Thursday, September 17, 2015

CPT 76492, 36470 and 22856, 76999

Hospital Outpatient Reimbursement (APC)

CPT code 22856, used to denote single level cervical disc arthroplasty, has recently been added to the Medicare Outpatient allowable list for 2013 and is therefore reimbursable by Medicare in this alternate setting of care. Previously, this procedure was only allowable by Medicare in the inpatient setting. The second level code, 0092T, has not been added to this outpatient list and is still considered an inpatient-only procedure for Medicare patients. Private payor guidelines may differ from Medicare, so that two-level cervical disc arthroplasty procedures may be permissible in the outpatient setting of care.

Hospital Outpatient Coding Pathways 

CPT code Description APC Medicare Hospital Outpatient Rate 20139

22856 Mobi-C Implantation

First Level

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical 0208 $3,759

The local coverage determination (LCD) for noncovered services was revised to remove several CPT® codes from noncoverage. CPT® code 76999 (ultrasound guided sclerotherapy) was removed from the “CPT®/HCPCS Codes - Unlisted Procedure Codes - Procedures” section of the LCD since this service (billed as CPT® codes 36470/36471 and 76942) is addressed in another LCD (treatment of varicose veins of the lower extremity). In addition, the “CPT®/HCPCS Codes – Listed Procedure Codes - Procedures” section of the LCD was revised to remove CPT® codes 22856, 22861, and 22864based on a reconsideration request. Removing a service from noncoverage should not be interpreted as a positive coverage statement and coverage by Medicare. Claims for such services, assuming all other requirements of the program are met, would always need to meet the medically reasonable and necessary threshold for coverage in a prepayment or post payment audit of the official medical record.
Effective date

The LCD revision for CPT® code 76999 is effective for claims processed on or after September 9, 2015, for dates of service on or after August 9, 2015. The LCD revision for CPT® codes 22856, 22861, and 22864 is effective for services rendered on or after September 9, 2015. First Coast Service Options Inc. LCDs are available through the CMS Medicare coverage database at external link.

Coding guidelines for an LCD (when present) may be found by selecting “Attachments” in the “Section Navigation” drop-down menu at the top of the LCD page.

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 They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 0095T, 0098T, 0163T, 0164T, 0165T, 0375T, 22856, 22857, 22858, 22861, 22862, 22864, 22865.

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.

Artificial Intervertebral Disc

1/3/07 Added the following new 2007 CPT codes: 0163T, 0164T, 0165T, 22857, 22862, and 22865 from "Billing/Coding section. Removed deleted CPT codes, 0091T, 0094T, and 0097T.

6/30/08 Specialty Matched Consultant Advisory Panel review 5/29/08. No changes to policy statement. References added.

1/5/09 Added CPT codes 22856, 22861, and 22864 to the "Billing/Coding" section. Removed deleted CPT codes 0090T, 0093T, and 0096T. (btw).

No comments:

Post a Comment

Popular Posts