Medical Review Frequently Asked Questions - January 2005
Web site posting January 2005 - Revised 12.31.07
Original Article Effective Date: January 31, 2005
Article Revision Effective Date: January 31, 2005
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. Providers may submit questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html.- Use of Mesh in Laparoscopic Ventral Hernia Repairs
- Frequency of Bone Mineral Density Testing
- A woman who has been determined by the physician or a qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings;
- An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture;
- An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 7.5 mg of prednisone, or greater, per day, for more than three months;
- An individual with primary hyperparathyroidism; or
- An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy.
- Hospice Claims
- Treatment of Varicose Veins
- Kyphoplasty for Vertebral Compression Fracture Surgery
Q: What CPT codes are to be used for kyphoplasty of vertebral compression fractures? Can bone biopsies be billed in addition kyphoplasty?
A: Prior to 010106, p roviders were to submit claims with CPT code 22899 (unlisted procedure, spine) and state "Kyphoplasty" in Item 19 of Form CMS-1500 form or in its electronic equivalent. For dates of service 010106 and forward, providers should submit the appropriate code(s) from CPT code series 22523-22525. Radiological supervision and interpretation may be billed as applicable with CPT codes 76012 – 76013 (for dates of service before 010107) or 72291-72292 (for dates of service 010107 forward). CPT codes 22325-22327 (Open treatment and or reduction of vertebral fractures and/or dislocations) are not appropriate to bill for this service and exceed the work performed in a kyphoplasty. Providers should not use these codes for billing kyphoplasty.
Casting or the removal of bone to create a cavity for the insertion of the tamp, sometimes submitted as a bone biopsy (i.e. CPT codes 20225-20251), are not separately billable. Bone biopsy would be considered a payable service if the medical record supported a separate effort and indication beyond the kyphoplasty procedure for osteoporotic compression fractures.
See also:
"Kyphoplasty Update" Web site/bulletin article http://www.cignagovernmentservices.com/partb/pubs/news/2003/1003/cope173.html
Q: How does a provider bill and get paid for this?
A: We can accept the mesh code, 49568, billed in addition to the unlisted laparoscopic procedure code for laparoscopic ventral/hernia repair. Please note in the exceptional circumstance when another hernia repair is done in addition to a laparoscopic or open ventral hernia repair, for example 49505-initial inguinal hernia repair, the mesh code will rebundle. In that scenario, you'd have to bill the unlisted lap procedure with a modifier 22 to receive reimbursement for the mesh.
Q: Long term use of certain medications is a covered indication for more frequent bone mineral density testing. What drugs would this include?
A: First of all, only for qualified individuals is bone mineral density testing a Medicare benefit. CMS defines this as:
Medicare pays for a bone mass measurement meeting the criteria as stated above once every two years (at least 23 months have passed since the month the last bone mass measurement was performed). However, if it is medically necessary, Medicare may pay for a bone mass measurement for a beneficiary more frequently than every two years. This would include monitoring patients on glucocorticoid therapy (e.g. prednisone) of greater than 3mos duration and/or FDA-approved drugs for osteoporosis (i.e. drugs which inhibit osteoclast activity and calcium resorption). Drugs such as calcium, vitamin D, and estrogen replacement therapy would not support the necessity of more frequent BMD testing in qualified individuals as they are neither glucocorticoids nor FDA-approved drugs for osteoporosis.
See also:
NC LCD: http://www.cignamedicare.com/partb/lmrp_lcd/nc/cms_fu/2003-004.html
TN LCD: http://www.cignamedicare.com/partb/lmrp_lcd/tn/cms_fu/97-31-07.html
CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 13, Section 140:
http://www.cms.hhs.gov/manuals/104_claims/clm104c13.pdf
Q: Why would these claims be denied?
A: The reason for any denial might be specific to the particular patient; but in general, the lack of modifiers on hospice claims may be the reason the services are being denied.
When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, who may be a nurse practitioner, not employed by the hospice, in addition to receiving care from hospice-employed physicians. The professional services of a nonhospice affiliated attending physician for the treatment and management of a hospice patient's terminal illness are not considered "hospice services." These attending physician services are billed to the carrier, provided they were not furnished under a payment arrangement with the hospice. The attending physician codes services with the GV modifier "Attending physician not employed or paid under agreement by the patient's hospice provider" when billing his/her professional services furnished for the treatment and management of a hospice patient's terminal condition.
Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider to the FI or carrier for non-hospice Medicare payment. These services are coded with the GW modifier "service not related to the hospice patient's terminal condition."
If another physician covers for a hospice patient's designated attending physician, the services of the substituting physician are billed by the designated attending physician under the reciprocal or locum tenens billing instructions. In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.
See also:
CMS Manual System, Pub 100-4, Chapter 11, Medicare Claims Processing Manual, Sections 10; 40; 50:
http://www.cms.hhs.gov/manuals/104_claims/clm104c11.pdf
Q: What codes are to be used for laser or radiofrequency ablation of varicose veins?
A: Patients must first qualify for coverage by satisfying the criteria outlined in the following Local Coverage Decisions and documented in the patients' medical record. For services prior to 01.01.05, the unlisted CPT code 37799 should be used. Providers may also bill CPT code 76986 * for intraoperative ultrasound. Claim reviews have revealed providers incorrectly billing CPT codes 36011(select catheterization of first order vein) and 75894(embolization radiologic supervision and interpretation) also being billed although the medical records do not support these services. There is neither introduction of a catheter into a first order vein as the code 36011 describes, nor is there embolization of vein being performed as represented by CPT code 75894. For any remaining 2004 endoluminal ablation of varicose veins claims, providers should bill the unlisted code as advised. For any charges of CPT codes 36011 or 75894 billed in error along with treatment of varicose veins, providers should refund these overpayments. Effective 01.01.05, providers may use CPT codes 36475-36476 and 36478-36479 for radiofrequency or laser ablation respectively. These new codes include all imaging guidance and monitoring which renders billing code 76986 no longer necessary for intraoperative ultrasound. Likewise, please note other imaging codes such as 75894 or 76942 rebundle into this service. Finally, the new 2005 codes also include any catheter introduction or establishing vascular access for these procedures. *Note: CPT code 76986 was deleted and replaced with code 76998 effective 010107. All imaging guidance including intraoperative ultrasound remains component to the procedure codes 36475-36479.
Revision 1
Date: February 3, 2005
Revision Explanation: Under item #4 (Treatment of Varicose Veins) the following statement has been corrected: "Effective 01.01.05, providers may use CPT codes 35475-35476 and 35478-35479." The CPT codes have been corrected to read, "use CPT codes 36475-36476 and 36478-36479
Other Versions
