Thursday, January 17, 2019

CPT 86152, 86153 - Liquid Biopsy - Circulating Tumor DNA

Coding 

The use of circulating tumor DNA and/or circulating tumor cells is considered investigational for all indications (see Table 1 for examples of liquid biopsy tests).

Code Description CPT

81479 Unlisted molecular pathology procedure

86152 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood);

86153 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required





Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

Introduction

Liquid biopsy is a when a blood sample (rather than a piece of tissue) is used to test for cancer cells or small genetic cancer pieces mixing in the blood. The blood sample is taken from the arm and is tested for cells or genetic pieces that cancers shed into the bloodstream. Identifying tumor cell material in the blood might help to diagnose cancer, track changes in a cancer over time or help select the right type of cancer treatment. However, there is not enough information from clinical studies to be certain that this works as well as a tissue biopsy in most people, because we don’t yet know that this works as well as tissue biopsy. This treatment is not yet proven.

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

Procedure Investigational

Circulating Tumor DNA, Circulating Tumor Cells 



Related Information 

This policy does not address the use of blood-based testing for epidermal growth factor receptor variants in non-small-cell lung cancer or the use of AR-V7 circulating tumor cells for metastatic prostate cancer.


Description

Circulating tumor DNA (ctDNA) and circulating tumor cells (CTCs) in peripheral blood, referred to as “liquid biopsy,” have several potential uses for guiding therapeutic decisions in patients with cancer or being screened for cancer. This policy evaluates uses for liquid biopsies not addressed in a separate policy. If a separate policy exists, then conclusions reached there supersede conclusions here.

Background
Liquid biopsy refers to analysis of circulating tumor DNA (ctDNA) or circulating tumor cells (CTCs) as methods of noninvasively characterizing tumors and tumor genome from the peripheral blood.

Circulating Tumor DNA

Normal and tumor cells release small fragments of DNA into the blood, which is referred to as cell-free DNA (cfDNA). cfDNA from nonmalignant cells is released by apoptosis. Most cell-free tumor DNA is derived from apoptotic and/or necrotic tumor cells, either from the primary tumor, metastases, or CTCs.

Unlike apoptosis, necrosis is considered a pathologic process, and generates larger DNA fragments due to incomplete and random digestion of genomic DNA. The length or integrity of the circulating DNA can potentially distinguish between apoptotic and necrotic origin. ctDNA can be used for genomic characterization of the tumor.

Circulating Tumor Cells 

Intact CTCs are released from a primary tumor and/or a metastatic site into the bloodstream. The half-life of a CTC in the bloodstream is short (1-2 hours), and CTCs are cleared through extravasation into secondary organs.

Most assays detect CTCs through the use of surface epithelial markers such as EpCAM and cytokeratins. The primary reason for in detecting CTCs is prognostic, through quantification of circulating levels.


Detecting ctDNA and CTCs

Detection of ctDNA is challenging because ctDNA is diluted by nonmalignant circulating DNA and usually represents a small fraction (<1 approaches="" are="" cfdna.="" eg="" methods="" more="" nbsp="" needed.="" of="" p="" sanger="" sensitive="" sequencing="" standard="" than="" the="" therefore="" total="">
Highly sensitive and specific methods have been developed to detect ctDNA, for both singlenucleotide mutations (eg, BEAMing [which combines emulsion polymerase chain reaction [PCR] with magnetic beads and flow cytometry] and digital PCR) and copy-number variants. Digital genomic technologies allow for enumeration of rare mutant variants in complex mixtures of DNA.

Approaches to detecting ctDNA can be considered targeted, which includes the analysis of known genetic mutations from the primary tumor in a small set of frequently occurring driver mutations, which can impact therapy decisions or untargeted without knowledge of specific variants present in the primary tumor, and include array comparative genomic hybridization, next-generation sequencing, and whole exome and genome sequencing.

CTC assays usually start with an enrichment step that increases the concentration of CTCs, either by biologic properties (expression of protein markers) or physical properties (size, density, electric charge). CTCs can then be detected using immunologic, molecular, or functional assays.


Summary of Evidence

For individuals who have advanced cancer who receive testing of ctDNA to select targeted treatment, the evidence includes observational studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, morbid events, and medication use. Given the breadth of methodologies available to assess ctDNA, the clinical validity of each commercially available test must be established independently, and these data are lacking. Published studies reporting clinical outcomes and/or clinical utility are lacking. The uncertainties concerning clinical validity and clinical utility preclude conclusions about whether variant analysis of ctDNA can replace variant analysis of tissue. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have advanced cancer who receive testing of CTCs to select targeted treatment, the evidence includes observational studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, morbid events, and medication use. Given the breadth of methodologies available to assess CTCs, the clinical validity of each commercially available test must be established independently, and these data are lacking. Published studies reporting clinical outcomes and/or clinical utility are lacking. The uncertainties concerning clinical validity and clinical utility preclude conclusions about whether the use of CTCs can replace variant analysis of tissue. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have cancer who receive testing of ctDNA to monitor treatment response, the evidence includes observational studies. Relevant outcomes are overall survival, diseasespecific survival, test accuracy and validity, morbid events, and medication use. Given the breadth of methodologies available to assess ctDNA, the clinical validity of each commercially available test must be established independently, and these data are lacking. Published studies reporting clinical outcomes and/or clinical utility are lacking. The uncertainties concerning clinical validity and clinical utility preclude conclusions about whether the use of ctDNA should be used to monitor treatment response. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have cancer who receive testing of CTCs to monitor treatment response, the evidence includes a randomized controlled trial, observational studies, and systematic reviews of observational studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, morbid events, and medication use. Given the breadth of methodologies available to assess CTCs, the clinical validity of each commercially available test must be established independently, and these data are lacking. The available randomized controlled trial found no effect on overall survival when patients with persistently increased CTC levels after first-line chemotherapy were switched to an alternative cytotoxic therapy. Other studies reporting clinical outcomes and/or clinical utility are lacking.

The uncertainties concerning clinical validity and clinical utility preclude conclusions about whether the use of CTCs should be used to monitor treatment response. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have received curative treatment for cancer who receive testing of ctDNA to predict risk of relapse, the evidence includes observational studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, morbid events, and medication use. Given the breadth of methodologies available to assess ctDNA, the clinical validity of each commercially available test must be established independently, and these data are lacking. Published studies reporting clinical outcomes and/or clinical utility are lacking. The uncertainties concerning clinical validity and clinical utility preclude conclusions about whether the use of ctDNA should be used to predict relapse response. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have received curative treatment for cancer who receive testing of CTCs to predict risk of relapse, the evidence includes observational studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, morbid events, and medication use. Given the breadth of methodologies available to assess CTCs, the clinical validity of each commercially available test must be established independently, and these data are lacking. Published studies reporting clinical outcomes and/or clinical utility are lacking. The uncertainties concerning clinical validity and clinical utility preclude conclusions about whether the use of CTCs should be used to predict relapse response. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who are asymptomatic and at high risk for cancer who receive testing of ctDNA to screen for cancer, no evidence was identified. Relevant outcomes are overall survival, diseasespecific survival, test accuracy, and test validity. Published data on clinical validity and clinical

Wednesday, December 19, 2018

CPT 0078U, 81225, 81226, 81227, 81291 - Pharmacogenetic Testing for Pain Management

Code Description CPT

0078U Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder (new code effective 10/1/18)

81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17)

81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)

81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6)

81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C)

81479 Unlisted molecular pathology procedure



Pharmacogenetic Testing for Pain Management

Introduction

When it comes to treating pain, there are a lot of different choices. These include things like over-the-counter remedies like acetaminophen and ibuprofen, medications that are rubbed onto the skin, and prescription drugs known as opioids. Antidepressants and antiseizure medications are also sometimes used to help with pain. Managing acute (sudden and intense) and chronic (long lasting) pain can be challenging.  Each person not only has a different response to pain, but they may also have a different response to pain medication. In short, what works for one person may not work for another. A person’s genetics may affect pain perception and how the body processes medications. Genetic tests have been developed to try to find out how a person might respond to drugs to treat pain. These genetic tests are investigational (unproven). There is not enough medical evidence in published studies to show whether these genetic tests will improve overall health results.

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



Policy Coverage Criteria 

Service Investigational
Genetic testing for pain management

Genetic testing for pain management is considered investigational for all indications.
This policy does not address testing for congenital insensitivity to pain.
This policy is not intended to address testing that is limited to cytochrome P450 genotyping, which is addressed in a separate medical policy, (see Related Policies).
Commercially-available genetic tests for pain management consist of single-nucleotide variants (SNVs) or (less commonly) individual SNV testing. SNVs implicated in pain management include the following (see also Table 1):

* 5HT2C (serotonin receptor gene)
* 5HT2A (serotonin receptor gene)
* SLC6A4 (serotonin transporter gene)
* DRD1 (dopamine receptor gene)
* DRD2 (dopamine receptor gene)
* DRD4 (dopamine receptor gene)
* DAT1 or SLC6A3 (dopamine transporter gene)
* DBH (dopamine beta-hydroxylase gene)
* COMT (catechol O-methyltransferase gene)

* MTHFR (methylenetetrahydrofolate reductase gene)
* *-aminobutyric acid (GABA) A receptor gene
* OPRM1 (ยต-opioid receptor gene)
* OPRK1 (*-opioid receptor gene)
* UGT2B15 (uridine diphosphate glycosyltransferase 2 family, member 15)
* Cytochrome p450 genes: CYP2D6, CYP2C19, CYP2C9, CYP3A4, CYP2B6, CYP1A2


 Evidence Review 

Description 


While multiple pharmacologic therapies are available for the management of acute and chronic pain, there is a lot of variability in the person’s response to pain, particularly in the management of chronic pain, and in the presence of adverse events (AEs). This has prompted interest in better targeting pain therapies through the use of pharmacogenetic testing of genes relevant to analgesic pharmacokinetics or pharmacodynamics. A number of panels of genetic tests for genes that have shown some association with the pharmacokinetics or pharmacodynamics of analgesic medications have been developed to aid in the management of pain.

Background

Pain is a universal human experience and an important contributor to outpatient and inpatient medical visits. The Institute of Medicine (IOM) reported in 2011 that common chronic pain conditions affect at least 116 million adults in the United States.
1
 Chronic pain may be due to cancer or chronic noncancer conditions. These noncancer conditions may include migraines, low back pain, or fibromyalgia. Multiple therapeutic options exist to manage pain, including pharmacotherapies, behavioral modifications, physical and occupational therapy, and complementary/alternative therapies. Nonetheless, the IOM has reported that many individuals receive inadequate pain prevention, assessment, and treatment. Given that pain is an individual and subjective experience, assessing and predicting response to pain interventions, including pain medications, is challenging.

Pain Management


A variety of medication classes are available to manage pain. These include non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), and opioid analgesics which target central nervous system pain perception. Adjuvant medications such as antiepileptic drugs (eg, gabapentin, pregabalin), antidepressants (eg, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors), and topical analgesics have also been used. The management of chronic pain has been driven, in part, by the World Health Organization’s analgesic ladder for pain management, which was developed for the management of cancer-related pain but has been applied to the management of other forms of pain. The ladder outlines a stepped approach to pain management, beginning with non-opioid analgesia and proceeding to a weak opioid (eg, codeine), with or without an adjuvant for persisting pain. If these fail to control pain, the next step is a strong opioid (eg, fentanyl, morphine), with or without an adjuvant for persisting or worsening pain. Various opioids are available in short- and long-acting preparations and administered through variety of routes, including oral, intramuscular, subcutaneous, sublingual, and transdermal.



Pharmacologic Treatment

For acute pain management, particularly postoperative pain, systemic opioids and non-opioid analgesics remain the mainstay of therapy. However, there has been growing interest in using alternative, nonsystemic treatments in addition to or instead of systemic opioids. These options include neuraxial anesthesia, a type of regional anesthesia including epidural or intrathecal opioid injection. This type of anesthesia may be managed by a patient-controlled anesthesia pump. Postoperative peripheral nerve blocks may also be used.

While available pain management therapies are effective for many patients, there is a great deal of variability in pain response, particularly in the management of chronic pain. In addition, many opioids have a significant risk of adverse events (AEs), ranging from mild (eg, constipation) to severe (eg, respiratory depression) and are associated with a risk of dependence, addiction, and abuse. Limitations in currently available pain management techniques have led to interest in the use of pharmacogenetics to improve the targeting of therapies in order to predict and avoid AEs.

Genetics of Pain Management

Genetic factors may influence many aspects of pain and pain control, including predisposition to conditions that lead to pain, pain perception, and the development of comorbid conditions that may affect pain perception. The currently available genetic tests relevant to pain management look at single-nucleotide variants (SNVs) in single genes potentially related to pharmacokinetic or pharmacodynamic processes. 

Broadly speaking, genes related to these clinical scenarios include those involved in neurotransmitter uptake, clearance, and reception; opioid reception; and hepatic drug metabolism. Panels of genetic tests have been developed and have been proposed for use in the management of pain. Genes identified as being relevant to pain management and that are included in currently available panels are summarized in Table 1.



Commercially Available Genetic Tests for Pain Management
Several test labs market panels of tests or individual tests designed to address one or more aspects of pain management, including but not limited to drug selection, drug dosing, or prediction of AEs. Specific variants included in the panels are shown in Table 2.
* GeneSight® Analgesic (Assurex Health, Mason, OH) is a genetic panel test that is intended to analyze “how patients’ genes can affect their metabolism and possible response to FDA [U.S. Food and Drug Administration]-approved opioids, NSAIDs and muscle relaxants commonly used to treat chronic pain.”

Results are provided with a color-coded report based on efficacy and tolerability, which displays which medications should be used as directed, used with caution, or used with increased caution and more frequent monitoring.


The company’s website does not specify the testing methods. Publications describing other tests provided by the company specify that testing is conducted via SNP sequencing performed via multiplex polymerase chain reaction.

* Proove Biosciences (Irvine, CA) offers several genetic panels that address pain control. The Proove® Opioid Risk Panel is a panel of 11 genes that is intended to predict opioid abuse and failure of opioid therapy. Genetic testing results are provided along with an overall “Dependence Risk Index.”

The company also markets the Proove® Pain Perception panel, which is a panel test for SNPs in several genes related to pain perception, including COMT and at least 3 other genes. Results are provided with a report which stratifies patients’ pain sensitivity based on COMT haplotype.

In addition, Proove offers panels designed to predict good and poor responders to opioid therapies and non-opioid pain therapies. These are the Proove® Opioid Response


Tuesday, November 27, 2018

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


CPT Code - Description

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

19499 Unlisted procedure, breast

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

32999 Unlisted procedure, lungs and pleura

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

47399 Unlisted procedure, liver

49999 Unlisted procedure, abdomen, peritoneum and omentum

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

53899 Unlisted procedure, urinary system (for renal tumors)

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

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





Microwave Tumor Ablation

Introduction

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

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

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

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

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

Description

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

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

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

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

Adverse Events

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

Applications

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

Summary of Evidence

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

Thursday, November 1, 2018

Plastic Surgery, cosmetic, reconstructive CPT codes list


Introduction

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

Note:

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

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

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

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

Cosmetic / Reconstructive CPT

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

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

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

Definition of Terms

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

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

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

Reconstructive surgery:

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

Administering the Contract Language ( also seeBenefit Application)

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

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

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

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

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

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

Wednesday, May 30, 2018

Billing Guideline for experimental or investigations procedure

EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES


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

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

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

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

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

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

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

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

UNIFORM PROVIDER CHARGING PRACTICES


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

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

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

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

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

Thursday, January 11, 2018

Crisis services billing - Medicaid Guid


CRISIS SERVICES

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

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

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

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

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

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

Crisis Residential Services

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



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

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

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

* Therapeutic support services;

* Medication management/stabilization and education;

* Behavioral services;

* Milieu therapy; and

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

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

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

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

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

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

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


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

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

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

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

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

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

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


The IPOS/treatment plan must contain:

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


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

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

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



Intensive/Crisis Stabilization Services

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


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

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

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


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


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

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

* Intensive individual counseling/psychotherapy;

* Assessments (rendered by the treatment team);

* Family therapy;

* Psychiatric supervision; and

* Therapeutic support services by trained paraprofessionals.

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

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

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

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

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

* Inpatient settings;

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

* Crisis residential settings.

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

The IPOS/treatment plan must contain:

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

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

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

Thursday, October 5, 2017

Facility claims billing to Medicaid and Medicare

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

* Covered Days

* Covered days must be reported using Value Code 80.

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

* Non-Covered Days

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

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

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


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

* Coinsurance Days

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

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

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

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

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

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

* Prior Stay Date

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

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

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

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

* Claim Examples

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

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