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

Monday, March 13, 2017

CPT FOR Neurophysiology evoked potential NEP

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
92585 Auditor evoke potent compre
92586 Auditor evoke potent limit

Group 2 Paragraph: N/A

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

Group 3 Paragraph: N/A

Group 3 Codes:
95930 Visual evoked potential test



Coverage Indications, Limitations, and/or Medical Necessity

Background

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

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

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

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

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

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


Indications

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

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

For one or more of the following conditions:

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

Preoperative baseline for:

Posterior fossa surgery
Cochlear implant

Postoperative testing for:

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

Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.

Detect optic neuritis at an early, subclinical stage.

Evaluate diseases of the optic nerve, such as:

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

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

Limitations

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

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



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

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



ICD-10 CODE DESCRIPTION

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

Monday, March 6, 2017

CPT 93224, 93225, 93228 , 93229 - ECG monitoring WEM

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
93224 Ecg monit/reprt up to 48 hrs
93225 Ecg monit/reprt up to 48 hrs
93226 Ecg monit/reprt up to 48 hrs
93227 Ecg monit/reprt up to 48 hrs
93228 Remote 30 day ecg rev/report
93229 Remote 30 day ecg tech supp
93268 Ecg record/review
93270 Remote 30 day ecg rev/report
93271 Ecg/monitoring and analysis
93272 Ecg/review interpret only


Coverage Indications, Limitations, and/or Medical Necessity

Long-term wearable electrocardiographic monitoring (WEM) is a diagnostic procedure that provides a record of the heart rhythm during daily activities. This procedure can often identify the existence and determine the frequency of clinically significant rhythm disturbances and waveform abnormalities that are missed on a standard electrocardiogram (ECG).

WEM are generally classified by the following:

Non-Activated Continuous Recorders (holter monitor/external electrocardiographic recording) (CPT codes 93224 – 93227) provide a continuous record of heart rhythm during a 48 hour period. This procedure can often identify the existence of ECG rhythm derived elements that are missed on a standard ECG.

This service is appropriate when arrhythmias are known or suspected to occur at least once in 48 hours 

Patient/Event-Activated Intermittent Recorders (loop event monitors, remote cardiovascular monitoring) (CPT codes 93228, 93229, and 93268 - 93272) are indicated when symptoms are sporadic to establish whether or not they are caused by transient arrhythmias. 

This service is an appropriate alternative to 48 hour monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope or syncope) or when a 48 hour service is not diagnostic.

Indications

The covered indications are:

To detect, characterize and document symptomatic transient arrhythmias.

To aid in regulating anti-arrhythmic drug dosage.

To aid in the search for the cause of unexplained syncope, dizziness or giddiness.

To monitor patients who have had surgical or ablative procedures for arrhythmias, since post ablation atrial fibrillation can be asymptomatic.

To aid in the search for the cause of TIA/CVA.


Limitations

A WEM service is medically unnecessary if it offers little or no potential for new clinical data beyond that which has been obtained from a previous test or if other tests are better suited to obtain the clinical data relevant to the patient’s condition. 

A test may be ordered only by a physician or other qualified health care professional treating the beneficiary.

WEMs are not covered for outpatient monitoring of recently discharged postinfarct patients.

When the billing of these services is split into components, it is expected that the appropriate components of the code series will be billed. 

For 30-day WEM service: 

WEM may be discontinued once the symptom-producing arrhythmia has been documented and diagnosed or following multiple transmissions during symptoms, without arrhythmia. It is unlikely that the arrhythmias would always be diagnosed on the first day of recording or that the service would always last only one day. The average duration of monitoring is anticipated to last 10–14 days or more.

WEM is a 30-day packaged service. Tests may not be billed more than once within 30 days of each other, even if the earlier of the tests was discontinued when arrhythmias were documented and the patient is now reconnected for follow-up of therapy or intervention.

Because the WEM service requires the diagnosis and evaluation of intermittent arrhythmias and patients must be continuously attached to presymptom loop recorders, each patient is required to have a recorder for his/her own exclusive use throughout the duration of the monitoring period. 

The receiving station must be staffed on a 24-hour basis. An answering service/answering machine would not fulfill this requirement.



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

G45.1 - G45.2 - Opens in a new window Carotid artery syndrome (hemispheric) - Multiple and bilateral precerebral artery syndromes

G45.8 - G46.2 - Opens in a new window Other transient cerebral ischemic attacks and related syndromes - Posterior cerebral 
artery syndrome

I20.0 - I20.9 - Opens in a new window Unstable angina - Angina pectoris, unspecified

I24.0 - I24.9 - Opens in a new window Acute coronary thrombosis not resulting in myocardial infarction - Acute ischemic 
heart disease, unspecified
I25.110 - I25.2 - Opens in a new window Atherosclerotic heart disease of native coronary artery with unstable angina pectoris 
- Old myocardial infarction

I25.5 - I25.799 - Opens in a new window Ischemic cardiomyopathy - Atherosclerosis of other coronary artery bypass graft(s) 
with unspecified angina pectoris

I25.89 - I25.9 - Opens in a new window Other forms of chronic ischemic heart disease - Chronic ischemic heart disease, 
unspecified

I34.0 - I35.9 - Opens in a new window Nonrheumatic mitral (valve) insufficiency - Nonrheumatic aortic valve disorder, 
unspecified

I42.0 Dilated cardiomyopathy

I42.5 Other restrictive cardiomyopathy

I42.8 - I42.9 - Opens in a new window Other cardiomyopathies - Cardiomyopathy, unspecified

I44.1 - I44.30 - Opens in a new window Atrioventricular block, second degree - Unspecified atrioventricular block

I44.4 - I45.2 - Opens in a new window Left anterior fascicular block - Bifascicular block

I45.5 - I45.9 - Opens in a new window Other specified heart block - Conduction disorder, unspecified
I47.0 - I48.92 - Opens in a new window Re-entry ventricular arrhythmia - Unspecified atrial flutter

I49.02 - I50.9 - Opens in a new window Ventricular flutter - Heart failure, unspecified

I63.40 - I63.49 - Opens in a new window Cerebral infarction due to embolism of unspecified cerebral artery - Cerebral 
infarction due to embolism of other cerebral artery

I66.01 - I66.3 - Opens in a new window Occlusion and stenosis of right middle cerebral artery - Occlusion and stenosis of 
cerebellar arteries

I66.9 Occlusion and stenosis of unspecified cerebral artery

I67.841 - I67.848 - Opens in a new window Reversible cerebrovascular vasoconstriction syndrome - Other cerebrovascular 
vasospasm and vasoconstriction

R00.0 - R00.2 - Opens in a new window Tachycardia, unspecified - Palpitations

R06.00 - R06.01 - Opens in a new window Dyspnea, unspecified - Orthopnea

R06.09 Other forms of dyspnea

R06.89 Other abnormalities of breathing

R07.2 Precordial pain

R07.82 - R07.9 - Opens in a new window Intercostal pain - Chest pain, unspecified

R40.4 Transient alteration of awareness

R42 Dizziness and giddiness

R55 Syncope and collapse

T82.110A - T82.111S - Opens in a new window Breakdown (mechanical) of cardiac electrode, initial encounter - Breakdown 
(mechanical) of cardiac pulse generator (battery), sequela

T82.120A - T82.121S - Opens in a new window Displacement of cardiac electrode, initial encounter - Displacement of 
cardiac pulse generator (battery), sequela


T82.190A - T82.191S - Opens in a new window Other mechanical complication of cardiac electrode, initial encounter - Other 
mechanical complication of cardiac pulse generator (battery), sequela

Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Z51.81 Encounter for therapeutic drug level monitoring

Z79.02 - Z79.1 - Opens in a new window Long term (current) use of antithrombotics/antiplatelets - Long term (current) use of 
non-steroidal anti-inflammatories (NSAID)

Z79.899 Other long term (current) drug therapy

Z95.0 Presence of cardiac pacemaker

Z95.9 Presence of cardiac and vascular implant and graft, unspecified

Tuesday, February 28, 2017

cpt 96360, 96361 - hydration therapy

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

96360 Hydration iv infusion init
96361 Hydrate iv infusion add-on



Coverage Indications, Limitations, and/or Medical Necessity



Indications

The clinical manifestations of dehydration or volume depletion are related to the volume and rate of fluid loss, the nature of the fluid that is lost, and the responsiveness of the vasculature to volume reduction. Rehydration with fluids containing sodium as the principal solute preferentially expands the extracellular fluid volume; a 1-liter infusion of normal saline may expand blood volume by about 300 ml. In general, an imbalance of less than 500 ml of volume is not likely to require intravenous rehydration.

Hydration services are indicated:

In documented volume depletion.

When performed in conjunction with chemotherapy, these CPT codes are covered only when infusion is prolonged and done sequentially [done hour(s) before and/or after administration of chemotherapy], and when the volume status of a patient is compromised or will be compromised by side effects of chemotherapy or an illness.

In some endocrine conditions with findings such as hypercalcemia, prolonged hydration can be medically necessary.

As an adjunct to the treatment of hypotension.
Limitations

Rehydration with the administration of an amount of fluid equal to or less than 500 ml is not reasonable and necessary.

These CPT codes are not to be used for routine IV drug injections.

Hanging of D5W or other fluid just prior to administration of chemotherapy is not hydration therapy and should not be billed with these codes.

When the sole purpose of fluid administration is to maintain patency of the access device, these infusion CPT codes should not be billed as hydration therapy.

Administration of fluid in the course of transfusions to maintain line patency or between units of blood product is not to be separately billed as hydration therapy.

Fluid used to administer drug(s) is incidental hydration and is not separately payable.

Rehydration via hydration therapy of extensively dehydrated patients can be accomplished in hours; therefore, the medical necessity of hydration beyond 12 hours must be documented in the medical record.

These CPT codes require the direct supervision of the physician or non-physician practitioner for the initiation of the service.




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.
N/A



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.

N/A




ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

E11.649 - E11.69 - Opens in a new window Type 2 diabetes mellitus with hypoglycemia without coma - Type 2 diabetes mellitus with other specified complication

E13.649 - E13.69 - Opens in a new window Other specified diabetes mellitus with hypoglycemia without coma - Other
specified diabetes mellitus with other specified complication

E83.52 Hypercalcemia

E86.0 - E87.0 - Opens in a new window Dehydration - Hyperosmolality and hypernatremia

I95.9 Hypotension, unspecified

K29.00 - K29.91 - Opens in a new window Acute gastritis without bleeding - Gastroduodenitis, unspecified, with bleeding

K52.89 - K52.9 - Opens in a new window Other specified noninfective gastroenteritis and colitis - Noninfective
gastroenteritis and colitis, unspecified

K92.0 Hematemesis

N18.3 Chronic kidney disease, stage 3 (moderate)

O21.1 - O21.8 - Opens in a new window Hyperemesis gravidarum with metabolic disturbance - Other vomiting complicating
pregnancy

R11.10 - R11.12 - Opens in a new window Vomiting, unspecified - Projectile vomiting

R11.2 Nausea with vomiting, unspecified

R19.7 Diarrhea, unspecified

R41.0 Disorientation, unspecified

R41.82 Altered mental status, unspecified

R42 Dizziness and giddiness

R55 Syncope and collapse

Z51.11 Encounter for antineoplastic chemotherapy

Z91.89 Other specified personal risk factors, not elsewhere classified

Thursday, February 23, 2017

CPT 95811, G0399, 95803 - Home sleep testing

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

G0398 HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND OXYGEN SATURATION

G0399 HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION

G0400 HOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3 CHANNELS

Group 2 Paragraph: CPT/HCPCS Codes Not Covered:


Group 2 Codes:

95803 ACTIGRAPHY TESTING, RECORDING, ANALYSIS, INTERPRETATION, AND REPORT (MINIMUM OF 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING)

95811 POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BILEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST



Coverage Indications, Limitations, and/or Medical Necessity

Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Such clinics are for diagnosis, therapy, and research. Sleep disorder clinics may provide some diagnostic or therapeutic services which are covered under Medicare. These clinics may be affiliated either with a hospital or a freestanding facility. Whether a clinic is hospital-affiliated or freestanding, coverage for diagnostic services under some circumstances is covered under provisions of the law different from those for coverage of therapeutic services. (CMS publication 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 70)

The physician services related to home sleep testing are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patient’s condition, meets all other Medicare requirements, and the physician who performs the service has sufficient training and experience to reliably perform the service.

A home sleep test is covered only when it is performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.

Home sleep testing is not covered for persons with comorbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure).

Home Sleep studies are only covered for the diagnosis of Obstructive Sleep Apnea. They are not covered for any other sleep disorders (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy) or for screening asymptomatic persons.


A. Medical Conditions for Which Testing is Covered

Sleep Apnea- Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. This is a potentially lethal condition where the patient stops breathing during sleep. Three types of sleep apnea have been described (central, obstructive, and mixed). The nature of the apnea episodes can be documented by appropriate diagnostic testing.(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).

Obstructive Sleep Apnea (OSA) is the collapse of the oropharyngeal walls and the obstruction of airflow occurring during sleep.

CMS PUB 100-03 NCD; 240.4.1 – Sleep Testing for Obstructive Sleep Apnea (OSA) finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA:

B. Covered Home Sleep Testing Devices

1. Type II sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA.
Type II monitors have a minimum of 7 channels (e.g., EEG, EOG, EMG, ECG-heart rate, airflow, breathing/respiratory effort, SaO2)-this type of device monitors sleep staging, so AHI can be calculated).

2. Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA.
Type III monitors have a minimum of 4 monitored channels including ventilation or airflow (at least two channels of respiratory movement or respiratory movement and airflow), heart rate or ECG, and oxygen saturation.

3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA.

Type IV devices may measure one, two, three or more parameters but do not meet all the criteria of a higher category device.

Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab
facility or attended in a sleep lab facility.


C. Physician and Technician Requirements for Home Sleep Testing:

The physician performing the service must meet one of the following:
be a diplomate of the American Board of Sleep Medicine (ABSM) and
Board Certified Pulmonologist, or a Board Certified Neurologist or

has a Sleep Certification issued by one of the following Boards:
American Board of Internal Medicine (ABIM),
American Board of Family Medicine (ABFM),
American Board of Pediatrics (ABP),
American Board of Psychiatry and Neurology (ABPN),
American Board of Otolaryngology (ABOto),
American Osteopathic Board of Neurology and Psychiatry (AOBNP),
American Osteopathic Board of Family Medicine, (AOBFP)
American Osteopathic Board of Internal Medicine, (AOBIM)
American Osteopathic Board of Ophthalmology and Otorhinolaryngology (AOBOO), or

be an active staff member of an accredited sleep center or laboratory. The sleep facility accreditation must be from the American Academy of Sleep Medicine (AASM), inpatient or outpatient, or the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation for Ambulatory care sleep centers.


Technician Credentials

The technician performing the service must meet one of the following:

American Board of Sleep Medicine (ABSM)
Registered Sleep Technologist (RST)

Board of Registered Polysomnographic Technologists (BRPT):
Registered Polysomnographic Technologist (RPSGT)

National Board for Respiratory Care (NBRC):
Certified Pulmonary Function Technologist (CPFT)
Registered Pulmonary Function Technologist (RPFT)
Certified Respiratory Therapist (CRT)
Registered Respiratory Therapist (RRT)

All centers billing sleep studies must maintain proper certification/ accreditation documentation as defined above, which include: Accreditation of sleep centers to include—AASM, or Joint Commission.


D. Actigraphy Testing:

Actigraphy measures movement of a limb. It can be measured as part of a sleep test but will not be paid for separately.

E. Home Sleep Testing (HST) is not covered in the following situations:

for the diagnosis of patients with chronic insomnia;
to preoperatively evaluate a patient undergoing a laser assisted uvulopalatopharyngoplasty without clinical evidence that obstructive sleep apnea is suspected;
to diagnose chronic lung disease (Nocturnal hypoxemia in patients with chronic, obstructive, restrictive, or reactive lung disease is usually adequately evaluated by oximetry. However, if the patient's symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography is considered medically necessary);
in cases where seizure disorders have not been ruled out;
in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated
for patients with epilepsy who have no specific complaints consistent with a sleep disorder
for patients with symptoms suggestive of the periodic limb movement disorder or restless leg syndrome unless symptoms are suspected to be related to a covered indication
for the diagnosis of insomnia related to depression
for the diagnosis of circadian rhythm sleep disorders [i.e., rapid time-zone change (jet lag), shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non 24-hour sleep wake disorder].

Criteria for Coverage of Diagnostic Tests

All reasonable and necessary diagnostic tests given for the medical conditions listed in subsection B are covered when the following criteria are met:

The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician;

Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s orders; and

The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests.

Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not reasonable and necessary under §1862(a)(1)(A) of the Act.


Home sleep studies/home sleep test may be considered medically necessary in adult patients (>18years of age) who are at high pre-test probability for moderate to severe obstructive sleep apnea (OSA), when ALL of the following criteria are met:

Patients considered high pre-test probability for moderate to severe OSA must have at least two of the following:
*Habitual snoring or gasping/choking episodes associated with awakenings;
*Observed apneas;
Excessive daytime sleepiness as evidenced by one of the following:
Questionnaires (Epworth Sleepiness Scale >10, Berlin, Wisconsin, STOP or STOP BANG)
Inappropriate day time napping (e.g. during driving, conversation or eating), or
sleepiness that interferes with daily activities not explained by other conditions;
A body mass index > 30 kg/m2;
Increased neck circumference >17 inches for men or >16 inches in women;
Morning headaches;
Sleep fragmentation or frequent unexplained arousals from sleep;
Decreased concentration/memory loss;
Treatment resistant hypertension/unexplained hypertension.
*If no bed partner is available to report snoring or observed apneas, the patient must still meet the criteria as it relates to other signs and symptoms suggestive of OSA.

AND

In addition, those patients eligible for an unattended home sleep study must have no evidence of a co-morbid medical condition including but not limited to any of the following as they might alter ventilation or require alternative treatment;
Moderate to Severe Pulmonary Disease
Congestive Heart Failure
Obesity hypoventilation syndrome
Neuromuscular disease (Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis).


AND

Must not be suspected of having other sleep disorders including but not limited to the following;
Central sleep apnea
Periodic limb movement disorder
Restless leg syndrome
Insomnia
Parasomnias
Narcolepsy.


AND

Any one of the following sleep monitoring devices;
sleep monitoring using a Type II device; or
sleep monitoring using a Type III device; or
sleep monitoring using a Type IV(A) device, which must measure a minimum of three channels and must provide measurement of apnea-hypopnea index (AHI).

Unsupervised (unattended) home sleep studies/home sleep testing for an asymptomatic individual is considered not medically necessary.

Sleep studies using devices that do not provide a measurement of apnea-hypopnea index (AHI) and oxygen saturation are considered not medically necessary because they do not provide sufficient information to prescribe treatment.


Notes

See Description information above for a full description of sleep monitoring devices.
Respiratory disturbance index (RDI) may be used in place of apnea/hypopnea index (AHI) in unattended sleep studies.

Unsupervised (unattended) home sleep study/home sleep test is typically performed over multiple nights with a single interpretation and is considered a single sleep study for purposes of reimbursement.

When a diagnosis of OSA is established following a home sleep study/home sleep test (portable study), home titration to determine a fixed CPAP pressure can be effectively completed using auto-titrating positive airway pressure. Evidence from several well-designed trials demonstrates that home PAP titration using APAP compared to in-facility titration results in similar outcomes in terms of improvement in AHI, Epworth Sleepiness scores, and CPAP acceptance and adherence. Therefore laboratory CPAP titration following unattended or home sleep testing is not considered medically necessary.


Repeat unsupervised (unattended) home sleep studies/home sleep testing may be considered medically necessary in adult patients for any of the following reasons;

To assess efficacy of surgery or oral appliances/devices.
A non-diagnostic home study within the past 3 months (e.g. technical complications or negative test with a high pretest probability of OSA).
Failure of resolution of symptoms or recurrence of symptoms during treatment.
To re-evaluate the diagnosis of OSA and need for continued PAP therapy (e.g. if there is a significant change in weight or change in symptoms suggesting that PAP therapy should be adjusted or possibly discontinued).



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.
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.
N/A


ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

G47.10 Hypersomnia, unspecified

G47.13 Recurrent hypersomnia

G47.14 Hypersomnia due to medical condition

G47.19 Other hypersomnia

G47.30 Sleep apnea, unspecified

G47.33 Obstructive sleep apnea (adult) (pediatric)

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