September 29, 2006 - Revised 12.31.07
Medical Review Frequently Asked Questions – September 2006
The following issue has been revised since it was originally published 092906. The correction can be found in the answer to question #6.
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
1. Shingles Vaccination |
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Q: |
Does Medicare cover Zostavax and its administration? | |
A: |
The vaccine for varicella-zoster was approved by the FDA in May 2006, but Medicare Part B will not be paying for this code under CPT code 90736 (or any other code) or for the associated administration fee. Likewise, providers should not bill an evaluation and management service when the patient is only receiving this injection. Providers may be able to be reimbursed by a patient’s Medicare Part D plan, but this would be subject to each individual plan’s guidelines and, again, is not a Part B paid service at this time. Please see the June 2007 Medical Review FAQ for updates to this topic. |
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2. Moderate Sedation Codes |
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Q: |
Does Medicare cover CPT codes 99143-99150 new for 2006? | |
A: |
Based on medical necessity for each individual patient’s circumstances and as documented in the medical record, CPT codes 99148-99150 (moderate sedation services provided by a physician other than the one performing the diagnostic or therapeutic service that the sedation supports, first 30 minutes and each additional 15 minutes) may be paid. In contrast, the codes for moderate sedation provided by the physician performing the diagnostic or therapeutic procedure will not be paid by Medicare Part B. Based on CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 50. A, separate payment for anesthesia performed by the physician who also furnished the medical or surgical service is not allowed as it is considered component to/included in the payment for the medical or surgical service. | |
3. Vitamin B-12 |
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Q: |
What are the coverage guidelines for B-12 injections? | |
A: |
CIGNA Government Services retired the Idaho, Tennessee, and
North Carolina local coverage determinations for B-12 effective
090106. The Centers for Medicaid and Medicare Services still
state in CMS Publication 100-2, the Medicare Benefit Manual,
Chapter 15, section 50 that the use of a drug or biological is "reasonable
and necessary for the diagnosis or treatment of the illness or
injury for which they are administered according to accepted
standards of medical practice." Also, in the same chapter
under section 50.4.3, it states "Medications given for
a purpose other than the treatment of a particular condition,
illness, or injury are not covered (except for certain immunizations). Charges
for medications, e.g., vitamins, given simply for the general
good and welfare of the patient and not as accepted therapies
for a particular illness are excluded from coverage." An
example of accepted standard of practice and covered B-12 therapy
would be the maintenance treatment of pernicious anemia via a
monthly injection. The medical record would also need to support
the diagnosis the drug administration and code for B-12 would
be referenced to, and an evaluation and management visit would
not be indicated unless it was necessary according to the patient’s
need for the provider to perform a separately identifiable service
beyond the assessment related to and customarily performed with
the B-12 administration. See the above information through the
following link: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf  |
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4. Critical Care Denials |
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Q: |
Why do some critical care visits deny? | |
A: |
If critical care is billed the same date of service as a procedure, the services represented by the critical care charges must go above and beyond any evaluation and management efforts normally included in the surgical procedure. When critical care exceeds the work included in the surgery and the patient is critically ill requiring the constant attendance of the physician, providers bill the critical care code(s) with modifier 25. Additionally, the Centers for Medicaid and Medicare Services specifically require for critical care to have a diagnosis different from the diagnosis for a procedure done the same date. Therefore, without an appropriate modifier and different diagnosis reported on the initial claim submission, critical care charges the same date as a procedure will edit to deny. Coverage for critical care and a procedure sharing the same diagnosis might be allowed at the Appeals/Redeterminations level with appropriate documentation submitted. A patient’s medical records should support the different diagnoses used for critical care and a procedure done on the same date of service. See CMS Publication 100-4, the Medicare Claims Processing
Manual, Chapter 12, Section 40.2, subsection A, #9 via the
following link for the information cited above: For critical care occurring postoperatively in the global period of a procedure, the same requirements apply except for the modifier to be used would be modifier 24. |
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5. Cyberknife |
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Q: |
Does Medicare cover this service? | |
A: |
Medicare does cover treatment by cyberknife if medically necessary and within accepted standard of practice. Codes 0082T and 0083T (for services prior to 010107) and 77373 and 77435 (for services 010107 and after) were established to describe daily stereotactic body radiation delivery and treatment of localized tumors or lesions anywhere in the body. Code 0082T is reported for daily treatment delivery and 0083T is reported for daily treatment management. Code 77373 is for treatment delivery per fraction to one or more lesions including image guidance and entire course not to exceed 5 fractions whereas 77435 is for treatment management per treatment course to one of more lesions including image guidance and entire course not to exceed 5 fractions. Stereotactic body radiation management will require additional and different work of the physician to evaluate and personally manage patients undergoing SBRT. This work includes the evaluating of the patient set-up, checking calculations against treatment plans, and managing the patient's general condition before, during, and after SBRT. |
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6. Physical Therapy |
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Q: |
Are cosignatures by physical therapists required on each treatment note written by a physical therapy assistant? | |
A: |
No, notes written by the physical therapy assistant would not have to be cosigned by the physical therapist. Requirements for treatment encounter notes can be found in CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, section 220.3.5, subsection B. See the above via the following link: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf |
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