March 29, 2007 - Revised 12.31.07
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
Optometry Visits in a Nursing Facility
Question: Can optometrists bill subsequent nursing facility CPT codes 99307-99310?
Answer: Optometrists may bill these codes if they are able to meet the individual code requirements. This type of evaluation and management visit requires that two of the three key components be met in order to bill the code. Being able to meet the requirements for the higher level codes within this series would be unlikely for optometrists considering their scope of practice, i.e. what they can assess, diagnose and treat. Rather than billing evaluation and management visits, the services optometrists render may be best represented by the codes under "General Ophthalmological Services" such as CPT codes 92012 or 92014.
Related to this question is the expectation that if a beneficiary in a nursing facility requires the services of an optometrist, the attending physician is first notified to evaluate the need and give the order for the service before it is rendered. Additionally, optometrists should not bill E&M visits for routine screening exams or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, or procedures performed (during the course of any eye examination) to determine the refractive state of the eyes as these are noncovered by Medicare as stated in the Social Security Act 1862 (a)(7).
Removal of Excess Skin after Bariatric Surgery
Question: Will Medicare cover lipectomies after bariatric surgery?
Answer: Medicare does not pay for cosmetic surgery as it is excluded from coverage under §l862(a)(l0) of the Social Security Act. After bariatric surgery weight loss, some patients may develop skin breakdown under excess skin. If this skin breakdown has not responded to conservative measures and is significant enough to merit surgery, Medicare may cover what would otherwise consider cosmetic; but the medical record documentation would need to clearly support the medical necessity including the progression to surgical treatment. Otherwise, lipectomies to shape or contour the body would be considered cosmetic and not covered by Medicare.
Post-operative Pain Management
Question: Can a pain management specialist visit a patient post-operatively?
Answer: Post-operative pain management is considered part of the global surgery package paid to the operating surgeon. We would expect the medical necessity of a pain management specialist beyond the operating surgeon’s global care to be rare. Additionally, the medical record would need to demonstrate the services of the pain management specialist did not merely replace the expected post-operative pain management by the operating surgeon.
Please see the 112107 article for additional information.
Anticoagulant Management
Question: Will Medicare cover the codes for monitoring and management of anticoagulant therapy?
Answer: CPT codes 99363 and 99364 are new for 2007, but they are currently not separately paid. These are considered bundled into payment for other services the same date of service. See question #4 under the April 2004 "Frequently Asked Questions" via the following link for guidelines on billing CPT 99211 in relation to patient visits for anticoagulation management:
http://www.cignagovernmentservices.com/partb/help/faqs/mr/04_04.html
