CPT

11970 Replacement of tissue expander with permanent prosthesis
11971 Removal of tissue expander(s)  without insertion of prosthesis
19316 Mastopexy
19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation; with prosthetic implant
19328 Removal of intact mammary implant
19330 Removal of mammary implant material
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in  reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in  reconstruction
19350 Nipple/areola reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19366 Breast reconstruction with other technique
19370 Open periprosthetic capsulotomy, breast
19371 Periprosthetic capsulectomy, breast
19380 Revision of reconstructed breast
21088 Impression and custom preparation; facial prosthesis
21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts  (includes obtaining autografts)
21280 Medial canthopexy (separate procedure)
21282 Lateral canthopexy

Non - covered Services
CPT
17380 Electrolysis epilation, each 30 minutes
69090 Ear piercing

Note :
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) . HCPCS  codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Definition of Terms

When specific definitions are not present in a member’s plan, the following definitions will be  applied.

Cosmetic:
In this policy, cosmetic services are those which are primarily intended to preserve or  improve appearance. Cosmetic surgery is performed to reshape normal structures of the body in  order to improve the patient’s appearance or self- esteem.

Physical functional impairment:In this policy, physical functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not  limited to, problems with ambulation, mobilization, communication, respiration, eating,  swallowing, vision, facial expression, skin integrity, distortion of nearby body part(s) or obstruction of an orifice. The physical functional impairment can be due to structure, congenital  deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments

Reconstructive surgery:

In this policy, reconstructive surgery refers to surgeries performed on abnormal structures of the body, caused by congenital defects, developmental a bnormalities, trauma, infection, tumors or disease. It is generally performed to improve function. Determination of Eligibility for Coverage The final determination of eligibility for coverage should be based on application of the specific contract language based on the etiology of the defect and the presence or absence of documented physical functional impairment .

Administering the Contract Language ( also seeBenefit Application)

The  following general principles describe the issues to be determined in properly administering  the contract language.

1.The eligibility of a service for coverage may be based on either a specific benefit addressing cosmetic or reconstructive services or on its specific exemption or exclusion for cosmetic or  reconstructive services or both.

2. Cosmetic services are usually considered to be those that are primarily to restore  appearance and that otherwise do not meet the definition of reconstructive.

The definition  of reconstructive may be based on two distinct factors:

o Whether the service is primarily indicated to improve or correct a functional impairment or is primarily to improve appearance; and
o The etiology of the defect (eg, congenital anomaly, anatomic variant, result of trauma, post-therapeutic intervention, disease process).

3.  The presence or absence of a functional impairment is a critical point in interpreting coverage eligibility. For musculoskeletal conditions, the concept of a functional impairment is straightforward. However, when considering dermatologic conditions, the function of the skin is more difficult to define. Procedures designed to enhance the appearance of the skin are typically considered cosmetic
 

Wednesday, May 30, 2018

Billing Guideline for experimental or investigations procedure

EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES


Any drug, device or medical treatment or procedure and related services that are experimental or investigational as defined by BCBSKS are non-covered services.

Experimental or investigational refers to the status of a drug, device or medical treatment or procedure:

A. if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished and the drug or device is not Research-Urgent as defined except for prescription drugs used to treat cancer when the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature; or
B. if Credible Evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis and the trials are not Research-Urgent as defined except for prescription drugs used to treat cancer when the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature; or

C. if Credible Evidence shows that the consensus among experts regarding the drug, device or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis and the trials are not Research-Urgent as defined except for prescription drugs used to treat cancer when the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature; or

D. if there is no Credible Evidence available that would support the use of the drug, device, medical treatment or procedure compared to the standard means of treatment or diagnosis except for prescription drugs used to treat cancer when the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature.

Credible evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol(s) used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure.

Research-Urgent shall mean a drug, device, medical treatment or procedure that may be covered (even though otherwise excluded by the contract as experimental or investigational) providing the specified criteria outlined in the contract is met.

Contracting providers shall notify the patient when services to be rendered are considered experimental or investigational and may not be covered under the member’s contract. Any patient being billed for services considered experimental or investigational must have a signed waiver in his/her file. The provider must discuss this with the patient in advance, document this in the medical record, and include the GA modifier (waiver on file) on the claim form (electronic or paper). (See Section X. WAIVER FORM) Failure to discuss and obtain a signed waiver in advance of the service will result in provider write-off.

UNIFORM PROVIDER CHARGING PRACTICES


Occasionally BCBSKS receives questions about what constitutes a provider’s usual charge when a provider offers cash customers a discount and what amount to bill BCBSKS. The term “usual charge” is defined in our Contracting Provider Agreements, but to specifically address this question, our policy is as follows:

A. Provider discounts or charging practices based upon individual patients’ situations (for example: patient hardship or professional courtesy) are acceptable and are not considered the provider’s usual charge. If a provider gives a patient a discount for cash, they must bill BCBSKS the same amount.

B. If a provider gives a lower charge to every patient who does not have health insurance, we consider that lower charge to be the “usual charge.”

Because a contracting provider agrees to not bill a BCBSKS member at the time of service, there should never be a circumstance in which a BCBSKS member pays anything other than a deductible, copayment, coinsurance, or non-covered procedure at the time of service. As an additional matter in regard to this point, our payments are timely enough that they are essentially cash for all practical purposes. If we are in fact late with payments, then the remedy is stated under the Prompt Payment law.

C. Agencies such as community mental health centers and county health departments would be allowed to use a sliding scale for charging practices due to agency regulations.

Thursday, January 11, 2018

Crisis services billing - Medicaid Guid


CRISIS SERVICES

Crisis Interventions Crisis Interventions are unscheduled activities conducted for the purpose of resolving a crisis situation requiring immediate attention. Activities include crisis response, crisis line, assessment, referral, and direct therapy.

The standard for whether or not a crisis exists is a "prudent layperson" standard. That means that a prudent layperson would be able to determine from the beneficiary’s symptoms that crisis services are necessary. Crisis means a situation in which an individual is experiencing the signs and symtoms of a serious behavioral health disorder, and one of the following applies:

* The individual can reasonably be expected within the near future to physically injure himself or another individual, either intentionally or unintentionally;

* The individual is unable to provide himself food, clothing, or shelter, or to attend to basic physical activities such as eating, toileting, bathing, grooming, dressing, or ambulating, and this inability may lead in the near future to harm to the individual or to another individual; or

* The individual’s judgment is so impaired that he is unable to understand the need for treatment and, in the opinion of the behavioral health professional, his continued behavior as a result of the behavioral health disorder can reasonably be expected in the near future to result in physical harm to the individual or to another individual.

If the beneficiary developed a crisis plan, the plan is followed with permission from the beneficiary.

Crisis Residential Services

Crisis residential services are intended to provide a short-term alternative to inpatient psychiatric services for beneficiaries experiencing an acute psychiatric crisis when clinically indicated. Services may be used to avert an inpatient psychiatric admission or to shorten the length of an inpatient stay. Additionally, these services are designed for a subset of beneficiaries who meet the ASAM Criteria for Level 3.7 Medically Monitored Intensive Inpatient Services admission criteria or are at risk of admission, but who can be appropriately served in settings less intensive than a hospital. This service is also designed for beneficiaries who are intoxicated and at risk of admission to an acute setting or another level of care but can be appropriately served in this less intensive setting. The goal of crisis residential services is to facilitate reduction in the intensity of those factors that lead to crisis residential admission through a personcentered/ individualized and recovery-oriented approach.



* Population: Services are designed for a subset of beneficiaries who meet psychiatric inpatient/substance use disorder residential admission criteria or are at risk of admission to a high level of care setting but who can be appropriately served in a less intensive setting.

* Covered Services: Services must be designed to resolve the immediate crisis and improve the functioning level of the beneficiary to allow them to return to less intensive community living as soon as possible. Covered crisis residential services include:

* Psychiatric supervision (for programs providing mental health services and/or co-occurring disorders);

* Therapeutic support services;

* Medication management/stabilization and education;

* Behavioral services;

* Milieu therapy; and

* Nursing/medical services (on-site nursing services are required for those beneficiaries who are in the detoxification process, and who require medications to manage the current crisis).

Beneficiaries who are admitted to crisis residential services must be offered the opportunity to explore and learn more about crises, mental health disorders, substance use disorders, identity, values, choices and choice-making, recovery and recovery planning. Recovery and recovery planning is inclusive of all aspects of life, including relationships, where to live, training, employment, daily activities, and physical well-being.

The program must include on-site nursing services (Registered Nurse [RN] or Licensed Practical Nurse [LPN] under appropriate supervision).

* For settings of 6 beds or fewer: on-site nursing must be provided at least one hour per day, per resident, seven days per week, with 24-hour availability on-call.

* For 7-16 beds: on-site nursing must be provided eight hours per day, seven days per week, with 24-hour availability on-call.

* Provider Criteria: The PIHP must seek and maintain MDHHS approval for the crisis residential program in order to use Healthy Michigan Plan funds for program services. Healthy Michigan Plan crisis residential programs may choose to provide a program for serious mental illness, intellectual/developmental disabilities, substance use disorders or a combined program. A program offering services for substance use disorders must be licensed for residential substance use disorder treatment services per the Administrative Rules for Substance Use Disorder Programs and appropriately accredited through one of the organizations identified in the Substance Abuse Services subsection of the Mental Health/Substance Abuse Chapter. Established residential programs that purport to offer this service for individuals with substance use disorders will be required to seek re-approval of the program by MDHHS when appropriate licensing and accreditation has been obtained. Programs currently approved to provide services for mental health and/or intellectual/developmental disabilities by MDHHS through the delivery of Medicaid State Plan, Habilitation Supports Waiver (HSW), or additional/B3 services do not require re-approval.

* Qualified Staff: Treatment services must be clinically supervised by a psychiatrist. A psychiatrist need not be present when services are delivered but must be available by telephone at all times. The psychiatrist must provide psychiatric evaluation or assessments at the crisis residential home. Medication reviews performed at the crisis residential home must be performed by a physician, physician assistant or a nurse practitioner under the clinical supervision of the psychiatrist. The covered crisis residential services must be supervised onsite eight hours a day, Monday through Friday (and on call at all other times). Supervision must be by a behavioral health professional (Mental Health Professional [MHP] and/or a Substance Abuse Treatment Specialist [SATS] depending on the scope of services being provided) possessing at least a master’s
degree in human services and one year of experience providing behavioral health services to individuals with serious mental illness and/or substance use disorders; or a bachelor’s degree in human services and at least two years of experience providing behavioral health services to individuals with serious mental illness and/or substance use disorders.


Treatment activities may be carried out by paraprofessional staff who have at least one year of satisfactory work experience providing behavioral health services to individuals with mental illness and/or substance use disorders, or who have successfully completed a PIHP/ MDHHS-approved training program for working with individuals with mental illness and/or substance use disorders.

Peer support specialists and/or recovery coaches may be part of the multidisciplinary team and can facilitate some of the activities based on their scope of practice, such as facilitating peer lead support groups, assisting in transitioning beneficiaries to less intensive services, and by mentoring beneficiaries towards recovery.

* Location of Services: Services must be provided to beneficiaries in licensed crisis residential foster care, group home settings not exceeding 16 beds in size, or in a licensed substance use disorder residential treatment program (when providing services for substance use disorders). Homes/settings must have appropriate licensure from the State and must be approved by MDHHS to provide specialized crisis residential services. Services must not be provided in a hospital
or other institutional setting.

 Admission Criteria: Crisis residential services may be provided to beneficiaries who are assessed by, and admitted through, the authority of the local PIHP.

Beneficiaries must meet psychiatric inpatient admission or residential substance use disorder level of care criteria but have symptoms and risk levels that permit them to be treated in such alternative settings. Services are designed for beneficiaries with mental health or substance use disorders, beneficiaries with a co-occurring mental health and substance use disorder, or beneficiaries with intellectual/developmental disabilities. For beneficiaries with a concomitant disorder with an intellectual/developmental disability, the primary reason for service must be mental illness or substance use disorder.

* Duration of Services: Services may be provided for a period up to 14 calendar days per crisis residential episode. Services may be extended and regularly monitored, if justified by clinical need, as determined by the interdisciplinary team. For substance use disorders, beneficiaries should be moved to another ASAM Level of Care within 14 days; however, services may be extended if justified by clinical need, medical necessity, and as determined by the interdisciplinary team.

* Individual Plan of Service/Treatment Plan: Services must be delivered according to an Individual Plan of Service (IPOS) or appropriate treatment plan process for substance use disorder beneficiaries (refer to the Treatment Planning subsection of the Mental Health/Substance Abuse Chapter) based on an assessment of immediate need. The IPOS/treatment plan must be developed within 48 hours of admission and signed by the beneficiary (if possible), the guardian, the psychiatrist, and any other professionals involved in the treatment planning process as determined by the needs of the beneficiary. If the beneficiary has an assigned case manager, the case manager must be involved in the treatment as soon as possible, and must also be involved in follow-up services.


The IPOS/treatment plan must contain:

* Clearly stated goals and measurable objectives, derived from the assessment of immediate need, stated in terms of specific observable changes in behavior, skills, attitudes, or circumstances, structured to resolve the crisis;


* Identification of the activities designed to assist the beneficiary to attain his goals and objectives; and

* Discharge plans, the need for aftercare/follow-up services, and the role of, and identification of, the case manager.

If the length of stay in the crisis residential program exceeds 14 days, an interdisciplinary team must develop a subsequent plan based on comprehensive assessments. The team is comprised of the beneficiary, the guardian, the psychiatrist,the case manager and other professionals whose disciplines are relevant to the needs  of the beneficiary, including the individual Assertive Community Treatment (ACT) team, outpatient services provider, when applicable. If the beneficiary did not have a case manager prior to initiation of the intensive/crisis residential service and the crisis episode exceeds 14 days, a case manager must be assigned and involved in treatment and follow-up care. (The case manager may be assigned prior to the 14 days
according to need.)



Intensive/Crisis Stabilization Services

Intensive/crisis stabilization services are structured treatment and support activities provided by a multidisciplinary team and designed to provide a short-term alternative to inpatient psychiatric services and/or substance use disorder residential treatment in a community setting. Services may be used to avert a psychiatric admission, residential substance use disorder admission, or to shorten the length of an inpatient or substance use disorder residential stay when clinically indicated.
Crisis situation means a situation in which an individual is experiencing the signs and symptoms of a serious behavioral health disorder, and one of the following applies:


* The individual can reasonably be expected within the near future to physically injure himself or another individual, either intentionally or unintentionally;

* The individual is unable to provide himself food, clothing, or shelter, or to attend to basic physical activities such as eating, toileting, bathing, grooming, dressing, or ambulating, and this inability may lead in the near future to harm to the individual or to another individual; or

* The individual’s judgment is so impaired that he is unable to understand the need for treatment and, in the opinion of the behavioral health professional, his continued behavior as a result of the behavioral health disorder can reasonably
be expected in the near future to result in physical harm to the individual or to another individual.


* Approval: The PIHP must seek and maintain MDHHS approval for the intensive/crisis stabilization services in order to use Healthy Michigan Plan funds for program services. A program that will be offering services for substance use disorders must be licensed for outpatient substance use disorder treatment services per the Administrative Rules for Substance Use Disorder Programs and appropriately accredited through one of the organizations identified in the Substance Abuse Services subsection of the Mental Health/Substance Abuse Chapter. Established crisis stabilization service programs that purport to offer this service for individuals with substance use disorders will be required to seek reapproval of the program by MDHHS when appropriate licensing and accreditation has been obtained. Programs currently approved to provide services for mental health and/or intellectual/developmental disabilities by MDHHS through the delivery of Medicaid State Plan, Habilitation Supports Waiver (HSW), or additional/B3 services do not require re-approval.


* Population: These services are for beneficiaries who have been assessed to meet criteria for psychiatric hospital admissions and/or substance use disorder residential/inpatient treatment but who, with intense interventions, can be stabilized and served in their usual community environments. These services may also be provided to beneficiaries leaving inpatient psychiatric services and/or substance use disorder residential/inpatient treatment if such services will result
in a shortened stay. Beneficiaries must have a diagnosis of mental illness, substance use disorder or mental illness with a co-occurring substance use disorder, or intellectual/developmental disability.

* Services: Intensive/crisis stabilization services are intensive treatment interventions delivered by an intensive/crisis stabilization treatment team under the supervision of a psychiatrist. Component services include:

* Intensive individual counseling/psychotherapy;

* Assessments (rendered by the treatment team);

* Family therapy;

* Psychiatric supervision; and

* Therapeutic support services by trained paraprofessionals.

* Qualified Staff: Intensive/crisis stabilization services must be provided by a treatment team of behavioral health professionals under the supervision of a psychiatrist. The psychiatrist need not provide on-site supervision at all times, but must be available by telephone at all times. The treatment team providing intensive/crisis stabilization services must be Mental Health Professionals and/or Substance Abuse Treatment Specialists. Nursing services/consultation must be available.

The treatment team may be assisted by trained paraprofessionals under appropriate supervision. Trained paraprofessionals must have at least one year of satisfactory work experience providing services to individuals with behavioral health disorders. Activities of trained paraprofessionals include assistance with therapeutic support services. In addition, the team may include one or more peer support specialists and/or recovery coaches.

* Location of Services: Intensive/crisis stabilization services may be provided where necessary to alleviate the crisis situation, and to permit the beneficiary to remain in, or return more quickly to, his usual community environment.

Intensive/crisis stabilization services must not be provided exclusively or predominantly at residential programs.

Exceptions: Intensive/crisis stabilization services may not be provided in:

* Inpatient settings;

* Jails or other settings where the beneficiary has been adjudicated; or

* Crisis residential settings.

* Individual Plan of Service/Treatment Plan: Intensive/crisis stabilization services may be provided initially to alleviate an immediate behavioral health crisis. However, following resolution of the immediate situation (and within no more than 48 hours), an intensive/crisis stabilization services IPOS or appropriate treatment plan process for substance use disorder beneficiaries (refer to the Treatment Planning subsection of the Mental Health/Substance Abuse Chapter) must be developed. The intensive/crisis stabilization IPOS/treatment plan must be developed through a person-centered planning process in consultation with the psychiatrist. Other professionals may also be involved if required by the needs of the beneficiary. The case manager (if the beneficiary receives case management services) must be involved in the treatment and follow-up services.

The IPOS/treatment plan must contain:

* Clearly stated goals and measurable objectives, derived from the assessment of immediate need, and stated in terms of specific observable changes in behavior, skills, attitudes, or circumstances structured to resolve the crisis.

* Identification of the services and activities designed to resolve the crisis and attain the beneficiary's goals and objectives.

* Plans for follow-up services (including other behavioral health services where indicated) after the crisis has been resolved. The role of the case manager must be identified, where applicable.

Thursday, October 5, 2017

Facility claims billing to Medicaid and Medicare

 REPORTING MEDICARE ON THE MEDICAID NURSING FACILITY CLAIM When reporting Medicare, nursing facilities must bill as outlined below.

* Covered Days

* Covered days must be reported using Value Code 80.

* Covered days are the days in which Medicare approves payment for the beneficiary’s skilled care. Covered days must be reported when the primary insurance makes a payment.

* Non-Covered Days

* Non-covered days must be reported using Value Code 81.

* Non-covered days are the days not covered by Medicare due to Medicare being exhausted or the beneficiary no longer requiring skilled care. Non-covered days must be reported in order to receive the proper Medicaid provider rate payment.

* When Medicare non-covered days are reported because Medicare benefits are exhausted, facilities must report Occurrence Code A3 and the date benefits were exhausted, along with Claim Adjustment Reason Code (CARC) 96 (Non-Covered Charges) or 119 (Benefit Maximum for the Time Period has been Reached).


* When Medicare non-covered days are reported because Medicare active care ended, facilities must report Occurrence Code 22 and the corresponding date Medicare active care ended, along with CARC 96 or 119.

* Coinsurance Days

* Medicare coinsurance days must be reported using Value Code 82.

* Coinsurance days are the days in which the primary payer (Medicare or Medicare Advantage Plan) applies a portion of the approved amount to coinsurance.

Coinsurance days must be reported in order to receive the proper coinsurance rate payment.

* When reporting Value Code 82, Occurrence Span Code 70 (Qualifying Stay Dates for SNF) and corresponding from/through dates (at least a three-day inpatient hospital stay which qualifies the resident for Medicare payment of SNF services) must also be
reported.

* Facilities billing for beneficiaries in a Medicare Advantage Plan must report CARC 2, and this must equal the Medicare Advantage Plan coinsurance rate times the number of coinsurance days. Facilities using CARC 2 must report it with the amount equal to the coinsurance rate times the number of coinsurance days reported.

* Medicare Advantage Plan coinsurance rates vary and do not always equal the Medicare Part A coinsurance rate. Providers must verify the beneficiary’s Medicare Advantage Plan coinsurance rate prior to billing Medicaid.

* Prior Stay Date

* If a SNF or nursing facility stay ended within 60 days of the SNF admission, Occurrence Span Code 78 and the from/through dates must be reported along with Occurrence Span Code 70 and the from/through dates.

* Nursing Facilities with Medicaid-Only Certified Beds Not Billing Medicare

* For nursing facilities with Medicaid-only certified beds not billing Medicare, claims submitted directly to Medicaid must be billed as outlined above. For example, for eneficiaries with Medicare coverage based on Medicaid’s TPL file, covered days
must be left blank if Medicare is not covering the service or benefits have exhausted as Medicare is the primary payer. The non-covered day must be completed and it must equal the service units billed for room and board revenue codes and/or leave
days revenue codes.

The reason Medicare is not covering the service (e.g., benefits exhausted) must also be reported.

* Claim Examples

* Nursing facility claim examples on how to report Medicare and commercial insurance on the Medicaid nursing facility secondary claim can be found on the MDHHS website

Thursday, May 18, 2017

NUCLEAR MEDICINE CPT code list


CPT CODE                DESCRIPTION

78000 THYROID RAI UPTAKE

78001 THYROID, MULTIPLE UPTAKES

78003 THYROID SUPPRESS OR STIMULATION

78006 THYROID UPTAKE AND SCAN

78007 THYROID, IMAGE, MULTIPLE UPTAKES

78010 THYROID SCAN ONLY

78011 THYROID IMAGING WITH FLOW

78015 THYROID MET IMAGING

78016 THYROID MET IMAGING WITH ADDITIONAL STUDIES

78018 THYROID SCAN WHOLE BODY

78020 THYROID CARCINOMA METASTASES UPTAKE

78070 PARATHYROID NUCLEAR IMAGING

78075 ADRENAL NUCLEAR IMAGING

78099 UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE

78102 BONE MARROW IMAGING, LIMITED

78103 BONE MARROW IMAGING, MULTIPLE

78104 BONE MARROW IMAGING, WHOLE BODY

78110 PLASMA VOLUME, SINGLE

78111 PLASMA VOLUME, MULTIPLE SAMPLING

78120 RED CELL VOLUME DETERMINATION, SINGLE SAMPLING

78121 RED CELL VOLUME DETERMINATION, MULTIPLE SAMPLING

78122 WHOLE BLOOD VOLUME DETERMINATION, SEP PLASMA & RED CELL

78130 RED CELL SURVIVAL STUDY

78135 DIFFERENTIAL ORGAN / TISSUES KINETIC

78140 LABELED RED CELL SEQUESTRATION

78160 PLASMA RADIOIRON DISAPEARANCE

78162 RADIOIRON ORAL ABSORPTION

78170 RED CELL IRON UTILIZATION

78172 TOTAL BODY IRON ESTIMATION

78185 SPLEEN IMAGING W & W/O VAS FLOW

78190 PLATELET SURVIVAL, KINETICS

78191 PLATELET SURVIVAL

78195 LYMPH SYSTEM IMAGING

78199 UNLISTED HEMATOPOIETIC DIAGNOSTIC NUCLEAR MED

78201 LIVER IMAGING

78202 LIVER IMAGING WITH FLOW

78205 LIVER IMAGING SPECT (3-D)

78206 LIVER IMAGING SPECT W/ VASCULAR FLOW

78215 LIVER & SPLEEN IMAGING

78216 LIVER & SPLEEN IMAGING WITH FLOW

78220 LIVER FUNCTION STUDY

78223 HIDA SCAN

78230 SALIVARY GLAND IMAGING

78231 SERIAL SALIVARY GLAND

78232 SALIVARY GLAND FUNCTION EXAM

78258 ESOPHOGUS MOTILITY STUDY

78261 GASTRIC MUCOSA IMAGING

78262 GASTROESOPHAGEAL REFLUX EXAM

78264 GASTRIC EMPTYING STUDY

78270 VIT-B12 ABSORPTION EXAM

78271 VIT-B12 ABSORPTION EXAM, LF

78272 VIT-B12 ABSORPTION EXAM COMBINED

78278 GI BLEEDER SCAN

78282 GI PROTEIN LOSS EXAM

78290 MECKEL’S DIVERTICULUM IMAGING

78291 LEVEEN SHUNT PATENCY EXAM

79299 UNLISTED GASTROINTESTINAL

78300 BONE OR JOINT IMAGING LTD

78305 BONE OR JOINT IMAGING MULTIPLE

78306 BONE SCAN WHOLE BODY

78315 BONE SCAN 3-PHASE STUDY

78320 BONE JOINT IMAGING TOMO TEST

78350 BONE MINERAL, SINGLE PHOTON

78351 BONE MINERAL, DUAL PHOTON

78399 UNLISTED MUSCULOSKELETAL

78414 NON-IMAGING HEART FUNCTION

78428 CARDIAC SHUNT IMAGING

78445 RADIONUCLIDE VENOGRAM NON-CARDIAC

78455 VENOUS THROMBOSIS STUDY

78457 VENOUS THROMBOSIS IMAGING UNILATERAL

78458 VENOUS THROMBOSIS IMAGES, BILATERAL

78460 THALLIUM SCAN REST ONLY

78461 MYOCARDIAL PERF STRESS OR REST MULTIPLE STUDY

78464 HEART IMAGE (3-D) SINGLE

78465 MYOCARDIAL PERF W/SPECT MULTIPLE

78466 MYOCARDIAL INFARCTION SCAN

78468 HEART INFARCT IMAGE EF

78469 HEART INFARCT IMAGE 3-D


78472 GATED HEART, RESTING

78473 CARDIAC BLOOD POOL M


Friday, April 7, 2017

CPT 70450, 70460, 70470 - CAT - Computerised axial tomography


CPT/HCPCS Codes

70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL

70460 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)

70470 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS


Coverage Indications, Limitations, and/or Medical Necessity

Computerized axial tomography (CAT) is a non-invasive neurodiagnostic tool that combines X-ray technology with computer capability to create a cross-sectional image. Scanning the head in successive layers by a narrow beam of X-rays enables the transmission of X-ray photons in each layer to be measured. A computer processes the accumulated X-ray photon data to construct a graphic image of a tomographic "slice". Normal intracranial structures and a wide variety of intracranial disorders may be demonstrated.

A diagnostic examination of the head performed by computerized tomography (CT) scanners is covered by Medicare if there is effective use of the scan for a specific condition, if it is reasonable and necessary for the individual patient, and if the scanning device is FDA approved. The use of the CCT scan must be found medically appropriate considering the patient’s symptoms and preliminary diagnosis.

A. A CCT scan is considered reasonable and necessary for the patient when the diagnostic exam is medically appropriate given the patient's symptoms and preliminary (or provisional) diagnosis.

B. CCT scans (as opposed to MRI evaluations) are used effectively in the following situations or conditions:

1. Patients who are not suitable candidates for MRI evaluation:

a) because of a pacemaker or intracranial metallic objects
b) because of extreme obesity
c) because of an inability to lie still


2. Patients whose condition requires the visualization of fine bone detail or calcification

3. Patients with the following conditions:

a) Acute CNS Hemorrhage
b) Strokes or encephalomalacia
c) New onset seizures, particularly if a focal component is present (contrast agent is appropriate for these patients)
d) Meningiomas or CNS lesions large enough to cause increased intracranial pressure (CCT scan is useful to determine gross margins between tumor and edematous brain)


C. There is no general rule that requires other diagnostic tests to be tried before CCT scanning is used. However, in individual cases it may be determined that use of a CCT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient’s symptoms or complaints as stated on the claim.

D. CCT imaging has not been useful in general for the evaluation of headache or dizziness and should be reserved for the patient whose presentation indicates a focal problem or who has experienced a significant change in symptomatology.

E. A CCT scan for the diagnosis of headache (ICD-10 code G44.1) can be allowed for the following:

1. After a head injury to rule out intracranial bleeding
2. Headache unusual in duration (greater than two weeks) not responding to medical therapy, to rule out the possibility of a tumor
3. A headache characterized by sudden onset and severity to rule out the possibility of an aneurysm, bleeding and/or arteriovenous malformation


F. A CCT Scan may be ordered without contrast, with contrast, or without contrast followed by contrast. Contrast administration is not without risk to the patient, and for some conditions, adds little or no benefit to the patient. The general indications for use of contrast CCT scanning (as opposed to non-contrast scanning) are to:

1. Assess perfusion (e.g. CVA)
2. Characterize a specific lesion
3. Detect defects in blood/brain barrier (e.g. infarct, tumor, infection, vasculitis)
4. Detect neovascularity (tumor), and
5. For staging of known lung cancer, breast cancer, and lymphomas likely to metastasize early to the brain


G. Intravenous contrast generally adds no information to CCT scans done secondary to head trauma (ICD-10 CM codes S02.XXA, S02.0XXB, S02.110A, S02.111A, S02.112A, S02.118A, S02.110B, S02.111B, S02.112B, S02.118B, S02.19XB, S02.2XXA, S02.2XXB, S02.69XA, S02.61XA, S02.62XA, S02.63XA, S02.64XA, S02.65XA, S02.66XA, S02.67XA, S02.69XA, S02.69XB, S02.61XB, S02.62XB, S02.63XB, S02.64XB, S02.65XB, S02.66XB, S02.67XB, S02.69XB, S02.411A, S02.412A, S02.413A, S02.411B, S02.412B, S02.413B, S2.411B, S02.412B, S02.413B, S02.3XXA, S02.3XXB, S02.42XA, S02.8XXA, S02.42XB, S02.8XXB, S06.6X0A, S06.6X1A, S06.6X2A, S06.6X3A, S06.6X4A, S06.6X5A, S06.6X6A, S06.6X7A, S06.6X8A, S06.6X0A, S06.5X0A, S06.5X1A, S06.5X2A, S06.5X3A, S06.5X4A, S06.5X5A, S06.5X6A, S06.5X7A, S06.5X8A, S06.5X0A, S06.4X0A, S06.4X1A, S06.4X2A, S06.4X3A, S06.4X4A, S06.4X5A, S06.4X6A, S06.4X7A, S06.4X8A, S06.340A, S06.350A, S06.341A, S06.342A, S06.351A, S06.352A, S06.343A, S06.344A, S06.353A, S06.354A, S06.345A, S06.355A, S06.346A, S06.347A, S06.348A, S06.356A, S06.357A, S06.358A, S06.890A, S06.1X0A, S06.2X0A, S06.810A, S06.820A, S06.890A, S06.1X1A, S06.1X2A, S06.2X1A, S06.2X2A, S06.811A, S06.812A, S06.821A, S06.822A, S06.891A, S06.892A, S06.1X3A, S06.1X4A, S06.2X3A, S06.2X4A, S06.813A, S06.814A, S06.823A, S06.824A, S06.893A, S06.894A, S06.1X5A, S06.2X5A, S06.815A, S06.825A, S06.895A, S06.1X6A, S06.1X7A, S06.1X8A, S06.2X6A, S06.2X7A, S06.2X8A, S06.816A, S06.817A, S06.818A, S06.826A, S06.827A, S06.828A, S06.896A, S06.897A, S06.898A). Additional symptoms suggesting a possible intracranial bleed may justify the use of contrast. These symptoms should be documented in the medical record, and if appropriate, included in the diagnostic codes listed on the claim.

H. More than one contrast CCT scan per episode of illness adds no information with the following exceptions:

1. CVA
2. Non-traumatic hemorrhage
3. TIA
4. Post-operative scan for residual tumor
5. Known brain tumor/metastases with a change in mental status



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.
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical 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.

0250 Pharmacy - General Classification
0254 Pharmacy - Drugs Incident to Other Diagnostic Services
0255 Pharmacy - Drugs Incident to Radiology
0258 Pharmacy - IV Solutions
0351 CT Scan - Head Scan


Computerized Axial Tomography (CT) Procedures - Medicare payment policy

A/B MACs (B) do not reduce or deny payment for medically necessary multiple CT scans of different areas of the body that are performed on the same day.The TC RVUs for CT procedures that specify “with contrast” include payment for high osmolar contrast media. When separate payment is made for low osmolar contrast media under the conditions set forth in §30.1.1, reduce payment for the contrast media as setforth in §30.1.2.

Bone Mass Measurements (BMMs)

(Rev. 1416; Issued: 01-18-08; Effective: 01-01-07; Implementation: 02-20-08) Sections 1861(s)(15) and (rr)(1) of the Social Security Act (the Act) (as added by §4106 of the Balanced Budget Act (BBA) of 1997) standardize Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B. This coverage is effective for claims with dates of service furnished on or after July 1, l998.

Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg. It also changed the definition of BMM by removing coverage for a single-photon absorptiometry as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act. Finally, it required that in the case of monitoring and confirmatory baseline BMMs, they be performed with a dual-energy xray absorptiometry (axial) test.

Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.

o Contractors will pay claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77080, and
• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0

as the ICD-9-CM diagnosis code or M81.0, M81.8, M81.6 or M94.9 as the ICD-10-CM diagnosis code.


o Contractors will deny claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and

• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code,



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

A06.6 Amebic brain abscess
A17.0 Tuberculous meningitis
A17.1 Meningeal tuberculoma
A17.81 Tuberculoma of brain and spinal cord
A17.82 Tuberculous meningoencephalitis
A17.83 Tuberculous neuritis
A17.89 Other tuberculosis of nervous system
A18.03 Tuberculosis of other bones
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A39.0 Meningococcal meningitis
A39.1 Waterhouse-Friderichsen syndrome
A39.2 Acute meningococcemia
A39.3 Chronic meningococcemia
A39.51 Meningococcal endocarditis
A39.52 Meningococcal myocarditis
A39.53 Meningococcal pericarditis
A39.81 Meningococcal encephalitis
A39.82 Meningococcal retrobulbar neuritis
A39.83 Meningococcal arthritis
A39.84 Postmeningococcal arthritis
A39.89 Other meningococcal infections
A50.32 Late congenital syphilitic chorioretinitis
A50.39 Other late congenital syphilitic oculopathy
A50.41 Late congenital syphilitic meningitis
A50.42 Late congenital syphilitic encephalitis
A50.43 Late congenital syphilitic polyneuropathy
A50.44 Late congenital syphilitic optic nerve atrophy
A50.45 Juvenile general paresis
A50.49 Other late congenital neurosyphilis
A50.51 Clutton's joints
A50.52 Hutchinson's teeth
A50.53 Hutchinson's triad
A50.54 Late congenital cardiovascular syphilis
A50.55 Late congenital syphilitic arthropathy
A50.56 Late congenital syphilitic osteochondropathy
A50.57 Syphilitic saddle nose
A50.59 Other late congenital syphilis, symptomatic
A50.6 Late congenital syphilis, latent
A52.11 Tabes dorsalis
A52.12 Other cerebrospinal syphilis
A52.13 Late syphilitic meningitis
A52.14 Late syphilitic encephalitis
A52.15 Late syphilitic neuropathy
A52.16 Charcot's arthropathy (tabetic)
A52.17 General paresis
A52.19 Other symptomatic neurosyphilis
A52.2 Asymptomatic neurosyphilis
A81.01 Variant Creutzfeldt-Jakob disease
A81.09 Other Creutzfeldt-Jakob disease
A81.1 Subacute sclerosing panencephalitis
A81.2 Progressive multifocal leukoencephalopathy
A81.81 Kuru
A81.82 Gerstmann-Straussler-Scheinker syndrome
A81.83 Fatal familial insomnia
A81.89 Other atypical virus infections of central nervous system
A83.0 Japanese encephalitis
A83.1 Western equine encephalitis
A83.2 Eastern equine encephalitis
A83.3 St Louis encephalitis
A83.4 Australian encephalitis
A83.5 California encephalitis
A83.6 Rocio virus disease
A83.8 Other mosquito-borne viral encephalitis
A84.0 Far Eastern tick-borne encephalitis [Russian spring-summer encephalitis]
A84.1 Central European tick-borne encephalitis
A84.8 Other tick-borne viral encephalitis
A85.0 Enteroviral encephalitis
A85.1 Adenoviral encephalitis
A85.8 Other specified viral encephalitis
A87.0 Enteroviral meningitis
A87.1 Adenoviral meningitis
A87.2 Lymphocytic choriomeningitis
A87.8 Other viral meningitis
A88.8 Other specified viral infections of central nervous system
A92.31 West Nile virus infection with encephalitis
B00.4 Herpesviral encephalitis
B01.0 Varicella meningitis
B01.11 Varicella encephalitis and encephalomyelitis
B01.12 Varicella myelitis
B01.2 Varicella pneumonia
B01.81 Varicella keratitis
B01.89 Other varicella complications
B01.9 Varicella without complication
B02.0 Zoster encephalitis
B02.1 Zoster meningitis
B02.21 Postherpetic geniculate ganglionitis
B02.22 Postherpetic trigeminal neuralgia
B02.23 Postherpetic polyneuropathy
B02.24 Postherpetic myelitis
B02.29 Other postherpetic nervous system involvement
B02.31 Zoster conjunctivitis
B02.32 Zoster iridocyclitis
B02.33 Zoster keratitis
B02.34 Zoster scleritis
B02.39 Other herpes zoster eye disease

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