Medical Review Frequently Asked Questions - July 2004
Website posting July 2004
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 website at http://www.cignamedicare.com/customer_service/disclaimer.html.
- Diversified Chiropractic Adjustive Techniques
Q: Can chiropractors no longer bill massages that manipulate the spine?
A: In the April 2004 (043004) website posting of Part B Medical Review Frequently Asked Questions, the following statement was included under question #6:
Furthermore, massages (including hydromassages) or any other "diversified adjustive technique" do not meet the definition of manual manipulation and should not be billed using CPT codes 98940-98943.
To clarify, coverage of chiropractor services extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand-held with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device. All other services ordered or furnished by chiropractors (e.g. massages that do not manipulate a spinal subluxation) are not covered.
See CMS Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 30.5: http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf - Enteryx Treatment for GERD
Q: What is the status of Medicare coverage of Enteryx for treatment of gastroesophageal reflux disease?
A: Based on the evaluation of peer reviewed literature and technology assessments, this is considered an investigational service at this present time. Any time providers bill for a service that is statutorily excluded or does not meet the definition of any Medicare benefit, they may append modifier GY. When billing for Enteryx, an unspecified code should be used (as there is no designated code). - Renal Angiography During Cardiac Catheterizations:
Q: What diagnoses would be accepted for medical necessity of renal angiography performed during cardiac catheterization?
A: There is no predefined set of covered diagnoses for selective or nonselective renal angiography when performed during cardiac catheterization. As for all services reimbursed by Medicare, medical reasonableness and necessity by Medicare's criteria must be present and documented in the medical record. The close proximity of the catheter to the renal arteries and the relative ease with which renal arteriograms could be accomplished is not sufficient, even if the patient suffers from a condition that under certain circumstances may require evaluation with renal arteriography. As an example, the mere presence of hypertension does not justify this study, unless the provider has reason to believe and documents in the medical record that the hypertension is renovascular (accelerated course, resistance to treatment, renal artery bruits, and other features of renovascular hypertension). Furthermore, renal angiography is typically not a first-line diagnostic modality.
Providers should code the diagnosis confirmed by the test; and, if no diagnosis is confirmed by the study, then the symptoms and findings the patient demonstrated necessitating the renal angiography should be coded. Therefore, the medical record would need to support the necessity of the test based on the patient's pertinent findings and how it (i.e. renal angiography) will impact the patient's treatment.
The report must be in keeping with the accepted standard of practice. This usually includes an indication, the description of the methodology, a detailed description of the findings, and an opinion.
Additionally, unless the patient's situation during the cardiac catheterization acutely necessitates the performance of a renal arteriogram, it is Medicare's expectation that this test is ordered specifically by the referring physician (if other than the performing cardiologist).
Please see the December 2003 issue of "Frequently Asked Questions" for additional information on renal angiography: http://www.cignamedicare.com/partb/faq/dec03.html - Billing Beneficiaries for NCCI Denials
Q: Can providers bill for services denied due to National Correct Coding Initiative (NCCI) edits?
A: Providers CANNOT bill beneficiaries for services denied based on NCCI edits. These denials are coding denials. They are NOT denials based on statutory exclusions for which a provider may elect to use an NEMB. They are also NOT medical necessity denials for which a provider may use an ABN (Advanced Beneficiary Notice). - The Use of Locum Tenens for Short Term Coverage
Q: Could a practice hire a locum tenens physician to cover for the regular physician on their weekly days off?
A: This situation does not match the locum tenens provision. The locum tenens arrangement is distinct from a temporary coverage situation, when one physician fills in for another for brief periods of time, such as after hours, weekends, vacations, and the like. Generally, the locum tenens physician has temporary contractor status. The arrangement cannot be a permanent employment situation in which the substitute "rotates" by covering for physicians on their weekly days off. This, in effect would constitute permanent employment and the application of the locum tenens rules in scenarios for which they were not designed. Whereas a provider's days off are a regularly recurring event without limit, the need for a "fill-in" physician exceeds the 60 day limit inherent to locum tenens. Therefore, a practice could not hire a "fill-in" physician to cover other doctors' days off and bill the services under the locum tenens provision.
See CMS Publication 100-4, Chapter One, Section 30.2.10-11 for specifics on locum tenens through the following link: http://www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf - Sensory Nerve Conduction Threshold Tests (SNCT) and Nerve
Conduction Studies
Q: In regards to the 033104 "What's New" article and May 2004 bulletin article, what CPT codes does this apply to?
A: The unique code for current perception threshold/sensory nerve testing (SNCT) is G0255. The noncoverage is included in the link to the national coverage determination below: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=160.23&ncd_version=2&basket=ncd%3A160%2E23%3A2%3ASensory+Nerve+Conduction+Threshold+Tests+%28sNCTs%29
Please note it states "...this procedure is different and distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different from short-latency somatosensory evoked potentials. Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for SNCT."
This was also published in the May 2004 bulletin:
http://www.cignamedicare.com/partb/bltin/all/04bltin/04_05/base_may05.html
And in Medlearn Matters:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3339.pdf
What's New Article publication 033104:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM2988.pdf - Virtual Colonoscopy
Q: What is the status of Medicare coverage of virtual colonoscopy
A: At this point and time the Medicare colon cancer screening benefit consists of fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and barium enema, as applicable. Virtual colonoscopy is not included. Also, based on the evaluation of peer reviewed literature and technology assessments, this is currently considered an investigational service. Any time providers bill for a service that is statutorily excluded or does not meet the definition of any Medicare benefit, they may append modifier GY. When billing for a virtual colonoscopy, an unspecified code should be used (as there is no designated code).
