Medical Review Frequently Asked Questions - December 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 posted on the website in July and published in the September 2003 bulletin. Providers may submit questions to the website at http://www.cignamedicare.com/customer_service/disclaimer.html.
- Website Inquiries
Q: Why wasn't my inquiry answered?:
A: : Providers may submit inquiries to our website at the following link:
http://www.cignamedicare.com/medicare_dynamic/customer_service/index.html
Please note Medicare allows the carrier up to 45 days to respond. Depending on the volume and nature of the inquiries, it may take us up to that time frame to research and answer your question. So, it could be your question has not been answered yet rather than it hasn't or won't be answered. Additionally, we have responded to inquiries that are returned to us due to the wrong email address being entered by the inquirer. To ensure your inquiry is answered, please carefully enter your email address to which a response should be sent. Finally, please do not transmit any patient specific information such as a beneficiary's HICN or the Medicare Provider Identification Number as this violates the HIPAA Privacy Rules.
- Anesthesia: 01996 vs. 99231
Q: Which code should be used for postoperative pain management via an epidural catheter?
A: Prior to 2003, all daily hospital management of epidural or subarachnoid continuous drug administration for postoperative pain management was billed using CPT code 01996. This code was revised in 2003 with the CPT manual instructing providers to bill for daily management with CPT code 01996 when the epidural catheter was placed for anesthesia and retained for postoperative pain management. CPT 2003 further instructs providers that daily management of an epidural that was not the method of anesthesia should be billed with an E/M code. Documentation should support the medical necessity and the level of the E&M code billed. The carrier will review claims for these services according to these guidelines for dates of services on or after the effective date of the change in this code. Unless this code and guidelines are further revised, providers should not continue to bill 01996 for daily management of an epidural that was not the method of anesthesia as was the practice for 2002.
- HCPCS code G0275
Q: Has there been a change in the instructions regarding this code
A: The July 2003 issue of the Medicare Bulletin instructs providers that HCPCS code G0275 should be used for select renal arteriography at the time of cardiac catheterization. CMS has since released an update of this code stating that it is for nonselective renal arteriography:
http://www.cms.hhs.gov/manuals/pm_trans/AB03119.pdf
Therefore, providers may bill services as this more recent CMS update instructs rather than as published in the July bulletin.
- Wound Debridement
Q: What's the difference between CPT codes 97601 and the CPT series 11040-11044?
A: Providers should select the appropriate debridement code according to the type of tissue removed. Medical reviews have found that providers are confusing the depth of the wound versus the type of tissue removed when billing for debridement. An example of this would be the beneficiary having a wound extending to the muscular layer, but the provider debrides only infected subcutaneous tissue. This service would be billed with CPT code 11042.
CPT codes 11040 - 11044 clearly describe the type of layer removed. If the debridement service consists of the removal of less defined devitalized (necrotic) tissue that is superficially lining the wound bed, commonly referred to as slough, then the provider should bill 97601. Generally, the performance of services described by CPT codes 11040 - 11044 requires more complex surgical skills, whereas, CPT code 97601 consists of the elimination of superficial debris, for example with a high pressure waterjet, scissors, scalpel, and tweezers. If the wound was only cleansed of exudate/drainage/secretions, then this service does not meet the definition of debridement; and none of the above codes should be billed for such care.
To ensure the debridement codes you file are correct and supported in the medical record, the provider should refer to the local medical review policy for coverage and utilization guidelines (including covered diagnoses and frequency of treatment) as well as document:
- a specific/detailed description of the procedure and method used
- the size, depth(or grade) and appearance of the ulcer or wound
- the type of tissue or material removed
97601 is intended for a single session of wound care that may treat one or more sites, whereas, there could be multiple charges of CPT codes 11040-11044 (corresponding to the number of different wound sites) in a single encounter.
Related LMRPs:
Idaho- http://www.cignamedicare.com/partb/lmrp/id/cms_fu/2002-01.htm
North Carolina- http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/2002-02.htm
Tennessee- http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/2002-01-02.html - Cap on Outpatient Rehabilitation Services
Q: In regards to the annual therapy cap on Medicare patients effective September2003, can providers have a different fee schedule for their Medicare patients?
A: Yes, as long as you do not charge anyone less than you would charge Medicare beneficiaries.
Related CMS Program Memorandum:
http://cms.hhs.gov/manuals/pm_trans/AB03097.pdf
