Medical Review Frequently Asked Questions - April 2003
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 www.cignamedicare.com/customer_service/disclaimer.html.
- Digitization of Mammography Images
Q: Why did charges for digitization of mammograms deny?
A: : Digitization of mammography images is billed using either HCPCS code G0263 or CPT code 76085. G0263 should be billed with diagnostic mammograms (CPT codes 76090 or 76091) whereas 76085 should be billed for digitization of screening mammograms (CPT code 76092). Claims for digitization will deny if the codes do not correspond as to whether a screening or diagnostic service was performed. In other words 76085, digitization of screening mammography, will deny if billed with 76090, a diagnostic unilateral mammogram. Please note 76085 was revised in 2003 from the 2002 descriptor which specifically included the term "screening." Even though the code was revised, it is still the appropriate code for digitization of screening mammography.
Related Bulletin Article: See January/February 2002 issue of Medicare Bulletin.
- Low Osmolar Contrast Material for Intrathecal Procedures
Q: Low osmolar contrast was used in the performance of an intrathecal procedure? Why would it be denied?
A: In accordance with national policy, separate payment is made for Low Osmolar Contrast Material (HCPCS codes A4644, A4645, and A4646) in the case of all medically necessary intrathecal radiologic procedures furnished to nonhospital patients. To expedite payment, providers must bill the intrathecal procedure and low osmolar contrast material on the same claim.
Related LMRP: See TN 96-03-02.
- Billing for Pachymetry
Q: We have been advised by a professional association to bill CPT code 92135 for pachymetry, but there is also code 0025T. Which is correct?
A: CPT code 92135 is for optical laser scan for glaucoma which is not the same as pachymetry. Pachymetry measures the thickness of the cornea and should be billed using CPT code 0025T (*).
Related bulletin article/LMRP: (*) See March 2003 Medicare Bulletin on Pachymetry.
- Billing GY Modifier on Covered Laboratory Services
Q: A covered lab test was denied by Medicare. Upon appeal by the patient, Medicare upheld the original denial making the patient responsible for payment. Why?
A: This happens when modifier "GY" is used inappropriately - namely in situations when a denial based on medical necessity might occur. Please note that modifier "GY" is reserved for statutorily nonpayable/noncovered services. Its use in other scenarios incorrectly assigns liability to the beneficiary and represents inappropriate billing. Providers are cautioned to use this modifier when appropriate and not in situations where the test is medically necessary.
- Diskography Radiology Charges
Q: Charges by the hospital's radiologist for diskography (see CPT code 72295 corresponding to 62290) were denied/recouped. Why?
A: Radiologic supervision and interpretation of diskography is typically done by the surgeon injecting the disk, but could be provided by a radiologist present in the operating room during the procedure. Some facilities have been performing "over-reads" of the images made intraoperatively by the surgeon then submitting charges to Medicare for professional interpretation. Subsequently, Medicare has been billed for two sets of radiologic supervision and interpretation of diskography. Medicare will pay only one provider per date of service for these charges. It is incumbent upon the providers to coordinate who is performing the service and how this will be billed.
- Consultations preceding screening services
Q: Can a consultation be done on beneficiaries in need of screening services, for example, a patient undergoing a screening colonoscopy?
A: A referral that does not ask for advice or opinion and only asks for a screening procedure to be done does not meet the requirement for a consult.
For example, a provider preparing to perform a screening colonoscopy cannot also bill for a pre-procedure visit to determine the suitability of the patient for the colonoscopy. These E/M services, to include consultations, are not separately payable. While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. Although no separate payment can be made for these visits currently, the fee schedule payment for all procedures, including colonoscopy, contains payment for the usual pre-procedure work associated with it. This reflects the principle that each procedure has an evaluative component.
See: AMA CPT 2003, TN LMRP 96-05-1.
- Multiple Level Laminectomies
Q: For a 2001 date of service, the provider performed multiple level re-do laminectomies billed using CPT code 63042 for each level treated. Payment was originally made then, later, some payment was recouped. Why?
A: As of January 1, 2001, additional levels of re-do laminectomies were to be billed using CPT code 63044 instead of 63042. The latter code is intended only for the initial level treated. In the above scenario, the provider was billing 63042 for each level treated which resulted in an overpayment as the reimbursement (as set by the Centers for Medicare & Medicaid Services) for 63042 is much greater than that for 63044.See: a related article this bulletin issue (April 2003) addressing billing for bilateral laminectomies of the same intervertebral space.
- Benign Lesion Removal
Q: I am a North Carolina provider, and I am having trouble getting my claim for benign lesion removal paid. Why?
A:The North Carolina local medical review policy for removal of benign lesions was revised late 2002. Diagnoses for warts and seborrheic keratoses and sebaceous cysts were added, but providers were instructed modifiers would be necessary for payment. Removal of benign lesions including the above types would be considered cosmetic unless there was medical necessity for removal as evidenced by the presence of one or more of the following: - The lesion has one or more of the following characteristics: 1) bleeding; 2) intense itching; 3) pain.
- The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema, etc.
- The lesion obstructs an orifice or clinically restricts vision.
- There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance.
- The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.
- Wart removals will be covered under the guidelines above. In addition, wart destructions will be covered when any one of the following clinical circumstances is present: 1) periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding; 2) warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients.
If the qualifying criteria have been met, then providers should bill for these services with the KX modifier. If none of the above criteria were met, then the lesion removal would be considered cosmetic, and the beneficiary would be responsible. No claim would have to be filed unless the beneficiary requested. In that case, providers should bill these services either with modifier "GY" or "GA."
Related bulletin article/LMRP: See December 2002 issue of Medicare Bulletin (NC insert); NC LMRP 96-001-04
