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

Thursday, March 30, 2017

cpt 92586, 95930, 95925, 95939 - NEP procedures

CPT/HCPCS Codes

Group 1 Codes:

92585 Auditor evoke potent compre
92586 Auditor evoke potent limit

Group 2 Paragraph: N/A

Group 2 Codes:
95925 Somatosensory testing
95926 Somatosensory testing
95927 Somatosensory testing
95928 C motor evoked uppr limbs
95929 C motor evoked lwr limbs
95938 Somatosensory testing
95939 C motor evoked upr&lwr limbs

Group 3 Paragraph: N/A

Group 3 Codes:
95930 Visual evoked potential test


Coverage Indications, Limitations, and/or Medical Necessity

Background

Neurophysiology Evoked Potentials (NEPs) for the purpose of this LCD include:

Somatosensory Evoked Potentials/Responses (SEPs/SERs),
Brainstem Auditory Evoked Potentials/Responses (BAEPs/BAERs), and
Visual Evoked Potentials/Responses (VEPs/VERs)
Evoked potential studies are recorded electrical responses to stimulation of a sensory system. When a sensory impulse reaches the brain, a specific Electroencephalographic (EEG) response is produced (evoked) in the cortical area appropriate to the modality and site of the stimulus. By computer averaging techniques, the evoked responses of repetitive stimuli can be separated from the spontaneous EEG activity. Evoked potentials are clinically useful in evaluating the functional integrity of the somatosensory or special sensory pathways. Different latencies and wave patterns help to localize lesions ranging from the end organ through the nervous system to the cerebral cortex. Often defects in these pathways are not otherwise evident. Evoked potentials are also used to monitor neural pathways when patients are anesthetized during surgery and to document brain death. The following are tests that evaluate potentials evoked by stimulation of the peripheral or cranial nerves:

SEPs/SERs evaluate the pathways from nerves in the extremities through the spinal cord, to the brainstem or cerebral cortex upon stimulation of peripheral axon.

SEPs has an advantage in that it evaluates the entire somatosensory pathway and it is possible to distinguish between lesions located in the peripheral nerve, in the dorsal column pathway, or both.

VEPs/VERs evaluate the visual nervous system pathways from the eyes to the occipital cortex of the brain. VEP or VER involves stimulation of the retina and optic nerve with a shifting checkerboard pattern or flash method. This external visual stimulus causes measurable electrical activity in neurons within the visual pathways. This is called the Visual Evoked Response (VER) and is recorded by electroencephalography electrodes located over the occiput. Using special computer techniques, the evoked responses measured over multiple trials are amplified and averaged. A characteristic waveform is produced. With pattern-shift VER, the waveform normally appears as a straight line with a single positive peak (100 msec after stimulus presentation). Abnormalities in this characteristic waveform may be seen in a variety of pathologic processes involving the optic nerve and its radiations. Pattern-shift VER is a highly sensitive means of documenting lesions in the visual system. It is especially useful when the disease process is subclinical, e.g., ophthalmologic exam is normal and patient lacks visual symptoms.

BAEPs/BAERs evaluate the auditory nerve pathways from the ears through the brain stem. A clicking sound is presented to one ear at a time. The electrical activity of this signal is recorded by electrodes on the scalp. The averaged response is displayed as a waveform that contains peaks and troughs, which correspond to various points along the hearing pathway. The time between these peaks is measured and compared to normal data. A delay in a component of the response might indicate an abnormality at specific anatomic sites in the acoustic nerve or brainstem.


Indications

Somatosensory Evoked Potentials and Responses (SEPs/SERs) (CPT codes 95925, 95926, 95927, 95928, 95929, 95938, 95939) are appropriate for the following indications:

Spinal cord trauma
Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy)
Multiple sclerosis
Spinocerebellar degeneration
Myoclonus
Coma
Intraoperative monitoring
Subacute combined degeneration
Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, and Pelizaeus-Merzbacher disease
Syringomyelia
Hereditary spastic paraplegia
Brainstem Auditory Evoked Potentials and Responses (BAEPs/BAERs) (CPT codes 92585 and 92586) are appropriate:

For one or more of the following conditions:

Asymmetric hearing loss
Unilateral tinnitus
Sudden hearing loss
Cerebellopontine angle tumor
Demyelinating disorder
Functional hearing loss
Ototoxic drug therapy monitoring including chemotherapy or antibiotics
Auditory neuropathy
Acoustic neuroma

Preoperative baseline for:

Posterior fossa surgery
Cochlear implant

Postoperative testing for:

Cochlear implant
Visual Evoked Potentials or Responses (VEPs/VERs) (CPT code 95930) are appropriate for the following indications:

Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.

Detect optic neuritis at an early, subclinical stage.

Evaluate diseases of the optic nerve, such as:

Ischemic optic neuropathy
Pseudotumor cerebri
Toxic amblyopias
Nutritional amblyopias
Neoplasms compressing the anterior visual pathways
Optic nerve injury or atrophy
Hysterical blindness (to rule out)

Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies).

Limitations

SEP studies are appropriate only when a detailed clinical history and neurologic examination and appropriate diagnostic tests such as imaging studies, electromyogram, and nerve conduction studies make a lesion (or lesions) of the central somatosensory pathways a likely and reasonable differential diagnostic possibility.

There is no need for SEPs in the diagnosis of most neuropathies because the conventional nerve conduction study can identify them and no added information is obtained from SEPs.






ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

D33.3 Benign neoplasm of cranial nerves
G10 Huntington's disease
G21.0 Malignant neuroleptic syndrome
G23.0 - G26 - Opens in a new window Hallervorden-Spatz disease - Extrapyramidal and movement disorders in diseases classified elsewhere
G35 - G36.8 - Opens in a new window Multiple sclerosis - Other specified acute disseminated demyelination
G37.0 - G37.8 - Opens in a new window Diffuse sclerosis of central nervous system - Other specified demyelinating diseases of central nervous system
G80.3 Athetoid cerebral palsy
G90.3 Multi-system degeneration of the autonomic nervous system
H46.00 - H46.9 - Opens in a new window Optic papillitis, unspecified eye - Unspecified optic neuritis
H81.01 - H81.09 - Opens in a new window Meniere's disease, right ear - Meniere's disease, unspecified ear
H81.41 - H81.49 - Opens in a new window Vertigo of central origin, right ear - Vertigo of central origin, unspecified ear
H83.3X1 - H83.3X9 - Opens in a new window Noise effects on right inner ear - Noise effects on inner ear, unspecified ear
H90.3 - H90.8 - Opens in a new window Sensorineural hearing loss, bilateral - Mixed conductive and sensorineural hearing loss, unspecified
H91.20 - H91.23 - Opens in a new window Sudden idiopathic hearing loss, unspecified ear - Sudden idiopathic hearing loss, bilateral
H93.11 - H93.19 - Opens in a new window Tinnitus, right ear - Tinnitus, unspecified ear
H93.3X1 - H93.3X9 - Opens in a new window Disorders of right acoustic nerve - Disorders of unspecified acoustic nerve
H94.00 - H94.03 - Opens in a new window Acoustic neuritis in infectious and parasitic diseases classified elsewhere, unspecified ear - Acoustic neuritis in infectious and parasitic diseases classified elsewhere, bilateral
R25.0 - R25.9 - Opens in a new window Abnormal head movements - Unspecified abnormal involuntary movements
R42 Dizziness and giddiness

ICD-10 CODE DESCRIPTION

A18.01 Tuberculosis of spine
A52.11 Tabes dorsalis
A52.13 - A52.15 - Opens in a new window Late syphilitic meningitis - Late syphilitic neuropathy
A52.17 - A52.19 - Opens in a new window General paresis - Other symptomatic neurosyphilis
A69.20 - A69.22 - Opens in a new window Lyme disease, unspecified - Other neurologic disorders in Lyme disease
A69.29 Other conditions associated with Lyme disease
A83.0 - A83.8 - Opens in a new window Japanese encephalitis - Other mosquito-borne viral encephalitis
A84.0 - A84.8 - Opens in a new window Far Eastern tick-borne encephalitis [Russian spring-summer encephalitis] - Other tick-borne viral encephalitis
A85.2 Arthropod-borne viral encephalitis, unspecified
B00.4 Herpesviral encephalitis
B00.82 Herpes simplex myelitis
B02.24 Postherpetic myelitis
B05.0 Measles complicated by encephalitis
B06.01 Rubella encephalitis
C41.2 Malignant neoplasm of vertebral column
C70.0 - C70.9 - Opens in a new window Malignant neoplasm of cerebral meninges - Malignant neoplasm of meninges, unspecified
C72.0 - C72.9 - Opens in a new window Malignant neoplasm of spinal cord - Malignant neoplasm of central nervous system, unspecified
C79.31 - C79.49 - Opens in a new window Secondary malignant neoplasm of brain - Secondary malignant neoplasm of other parts of nervous system
D32.0 - D33.7 - Opens in a new window Benign neoplasm of cerebral meninges - Benign neoplasm of other specified parts of central nervous system
D42.0 - D43.2 - Opens in a new window Neoplasm of uncertain behavior of cerebral meninges - Neoplasm of uncertain behavior of brain, unspecified
D43.4 Neoplasm of uncertain behavior of spinal cord
D44.3 - D44.5 - Opens in a new window Neoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal gland
D49.6 Neoplasm of unspecified behavior of brain
E03.5 Myxedema coma
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy
E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E71.50 - E71.548 - Opens in a new window Peroxisomal disorder, unspecified - Other peroxisomal disorders
E75.23 Krabbe disease
E75.25 - E75.29 - Opens in a new window Metachromatic leukodystrophy - Other sphingolipidosis
F44.4 - F44.7 - Opens in a new window Conversion disorder with motor symptom or deficit - Conversion disorder with mixed symptom presentation
G05.4 Myelitis in diseases classified elsewhere
G06.1 Intraspinal abscess and granuloma
G11.0 - G11.8 - Opens in a new window Congenital nonprogressive ataxia - Other hereditary ataxias
G13.0 - G13.1 - Opens in a new window Paraneoplastic neuromyopathy and neuropathy - Other systemic atrophy primarily affecting central nervous system in neoplastic disease
G23.0 - G23.9 - Opens in a new window Hallervorden-Spatz disease - Degenerative disease of basal ganglia, unspecified
G32.0 - G32.81 - Opens in a new window Subacute combined degeneration of spinal cord in diseases classified elsewhere - Cerebellar ataxia in diseases classified elsewhere
G35 - G36.8 - Opens in a new window Multiple sclerosis - Other specified acute disseminated demyelination
G37.0 - G37.8 - Opens in a new window Diffuse sclerosis of central nervous system - Other specified demyelinating diseases of central nervous system
G45.0 - G45.2 - Opens in a new window Vertebro-basilar artery syndrome - Multiple and bilateral precerebral artery syndromes
G45.8 Other transient cerebral ischemic attacks and related syndromes
G46.0 - G46.2 - Opens in a new window Middle cerebral artery syndrome - Posterior cerebral artery syndrome
G54.0 - G54.8 - Opens in a new window Brachial plexus disorders - Other nerve root and plexus disorders
G55 Nerve root and plexus compressions in diseases classified elsewhere
G56.40 - G56.42 - Opens in a new window Causalgia of unspecified upper limb - Causalgia of left upper limb
G57.00 - G57.92 - Opens in a new window Lesion of sciatic nerve, unspecified lower limb - Unspecified mononeuropathy of left lower limb
G58.7 Mononeuritis multiplex
G60.0 - G60.8 - Opens in a new window Hereditary motor and sensory neuropathy - Other hereditary and idiopathic neuropathies
G61.0 - G61.89 - Opens in a new window Guillain-Barre syndrome - Other inflammatory polyneuropathies
G62.0 - G62.89 - Opens in a new window Drug-induced polyneuropathy - Other specified polyneuropathies
G63 Polyneuropathy in diseases classified elsewhere
G65.0 - G70.89 - Opens in a new window Sequelae of Guillain-Barre syndrome - Other specified myoneural disorders
G73.1 - G73.3 - Opens in a new window Lambert-Eaton syndrome in neoplastic disease - Myasthenic syndromes in other diseases classified elsewhere
G80.0 - G80.2 - Opens in a new window Spastic quadriplegic cerebral palsy - Spastic hemiplegic cerebral palsy
G80.4 - G80.8 - Opens in a new window Ataxic cerebral palsy - Other cerebral palsy
G81.00 - G81.94 - Opens in a new window Flaccid hemiplegia affecting unspecified side - Hemiplegia, unspecified affecting left nondominant side
G90.3 Multi-system degeneration of the autonomic nervous system
G93.2 Benign intracranial hypertension
G95.0 - G95.19 - Opens in a new window Syringomyelia and syringobulbia - Other vascular myelopathies
G95.81 - G95.89 - Opens in a new window Conus medullaris syndrome - Other specified diseases of spinal cord
G99.2 Myelopathy in diseases classified elsewhere
I60.00 - I62.1 - Opens in a new window Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation - Nontraumatic extradural hemorrhage
I63.011 - I63.09 - Opens in a new window Cerebral infarction due to thrombosis of right vertebral artery - Cerebral infarction due to thrombosis of other precerebral artery
I63.111 - I63.19 - Opens in a new window Cerebral infarction due to embolism of right vertebral artery - Cerebral infarction due to embolism of other precerebral artery
I63.211 - I63.239 - Opens in a new window Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries - Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
I63.30 - I63.49 - Opens in a new window Cerebral infarction due to thrombosis of unspecified cerebral artery - Cerebral infarction due to embolism of other cerebral artery
I63.59 - I63.6 - Opens in a new window Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery - Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I65.01 - I65.8 - Opens in a new window Occlusion and stenosis of right vertebral artery - Occlusion and stenosis of other precerebral arteries
I66.01 - I66.3 - Opens in a new window Occlusion and stenosis of right middle cerebral artery - Occlusion and stenosis of cerebellar arteries
I66.9 Occlusion and stenosis of unspecified cerebral artery
I67.1 Cerebral aneurysm, nonruptured
M05.50 - M05.59 - Opens in a new window Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site - Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M34.83 Systemic sclerosis with polyneuropathy
M40.00 - M41.9 - Opens in a new window Postural kyphosis, site unspecified - Scoliosis, unspecified
M43.8X1 - M43.9 - Opens in a new window Other specified deforming dorsopathies, occipito-atlanto-axial region - Deforming dorsopathy, unspecified
M47.011 - M47.029 - Opens in a new window Anterior spinal artery compression syndromes, occipito-atlanto-axial region - Vertebral artery compression syndromes, site unspecified
M47.11 - M47.16 - Opens in a new window Other spondylosis with myelopathy, occipito-atlanto-axial region - Other spondylosis with myelopathy, lumbar region
M50.00 - M50.03 - Opens in a new window Cervical disc disorder with myelopathy, unspecified cervical region - Cervical disc disorder with myelopathy, cervicothoracic region
M51.04 - M51.06 - Opens in a new window Intervertebral disc disorders with myelopathy, thoracic region - Intervertebral disc disorders with myelopathy, lumbar region
M51.9 - M53.1 - Opens in a new window Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder - Cervicobrachial syndrome
M96.2 - M96.5 - Opens in a new window Postradiation kyphosis - Postradiation scoliosis
Q05.0 - Q05.9 - Opens in a new window Cervical spina bifida with hydrocephalus - Spina bifida, unspecified
Q07.00 - Q07.03 - Opens in a new window Arnold-Chiari syndrome without spina bifida or hydrocephalus - Arnold-Chiari syndrome with spina bifida and hydrocephalus
R20.0 - R20.9 - Opens in a new window Anesthesia of skin - Unspecified disturbances of skin sensation
R26.0 - R26.1 - Opens in a new window Ataxic gait - Paralytic gait
R26.81 - R27.9 - Opens in a new window Unsteadiness on feet - Unspecified lack of coordination
R29.5 Transient paralysis
R40.20 - R40.2124 - Opens in a new window Unspecified coma - Coma scale, eyes open, to pain, 24 hours or more after hospital admission

Friday, March 24, 2017

cpt g0151 - g0300 - Home based fall evaluation


CPT/HCPCS Codes

G0151 SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0152 SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0299 DIRECT SKILLED NURSING SERVICES OF A REGISTERED NURSE (RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

G0300 DIRECT SKILLED NURSING SERVICES OF A LICENSE PRACTICAL NURSE (LPN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

The process of falls evaluation and intervention is a complex task for which there exists evidence-based procedures. The translation of these evidence-based procedures into clinical care, however, has been limited by an incomplete understanding of Medicare coverage rules. While no Medicare benefit category exists for a specific suite of “falls evaluation and intervention” services, some evidence-based falls evaluation and intervention procedures utilize home-based components that may be covered by Medicare with the appropriate documentation. The goal of this policy is to provide the framework for covered skilled nursing, physical therapy, and occupational therapy evaluations and interventions in the population of Medicare beneficiaries with a history of falls.

The complexity of both the evidence-based fall evaluations and interventions and the applicable Medicare coverage instructions, require that documentation be as patient-centered as possible (i.e., reflect the unique needs and circumstances of the patient and the available therapeutic options). The coverage of component, skilled services requires that beneficiaries first be eligible for an existing Medicare defined benefit and then under a physician’s order receive covered services that are “reasonable and necessary” with regard to amount, type, frequency and duration.

Home Health Benefit (Bill type 32X): 

Once eligibility for the Medicare Home Health Benefit has been established, physicians may request that Medicare-certified Home Health Agency (HHA) evaluate the circumstances of fall events and establish a plan of care to intervene by identifying and modifying known risk factors for fall events. The skilled nursing service and/or a therapist must be reasonable and necessary to the diagnosis and treatment of the patient's illness or injury within the context of the patient's unique medical condition. To be considered reasonable and necessary for the diagnosis or treatment of the patient's illness or injury, the services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, and accepted standards of medical and nursing practice. The determination of whether the services are reasonable and necessary should be made in consideration that a physician has determined that the services ordered are reasonable and necessary. The services must, therefore, be viewed from the perspective of the condition of the patient when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury throughout the certification period. A patient's overall medical condition, without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time, should be considered in deciding whether skilled services are needed. A patient's diagnosis should never be the sole factor in deciding that a service the patient needs is either skilled or not skilled. Skilled care may, depending on the unique condition of the patient, continue to be necessary for patients whose condition is stable. The documentation of each component service must substantiate the need for the skilled services, be specified in the care plan and not be duplicative. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services. Beneficiary-appropriate goals and objectives, with measurable outcomes must be included in the documentation. Documentation must also show that the skills of a nurse or therapists are required. Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record. If the measurement results do not reveal progress toward therapy goals and/or do not indicate that therapy is effective, but therapy continues, the qualified therapist(s) must document why the physician and therapist have determined therapy should be continued.

Coverage of skilled nursing care does not turn on the presence or absence of a patient’s potential for improvement from the nursing care, but rather on the patient’s need for skilled care.

Skilled nursing and/or therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.

In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction. Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered. Where the teaching constitutes reinforcement, an analysis of the patient's retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits. Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home. Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.

Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient's condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.

Part B Outpatient Therapy Benefit (Bill type 34X):

Medicare beneficiaries not meeting the eligibility criteria for the Home Health Benefit, but otherwise in need of Medicare-covered, home-based therapy services for the evaluation and intervention of falls, may be eligible for the component physical and occupational therapy services available through the Part B outpatient Medicare benefit. Assuming all other eligibility and coverage criteria have been met, the skilled therapy services must be reasonable and necessary to the treatment of the patient's illness or injury within the context of the patient's unique medical condition.

To be considered reasonable and necessary for the treatment of the illness or injury:
a. The services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, including the requirement that the amount, frequency, and duration of the services must be reasonable; and

b. The services must be considered, under accepted standards of medical practice, to be specific, safe, and effective treatment for the patient's condition, meeting the standards" listed in Publication 100-02, Chapter 7, Section 40.2.1. The home health record must specify the purpose of the skilled service provided.

if it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.

Maintenance Program

Coverage of therapy services (not an assistant) to perform a maintenance program is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. Assuming all other eligibility and coverage requirements are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services will not be covered.

Palmetto GBA recommends use of the concepts contained within the World Health Organization’s (WHO’s) International Classification of Functioning, Disability, and Health (ICF) to organize the necessary data and communicate the patient-centered information describing the unique health status of each beneficiary. Such communication is critical to both documenting and delivering reasonable and necessary home-based Medicare services to the heterogeneous population of Medicare beneficiaries experiencing fall events.

The component Home Health skilled nursing services (e.g., “observation and assessment”) and the corresponding skilled therapy services must adhere to the coverage criteria outlined in the CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7 – Home Health Services, Sections 40.1 and 40.2 respectively. The component Outpatient skilled physical and occupational therapy services must adhere to the CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§220-230.2. For unsuccessful interventions the reason(s) why the intervention(s) were unsuccessful should be documented in the record.

Saturday, March 11, 2017

Myocardial perfusion Imaging - cpt 78452


CPT/HCPCS Codes

Group 1 Codes:

78451 Ht muscle image spect sing

78452 Ht muscle image spect mult

78453 Ht muscle image planar sing

78454 Ht musc image planar mult

78466 Heart infarct image

78468 Heart infarct image (ef)

78469 Heart infarct image (3D)


Coverage Indications, Limitations, and/or Medical Necessity



Indications

The usual indications for performing myocardial perfusion imaging (MPI) procedures are:
New onset of symptoms in patients having probability of coronary artery disease (CAD);

A significant change in symptoms in an individual with known coronary artery disease;

Suspicion of chest pain of cardiac origin;

Probability of coronary artery disease (multiple risk factors and strongly suggestive symptoms) with an abnormal exercise ECG;

Abnormal cardiovascular diagnostic studies in asymptomatic patients with significant cardiac risk factors, e.g. diabetes mellitus;

Risk of a subsequent cardiac event following acute myocardial infarction;

Preoperative evaluation prior to increased risk noncardiac surgical procedures in the moderate cardiac risk patient with recent cardiac history, symptoms, or findings. Cardiac catheterization should be considered in the high risk cardiac patient’;

Postoperative assessment following myocardial revascularization procedures (e.g.,CABG, PTCA) in symptomatic patients;

Assessing postoperative asymptomatic patients after PTCA or CABG, such as in patients with an abnormal ECG response to exercise or those with rest ECG changes precluding identification of ischemia during exercise;

Assessing the patient with angiographic proven disease when it is necessary to identify the "culprit" lesion for revascularization with surgery or angioplasty;

Differentiating ischemic and non-ischemic cardiomyopathy;

Evaluating right ventricular function in patients with pulmonary hypertension; or

Evaluation following cardiac transplantation.


Limitations

Myocardial perfusion imaging is not indicated:
In the absence of symptoms following normal coronary angiography.

When there is no probability of intervention:
risk too high;
patient refuses to consider; or
unacceptable comorbidities.

As repetitive, frequent testing in the absence of changing clinical parameters, especially in individuals with known CAD.

Screening for coronary disease is not a Medicare covered indication.



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.
999x Not 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.

99999 Not Applicable



Monday, March 6, 2017

CPT 75571 - 75574

CPT/HCPCS Codes  Group 1 Codes:

75572 Ct hrt w/3d image
75573 Ct hrt w/3d image congen
75574 Ct angio hrt w/3d image


Group 2 Codes:

75571 Ct hrt w/o dye w/ca test


Coverage Indications, Limitations, and/or Medical Necessity

Indications

As an alternative to invasive coronary angiography following a stress test that is equivocal or suspected to be inaccurate.

Instead of myocardial perfusion imaging in the evaluation of coronary artery disease in those patients who have moderate pre-test probability of disease based on clinical risk factors and abnormal diagnostic studies, not symptoms alone.

To evaluate the cause of symptoms in patients with known coronary artery disease.

Assessment of suspected congenital anomalies of coronary circulation or great vessels.

Assessment of coronary or pulmonary venous anatomy for the procedures described below:

CTA of the coronary veins is indicated when imaging of the coronary venous anatomy is necessary for biventricular pacemaker lead insertion.

CTA of the pulmonary veins is indicated when imaging of the pulmonary vasculature is necessary for pulmonary vein catheter ablation procedures for atrial fibrillation.
Limitations

Since the majority of the clinical research utilized a 64-slice CT scanner it is the recommended equipment. However, the intent of this LCD is not to monitor equipment utilization.

The procedure must be performed under the direct supervision of and interpreted by a cardiologist or radiologist who meets the competency guidelines outlined by the published guidelines, ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance, or American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging.

NOT COVERED:

CPT 75571
Using 71275 or 76497
Screening tests are defined as those tests done in the absence of signs, symptoms, or presence of disease. The use of these procedures (75572, 75573, 75574 for coronary CT angiography) in patients without signs, symptoms or presence of disease is considered to be screening by this Contractor.

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.
999x Not 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.

99999 Not Applicable

ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

I20.1 - I20.9 - Opens in a new window Angina pectoris with documented spasm - Angina pectoris, unspecified
I25.10 - I25.119 - Opens in a new window Atherosclerotic heart disease of native coronary artery without angina pectoris - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.41 - I25.739 - Opens in a new window Coronary artery aneurysm - Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 - I25.759 - Opens in a new window Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 - I25.810 - Opens in a new window Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.82 - I25.9 - Opens in a new window Chronic total occlusion of coronary artery - Chronic ischemic heart disease, unspecified
I48.0 - I48.92 - Opens in a new window Paroxysmal atrial fibrillation - Unspecified atrial flutter
Q20.0 - Q25.0 - Opens in a new window Common arterial trunk - Patent ductus arteriosus
Q25.3 - Q26.4 - Opens in a new window Supravalvular aortic stenosis - Anomalous pulmonary venous connection, unspecified
Q26.8 Other congenital malformations of great veins
R06.02 Shortness of breath
R07.2 Precordial pain
R94.30 - R94.39 - Opens in a new window Abnormal result of cardiovascular function study, unspecified - Abnormal result of other cardiovascular function study
Z01.810 Encounter for preprocedural cardiovascular examination

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