Medical Review Frequently Asked Questions - January 2004
Website posting January 2004
The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly "Frequently Asked Questions" related to coverage and local coverage determination issues. The previous issue was published in the December 2003 website bulletin. New issues of FAQ's are, generally, first posted on the website "What's New" section and list served to registered providers. Providers may submit questions to the website at http://www.cignamedicare.com/customer_service/disclaimer.html. Providers may register for list serve announcements at the following website: http://www.cignamedicare.com/mailer/subscribe.asp.
- Credentialed Facilities and Staff for Noninvasive Vascular Tests
Q: Have there been changes in the coverage of noninvasive vascular tests?
A: : Each state's local medical review policy requires the facility and staff performing noninvasive vascular testing to be credentialed. This guideline was effective for North Carolina on January 1, 2002 and January 1, 2004 for Tennessee and Idaho. (See links to the current lmrps below).
We have received a variety of questions with the carrier's responses summarized as follows:
- "Incident to" guidelines do not apply to technologists. Therefore, a noncredentialed technologist cannot perform these tests under the supervision of a credentialed technologist.
- Physician supervision at the appropriate level (as directed by the MFSDB physician supervision indicator--see attached link) would still be required for credentialed technologists
Medicare Physician Fee Schedule Database: http://www.cms.hhs.gov/physicians/mpfsapp/step1.asp
NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/2000-008-08.htm
ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/2003-04.html
TN LMRP: http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/96-07-05.html
- Lipid Testing
Q: How often can lipid testing be done? What about measuring the direct LDL?
A: Previously, there were local medical review policies for lipid testing, but these were retired in deference to the implementation of a national coverage determination by CMS that can be viewed at the following link:
http://cms.gov/mcd/viewncd.asp?ncd_id=40-12&ncd_version=7&show=all
The above addresses indications for performing and frequency of testing. Deviating from these guidelines would need to be supported by clinical indication(s) as documented in the medical record. Providers have inquired about separately billing for a direct LDL beyond the calculated LDL included in a lipid profile (as the latter can be an inaccurate value if the triglycerides are high). If the patient's treatment will be impacted by these results (i.e. by additional dietary or pharmacological therapy) then it is acceptable to separately bill a direct LDL with modifier 59 in addition to the lipid panel. There is no set guideline for a triglyceride level that should be followed with a direct LDL measurement. Testing should be driven by medical reasonableness and necessity rather than an institutional protocol level for triglycerides.
- PA's and NP's Performing "Incident To" in SNF/NF
Q: How does CIGNA audit records for evaluation and management visits in nursing facilities (skilled or otherwise)?
A: CMS stipulates that "incident to" is not covered in an inpatient setting. Therefore, if claims reviewed find that nonphysician practitioners (i.e. physician assistants, nurse practitioners, etc.) perform these visits and not the physician whose provider number the service is being billed under, the service will be denied. The nonphysician practitioners should bill their inpatient visits under their own provider numbers.
- Separately Billable Arthroscopic Knee Surgeries
Q: What is the status of codes G0289 and 29877 in relation to other arthroscopic knee procedures?
A: CPT code 29877 is arthroscopic debridement/shaving of articular cartilage (chondroplasty) which is a component of more comprehensive procedures such as 29881 (arthroscopic medial or lateral meniscectomy) and 29883 (arthroscopic repair of medial and lateral meniscus). This code has been through multiple revisions as far as NCCI rebundling edits. Furthermore, there has been the addition of the HCPCS code G0289 (arthroscopy of knee for removal of loose or foreign body, chondroplasty at the time of other surgical knee arthroscopy in a different compartment of the same knee). effective 030103. Presently, code 29877 may be separately billed if performed in a different compartment of the same knee (as also being treated with, for example 29881 or 29883) or in the contralateral knee for dates of service prior to 030103. For dates of service after 030103, providers should use G0289; but providers should not use 29877 or G0289 for chondroplasties done in the same compartments as more comprehensive procedures. For example, Medical Review has seen claims for 29877 after 030103 denied as component to the also performed 29883 only to be subsequently refiled and paid as G0289. On inquiry, it has been found that the chondroplasty was done in a compartment of the same knee also treated by medial and lateral meniscus repair. The manner in which the charges were resubmitted represents incorrect use of code G0289. In summary, 29877 and G0289 are to be used in addition to comprehensive procedures for arthroscopic procedures performed in either a different compartment of the same knee or for a compartment treated in the contralateral knee.
- Cryotherapy for Acne (CPT code 17340)
Q: Are there coverage guidelines for this service?
A: Even though this code is an active/payable code according to the Medicare Physician Fee Schedule Data Base, the service might be performed for cosmetic reasons which would exclude it as a Medicare benefit. In other words, unless the acne poses a threat to health or creates a functional impairment, the service to treat the acne would be considered cosmetic and not payable. Claims for this service may be developed for medical review. If the treatment is done for cosmetic purposes, providers could append modifier -GY to facilitate processing.
NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/96-001-06.html
TN LMRP: http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/96-10-06.html
ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/96-104.html
- Face-to-Face time required in E&M visits
Q: Can an evaluation and management visit be billed without the provider seeing the patient?
A: Face-to-face time is an inherent component to evaluation and management visits. Even though some E&M codes require only two of three components for the level of service billed, this does not remove the requirement that patient contact by the billing provider must be made and documented. For example, CIGNA Government Services has seen instances where the provider billing an E&M visit (i.e. 99232-subsequent hospital care) reviewed only the hospital record then summarized a history of present illness and rendered complex decision-making via new or revised orders without ever seeing the patient. The components of E&M codes and, subsequently, the level of service billed require the billing provider's performance of these components by way of his or her direct contact with the patient. Services performed by the staff of a hospital cannot be counted towards the level of service billed by the physician. This guideline would not be limited to subsequent hospital visits but would also extend to inpatient consult visits, nursing facility visits, etc.
- Hyperbaric Oxygen Used for Treatment Wounds
Q: Is HBO covered for wound care?
A: The national coverage decision for Hyperbaric Oxygen Therapy was expanded effective April 1, 2003 to allow treatment of diabetic wounds of the lower extremities provided the following conditions are met:
- Patient has type I or II diabetes
- Patient has a lower extremity wound due to diabetes
- The wound is classified as Wagner grade III or higher
- Patient has failed an adequate course of standard wound therapy (i.e. patient does not demonstrate any measurable signs of healing for at least 30 days with standard wound therapy).
The NCD can be seen at the following link:
http://cms.gov/mcd/viewncd.asp?ncd_id=35-10&ncd_version=8&show=all
The NCD further defines "standard wound care" and stipulates how long HBO therapy could be covered. Specifically, wounds must be evaluated at least every 30 days for measurable signs of healing. If none have been demonstrated within any 30 day period, then ongoing HBO therapy would no longer be covered.
CIGNA Government Services would review and expect to find medical record documentation in accordance with this NCD. Providers using HBO for this indication should include diagnoses for both diabetes and the wound to facilitate claims processing.
- Initial Hospital Visits
Q: Does the initial hospital visit have to be done the date of admission?
A: The initial hospital visit should be billed the date the service was delivered. We have seen some instances when providers billed initial visits for the date of admission but did not actually see the patient till the next day-- for which they also billed a subsequent hospital visit. Providers are cautioned to avoid this error which can result in an overpayment and recoupment.
- Manuals on the CMS Website
Q: How have these changed?
A: Effective October 2003, CMS reduced over 40,000 pages of hard-copy instructions from multiple manuals to approximately a single 5000 page manual system entitled IOM for "Internet Only Manuals". The Internet Only Manual system can be accessed through the following link:
http://www.cms.hhs.gov/manuals/
The new system is organized according to functional area (i.e. Medicare Claims Processing, Medicare Benefit Policy, etc.) versus per user (such as carrier or intermediary). See the index of functional areas at the attached link:
http://cms.gov/manuals/cmsindex.asp
Please note these instructions supercede those previously published in the paper-based manuals but can be revised with new transmittal releases.
- G0127 vs. 11719-11721
Q: How should a provider determine which code to bill?
A: The attached link connects to an article previously published foot care:
http://www.cignamedicare.com/partb/bltin/all/01bltin/01_1/tn/b0101tn04b.asp
The following table includes the same information but formatted differently to facilitate code selection.
Code
Nail Pathology
Systemic Condition(s)? (*)
# of Nails
Symptoms Required?
G0127
Dystrophic
yes
any #
no
11719
Non-dystrophic
no
any #
no
11720
Dystrophic
May or may not be present
1-5 nails
yes (**)
11721
Dystrophic
May or may not be present
6 or more
Yes (**)
*requires documentation of class findings if systemic condition(s) present
**symptoms of a "sick foot" as manifested by 1)marked limitation of ambulation, infected toenail plate (for an ambulatory patient) or 2) pain or secondary infection pain, or secondary infection resulting from the thickening and dystrophy of the resulting from the thickening and dystrophy of the infected toenail plate (in the nonambulatory patient)
