Part B Site LinksJune 27, 2007
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.
Guidelines for X-Stop Device
Question: What are the criteria for coverage of this procedure?
Answer: This procedure is covered for patients ages 50 and above who have a diagnosis of lumbar stenosis and have undergone six months' of nonoperative treatment without improvement. The first level would be billed for using CPT code 0171T. If medically necessary for the individual patient, one additional level may be paid using code 0172T. These claims are carrier-priced; and therefore, each claim is considered on a case-by-case basis. Therefore, if on initial claim submission, if the patient has met the age and diagnosis criteria, providers will be sent a request for documentation to determine if the other criteria have been met.
Guidelines for physician supervised weight loss prior to Bariatric surgery
Question: What documentation is required to be in the chart of patients undergoing weight loss surgery to show they have participated in a supervised weight loss program?
Answer: We would expect that the medical record reflect at least three failed attempts to lose weight on a supervised non-surgical weight loss program of which one of these attempts having been a physician directed program for at least 6 consecutive months (with corresponding monthly notes that included the assessments as follows and as itemized in the each state's local coverage decision):
- Vital signs to include weight
- Current dietary program
- Physical activity/exercise program
- Behavioral interventions
- Consideration of or use of pharmacotherapy with FDA-approved medication, if appropriate
We'd expect that the physician directed program would have recently preceded (i.e. no more than 12-18 months before) the referral to surgical treatment. Please closely review the policy for all requirements:
Therapy recertification & MD visits
Question: Does the patient have to see the doctor every 30 days in order to continue therapy?
Answer: CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3, subsection C, addresses this question under "Physician/NPP options for Certification." It states:
(via this link: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf)
"Physicians/NPPs (non-physician practitioners) may require that the patient make a visit for an examination if, in the professional's judgment, the visit is needed prior to certifying the plan. Physicians/NPPs should indicate their requirement for visits, preferably on an order preceding the treatment, or on the plan of care. Physicians/NPPs should not sign a certification if they require a visit and a visit was not made. However, Medicare does not require a visit unless the National Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-03, §270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds)."
Update on Shingles Vaccination (previously published 092906)
Question: Does Medicare cover Zostavax and its administration?
Answer: Effective January 1, 2007, physicians administering a Part D vaccine should bill to their Part B carrier HCPCS code G0377. Medicare will not pay for the vaccine itself. If the beneficiary is enrolled in Part D, payment for the Part D covered vaccine is made solely by the participating Prescription Drug Plan.
As of January 1, 2008, HCPCS code G0377 can no longer be billed to Part B. At that time, providers will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.
For additional information see the attached CMS articles:
- http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5486.pdf
- http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0723.pdf
Previous FAQ (question #1 September 2007 issue):
Update on sodium hyaluronates (previously published 060106)
Question: Does Medicare cover viscosupplementation treatment of the knee?
Answer: The following link is to an article from January 12, 2007 publishing the most recent guidelines for these services:
Four interim Q codes are in effect for these products as of January 1, 2007, i.e. Q4083 (Hyalgan/supartz injection per does), Q4084 (Synvisc injection per dose), Q4085 (Euflexxa injection per dose), and Q4086 (Orthovisc injection per dose). These replace HCPCS codes J7317 and J7320 referenced in the June 2006 issue of "Frequently Asked Questions." The remainder of the 011207 article details covered diagnoses, guidelines for repeat use, and guidelines for billing an evaluation and management service the same date as the joint injection of one of these drugs.
For additional information see the attached CMS article:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf
Previous FAQ (question #6 June 2006 issue):
