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

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

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