December 29, 2006
Medical Review Frequently Asked Questions
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 medical review policy issues. Providers may submit questions to the website at http://www.cignagovernmentservices.com/medicare_dynamic/customer_service/index.html
Nerve Conduction Testing
Question: Can a family practitioner bill for CPT codes 95903 & 95904?
Answer: These codes represent nerve conduction studies (NCS). Generally, a provider can bill any code for services he or she is qualified to perform. That being said there has been increasing utilization of these highly specialized tests due to the availability of equipment that would allow in-office testing generating immediate results.These devices and tests do not conform to the current descriptors of existing CPT codes and should not be billed with 95900, 95903 or 95904. If performed and billed to Medicare, they should be billed with the non-specific CPT code 95999. Regardless of this facilitated testing, it remains that there is a local coverage policy for nerve conduction studies indicating the following:
"Training in the performance of electrodiagnostic procedures, in isolation without awareness and ability to diagnose and manage neuromuscular diseases, is not always adequate for electrodiagnostic consultation. Recognition and experience in the management of disparate diseases that produce common electrodiagnostic findings may be necessary…Without awareness of the disease spectrum, diagnosis solely by EMG-NCV findings may be either wrong or detrimental to the patient.
Additionally, an appropriate provider would not only be one who could use the information from these tests in the diagnosis and management of these patients but is also able to determine in the first place if the patient is appropriate for this type of testing.
Therefore, we do not generally expect billing for nerve conduction studies to be done by non-specialists. Charges for NCS will be monitored and probed if necessary to determine if performed in compliance with local policy. Providers are cautioned to not to bill for these services based solely on having acquired this equipment.
Bilateral Knee Replacement Billing
Question: How are providers supposed to bill for bilateral knee replacements?
Answer: Bilateral knee replacement surgery during the same encounter is considered a procedure subject to bilateral pricing per CMS. Many times the bilateral knee replacements are accomplished by two surgeons who each replace a distinct knee. Even though each surgeon is doing a separate knee, the two surgeons are actually operating as co-surgeons for bilateral knee replacement and should each bill their part with CPT code 27447 with modifiers 50 and 62.
Additionally, according to the Medicare Physicians; Fee Schedule Database, co-surgery for bilateral knee replacement is covered if medically necessary. It is expected the medical records will support the medical necessity for bilateral knee replacement.
Bone Density Testing and Denials
Question: My provider billed a claim for 76075 and 76076 the same date of service, and the 76076 was denied. Why?
Answer: CPT codes 76075 and 76076 are both bone density studies. These codes are used to report services prior to 010107. For services done 010107 and after, CPT codes 76075 and 76076 are to be reported using CPT codes 77080 and 77081 respectively.
The bone density testing represented by codes 76075/77080 is for the measurement of an axial skeleton site whereas 76076/77081 is measurement of a peripheral or appendicular skeleton site. The national coverage for measurement of bone density on qualified individuals is one test every 2 years. We are seeing providers doing both of these studies on the same date which amounts to the every 2 year benefit being exceeded on a single day. In many cases, we have seen providers cite the same diagnosis for both tests which raises further questions as to whether both tests done the same date of service are medically necessary. In the rare incidence that a second bone density test is needed the same date of service due to another having been inconclusive, providers could present these reasons on an appeal basis.
Intervertebral Decompression
Question: Is Intervertebral Differential Dynamics covered? How do I bill for it?
Answer: At this time, Intervertebral Differential Decompression or Intervertebral Differential Dynamics (IDD) is not covered by Part B Medicare. This service is accomplished using equipment such as the Accu-Spina device/DRS,DRX 9000, etc. Providers rendering this service say this procedure is represented by HCPCS code S9090. This code per its description is for "vertebral axial decompression (VAD)." This code though is not valid for billing Medicare. Some providers have asked if this service can be billed with CPT code 97012. CPT code 97012 is an active, i.e. payable, code for Medicare and is used for application of mechanical traction. Other forms of traction are payable by Medicare using this CPT code, but vertebral axial decompression (i.e. IDD) is not. Therefore, when performing VAD/IDD, providers should use CPT Code 97012 + modifier GY. Modifier GY represents a service that is statutorily noncovered, and this is appropriate based on the attached national coverage determination established by the Centers for Medicare and Medicaid Services dealing with this issue/treatment.
Since this service will be denied investigational and become a beneficiary responsibility for payment, we would advise you to clearly inform the patient of this prior to the service.
Port Flushing
Question: How do you bill for flushing of a port when this is the only service during the patient encounter?
Answer: Previously, per an article from the April/May 1997 Medicare Bulletin, we advised providers to bill for a port flush using CPT code 99211. Effective 2006, there is a new code, CPT code 96523, that should be used instead of billing 99211. You would not bill CPT code 96523 if there is a visit or other injection or infusion provided on the same day the port flush would be considered component to these other services. See CMS Manual 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.5, subsection E via the following link for this advice:
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
Foot Care Frequency
Question: How often can foot care be done?
Answer: Generally, routine foot care is excluded from Medicare coverage unless the patient has a systemic condition that prompts for the skills of a professional to safely perform the routine foot care or the patient has mycotic nails that limit his/her ambulation, results in pain or causes secondary infection. (See CMS Publication 100-2, The Medicare Benefit Policy Manual, Chapter 15, section 290 via the following link** for the specific guidelines on coverage of foot care).
The Code of Federal Regulations is the basis for excluding routine foot care from Medicare coverage. The exceptions to this are also detailed here - specifically 42 CFR 411.15 that states exceptions to routine foot care exclusion as follows:
"Treatment of mycotic toenails may be covered if it is furnished no more often than every 60 days or the billing physician documents the need for more frequent treatment"
Therefore, routine foot care more frequently than every 60 days may be subject to medical review to determine if the patient qualifies for coverage and if the frequency of the foot care performed is medically necessary.
