Tuesday, June 20, 2017

Home Health revenue codes 0420, 0430, 0424, 0421

Revenue Code Description

Home Health Care Visits

0642 Home iv therapy services-iv site care, central line

0643 Home iv therapy services- IV start/change, peripheral line

0644 Home iv therapy services-non-routine nursing, peripheral line

0645 Home iv therapy services-training patient/caregiver, central line

0646 Home iv therapy services-training, disabled patient, central line

0647 Home iv therapy services-training, patient/caregiver, peripheral line

0648 Home iv therapy services-training, disabled patient, peripheral line

0649 Home iv therapy services-other iv therapy services

Therapy by a Home Health Care Agency/Facility

Coding Clarification: These codes apply to the Home Health Care Visit limit with the following Bill Type:

• 032x : Home health - Home Health Services under a plan of treatment

* 034x : Home health - Home Health Services not under a plan of treatment

0420 Physical therapy-general

0421 Physical therapy-visit charge

0422 Physical therapy-hourly charge

0423 Physical therapy-group rate

0424 Physical therapy-evaluation or reevaluation

0429 Physical therapy-other physical therapy

0430 Occupational therapy-general

0431 Occupational therapy-visit charge

0432 Occupational therapy-hourly charge

0433 Occupational therapy-group rate

0434 Occupational therapy-evaluation or reevaluation

0439 Occupational therapy-other occupational therapy

0440 Speech therapy-language pathology-general

0441 Speech therapy-language pathology-visit charge

0442 Speech therapy-language pathology-hourly charge

0443 Speech therapy-language pathology-group rate

0444 Speech therapy-language pathology-evaluation or reevaluation

0449 Speech therapy-language pathology-other speech-language pathology


Hemophilia

For coverage of assisted administration of clotting factors and coagulant blood products, refer to the policy titled Assisted Administration of Clotting Factors and Coagulant Blood Products. For coverage of clotting factor and coagulant blood products, refer to the policy titled Clotting Factors and Coagulant Blood Products.

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.



COVERAGE RATIONALE

Indications for Coverage

The services being requested must meet all of the following:

** Be ordered and directed by a treating practitioner or specialist (M.D., D.O., P.A. or N.P); and

** The care must be delivered or supervised by a licensed professional in order to obtain a specified medical outcome; and

** Services must be skilled care in nature (refer to the policy titled Skilled Care and Custodial Care Services and the Definitions section below); and

** Services must be intermittent and part time (typically provided for less than 4 hours per day; refer to the member specific benefit plan document for intermittent definitions, if provided); and

** Services are provided in the home in lieu of skilled care in another setting (such as but not limited to a nursing facility, acute inpatient rehabilitation or a hospital); and

** Services must be clinically appropriate and not more costly than an alternative health services; and

** A written treatment plan must be submitted with the request for specific services and supplies’ periodic review of the written treatment plan may be required for continued Skilled Care needs and progress toward goals; and

** Services are not provided for the comfort and convenience of the member or the member’s family; and

** Services are not custodial care in nature. Medical Necessity Plans

Use the criteria above where applicable.

Additional Information

** Medical supplies and medications that are used in conjunction with a home health care visit are covered as part of
that visit. Some examples are, but not limited to, surgical dressing, catheters, syringes, irrigation devices.

Reimbursement for home health care visits and supplies are contractually determined. ** Eligible physical, occupational and speech therapy received in the home from a Home Health Agency is covered under the Home Health Care section of the member’s certificate of coverage and/or summary of benefits. The Home Health Care section only applies to services that are rendered by a Home Health Agency.




Friday, May 19, 2017

CPT code 36005, 36010, 36011, 33282, 33284

36005 Injection procedure for extremity venography 0.95 $328 $50

36010 Introduction of catheter, superior or inferior vena cava 2.18 $492 $114

36011 Selective catheter placement, venous system; first order branch 3.14 $842 $164

36012 Second order, or more selective, branch 3.51 $868 $181


Insertion 33282 Implantation of patient-activated cardiac event recorder Removal 33284 Removal of an implantable, patient-activated cardiac event recorder

CPT code 36005 (injection procedure for extremity venography (including introduction of needle or intracatheter)) should not be utilized to report venous catheterization unless it is for the purpose of an injection procedure for extremity venography. Some physicians have misused this code to report any type of venous catheterization.

Reimbursement and Billing Instructions

The procedure code for the implantation of the patient-activated event recorder – ILR is CPT code 33282.The code for the removal of this device is 33284. These procedure codes have a 90-day global postoperative care designation for which care related to the surgical procedure is not separately reimbursable unless such care is nonroutine, such as treatment of complications. Note that removal of a patient-activated event recorder – ILR on the same day as the insertion of a cardiac pacemaker is considered part of the pacemaker insertion procedure and is not reimbursed separately.

Table 9 illustrates billing instructions for each place of service:

* If the procedure is performed when the patient is an inpatient for a related problem, submit an institutional claim (UB-04 claim form or electronic equivalent) using a medically necessary diagnosis code.

* If the procedure is performed on an outpatient basis, submit an institutional claim (UB-04 claim form or electronic equivalent) using revenue code 360 and CPT code 33282 for implantation. The facility should bill for the device itself on a professional claim (CMS-1500 claim form or electronic equivalent) using HCPCS code E0616 with medically necessary primary diagnosis codes. Use CPT code 33284 with revenue code 360 to bill for removal of the device. Physician’s charges for the surgery should be billed by the physician on a professional claim.

* If the procedure is performed in a physician’s office, the physician should bill CPT code 33282 for implantation and E0616 for the device. Both codes are billed on a professional claim (CMS-1500 claim form or electronic equivalent). 

Type of Claim Institutional Institutional (and professional, if billing for device) Professional Revenue and

CPT Codes Revenue code 360

CPT code not needed Revenue code 360

CPT code 33282 for insertion

CPT code 33284 for removal Revenue code not applicable

CPT code 33282 for insertion

CPT code 33284 for removal

HCPCS Code Not needed On professional claim – E0616 On institutional claim – Not needed E0616

Note: Institutional claim formats include the UB-04 paper claim form, the 837I electronic transaction, and the institutional claim type on the Provider Healthcare Portal. Professional claim formats include the CMS-1500 paper claim form, the 837P electronic transaction, and the professional claim type on the Provider Healthcare Portal



Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 33282, 33284, E0616,0295T, 0296T, 0297T, 0298T

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Wednesday, May 17, 2017

Time span code billing guidelines - 93268 , 93272, 94005

REIMBURSEMENT GUIDELINES

Time Span Codes

Oxford will reimburse a CPT or HCPCS Level II code that specifies a time period for which it should be reported (e.g., weekly, monthly), once during that time period. The time period is based on sourcing from the AMA or CMS including: the CPT or HCPCS code description, CPT book parentheticals and other coding guidance in the CPT book, other AMA publications or CMS publications.

For example: Within the CPT book, the code description for CPT code 95250 states, “Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording”. In addition to that code description, there is also a parenthetical that provides further instructions with regard to the frequency the code can be reported. The parenthetical states, “Do not report 95250 more than once per month”. Oxford will reimburse CPT Code 95250 only once per month for the same member, for services provided by the Same Group Physician and/or Other Health Care Professional. In order to consider reimbursement for these services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

CPT coding guidelines specify for physicians or other qualified health care professionals to select the name of the procedure or service that accurately identifies the services performed.



End-Stage Renal Disease Services (ESRD) 90951-90962 

CPT codes 90951-90962 are grouped by age of the patient and the number of face-to-face physician or other qualified health care professional visits provided per month (i.e., 1, 2-3, or 4 or more). Oxford will reimburse the single most comprehensive outpatient ESRD code submitted per age category (i.e., under 2 years of age, 2-11 years of age, 11- 19 years of age, and 20 years of age and older) once per month. This aligns with CPT coding guidance which states to report the age-specific ESRD codes should be reported once per month for all physician or other health care professional face-to-face outpatient services.




Time Span Comprehensive and Component Codes

When related Time Span Codes which share a common portion of a code description are both reported during the same time span period by the Same Group Physicians and/or Other Health Care Professional for the same patient, the code with the most comprehensive description is the reimbursable service. The other code is considered inclusive and is not a separately reimbursable service. No modifiers will override this denial. The following example illustrates how the CPT book lists code 93268 first as it is the comprehensive code. CPT codes 93270, 93271, and 93272 are indented and each share a common component of their code description with CPT code 93268.


When CPT code 93270, 93271, or 93272 are reported with CPT 93268 during the same 30 day period by the Same Group Physician and/or Other Health Care Professional for the same patient, only CPT code 93268 is the reimbursable service.

The Time Span Comprehensive and Component Codes list includes applicable comprehensive and related component Time Span Codes.

DEFINITIONS Calendar Month: Oxford defines Calendar Month as the time span referring to an individually named month of the year, (e.g., January, February) and includes codes with Calendar Month in their description.



Same Group Physician and/or Other Health Care Professional: All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

Time Span Code: A CPT or HCPCS code that specifies a time period for which it should be reported (e.g., weekly, monthly).



APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.


CPT Code Description

93268

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation 93270 Recording (includes connection, recording, and disconnection) 93271 Transmission and analysis

93272 Review and interpretation by a physician or other qualified health care professional CPT® is a registered trademark of the American Medical Association QUESTIONS AND ANSWERS



1 Q: How does Oxford determine the “time span” for codes with a description of calendar month, per month or monthly?

A: The date of service (DOS) is the reference point for determining the frequency of code submission and subsequent reimbursement during that period. See the examples below: Calendar Month

CPT code 94005 (home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more) is submitted March 13. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on April 5. Both codes are considered eligible for reimbursement as a Time Span Code because the service was provided in a different Calendar Month.


Per Month/or Monthly

HCPCS code A4595 [Electrical stimulator supplies, 2 lead, per month, (e.g. tens, nmes)] is submitted August 31. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on September 30. Both codes are considered eligible for reimbursement.

In order to consider reimbursement for services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

2 Q: Does Oxford recognize modifiers, (e.g., 59, 76), through the Time Span Codes Policy to allow reimbursement for additional submissions of a code within the designated time span?

A: No. Reimbursement for codes included in the Time Span Codes Policy is based on the time span parameter specified in the code description, CPT book parentheticals and/or other coding guidance from the AMA or CMS.

Wednesday, May 10, 2017

CPT 99026, 99027, 99360, 99464


CPT Code Description

Non-Reimbursable

99026 Hospital mandated on call service; in-hospital, each hour

99027 Hospital mandated on call service; out-of-hospital, each hour

99360 Standby service, requiring prolonged physician attendance, each 30 minutes (e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)


QUESTIONS AND ANSWERS

1 Q: If a pediatrician or other physician is requested by the delivering physician to attend at delivery and provide services to stabilize a newborn, are those services considered standby services?

A: No. If a physician is requested by the delivering physician to attend at delivery and to provide stabilization of a newborn, the physician may bill for those direct face-to-face services provided to the newborn using CPT code 99464.


APPLICABLE LINES OF BUSINESS/PRODUCTS

This policy applies to Oxford Commercial plan membership.

This reimbursement policy applies to services reported using the UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms. This policy applies to all network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified healthcare professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.



OVERVIEW

This reimbursement policy addresses reimbursement for standby services and hospital mandated on-call services.



Current Procedural Terminology

Per Current Procedural Terminology (CPT) definition, code 99360 is used to report physician or other qualified health care professional standby services that are requested by another individual that involves prolonged attendance without direct (face-to-face) patient contact. Care or services may not be provided to other patients during this period.

This code is not used to report time spent proctoring another individual. It is also not used if the period of standby ends with the performance of a procedure subject to a surgical package by the individual who was on standby.




REIMBURSEMENT GUIDELINES

Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) does not reimburse for physician standby services. These services are considered by CMS to be included in the payment to a facility as part of providing quality care and are not separately reimbursable.

Standby Services

In accordance with CMS, Oxford does not reimburse physician or other qualified health care professional standby services submitted with CPT code 99360. If a specific service is directly rendered to the patient by the standby physician or other qualified health care professional (i.e., tissue examination of frozen section biopsy), the service or procedure would be reported under the appropriate CPT code (i.e., 88331).


Mandated Hospital On-Call Service 

Oxford does not reimburse for hospital mandated on-call services billed under CPT codes 99026 and 99027 because they do not involve direct patient contact.

Friday, April 21, 2017

Denial code N290 AND N257



NPI: Troubleshooting Rejections

Denial Reason, Reason/Remark Code(s)

N257: Information missing/invalid in Item 33 - Missing/incomplete/invalid billing provider supplier primary identifier

N290: Information missing/invalid in Item 24J - Missing/incomplete/invalid rendering provider primary identifier


Resolution/Resources:

Each NPI must match one Provider Transaction Access Number (PTAN) on the NPI crosswalk file.

Step 1: If you contract with a billing service, find out if they have had communication with Palmetto GBA about NPI claim rejections. They may have important information that will help you resolve these claims.

Step 2: Verify the information on file with the NPI Enumerator. Call the NPI Enumerator at 800-465-3203 or access their website external link  to verify your information.


Pay special attention to the following fields in your NPPES record:

Each 'sole proprietor' should have an Individual (Entity Type 1) NPI and not an Organization (Entity Type 2) NPI
List your correct, current Medicare PTAN in the 'Other Provider Identifiers' section

If your NPI matches a PTAN that you no longer use (e.g., an old practice location), obtain and complete a new CMS-855 application and mail it to Palmetto GBA. Applications are available from the CMS 855 form external link  from the Enrollment Application Finder tool. We will be happy to assist you if you have questions about how to complete the application.


Step 3: If you are continuing to receive claim rejections after verifying information on file with the NPI Enumerator, verify the information you have on file with Palmetto GBA. Changes in this information require that you complete a new CMS-855 application.


Pay special attention to the Taxpayer Identification Number (TIN), which is used to report your income to the IRS on Form 1099


Consider consolidating multiple PTANs into a single number to ensure a one-to-one NPI to PTAN match. You may collapse PTANs that are assigned to additional locations only if the additional locations are all assigned the same TIN and are within the same pricing locality. More information about consolidating multiple PTANs is available in the CMS MLN Matters article MM5906
Step 4: Be aware of NPIs submitted for ordering/referring providers and attending/operating/other/service facilities

NPI numbers submitted in these fields must be valid. You may access the CMS NPI Registry to obtain these numbers.

Wednesday, March 29, 2017

CPT CODE 96910, 96912, 96920


CPT/HCPCS Codes:

96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

96912 Photochemotherapy; psoralens and ultraviolet A (PUVA)


96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings)


96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq. cm

96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq. cm to 500 sq. cm


96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq. cm


DESCRIPTION 2014 Total  RVUs1 2013 Total RVUs2 Total RVUs % Difference 2014 payment in $ assuming 35.6653 CF3


96900: Ultraviolet light therapy 0.58 0.65 -10.77% $20.69 $22.11 -6.46% 97,972

96910: Photochemotherapy with uv-b 1.10 2.24 -50.89% $39.23 $76.21 -48.52% 383,029

96912: Photochemotherapy with uv-a 1.10 2.87 -61.67% $39.23 $97.65 -59.82% 34,307


Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 96900, 96912, 96913, 96920, 96921, 96922 There is no specific CPT code for laser therapy for vitiligo. It should currently be reported using the unlisted CPT 96999, but the CPT codes for laser therapy for psoriasis (96920-96922) might be used. BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information neede  to make a medical necessity determination is included

How Treatment Codes 96900, 96910, and 96912 are used: Phototherapy or light therapy, is a first-line treatment for psoriasis and involves exposing the skin to ultraviolet light B (UVB) or ultraviolet light A (UVA) on a regular basis under medical supervision. Phototherapy is one of the safest and most costeffective therapies for psoriasis and may be the only therapy option for certain subsets of psoriasis patients, i.e. children, pregnant women and immuno-suppressed patients. Both treatments work by penetrating the skin and slowing the growth of affected skin cells.

Why is CMS proposing this change? Where CMS found reimbursements to be higher in a  non-facility setting than in a facility setting, non-facility practice expense relative value units (RVUs) were reduced toalign with the Medicare's Hospital Outpatient Prospective Payment System (OPPS) payment for the same service.4

In other words, non-facility RVUs were capped at the OPPS level.5 RVUs are a calculation of physician work, practice expense, and malpractice expense. For services with no work RVUs (including phototherapy), CMS is proposing to compare the total non-facility PFS payment to the OPPS payment rates directly since no PFS payment is made for these services when furnished in the facility setting.


CMS suggests that the unaligned payments are not the result of appropriate payment differentials between the services furnished in different settings. Rather, they believe it is due to anomalies in the data they use under the PFS and in the application of the resource-based practice expense (PE) methodology to the particular services.6


Flaw with CMS rationale: The rationale underlying the phototherapy cuts in the CY 2014 Physician Fee Schedule is fundamentally flawed because the OPPS and ambulatory surgical center (ASC) fee setting does not evaluate the costs of the resources that are used to provide services and fails to recognize the extent to which a hospital or ASC may offset the costs of providing these services. OPPS and ASC fees are grouped into Ambulatory Payment Classifications (APCs) which are intended to cover the costs of providing services in those settings, but which may actually pay more or less than the costs incurred. Hospitals and ASCs are able to offset the underpaid services with those that pay more than costs that are incurred, something physicians are unable to do. There is no evidence that the fees OPPS or ASC fee schedule accurately reflect the cost of providing services, and they certainly do not reflect the cost of providing services in the physician’s office. Using APCs incomplete fees to value services that are performed 90.6% and 91.8% of  the time respectively (for codes 96910 and 96912) in a physician’s office is not in the best interest of Medicare beneficiaries.


Likely Patient Impact: There is already a shortage of phototherapy units in the country, and these cuts would likely lead to additional closures of phototherapy units and decreased availability of these treatments, adversely affecting millions of patients. Should this treatment option disappear, many patients would be forced to go without treatment or transition to a systemic therapy that includes biologics, which can cost more than 10 times the expense of phototherapy treatments. (Phototherapy costs approximately $2,000- $3,000 a year.)


Description CODE RULE CODE 

96912 Incidental 96910

96910

96912 Incidental 96913 Rationale

Anthem Central Region bundles 96912 as redundant/mutually exclusive to 96910. Based on the National Correct Coding Initiative Edits, code 96912 is listed as a component code to code 96910. Therefore, if 96912 is submitted with 96910—only 96910 reimburses. 

Anthem Central Region bundles 96910 and 96912 as incidental with 96913. Procedure 96910 (Glockerman treatment) and 96912 (Ultraviolet A (PUVA) treatment) which are both components of 96913. Therefore if 96910 and /or 96912 is submitted with 96913—only 96913 reimburses.




On a case-by-case basis, coverage consideration will be given for excimer laser treatment confined to areas of the face, neck or hands only. (Claims must be submitted using CPT codes 96920, 96921, 96922 or 96567)

Prior to Medical Director consideration, substantiating documentation must first be submitted for review; these include:

1. Progress notes indicative of the following:

a. Baseline skin color.

b. Treatment history; documented failure of adherent 3-month trial of both:

i. high-potency (Class II steroids)

ii. Protopic.

c. Extent and distribution of vitiligo to the face, neck and or hands.

2. Photographic evidence.




Applicable Procedure Codes

96567 Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin
and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session

96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

96912 Photochemotherapy; psoralens and ultraviolet A (PUVA)

96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to
eight hours of care under direct supervision of the physician (includes application of medication and dressings)

96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm

96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm

96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

96999 Unlisted special dermatological service or procedure

E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less

E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 4 ft. panel

E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 6 ft. panel

E0694 Ultraviolet multidirectional light therapy system in 6 ft. cabinet, includes bulbs/lamps, timer, and eye protection

A4633 Replacement bulb/lamp for ultraviolet light therapy system, each

J7308 Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg)

J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g


Tuesday, March 21, 2017

CT abd CPT CODES 74176- 74178


CPT/HCPCS Codes

Group 1 Codes:
72192 Ct pelvis w/o dye
72193 Ct pelvis w/dye
72194 Ct pelvis w/o & w/dye
74150 Ct abdomen w/o dye
74160 Ct abdomen w/dye
74170 Ct abdomen w/o & w/dye
74176 Ct abd & pelvis w/o contrast
74177 Ct abd & pelv w/contrast
74178 Ct abd & pelv 1/> regns

Coverage Indications, Limitations, and/or Medical Necessity

Indications

Evaluation of abdominal or pelvic pain.

Evaluation of known or suspected abdominal or pelvic masses or fluid collections, primary or metastatic malignancies, abdominal or pelvic inflammatory processes, and abnormalities of abdominal or pelvic vascular structures.

Evaluation of abdominal or pelvic trauma.

Clarification of findings from other imaging studies or laboratory abnormalities.

Evaluation of known or suspected congenital abnormalities of abdominal or pelvic organs.

Treatment planning for radiation therapy.

Limitations

Three dimension reconstruction of CT of Abdomen and Pelvis (CPT code 76376 or 76377) is not expected to be utilized routinely. CPT code 76376 or 76377 are not an appropriate part of every CT examination.


Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

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

99999 Not Applicable



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

A06.2 - A06.6 - Opens in a new window Amebic nondysenteric colitis - Amebic brain abscess
A06.81 - A06.89 - Opens in a new window Amebic cystitis - Other amebic infections
A18.10 - A18.18 - Opens in a new window Tuberculosis of genitourinary system, unspecified - Tuberculosis of other female genital organs
A18.31 - A18.39 - Opens in a new window Tuberculous peritonitis - Retroperitoneal tuberculosis
A18.7 Tuberculosis of adrenal glands
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
A18.85 Tuberculosis of spleen
A31.0 Pulmonary mycobacterial infection
A31.2 Disseminated mycobacterium avium-intracellulare complex (DMAC)
A34 Obstetrical tetanus
A39.1 Waterhouse-Friderichsen syndrome
A40.0 - A41.9 - Opens in a new window Sepsis due to streptococcus, group A - Sepsis, unspecified organism
A42.7 Actinomycotic sepsis
A50.04 Early congenital syphilitic pneumonia
A50.06 - A50.09 - Opens in a new window Early cutaneous congenital syphilis - Other early congenital syphilis, symptomatic
A51.49 Other secondary syphilitic conditions
A52.74 - A52.75 - Opens in a new window Syphilis of liver and other viscera - Syphilis of kidney and ureter
A56.11 Chlamydial female pelvic inflammatory disease
B15.0 - B19.9 - Opens in a new window Hepatitis A with hepatic coma - Unspecified viral hepatitis without hepatic coma
B25.1 - B25.2 - Opens in a new window Cytomegaloviral hepatitis - Cytomegaloviral pancreatitis
B37.7 Candidal sepsis
B65.0 - B65.9 - Opens in a new window Schistosomiasis due to Schistosoma haematobium [urinary schistosomiasis] - Schistosomiasis, unspecified
B67.0 Echinococcus granulosus infection of liver
B67.5 Echinococcus multilocularis infection of liver
B67.8 - B67.99 - Opens in a new window Echinococcosis, unspecified, of liver - Other echinococcosis
C00.0 - C43.9 - Opens in a new window Malignant neoplasm of external upper lip - Malignant melanoma of skin, unspecified
C4A.0 - C4A.9 - Opens in a new window Merkel cell carcinoma of lip - Merkel cell carcinoma, unspecified
C44.00 - C49.9 - Opens in a new window Unspecified malignant neoplasm of skin of lip - Malignant neoplasm of connective and soft tissue, unspecified
C50.011 - C75.9 - Opens in a new window Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of endocrine gland, unspecified
C7A.00 - C7B.8 - Opens in a new window Malignant carcinoid tumor of unspecified site - Other secondary neuroendocrine tumors
C76.0 - C79.9 - Opens in a new window Malignant neoplasm of head, face and neck - Secondary malignant neoplasm of unspecified site
C80.0 - C84.79 - Opens in a new window Disseminated malignant neoplasm, unspecified - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites
C84.A0 - C84.Z9 - Opens in a new window Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites
C84.90 - C84.99 - Opens in a new window Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
C85.10 - C86.6 - Opens in a new window Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-cell proliferations
C88.2 - C91.62 - Opens in a new window Heavy chain disease - Prolymphocytic leukemia of T-cell type, in relapse
C91.A0 - C91.Z2 - Opens in a new window Mature B-cell leukemia Burkitt-type not having achieved remission - Other lymphoid leukemia, in relapse
C91.90 - C91.92 - Opens in a new window Lymphoid leukemia, unspecified not having achieved remission - Lymphoid leukemia, unspecified, in relapse
C92.00 - C92.62 - Opens in a new window Acute myeloblastic leukemia, not having achieved remission - Acute myeloid leukemia with 11q23-abnormality in relapse
C92.A0 - C92.Z2 - Opens in a new window Acute myeloid leukemia with multilineage dysplasia, not having achieved remission - Other myeloid leukemia, in relapse
C92.90 - C92.92 - Opens in a new window Myeloid leukemia, unspecified, not having achieved remission - Myeloid leukemia, unspecified in relapse
C93.00 - C93.32 - Opens in a new window Acute monoblastic/monocytic leukemia, not having achieved remission - Juvenile myelomonocytic leukemia, in relapse
C93.Z0 - C93.Z2 - Opens in a new window Other monocytic leukemia, not having achieved remission - Other monocytic leukemia, in relapse
C93.90 - C93.92 - Opens in a new window Monocytic leukemia, unspecified, not having achieved remission - Monocytic leukemia, unspecified in relapse
C94.00 - C94.32 - Opens in a new window Acute erythroid leukemia, not having achieved remission - Mast cell leukemia, in relapse
C94.80 - C96.4 - Opens in a new window Other specified leukemias not having achieved remission - Sarcoma of dendritic cells (accessory cells)
C96.A - C96.Z - Opens in a new window Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
D00.1 - D01.9 - Opens in a new window Carcinoma in situ of esophagus - Carcinoma in situ of digestive organ, unspecified
D03.0 - D03.9 - Opens in a new window Melanoma in situ of lip - Melanoma in situ, unspecified
D06.0 - D09.19 - Opens in a new window Carcinoma in situ of endocervix - Carcinoma in situ of other urinary organs
D12.0 - D12.9 - Opens in a new window Benign neoplasm of cecum - Benign neoplasm of anus and anal canal
D13.1 - D13.9 - Opens in a new window Benign neoplasm of stomach - Benign neoplasm of ill-defined sites within the digestive system
D16.8 Benign neoplasm of pelvic bones, sacrum and coccyx
D17.5 Benign lipomatous neoplasm of intra-abdominal organs
D17.71 Benign lipomatous neoplasm of kidney
D18.03 Hemangioma of intra-abdominal structures
D18.1 Lymphangioma, any site
D19.1 Benign neoplasm of mesothelial tissue of peritoneum
D20.0 - D20.1 - Opens in a new window Benign neoplasm of soft tissue of retroperitoneum - Benign neoplasm of soft tissue of peritoneum
D21.20 - D21.22 - Opens in a new window Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip - Benign neoplasm of connective and other soft tissue of left lower limb, including hip
D21.4 - D21.5 - Opens in a new window Benign neoplasm of connective and other soft tissue of abdomen - Benign neoplasm of connective and other soft tissue of pelvis
D25.0 - D28.9 - Opens in a new window Submucous leiomyoma of uterus - Benign neoplasm of female genital organ, unspecified
D30.00 - D30.9 - Opens in a new window Benign neoplasm of unspecified kidney - Benign neoplasm of urinary organ, unspecified
D35.00 - D35.02 - Opens in a new window Benign neoplasm of unspecified adrenal gland - Benign neoplasm of left adrenal gland
D35.6 Benign neoplasm of aortic body and other paraganglia
D3A.00 - D3A.8 - Opens in a new window Benign carcinoid tumor of unspecified site - Other benign neuroendocrine tumors
D37.1 - D37.9 - Opens in a new window Neoplasm of uncertain behavior of stomach - Neoplasm of uncertain behavior of digestive organ, unspecified
D39.0 - D39.9 - Opens in a new window Neoplasm of uncertain behavior of uterus - Neoplasm of uncertain behavior of female genital organ, unspecified
D40.0 - D41.9 - Opens in a new window Neoplasm of uncertain behavior of prostate - Neoplasm of uncertain behavior of unspecified urinary organ
D44.10 - D44.12 - Opens in a new window Neoplasm of uncertain behavior of unspecified adrenal gland - Neoplasm of uncertain behavior of left adrenal gland
D44.6 - D44.7 - Opens in a new window Neoplasm of uncertain behavior of carotid body - Neoplasm of uncertain behavior of aortic body and other paraganglia
D45 Polycythemia vera
D48.3 - D48.4 - Opens in a new window Neoplasm of uncertain behavior of retroperitoneum - Neoplasm of uncertain behavior of peritoneum
D49.0 Neoplasm of unspecified behavior of digestive system
D57.02 Hb-SS disease with splenic sequestration
D57.212 Sickle-cell/Hb-C disease with splenic sequestration
D57.412 Sickle-cell thalassemia with splenic sequestration
D57.812 Other sickle-cell disorders with splenic sequestration
D73.1 - D73.2 - Opens in a new window Hypersplenism - Chronic congestive splenomegaly
D73.81 Neutropenic splenomegaly
D75.0 - D75.1 - Opens in a new window Familial erythrocytosis - Secondary polycythemia
D78.01 - D78.22 - Opens in a new window Intraoperative hemorrhage and hematoma of the spleen complicating a procedure on the spleen - Postprocedural hemorrhage of the spleen following other procedure
D86.0 - D86.2 - Opens in a new window Sarcoidosis of lung - Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.84 Sarcoid pyelonephritis
D86.89 - D86.9 - Opens in a new window Sarcoidosis of other sites - Sarcoidosis, unspecified
E08.51 - E08.52 - Opens in a new window Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene - Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E09.51 - E09.52 - Opens in a new window Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene - Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.51 - E10.52 - Opens in a new window Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene - Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.51 - E11.52 - Opens in a new window Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene - Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.51 - E13.52 - Opens in a new window Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene - Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E16.3 - E16.8 - Opens in a new window Increased secretion of glucagon - Other specified disorders of pancreatic internal secretion
E24.0 Pituitary-dependent Cushing's disease
E24.2 - E27.9 - Opens in a new window Drug-induced Cushing's syndrome - Disorder of adrenal gland, unspecified
E28.2 Polycystic ovarian syndrome
E35 - E36.12 - Opens in a new window Disorders of endocrine glands in diseases classified elsewhere - Accidental puncture and laceration of an endocrine system organ or structure during other procedure
E74.00 - E74.09 - Opens in a new window Glycogen storage disease, unspecified - Other glycogen storage disease
E83.10 - E83.19 - Opens in a new window Disorder of iron metabolism, unspecified - Other disorders of iron metabolism
E84.0 - E85.9 - Opens in a new window Cystic fibrosis with pulmonary manifestations - Amyloidosis, unspecified
E89.6 Postprocedural adrenocortical (-medullary) hypofunction

Popular Posts