Medical Review Frequently Asked Questions - September 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. The previous issue was published on April 2003 website bulletin. Providers may submit questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html.
- Trigger Point and Tendon Sheath Injections
Q: Are there any restrictions on these codes?:
A: Each of the carrier's three states (ID, NC and TN) have their own respective policies for these CPT codes including diagnosis requirements (see attached links). The most significant issue as far as billing of these services came about with the 2002 change in the CPT codes-especially for trigger point injections. Prior to January 1, 2002, each trigger point injected could be billed using CPT code 20550. After January 1, 2002, billing of trigger points switched from per injection to single or multiple injections per number of muscles (CPT code 20552 for single or multiple injections of one or two muscles vs. CPT code 20553 for single or multiple injections of three or more muscles). Also revised were codes for single or multiple injections tendon sheath or ligament (CPT code 20550) and tendon origin/insertion (CPT code 20551).
Since that time, we have noted that some providers who had been billing multiple trigger point injections along the spine have now moved to billing for multiple tendon origin/insertion codes - same locations/same beneficiaries (previously treated with trigger point injections). For these injections of tendon sheaths/origins/insertions to be medically necessary, there must be an inflammatory process in a given tendon (tendonitis) or tendon sheath tenosynovitis). Unless there is a systemic underlying illness (autoimmune or the like), the inflammation of multiple tendons, tendon sheaths, and muscle insertions - especially along the spine - should be extraordinarily rare.
TN LMRP: http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/9301-01.htm
NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/97-016-03.htm
ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/9900201.htm - Nonselective versus Selective Catheterizations
Q: Why would charges for aortograms or intro of a catheter into an extremity artery (CPT codes 36200 and 36140 respectively) be denied?
A: Per the CPT manual, selective catheterization includes introduction and all lesser order selective catheterization used in the approach to the target vessel. Codes 36200 and 36140 represent nonselective catheterization and, therefore, should not be separately paid from the selective catheterization codes (e.g. CPT codes 36215-36217 and 36245-36247). In other words, nonselective catheterization is component to the more comprehensive selective catheterizations. We have recently discovered that the CCI tables do not reflect all of these bundling pairs. We referred this issue to CCI, and we have learned CMS will add the following column1 code/column 2 code edits: (36215-36217)/36200 and 36245/36140. Therefore, we will be editing for these codes to keep any overpayments from being made.
- Gastric Bypass
Q: Does Medicare cover gastric bypass?
A: Medicare may cover gastric bypass procedures provided the guidelines outlined in the following Coverage Issue Manual and National Coverage Determination references are met. These procedures may be considered medically reasonable and necessary if the patient's obesity is aggravating a condition such as hypertension, asthma, diabetes, etc, and the treatment of the obesity is integral to the treatment of the underlying disease. The medical record should include such supporting documentation as well as the patient's weight and body mass index. CPT codes 43846 and 43847 are to be used for open procedures but laparoscopic procedures should be billed with an unlisted code and submitted with the above supporting documentation.
Related Coverage Issue Manual topics (35-26, 35-33 and 35-40) and National Coverage Determination:
http://www.cms.gov/manuals/06_cim/ci35.asp#_35_26
http://www.cms.gov/manuals/06_cim/ci35.asp#_35_33
http://cms.hhs.gov/manuals/06_cim/ci35.asp#_1_46
http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=35-40&ncd_version=1&show=all - Documentation for ER visits
Q: Can the physician count notes documented by the triage nurse toward the level of service billed?
A: The physician's services are supported by his or her documentation alone. Documentation by hospital staff cannot count towards the level of physician's service billed--be it in the ER or for other visits such as subsequent hospital visits. For example, if a hospital triage nurse documented most of the patient's exam then the physician would only report that level of service equal to the exam he or she performed. Please note ER visits using CPT codes 99281-99285 require the three key components (history, exam and decision-making); and the lower the levels of these components yields a lower level of service to be billed.
Related Bulletin article: November/December 1999 issue of Medicare Bulletin, TN insert "Focused Medical Review of Subsequent Hospital Visits" - Bone Marrow Aspiration and Biopsy
Q: If both a bone marrow aspiration and biopsy are done from the same sites what codes can I bill?
A: The following answer is taken from the National Correct Coding Policy Manual for Part B Carriers (version 8.3): When bone marrow aspiration is performed alone, the appropriate code to report is CPT code 38220. When a bone marrow biopsy is performed, the appropriate code is CPT code 38221 (bone marrow biopsy); this code cannot be reported with CPT code 20220 (bone biopsy). CPT codes 38220 and 38221 may only be reported together if the two procedures are performed at separate sites or at separate patient encounters. When both a bone marrow biopsy (CPT code 38221) and bone marrow aspiration (CPT code 38220) are performed at the same site through the same incision, only the bone marrow biopsy ( CPT 38221) should be reported.
- Monitored Anesthesia Care
Q: I am having trouble getting claims for MAC paid. What could be the problem?
A: First of all, each state has a LMRP for MAC (Monitored Anesthesia Care). Within these policies there are anesthesia codes for which no other documentation is necessary to support the necessity of MAC (column A codes). Column B codes are those that require a diagnosis or physical status indicator supporting the necessity of MAC. Each LMRP has a list of diagnosis codes which support the necessity of MAC (see exhibit A under "ICD-9 codes that support Medical Necessity"). Therefore, column B anesthesia requires an exhibit A diagnosis or an ASA physical status indicator of P3, P4 or P5 indicating that one of the diagnoses in Exhibit A is present. Sometimes providers do not include a physical status indicator or an appropriate diagnosis (such as code is not a covered diagnosis or is longer valid such as it must be coded to a higher level of specificity). These omissions would result in denials.
Modifier QS is used to reflect MAC was done. Modifier G8 is to be used on those anesthesia codes designated by an asterisk in the policy. This modifier indicates that the procedure was deep, complex, complicated or markedly invasive and performed on an area of the body that is very sensitive and includes the face (00100 and 00160), neck (00300), breast (00400), or male genitalia (00920) and for access to the central venous circulation (00532). The MAC modifier G9 is used with a column B procedure code to indicate that the patient has, or has had a severe cardiopulmonary condition or that there is significant risk of an exacerbation in a stable patient during the procedure. It is not necessary to use modifier QS in addition to G8 or G9, nor is it necessary to include a physical status indicator when modifier G8 or G9 is used.
See: TN LMRP http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/9706-02.htm
NC LMRP http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/9706-02.htm
ID LMRP http://www.cignamedicare.com/partb/lmrp/id/id96011.html - Electrical stimulation for other than wound care
Q: Why are my charges for 97014 being denied?
A: 97014 was made an inactive code this year when HCPCS code G0283 (Electrical Stimulation, unattended, to one or more areas, for indication(s) other than wound care, as part of a therapy plan of care) was established by CMS. - Drug Eluting Stents
Q: What codes should be billed for the insertion of drug eluting stents?
A: Providers should use the CPT codes 92980-92981 for stent insertion regardless of whether stents are coated (i.e. "drug-eluting") or not. HCPCS codes G0290/G0291 are new codes for 2003 specifically for drug eluting stents, but these codes were intended for only the HOPPS setting (Hospital Outpatient Prospective Payment System). - Facility Payment for Extracorporeal Shock Wave Therapy
Q: How is pricing assigned for the facility and technical components for these procedures (HCPCS codes 0020T and G0279)?
A: These services are not designated as procedures payable in an ASC. Whenever any of these services are performed in an ambulatory surgical center, only the physician's services can be billed, and this is paid at a nonfacility rate. - Injection Procedures during Cardiac Catheterizations
Q: Are CPT codes 93539-93556 intended to be used per session or per vessel/structure injected?
A: The carrier will interpret and edit for these codes as per session. Should the beneficiary require a return to the catheterization lab the same date of service, then these procedures would be appropriately billed again with modifier 76 appended. A provider may also append the 22 modifier in those cases the provider feels were unusually long or complicated. The latter would require submission of the operative report and modifier 22 explanation form. - Evaluation and Management Visit prior to Screening Colonoscopy
Q: Can a provider bill an E&M visit if a beneficiary is referred for a screening colonoscopy?
A: 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. - Index of Payable Diagnoses per CPT Code
Q: I'd like to know where to find a website that will tell me, when I put in a procedure code, what diagnosis codes are approved for payment thru CMS. All I find is a list of procedures, not one I can input into a database and get results from that.
A: There are certain diagnosis codes that may support medical necessity for certain procedures. These may be listed in the local medical review policies as applicable.
Please note it is not enough to link a procedure code to a correct/payable ICD-9code. The condition must be present for the procedure to be paid.
Related Link: http://www.cignamedicare.com/partb/lmrp/index.html
