March 31, 2008
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 through our Online Inquiry System.
Percutaneous Tibial Nerve Stimulation (PTNS) for treatment of Overactive Bladder
Question: How should this be billed?
Answer: Our research shows PTNS is an alternative to sacral nerve stimulation, but PTNS is still investigational. Therefore, Medicare would not cover this service. Providers have reported they have been advised to code this with CPT code 64555, percutaneous implantation of neurostimulator electrodes, peripheral nerve. Since CPT code 64555 does not involve ''implantation'' but simply the insertion of an electrode for temporary stimulation, providers should instead bill CPT code 64999. Claims for this will be denied as lack of medical necessity with provider liability unless the patient is informed prior to the service and signs an appropriate ABN assuming responsibility for payment of the service.
“Incident To” and Smoking and Tobacco Cessation
Question: For the new CPT Codes 99406 and 99407 can a RN or LPN provide the counseling for this code or does a Nurse Practitioner or Physician have to provide the counseling?
Answer: The billing physician or nurse practitioner/physician assistant performing "incident to" visits should provide and document the counseling--not a RN or LPN. Additionally, they must document the time spent doing this in order to justify the code they billed and distinguish it as a service separate from an E&M visit if one billed the same day.
The following CMS MLN Matters article announces that the 2008 Medicare Physician Fee Database (MPFSDB) included two new CPT codes for smoking and tobacco use cessation counseling services; replacing the temporary HCPCS G codes (G0375 and G0376) previously used for billing these services:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5878.pdf
Hospice Election Evaluation
Question: Does Part B pay for a consult for Hospice consideration?
Answer: A Hospice-Pre-Election Evaluation and Counseling Service should not be billed as a consult to Part B Medicare, but it should be billed to the fiscal intermediary/Part A using code HCPCS code G0337 if performed consistent with the guidelines from CMS Publication 100-4, the Medicare Claims Processing Manual , chapter 11, section 80 (accessible via the following link: http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf).
Palliative Care
Question: Does Medicare cover?
Answer: Medicare may cover this service if it is medically necessary and does not duplicate what an attending/treating physician or other provider has already done nor duplicates care that is part of what a facility (e.g. a nursing facility) or Hospice should already be providing for its residents/patients.
Observation Care
Question: If a doctor gives orders over the phone to admit a patient to observation but does not see the patient till the next day and then decides to discharge the patient, what code would be billed?
Answer: In this example, the doctor neither admitted the patient on the actual date of admission nor did a true "admission and discharge” service the same date of service as represented by CPT codes 99234-99236. These codes include an admission, keeping a record of observations/assessments performed by the physician, and discharge. In this example, the doctor made only one evaluative visit and decided to discharge the patient. The provider may bill a code from the series 99218-99220 if his/her documentation meets the code’s descriptor. A discharge visit (99217) should not be billed.
See MLN Matters articles # 5793 and 5791 for appropriate coding of other observation status scenarios via the following links:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5793.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5791.pdf
Implantable Cardiac Defibrillators
Question: Which coverage policy do we use to allow payment for Implantable Cardiac Defibrillators (ICD) CPT code 33249?
Answer: NCD 20.4 is guidance for the Automatic Implantable Cardiac Defibrillator (ICD). There is also an MLN Matters article MM4273 that specifically states what diagnosis codes are payable for this service when not performed as part of a clinical trial. LCDs L11585-NC, L12193-ID, and L6853-TN are for Resynchronization Therapy for Congestive Heart Failure (Biventricular Pacing) and also include CPT code 33249. The information in the MLN Matters article does not apply to these. This CPT code can be used for either service. However, because an NCD always supersedes an LCD follow the guidance of the NCD and the associated MLN Matters Article in billing for this service .
