Monday, November 13, 2017

Extended Care services

The term “extended care services” means the following items and services furnished to an inpatient of a skilled nursing facility (SNF) either directly or under arrangements as noted in the list below:

• Nursing care provided by or under the supervision of a registered professional nurse;

• Bed and board in connection with furnishing of such nursing care;

• Physical or occupational therapy and/or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility;

• Medical social services;

• Such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients;

• Medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement (see §50.7) under an approved teaching program of the hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect, and

• Other services necessary to the health of the patients as are generally provided by skilled nursing facilities, or by others under arrangements.

Skilled Nursing Facility Level of Care - General

Care in a SNF is covered if all of the following four factors are met:

• The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;

• The patient requires these skilled services on a daily basis (see §30.6); and

• As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)

• The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

In reviewing claims for SNF services to determine whether the level of care requirements are met, the A/B MAC (A) first considers whether a patient needs skilled care. If a need for a skilled service does not exist, then the “daily” and “practical matter” requirements are not addressed. See section 30.2.2.1 for a discussion of the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care. Additional material on documentation appears in the various clinical scenarios that are presented throughout these level of care guidelines.

Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care and/or therapy, but rather on the beneficiary’s need for skilled care. Eligibility for SNF Medicare A coverage has not changed with the inception of PPS. However, the skilled criteria and the medical review process have changed slightly. For Medicare to render payment for skilled services provided to a beneficiary during a SNF Part A stay, the facility must complete an MDS.

EXAMPLE: Even though the irrigation of a suprapubic catheter may be a skilled nursing service, daily irrigation may not be “reasonable and necessary” for the treatment of a patient’s illness or injury.

A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner (NP), a clinical nurse specialist (CNS) or, effective with items and services furnished on or after January 1, 2011, a physician assistant (PA)) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.

In this context, the definition of a “direct employment relationship” is set forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under the regulations at 42 CFR 424.20(e)(2)(ii), when a physician extender has a direct employment relationship with an entity other than the facility, and the employing entity has an agreement with the facility that includes the provision of general nursing services under the regulations at 42 CFR 409.21, an “indirect employment relationship” exists between the physician extender and the facility. By contrast, such an indirect employment relationship does not exist if the agreement between the facility and the physician extender’s employer solely involves the performance of delegated physician tasks under the regulations at 42 CFR 483.40(e).

Patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services. Payment may be based on reasonable cost or be under the SNF Prospective Payment System (see §10). The facility may charge the beneficiary for services they request that are not included in the PPS rate or otherwise covered by Medicare (i.e. extra meals for family members).

An inpatient is a person who has been admitted to a skilled nursing facility or swing bedhospital for bed occupancy for purposes of receiving inpatient services. A person is considered an inpatient if formally admitted as an inpatient with the expectation that they will remain at least overnight and occupy a bed even though it later develops that they can be discharged and do not actually use a bed overnight.

Physical Therapy, Speech-Language Pathology, and Occupational

Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision

For Speech-Language Pathology, see Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” §100. For Occupational Therapy, see Medicare Benefit Policy Manual, Chapter 1,"Inpatient Hospital Services,” §90.

Note these services must be provided by the SNF or by others under arrangements with the SNF for beneficiaries in either a covered Part A stay or a non-covered stay in the SNF. Bundling to the SNF is not required for beneficiaries residing in a non-certified portion of a facility containing a distinct part SNF if the facility as whole is not primarily engaged in the provision of skilled care

Drugs and Biologicals

Drugs and biologicals for use in the facility, which are ordinarily furnished by the facility for the care and treatment of inpatients, are covered. Such drugs and biologicals are not limited to those routinely stocked by the skilled nursing facility but include those obtained for the patient from an outside source, such as a pharmacy in the community. Drugs and biologicals are included in the SNF PPS except for those Part B drugs specifically excluded. Since the provision of drugs and biologicals is considered an essential part of skilled nursing care, a facility must assure their availability to inpatients

in order to be found capable of furnishing the level of care required for participation in the program. When a facility secures drugs and biologicals from an outside source, their availability is assured only if the facility assumes financial responsibility for the necessary drugs and biologicals, i.e., the supplier looks to the facility, not the patient, for payment.

The use of an operating room and any special equipment, supplies, or services would not constitute covered extended care services except when furnished to the facility by a hospital with which the facility has a transfer agreement, since operating rooms are not generally maintained by skilled nursing facilities. However, supplies and nursing services connected with minor surgery performed in a skilled nursing facility that does not require the use of an operating room or any special equipment or supplies associated with such a room would be covered extended care services and paid as part of inpatient SNF PPS.

Tuesday, October 31, 2017

Maternity care billing TIPS - Twins, physician changing

 MATERNITY CARE SERVICES

Coding CPT guidelines for reporting prenatal care and delivery services apply. Bill the global obstetrical package or the antepartum, delivery, and postpartum components as  appropriate per Medicaid NCCI guidelines.



Delivery Delivery is part of the global maternity package and should not be billed separately if the global package is billed. If the beneficiary is seen for fewer than seven antepartum visits, delivery and postpartum care should be billed separately. Use appropriate CPT guidelines.

Global Service The global maternity package should be billed if the beneficiary is seen for seven or more antepartum visits with delivery and postpartum performed by the same physician or physician group. The provider or group may choose to bill the antepartum, delivery, and postpartum components separately as allowed by Medicaid NCCI editing.

Multiple Gestation For twin gestation, report the service on two lines with no modifier on the first line and modifier 51 on the second line. If all maternity care was provided, report the global maternity package code for the first infant, and report the appropriate delivery-only code for the second infant using modifier 51. If multiple gestation for more than twins is encountered, report the first delivery on one line and combine all subsequent deliveries on the second line with modifiers 51 and 22. Provide information in the remarks section or submit an attachment to the claim explaining the number of babies delivered.


Physician Change During Antepartum Care

If the beneficiary changes physicians during the antepartum care (other than physicians within the same group), use the appropriate maternity CPT codes and guidelines for the services performed. The global package should not be billed by either physician regardless of the number of antepartum visits provided.

Postpartum Care Postpartum care is included in the global maternity package and in the global surgical delivery period when the services are provided by the same physician or physician group. When the postpartum exam is performed by a physician not billing the global package or performing the delivery, the postpartum exam may be billed as a separate service.

Prenatal/Antepartum Care

If the beneficiary receives fewer than seven but greater than three antepartum visits, use the appropriate antepartum CPT code. Individual E/M codes should be used when three or fewer antepartum visits are performed.

NEWBORN CARE

When billing for medical services provided to the newborn, providers must use the newborn's Medicaid ID number, except if the delivering physician performs the newborn care and circumcision during the mother's inpatient stay, the delivering physician may bill for the newborn care and circumcision on the same claim as the delivery under the mother's Medicaid ID number.

Wednesday, October 18, 2017

List of provider should use CMS 1500 form

GENERAL INFORMATION


The following providers must use the ASC X12N 837 5010 professional format when submitting electronic claims and the CMS 1500 claim form for paper claims.


* Ambulance

* Ambulatory Surgical Centers

* Anesthesiologist Assistants

* Certified Nurse Midwives

* Certified Nurse Practitioners

* Certified Registered Nurse

Anesthetists

* Chiropractors

* Community Mental Health Services Programs/Prepaid Inpatient Health Plans

* Family Planning Clinics

* Federally Qualified Health Centers

* Hearing Aid Dealers

* Hearing Centers

* Independent Laboratories

* Indian Health Centers

* Maternal Infant Health Program

* Medical Clinics

* Medical Suppliers

* Optical Companies

* Optometrists

* Oral-Maxillofacial Surgeons

* Orthotists and Prosthetists

* Physician Assistants

* Physical Therapists

* Physicians (MD & DO)

* Podiatrists

* Private Duty Nurses (Individually Enrolled)

* Rural Health Clinics

* School Based Services

* Shoe Stores

* Urgent Care Centers

Claims for services rendered as a result of an order or referral must contain the name and individual NPI of the provider who ordered or referred the service/item. The following are the authorized health professionals who may order, prescribe or refer services to Medicaid beneficiaries:

* Physician

* Physician Assistant

* Nurse Practitioner

* Certified Nurse Midwife

* Dentist

* Podiatrist

* Optometrist

* Chiropractor (limited to spinal x-rays only)

Examples of services that require an order, prescription or referral include, but are not limited to,:

* Ambulance non-emergency transports

* Ancillary services for beneficiaries residing in nursing facilities (e.g., chiropractic, dental, podiatry, vision)

* Childbirth/parenting and diabetes self-management education

* Consultations

* Diagnostic radiology services, unless rendered by the ordering physician

* Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

* Hearing and hearing aid dealer services

* Home health services

* Hospice services

* Laboratory services

* Certain mental health and substance abuse children's waiver services

* Certain Maternal Infant Health Program (MIHP) services

* Pharmacy services

* Private Duty Nursing services

* Certain School Based Services

* Therapy services (occupational therapy (OT), physical therapy (PT) and speech)

* Certain vision supplies

Thursday, October 5, 2017

Facility hospice claim billing - revenue code 0651, 0658 - 0659

BILLING INSTRUCTIONS FOR HOSPICE CLAIM COMPLETION

Use UB 04 form

* Admission Date: Include the admission date for hospice care.

* Inpatient Respite Care: "Occurrence Span Code" - include occurrence span code M2 and complete the "from and through" dates for an episode of inpatient respite care.

* Core Based Statistical Area (CBSA): "Value Codes" - include value code 61 in the value code field and report the CBSA number. Hospice claims must be reported with a valid CBSA code based on the location of the beneficiary receiving services.

* Use the Revenue Codes listed below:

Revenue Code Description

0651 Routine Home Care I

0652 Continuous Home Care

0655 Inpatient Respite Care

0656 General Inpatient Care

0657 Physician Services

0658 Other Hospice I (Room & Board)

0659 Other Hospice Service – Facility Innovative Design


Supplemental (FIDS) Bed

* To bill for room and board in a nursing facility, licensed hospice long-term care unit, or Ventilator Dependent Care Unit (VDCU), use Revenue Code 0658. Providers must bill their customary room and board rate and Medicaid pays the usual and customary rate or the Medicaid fee screen, whichever is less. Room and board is reimbursable on the day of discharge if the discharge is due to resident death or the resident is discharged from hospice but remains in the NF. NOTE:

To ensure proper payment for a beneficiary in a VDCU, the VDCU provider identification number must be on the Hospice Membership Notice (DCH-1074). When a beneficiary resides in a VDCU/Dialysis Unit under which the VDCU has a special agreement with Medicaid and elects hospice, a prior authorization (PA) number for hospice is not required.

* To bill for room and board in a nursing facility when the beneficiary resides in a Facility Innovative Design Supplemental (FIDS) bed, use Revenue Code 0659.

* Revenue Code 0657 Physician Services requires inclusion of a HCPCS code on the claim line. Each Physician service must be billed on a separate claim line.

* Revenue Code 0652 Continuous Home Care must be billed for each date of service on separate claim lines. To receive the Continuous Home Care rate under code 0652, a minimum of 8 hours1 of care, not necessarily consecutive, in a 24-hour period is required. Less than 8 hours is reported under code 0651. A portion of an hour counts as an hour for this determination.

* Hospital Leave Days must be billed using Revenue Code 0185 (must not exceed 10 consecutive days). Reimbursement is at 100 percent of class-wide Nursing Facility Hospital Leave Day rate for qualifying facilities.

* Therapeutic Leave Days must be billed using Revenue Code 0183 (must not exceed 18 total days for the year) or Revenue Code 0189, Therapeutic Leave Days, for a beneficiary in a Facility Innovative Design Supplemental (FIDS) bed. Reimbursement is at 95 percent of Nursing Facility rate for leave days.

* Hospice services are reimbursable for day of discharge if services were rendered, regardless of the setting in which the services were provided. (See first bullet for instructions regarding room and board.)

* When billing for a hospice/NF resident who has been approved for complex care, bill revenue code 0120 and include the assigned PA number in F.L. 84, as obtained from the NF.

The Michigan Medicaid program, including Medicaid Health Plans (MHPs) and MIChild, as well as CSHCS, covers hospice care for children under 21 years of age concurrently with curative treatment of the child’s terminal illness when the child qualifies for hospice as described in the Hospice Chapter of this manual.


Hospice services and curative treatment are billed and reimbursed separately under this policy. Prior to billing, it is important that providers differentiate between services that are palliative and therefore included in hospice reimbursement, and those that are curative and separately reimbursable under Medicaid. Each child’s circumstances will need to be taken into consideration when making this distinction. Caution should be taken to avoid billing both the hospice and Medicaid for the same service as this represents double billing and may constitute fraud.

Tuesday, September 19, 2017

icd 10 code for dermatitis


Viral infections characterized by skin and mucous membrane lesions (B00-B09) 

B00 Herpesviral [herpes simplex] infections

Excludes1: congenital herpesviral infections (P35.2)

Excludes2: anogenital herpesviral infection (A60.-) gammaherpesviral mononucleosis (B27.0-) herpangina (B08.5)

B00.0 Eczema herpeticum Kaposi's varicelliform eruption

B00.1 Herpesviral vesicular dermatitis

Herpes simplex facialis
Herpes simplex labialis
Herpes simplex otitis externa
Vesicular dermatitis of ear
Vesicular dermatitis of lip

B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis Herpesviral pharyngitis
B00.3 Herpesviral meningitis
B00.4 Herpesviral encephalitis Herpesviral meningoencephalitis Simian B disease Excludes1: herpesviral encephalitis due to herpesvirus 6 and 7 (B10.01,
B10.09) non-simplex herpesviral encephalitis (B10.0-)
B00.5 Herpesviral ocular disease
B00.50 Herpesviral ocular disease, unspecified
B00.51 Herpesviral iridocyclitis Herpesviral iritis  Herpesviral uveitis, anterior
B00.52 Herpesviral keratitis Herpesviral keratoconjunctivitis
B00.53 Herpesviral conjunctivitis
B00.59 Other herpesviral disease of eye Herpesviral dermatitis of eyelid
B00.7 Disseminated herpesviral disease Herpesviral sepsis
B00.8 Other forms of herpesviral infections
B00.81 Herpesviral hepatitis
B00.82 Herpes simplex myelitis
B00.89 Other herpesviral infection Herpesviral whitlow
B00.9 Herpesviral infection, unspecified Herpes simplex infection NOS
B08 Other viral infections characterized by skin and mucous membrane lesions, not elsewhere classified

Excludes1: vesicular stomatitis virus disease (A93.8)

B08.0 Other orthopoxvirus infections

Excludes2: monkeypox (B04)

B08.01 Cowpox and vaccinia not from vaccine
B08.010 Cowpox
B08.011 Vaccinia not from vaccine Excludes1: vaccinia (from vaccination) (generalized) (T88.1)
B08.02 Orf virus disease Contagious pustular dermatitis Ecthyma contagiosum
B08.03 Pseudocowpox [milker's node]
B08.04 Paravaccinia, unspecified
B08.09 Other orthopoxvirus infections Orthopoxvirus infection NOS
B08.1 Molluscum contagiosum
B08.2 Exanthema subitum [sixth disease] Roseola infantum
B08.20 Exanthema subitum [sixth disease], unspecified Roseola infantum, unspecified
B08.21 Exanthema subitum [sixth disease] due to human herpesvirus 6 Roseola infantum due to human herpesvirus 6

B37 Candidiasis Includes: candidosis moniliasis

Excludes1: neonatal candidiasis (P37.5)
B37.0 Candidal stomatitis Oral thrush
B37.1 Pulmonary candidiasis Candidal bronchitis Candidal pneumonia
B37.2 Candidiasis of skin and nail Candidal onychia Candidal paronychia

Excludes2: diaper dermatitis (L22)

B37.3 Candidiasis of vulva and vagina Candidal vulvovaginitis Monilial vulvovaginitis Vaginal thrush
B37.4 Candidiasis of other urogenital sites
B37.41 Candidal cystitis and urethritis
B37.42 Candidal balanitis
B37.49 Other urogenital candidiasis Candidal pyelonephritis
B37.5 Candidal meningitis
B37.6 Candidal endocarditis
B37.7 Candidal sepsis Disseminated candidiasis Systemic candidiasis
B37.8 Candidiasis of other sites
B37.81 Candidal esophagitis
B37.82 Candidal enteritis Candidal proctitis
B37.83 Candidal cheilitis
B37.84 Candidal otitis externa
B37.89 Other sites of candidiasis Candidal osteomyelitis
B37.9 Candidiasis, unspecified Thrush NOS

Helminthiases (B65-B83)

B65 Schistosomiasis [bilharziasis]

Includes: snail fever

B65.0 Schistosomiasis due to Schistosoma haematobium [urinary schistosomiasis]
B65.1 Schistosomiasis due to Schistosoma mansoni [intestinal schistosomiasis]
B65.2 Schistosomiasis due to Schistosoma japonicum Asiatic schistosomiasis
B65.3 Cercarial dermatitis Swimmer's itch
B65.8 Other schistosomiasis
Infection due to Schistosoma intercalatum
Infection due to Schistosoma mattheei
Infection due to Schistosoma mekongi

B65.9 Schistosomiasis, unspecified

B88 Other infestations
B88.0 Other acariasis
Acarine dermatitis
Dermatitis due to Demodex species
Dermatitis due to Dermanyssus gallinae
Dermatitis due to Liponyssoides sanguineus
Trombiculosis

Excludes2: scabies (B86)

B88.1 Tungiasis [sandflea infestation]

B88.2 Other arthropod infestations Scarabiasis

B88.3 External hirudiniasis Leech infestation NOS

Excludes2: internal hirudiniasis (B83.4)
B88.8 Other specified infestations Ichthyoparasitism due to Vandellia cirrhosa Linguatulosis Porocephaliasis
B88.9 Infestation, unspecified Infestation (skin) NOS Infestation by mites NOS Skin parasites NOS

D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified
D89.81 Graft-versus-host disease Code first underlying cause, such as: complications of transplanted organs and tissue (T86.-) complications of blood transfusion (T80.89)

Use additional code to identify associated manifestations, such as: desquamative dermatitis (L30.8) diarrhea (R19.7) elevated bilirubin (R17) hair loss (L65.9)

D89.810 Acute graft-versus-host disease
D89.811 Chronic graft-versus-host disease
D89.812 Acute on chronic graft-versus-host disease
D89.813 Graft-versus-host disease, unspecified
D89.82 Autoimmune lymphoproliferative syndrome [ALPS]
D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified
Excludes1: human immunodeficiency virus disease (B20)
D89.9 Disorder involving the immune mechanism, unspecified

Immune disease NOS

E08.6 Diabetes mellitus due to underlying condition with other specified complications
E08.61 Diabetes mellitus due to underlying condition with diabetic arthropathy
E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy Diabetes mellitus due to underlying condition with Charcot's joints
E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy
E08.62 Diabetes mellitus due to underlying condition with skin complications
E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis Diabetes mellitus due to underlying condition with diabetic necrobiosis lipoidica
E08.621 Diabetes mellitus due to underlying condition with foot ulcer Use additional code to identify site of ulcer (L97.4-, L97.5-)
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer Use additional code to identify site of ulcer (L97.1-
L97.9, L98.41-L98.49)
E08.628 Diabetes mellitus due to underlying condition with other skin complications
E08.63 Diabetes mellitus due to underlying condition with oral complications
E08.630 Diabetes mellitus due to underlying condition with periodontal disease
E08.638 Diabetes mellitus due to underlying condition with other oral complications
E08.64 Diabetes mellitus due to underlying condition with hypoglycemia
E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma

E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication Use additional code to identify complication
E08.8 Diabetes mellitus due to underlying condition with unspecified complications
E08.9 Diabetes mellitus due to underlying condition without complications

E10.6 Type 1 diabetes mellitus with other specified complications
E10.61 Type 1 diabetes mellitus with diabetic arthropathy
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy

Type 1 diabetes mellitus with Charcot's joints

E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.62 Type 1 diabetes mellitus with skin complications
E10.620 Type 1 diabetes mellitus with diabetic dermatitis Type 1 diabetes mellitus with diabetic necrobiosis lipoidica
E10.621 Type 1 diabetes mellitus with foot ulcer Use additional code to identify site of ulcer (L97.4-, L97.5-)
E10.622 Type 1 diabetes mellitus with other skin ulcer Use additional code to identify site of ulcer (L97.1-
L97.9, L98.41-L98.49)
E10.628 Type 1 diabetes mellitus with other skin complications
E10.63 Type 1 diabetes mellitus with oral complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.64 Type 1 diabetes mellitus with hypoglycemia
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma

E13.6 Other specified diabetes mellitus with other specified complications

E13.61 Other specified diabetes mellitus with diabetic arthropathy

E13.610 Other specified diabetes mellitus with
diabetic neuropathic arthropathy
Other specified diabetes mellitus with Charcot's joints

E13.618 Other specified diabetes mellitus with other diabetic arthropathy

E13.62 Other specified diabetes mellitus with skin complications

E13.620 Other specified diabetes mellitus with diabetic dermatitis Other specified diabetes mellitus with diabetic necrobiosis lipoidica
E13.621 Other specified diabetes mellitus with foot ulcer Use additional code to identify site of ulcer (L97.4-, L97.5-)
E13.622 Other specified diabetes mellitus with other skin ulcer Use additional code to identify site of ulcer (L97.1- L97.9, L98.41-L98.49)
E13.628 Other specified diabetes mellitus with other skin complications
E13.63 Other specified diabetes mellitus with oral complications
E13.630 Other specified diabetes mellitus with periodontal disease
E83.1 Disorders of iron metabolism
Excludes1: iron deficiency anemia (D50.-) sideroblastic anemia (D64.0-D64.3)
E83.10 Disorder of iron metabolism, unspecified
E83.11 Hemochromatosis
E83.19 Other disorders of iron metabolism
E83.2 Disorders of zinc metabolism Acrodermatitis enteropathica
E83.3 Disorders of phosphorus metabolism and phosphatases

Excludes1: adult osteomalacia (M83.-) osteoporosis (M80-)

E83.30 Disorder of phosphorus metabolism, unspecified

E83.31 Familial hypophosphatemia

Vitamin D-resistant osteomalacia
Vitamin D-resistant rickets

Excludes1: vitamin D-deficiency rickets (E55.0)

E83.32 Hereditary vitamin D-dependent rickets (type 1) (type 2) 25-hydroxyvitamin D 1-alpha-hydroxylase deficiency Pseudovitamin D deficiency Vitamin D receptor defect

E83.39 Other disorders of phosphorus metabolism
Acid phosphatase deficiency Hypophosphatasia

E83.4 Disorders of magnesium metabolism
E83.40 Disorders of magnesium metabolism, unspecified
E83.41 Hypermagnesemia
E83.42 Hypomagnesemia
E83.49 Other disorders of magnesium metabolism
E83.5 Disorders of calcium metabolism

Excludes1: chondrocalcinosis (M11.1-M11.2) hungry bone syndrome (E83.81) hyperparathyroidism (E21.0-E21.3)

E83.50 Unspecified disorder of calcium metabolism
E83.51 Hypocalcemia
E83.52 Hypercalcemia Familial hypocalciuric hypercalcemia
E83.59 Other disorders of calcium metabolism Idiopathic hypercalciuria
E83.8 Other disorders of mineral metabolism
E83.81 Hungry bone syndrome
E83.89 Other disorders of mineral metabolism
E83.9 Disorder of mineral metabolism, unspecified
F54 Psychological and behavioral factors associated with
disorders or diseases classified elsewhere
Psychological factors affecting physical conditions

Code first the associated physical disorder, such as:

asthma (J45.-)
dermatitis (L23-L25)
gastric ulcer (K25.-)
mucous colitis (K58.-)
ulcerative colitis (K51.-)
urticaria (L50.-)

Excludes2: tension-type headache (G44.2)

F68 Other disorders of adult personality and behavior

F68.1 Factitious disorder Compensation neurosis

Elaboration of physical symptoms for psychological reasons Hospital hopper syndrome M?nchhausen's syndrome Peregrinating patient

Excludes2: factitial dermatitis (L98.1) person feigning illness (with obvious motivation) (Z76.5)

F68.10 Factitious disorder, unspecified

F68.11 Factitious disorder with predominantly psychological signs and symptoms

F68.12 Factitious disorder with predominantly physical signs and symptoms

F68.13 Factitious disorder with combined psychological and physical signs and symptoms

F68.8 Other specified disorders of adult personality and behavior

H01.1 Noninfectious dermatoses of eyelid

H01.11 Allergic dermatitis of eyelid Contact dermatitis of eyelid

H01.111 Allergic dermatitis of right upper eyelid
H01.112 Allergic dermatitis of right lower eyelid
H01.113 Allergic dermatitis of right eye, unspecified eyelid
H01.114 Allergic dermatitis of left upper eyelid
H01.115 Allergic dermatitis of left lower eyelid
H01.116 Allergic dermatitis of left eye, unspecified eyelid
H01.119 Allergic dermatitis of unspecified eye, unspecified eyelid
H01.12 Discoid lupus erythematosus of eyelid
H01.121 Discoid lupus erythematosus of right upper eyelid
H01.122 Discoid lupus erythematosus of right lower eyelid
H01.123 Discoid lupus erythematosus of right eye, unspecified eyelid
H01.124 Discoid lupus erythematosus of left upper eyelid
H01.125 Discoid lupus erythematosus of left lower eyelid
H01.126 Discoid lupus erythematosus of left eye, unspecified eyelid
H01.129 Discoid lupus erythematosus of unspecified eye, unspecified eyelid
H01.13 Eczematous dermatitis of eyelid
H01.131 Eczematous dermatitis of right upper eyelid
H01.132 Eczematous dermatitis of right lower eyelid
H01.133 Eczematous dermatitis of right eye, unspecified eyelid
H01.134 Eczematous dermatitis of left upper eyelid
H01.135 Eczematous dermatitis of left lower eyelid
H01.136 Eczematous dermatitis of left eye, unspecified eyelid
H01.139 Eczematous dermatitis of unspecified eye, unspecified eyelid
H01.14 Xeroderma of eyelid
H01.141 Xeroderma of right upper eyelid
H01.142 Xeroderma of right lower eyelid
H01.143 Xeroderma of right eye, unspecified eyelid
H01.144 Xeroderma of left upper eyelid
H01.145 Xeroderma of left lower eyelid
H01.146 Xeroderma of left eye, unspecified eyelid
H01.149 Xeroderma of unspecified eye, unspecified eyelid
H01.8 Other specified inflammations of eyelid
H61 Other disorders of external ear
H61.0 Chondritis and perichondritis of external ear Chondrodermatitis nodularis chronica helicis

Perichondritis of auricle
Perichondritis of pinna

H61.00 Unspecified perichondritis of external ear
H61.001 Unspecified perichondritis of right external ear
H61.002 Unspecified perichondritis of left external ear
H61.003 Unspecified perichondritis of external ear, bilateral
H61.009 Unspecified perichondritis of external ear, unspecified ear
H61.01 Acute perichondritis of external ear
H61.011 Acute perichondritis of right external ear
H61.012 Acute perichondritis of left external ear
H61.013 Acute perichondritis of external ear, bilateral
H61.019 Acute perichondritis of external ear, unspecified ear
H61.02 Chronic perichondritis of external ear
I83.1 Varicose veins of lower extremities with inflammation Stasis dermatitis
I83.10 Varicose veins of unspecified lower extremity with inflammation
I83.11 Varicose veins of right lower extremity with inflammation
I83.12 Varicose veins of left lower extremity with inflammation
L10-L14 Bullous disorders
L20-L30 Dermatitis and eczema
L40-L45 Papulosquamous disorders
L49-L54 Urticaria and erythema
L55-L59 Radiation-related disorders of the skin and subcutaneous tissue
L60-L75 Disorders of skin appendages
L76 Intraoperative and postprocedural complications of skin and subcutaneous tissue

L80-L99 Other disorders of the skin and subcutaneous tissue

Infections of the skin and subcutaneous tissue (L00- L08)

Use additional code (B95-B97) to identify infectious agent.

Excludes2: hordeolum (H00.0)

infective dermatitis (L30.3)

local infections of skin classified in Chapter 1

lupus panniculitis (L93.2)

panniculitis NOS (M79.3)

panniculitis of neck and back (M54.0-)

perl?che NOS (K13.0)

perl?che due to candidiasis (B37.0)

perl?che due to riboflavin deficiency (E53.0)

pyogenic granuloma (L98.0)

relapsing panniculitis [Weber-Christian] (M35.6)

viral warts (B07.-)

zoster (B02.-) 

L08.0 Pyoderma Purulent dermatitis Septic dermatitis Suppurative dermatitis

Excludes1: pyoderma gangrenosum (L88) pyoderma vegetans (L08.81)

L12 Pemphigoid

Excludes1: herpes gestationis (O26.4-) impetigo herpetiformis (L40.1)

L12.0 Bullous pemphigoid

L12.1 Cicatricial pemphigoid Benign mucous membrane pemphigoid

L12.2 Chronic bullous disease of childhood Juvenile dermatitis herpetiformis

L12.3 Acquired epidermolysis bullosa

Excludes1: epidermolysis bullosa (congenital) (Q81.-)

L12.30 Acquired epidermolysis bullosa, unspecified

L12.31 Epidermolysis bullosa due to drug

Code first (T36-T50) to identify drug

L12.35 Other acquired epidermolysis bullosa

L12.8 Other pemphigoid

L12.9 Pemphigoid, unspecified

L13 Other bullous disorders

L13.0 Dermatitis herpetiformis Duhring's disease

Hydroa herpetiformis

Excludes1: juvenile dermatitis herpetiformis (L12.2) senile dermatitis herpetiformis (L12.0)

L13.1 Subcorneal pustular dermatitis Sneddon-Wilkinson disease

L13.8 Other specified bullous disorders

L13.9 Bullous disorder, unspecified  Dermatitis and eczema (L20-L30)

Note: In this block the terms dermatitis and eczema are used synonymously and interchangeably.

Excludes2: chronic (childhood) granulomatous disease (D71)

dermatitis gangrenosa (L88)

dermatitis herpetiformis (L13.0)

dry skin dermatitis (L85.3)

factitial dermatitis (L98.1)

perioral dermatitis (L71.0)

radiation-related disorders of the skin and subcutaneous tissue (L55-L59) stasis dermatitis (I83.1-I83.2)

L20 Atopic dermatitis

L20.0 Besnier's prurigo

L20.8 Other atopic dermatitis

Excludes2: circumscribed neurodermatitis (L28.0)

L20.81 Atopic neurodermatitis Diffuse neurodermatitis

L20.82 Flexural eczema

L20.83 Infantile (acute) (chronic) eczema

L20.84 Intrinsic (allergic) eczema

L20.89 Other atopic dermatitis

L20.9 Atopic dermatitis, unspecified

L21 Seborrheic dermatitis

Excludes2: infective dermatitis (L30.3)

seborrheic keratosis (L82.-)

L21.0 Seborrhea capitis Cradle cap

L21.1 Seborrheic infantile dermatitis

L21.8 Other seborrheic dermatitis

L21.9 Seborrheic dermatitis, unspecified

Seborrhea NOS

L22 Diaper dermatitis

Includes: Diaper erythema

Diaper rash

Psoriasiform diaper rash

L23 Allergic contact dermatitis

Code first (T36-T65), to identify drug or substance

Excludes1: allergy NOS (T78.40)

contact dermatitis NOS (L25.9)

dermatitis NOS (L30.9)

Excludes2: dermatitis due to substances taken internally (L27.-)

dermatitis of eyelid (H01.1-)

diaper dermatitis (L22)

eczema of external ear (H60.5-)

irritant contact dermatitis (L24.-)

perioral dermatitis (L71.0)

radiation-related disorders of the skin and subcutaneous tissue (L55- L59)

L23.0 Allergic contact dermatitis due to metals

Allergic contact dermatitis due to chromium

Allergic contact dermatitis due to nickel

L23.1 Allergic contact dermatitis due to adhesives

L23.2 Allergic contact dermatitis due to cosmetics

L23.3 Allergic contact dermatitis due to drugs in contact with skin

Excludes2: dermatitis due to ingested drugs and medicaments (L27.0- L27.1)

L23.4 Allergic contact dermatitis due to dyes

L23.5 Allergic contact dermatitis due to other chemical products

Allergic contact dermatitis due to cement

Allergic contact dermatitis due to insecticide

Allergic contact dermatitis due to plastic

Allergic contact dermatitis due to rubber

L23.6 Allergic contact dermatitis due to food in contact with the skin

Excludes2: dermatitis due to ingested food (L27.2)

L23.7 Allergic contact dermatitis due to plants, except food

Excludes2: allergy NOS due to pollen (J30.1)

L23.8 Allergic contact dermatitis due to other agents

L23.81 Allergic contact dermatitis due to animal (cat) (dog) dander

Allergic contact dermatitis due to animal (cat) (dog) hair

L23.89 Allergic contact dermatitis due to other agents

L23.9 Allergic contact dermatitis, unspecified cause

Allergic contact eczema NOS

L24 Irritant contact dermatitis

Code first (T36-T65) to identify drug or substance

Excludes1: allergy NOS (T78.40)

contact dermatitis NOS (L25.9)

dermatitis NOS (L30.9)

Excludes2: allergic contact dermatitis (L23.-)

dermatitis due to substances taken internally (L27.-)

dermatitis of eyelid (H01.1-)

diaper dermatitis (L22)

eczema of external ear (H60.5-)

perioral dermatitis (L71.0)

radiation-related disorders of the skin and subcutaneous tissue (L55- L59)

L24.0 Irritant contact dermatitis due to detergents

L24.1 Irritant contact dermatitis due to oils and greases

L24.2 Irritant contact dermatitis due to solvents

Irritant contact dermatitis due to chlorocompound

Irritant contact dermatitis due to cyclohexane

Irritant contact dermatitis due to ester

Irritant contact dermatitis due to glycol

Irritant contact dermatitis due to hydrocarbon

Irritant contact dermatitis due to ketone

L24.3 Irritant contact dermatitis due to cosmetics

L24.4 Irritant contact dermatitis due to drugs in contact with skin

L24.5 Irritant contact dermatitis due to other chemical products

Irritant contact dermatitis due to cement

Irritant contact dermatitis due to insecticide

Irritant contact dermatitis due to plastic

Irritant contact dermatitis due to rubber

L24.6 Irritant contact dermatitis due to food in contact with skin

Excludes2: dermatitis due to ingested food (L27.2)

L24.7 Irritant contact dermatitis due to plants, except food

Excludes2: allergy NOS to pollen (J30.1)

L24.8 Irritant contact dermatitis due to other agents

L24.81 Irritant contact dermatitis due to metals

Irritant contact dermatitis due to chromium

Irritant contact dermatitis due to nickel

L24.89 Irritant contact dermatitis due to other agents Irritant contact dermatitis due to dyes

L24.9 Irritant contact dermatitis, unspecified cause Irritant contact eczema NOS

L25 Unspecified contact dermatitis

Code first (T36-T65), to identify drug or substance

Excludes1: allergic contact dermatitis (L23.-)

allergy NOS (T78.40)

dermatitis NOS (L30.9)

irritant contact dermatitis (L24.-)

Excludes2: dermatitis due to ingested substances (L27.-)

dermatitis of eyelid (H01.1-)

eczema of external ear (H60.5-)

perioral dermatitis (L71.0)

radiation-related disorders of the skin and subcutaneous tissue (L55- L59)

L25.0 Unspecified contact dermatitis due to cosmetics

L25.1 Unspecified contact dermatitis due to drugs in contact with skin

Excludes2: dermatitis due to ingested drugs and medicaments (L27.0- L27.1)

L25.2 Unspecified contact dermatitis due to dyes

L25.3 Unspecified contact dermatitis due to other chemical products

Unspecified contact dermatitis due to cement

Unspecified contact dermatitis due to insecticide

L25.4 Unspecified contact dermatitis due to food in contact with skin

Excludes2: dermatitis due to ingested food (L27.2)
L25.5 Unspecified contact dermatitis due to plants, except food

Excludes1: nettle rash (L50.9)

Excludes2: allergy NOS due to pollen (J30.1)

L25.8 Unspecified contact dermatitis due to other agents
L25.9 Unspecified contact dermatitis, unspecified cause
Contact dermatitis (occupational) NOS
Contact eczema (occupational) NOS

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.

Popular Posts