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May 2003 Part B Medicare Bulletin

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Important Notice to All CIGNA Government Services Providers

Effective May 1, 2003, the CIGNA Government Services Web site - www.cignamedicare.com - will be the official notification medium used for all notices developed and distributed by CIGNA Government Services. The CIGNA Government Services Web site serves as the legal notice to providers and suppliers concerning responsibilities and requirements imposed upon them by Medicare law, regulations, and guidelines. The provider is obligated and responsible for remaining updated on current Medicare issues and legislation as it is posted on the CIGNA Government Services Web site.

The CIGNA Government Services Web site is updated on a daily basis, and time-sensitive information is distributed to providers either by posting it in the “What's New” section of the Web site or via the CIGNA Government Services ListServ (E-Mail Express Notification System). The Medicare Bulletin is published monthly on the CIGNA Government Services Web site. Each quarter, the information that is contained in each of the monthly Medicare Bulletins is compiled and produced in CD-ROM format and mailed to the provider community, unless the provider has requested a paper copy in lieu of the CD-ROM. As with the printed Medicare Bulletin, only one copy will be sent to the same location as Medicare checks. Provider groups will receive one copy of the CD-ROM. Each individual provider in that group will not receive their own copy for his/her individual provider identification number. However, the entire contents of the CD-ROM are available for viewing or for download on the CIGNA Government Services Web site.

The Centers for Medicare & Medicaid Services (CMS) has encouraged CIGNA Government Services, and other carriers, to use the Internet and other electronic media to disseminate information about the Medicare program. CIGNA Government Services will continue to mail the quarterly CD-ROM version of Medicare Bulletin, which includes several other important resources as well. CIGNA Government Services will also make available a printed copy of the Medicare Bulletin in lieu of the CD-ROM to those providers who request it. You can mail or fax your request to:

CIGNA Government Services
Communications Department
Two Vantage Way
Nashville, TN 37228
Fax: 615.782.4445

Please be sure to include your Medicare provider number on the request.

CIGNA Government Services's Local Medical Review Policies (LMRPs) are listed on our Web site, which also serves as the official notification medium for all information related to LMRPs. This includes the initial publication, the publication of revisions, and other pertinent information. In order to allow providers time for access and review, the “Start Date of Notice Period” may not coincide with the date of Internet posting. Generally, the posting date will precede the “Start Date of Notice Period” by several days. Please abide by the date listed as “Start Date of Notice Period” on the document, not the posting date.

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EDI and HIPAA - A Winning Combination!

CIGNA Government Services offers a variety of EDI services for your office! Not only can you send your Medicare claims electronically, you can also check the status of your assigned claims, determine whether a patient is eligible for the Medicare program - even receive your Medicare payments electronically! Plus - you can even receive your Remittance Notice, receipt listings and error reports electronically! Does this sound good to you?

Health care providers who use EDI see improvements in office operations including reduced administrative costs, streamlined cash flow and fewer claim-related errors.

And - EDI makes it easy to submit corrected or rejected claims…electronically. Imagine! No more paper claims!

Combine the power of EDI with the new HIPAA (Health Insurance Portability and Accountability Act) standards and you have a WIN-WIN combination! Why settle for manual preparation and longer payment periods when you can streamline the process and improve your cash flow? Log on to our Web site for details on EDI services, www.cignamedicare.com/edi/Index.html.

While you’re online, don’t forget to register for one of our Medicare workshops. We’ll show you even more benefits of EDI and HIPAA!

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Ambulatory Blood Pressure Monitoring

Section 50-42, Ambulatory Blood Pressure Monitoring, is revised to specify that a physician is required to perform the interpretation of the data obtained through ambulatory blood pressure monitoring, but that there are no requirements regarding the setting in which the interpretation is performed. Everything else in this national coverage determination remains unchanged.

This revision to the Coverage Issues Manual is a national coverage decision (NCD). The NCDs are binding on all Medicare carriers, intermediaries, peer review organizations, health maintenance organizations, competitive medical plans, and health prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on a Medicare+Choice Organization. In addition, an administrative law judge may not review an NCD. (See §1869(f)(1)(A)(i) of the Social Security Act.)

Ambulatory blood pressure monitoring (ABPM) involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM must be performed for at least 24 hours to meet coverage criteria.

ABPM is only covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is defined as

The information obtained by ABPM is necessary in order to determine the appropriate management of the patient. ABPM is not covered for any other uses. In the rare circumstance that ABPM needs to be performed more than once in a patient, the qualifying criteria described above must be met for each subsequent ABPM test.

For those patients that undergo ABPM and have an ambulatory blood pressure of <135/85 with no evidence of end-organ damage, it is likely that their cardiovascular risk is similar to that of normotensives. They should be followed over time. Patients for which ABPM demonstrates a blood pressure of >135/85 may be at increased cardiovascular risk, and a physician may wish to consider antihypertensive therapy. (This NCD last reviewed January 16, 2003) [EM 2003-0264/CR 2625]

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Anesthesia Conversion Factors for 2003

Idaho $15.62
North Carolina $15.99
Tennessee $15.98

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2003 Clinical Laboratory Gap-filled

  Idaho North Carolina Tennessee
82274 $27.12 $27.12 $27.12

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Heart Transplants - Coverage Issues Manual Update

(Effective for services rendered on or after October 17, 1986)

Section 35-87, Heart Transplants, of the Coverage Issues Manual is being updated to reflect the policy regarding the coverage of artificial hearts and ventricular assist devices (VAD) in § 65-15 of this manual.

This revision to the Coverage Issues Manual is a national coverage decision (NCD). NCDs are binding on all Medicare carriers, intermediaries, peer review organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans. Under 42 CFR 422.256 (b), an NCD that expands coverage is also binding on a Medicare+Choice Organization. In addition, an administrative law judge may not review an NCD. (See §1869(f)(1)(A)(i) of the Social Security Act.)

The following paragraph has been added.

F. Artificial Hearts.—Medicare does not cover the use of artificial hearts as a permanent replacement for a human heart or as a temporary life-support system until a human heart becomes available for transplant (often referred to as a “bridge to transplant”). Medicare does cover a ventricular assist device (VAD) when used in conjunction with specific criteria listed in CIM §65-15.

[EM 2003-0309/CR 2481]

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Implementation of the HIPAA Health Care Eligibility Benefit Inquiry and Response (270/271 Version 4010A1) Transaction

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA) administrative simplification provisions, the 270/271 Version 4010A1 transaction set has been named as the Electronic Data Interchange standard for Health Care Eligibility Benefit Inquiry and Response. Medicare will implement the 270/271 Version 4010A1, using either Direct Data Entry (DDE), or TCP/IP, in an interactive, real-time response mode by July 11, 2003. All other EDI formats for this transaction will become obsolete on October 16, 2003.

In the “pre-HIPAA” days, Eligibility Benefit Inquiries were submitted in batch mode, with responses being returned the following day. With the 270/271 Version 4010A1, Trading Partners may submit an eligibility inquiry (270), and receive a response (271) within seconds (a “real-time” response). This feature is expected to generate increased interest in Eligibility Benefit Inquiry and Response software within the Provider community.

In accordance with Medicare security and privacy standards, CIGNA Government Services must have an EDI Enrollment Form on file in order for Providers and their agents to receive eligibility benefit information electronically. Also, an AT&T Network Service Agreement must be on file for network service vendors to receive eligibility benefit information on behalf of their clients. These documents can be found on the EDI portion of CIGNA Government Services's Web site at www.cignamedicare.com/edi.

To assist our electronic trading partner community in understanding the reporting operation of the 270/271 transaction set, a brief summary of the reports that can be generated from this transaction set follows:

Summary of 270/271 Transaction Set Reports

TA1 and/or a 997

271 Response

Miscellaneous

To comply with the requirements set forth by the Centers for Medicare & Medicaid Services (CMS), CIGNA Government Services Electronic Trading Partners should be aware of the following important points regarding the 270/271 transactions:

[EM 2003-0231/CR 2576]

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CMS Introduces a New HIPAA Information Resource

You can now access a new document-on-request service to help you toward HIPAA transactions compliance. Have your fax number handy and call this toll-free number - 800.874.5894. Select option 1 for the starter set - which includes HIPAA information, resources, and transactions checklist - then follow the prompts. The information will then be delivered to you via your fax machine. It's that easy! Other documents are also available; for example, information on Medicare's free billing software, and a HIPAA glossary. Comments and suggestions may be sent to Sharon Vogt at svogt@cms.hhs.gov or 404.562.7377. [EM 2003-0281]

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Hospice Care Enhances Dignity and Peace As Life Nears Its End

Much of the pain and sense of hopelessness that may accompany terminal illness can be eased by services specifically designed to address these needs. Hospice care, a fully reimbursable Medicare Part A benefits option for beneficiaries and providers since 1983, offers the services designed to address the physical and emotional pain through effective palliative treatment when cure is not possible. In the event that a beneficiary has been advised by his/her physician, that a cure for his/her illness is no longer possible, Medicare beneficiaries may discuss hospice care as an option. Physicians and other health care practitioners can be encouraged that the Medicare program includes a hospice benefit that provides coverage for a variety of services and products designed for those with terminal diagnoses. When properly certified and appropriately managed, hospice care is a supportive and valuable covered treatment option.

Physicians and health care providers in the community, skilled nursing facilities, and hospitals are urged to raise awareness among their patients about the hospice benefit and its availability. Further, a beneficiary may independently elect hospice care. The beneficiary may discuss this option in the event that he or she has a terminal diagnosis; however, in all such cases, a physician must certify that the beneficiary has a terminal diagnosis with a six month prognosis, if the illness runs its usual course.

Hospice care that is covered by Medicare is chosen for specified amounts of time known as “election periods.” Essentially, a physician may certify a patient for hospice care coverage for two initial 90-day election periods, followed by an unlimited number of 60-day election periods. Each election period requires that the physician certify a terminal illness. Payment is made for each day of the election period based on one of four per diem rates set by Medicare, commensurate with the level of care.

Generally speaking, the hospice benefit is intended primarily for use by patients whose prognosis is terminal, with six months or less of life expectancy. The Medicare program recognizes that terminal illnesses do not have entirely predictable courses, therefore, the benefit is available for extended periods of time beyond six months provided that proper certification is made at the start of each coverage period.

Recognizing that prognoses can be uncertain and may change, Medicare's benefit is not limited in terms of time. Hospice care is available as long as the patient's prognosis meets the law's six month test.

This test is a general one. As the governing statute says: “The certification of terminal illness of an individual who elects hospice shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.”

CMS recognizes that making medical prognostication of life expectancy is not always an exact science. Thus, physicians need not be concerned. There is no risk to a physician about certifying an individual for hospice care that he or she believes to be terminally ill.

Many physicians appreciate the fact that hospice care enables family and loved ones to participate in the experience and to get help from the hospice in managing their own feelings and reactions to the illness. The value of hospice care is recognized and advanced by many physicians and other health professionals. One professional organization, the American Academy of Hospice and Palliative Medicine (formerly the Academy of Hospice Physicians) focuses its efforts on the “prevention and relief of suffering among patients and families” through palliative therapy, education and counseling. Among the Academy's objectives are to “bring the hospice approach into mainstream medicine and eliminate the dichotomy whereby patients receive either curative or palliative care.”

This distinction is important because despite a growing appreciation for hospice care both as a philosophy and as a fully covered Medicare benefit, there appears to be two perceived barriers to its broader acceptance.
First is an understandable reticence to contemplate the end of life. A 1999 survey conducted by the National Hospice and Palliative Care Organization (NHPCO) found that Americans generally are reticent to discuss hospice care with their elderly parents. According to the survey, less than one in four of us have put into writing how we wish to be cared for at life's end. About one in five have not contemplated the subject at all, and a slightly smaller number told the surveyors they have thought about it but have not shared their thoughts with others.

The second perceived barrier is a lack of knowledge on the part of both patients and practitioners that the covered hospice benefits are both broad and readily available virtually everywhere in the country. As with other covered services, payments for hospice care generally are made to providers based on prospectively-set rates that are updated every year for inflation. Hospice care is primarily a specialized type of home health care, and as is the case with the home health care benefit, hospices are served by regional intermediaries for Medicare billings, payments, cost reports and audits.

Medicare covers a number of specific services as defined in regulation and in the Medicare Hospice Program Manual. Most of these services are familiar to health care professionals and other practitioners who have worked with skilled nursing facilities (SNFs) and home health services. Covered services include:

Hospice care also is covered by Medicaid in many states.

In 1999, 474,270 individuals received hospice care at 2,281 certified hospice programs in the United States. In 2000 there were 2,266 certified hospices. In 2001, approximately 580,000 individuals received hospice care at 2,277 (as of August 2001) certified hospice programs. The hospice setting also is appropriate for patients who suffer from terminal illnesses such as lung disease or end-stage heart ailments, cancer, Alzheimer's disease, and terminally ill AIDS patients. Hospice is not about death, but rather about the quality of life as it nears its end, for all concerned - the patient, family and friends, and the health professional community.

For more information check the Medicare Learning Network at www.cms.gov/medlearn/; or see a related informational brochure on hospice care at: www.medicare.gov/publications/home.asp. [EM 2003-0267/CR 2570]

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Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Wounds of the Lower Extremities - Coverage

Hyperbaric oxygen therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Effective April 1, 2003, a National Coverage Decision expanded the use of Hyperbaric Oxygen (HBO) therapy to include coverage for the treatment of diabetic wounds of the lower extremities in patients who meet the following criteria:

  1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; (ICD-9-CM diagnosis 250.7, 250.8, 707, 707.1, 707.10, 707.12, 707.13, 707.14, and 707.19).
  2. Patient has a wound classified as Wagner grade III or higher; and
  3. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy will be covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient's vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO treatment is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

CMS has concluded that special supervision and credentialing requirements should not be imposed on physicians who perform HBO therapy. CMS encourages physicians who perform HBO therapy to obtain adequate training in the use of HBO therapy and in advanced cardiac life support.

NOTE: Topical application of oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy had not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.

The following HCPCS Code applies:

99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session

Claims Requirements

Follow the general instruction for preparing claims in §2010, Purpose of Health Insurance Claim Form CMS-1500, Medicare Carriers Manual (MCM) Part 4, Chapter 2. Claims for this service should be submitted on health insurance claim Form CMS-1500 or electronic equivalent.

Payment Requirements

Payment and pricing information will be on the April update of the Medicare Physician Fee Schedule Database (MPFSDB). Deductible and coinsurance apply. Claims from physicians or other practitioners where assignment was not taken are subject to the Medicare limiting charge (refer to MCM Part 3, chapter VII, §7555 for more information).

Covered Conditions

Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:

  1. Acute carbon monoxide intoxication, (ICD-9-CM diagnosis 986).
  2. Decompression illness, (ICD-9-CM diagnosis 993.2, 993.3).
  3. Gas embolism, (ICD-9-CM diagnosis 958.0, 999.1).
  4. Gas gangrene, (ICD-9-CM diagnosis 0400).
  5. Acute traumatic peripheral ischemia. HBO therapy is an adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 902.53, 903.01, 903.1, 904.0, 904.41.)
  6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 927.00-927.03, 927.09-927.11, 927.20-927.21, 927.8-927.9, 928.00-928.01, 928.10-928.11, 928.20-928.21, 928.3, 928.8-928.9, 929.0, 929.9, 996.90-996.99.)
  7. Progressive necrotizing infections (necrotizing fasciitis), (ICD-9-CM diagnosis 728.86).
  8. Acute peripheral arterial insufficiency, (ICD-9-CM diagnosis 444.21, 444.22, 444.81).
  9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), (ICD-9-CM diagnosis 996.52; excludes artificial skin graft).
  10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, (ICD-9-CM diagnosis 730.10-730.19).
  11. Osteoradionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 526.89).
  12. Soft tissue radionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 990).
  13. Cyanide poisoning, (ICD-9-CM diagnosis 987.7, 989.0).
  14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment, (ICD-9-CM diagnosis 039.0-039.4, 039.8, 039.9).

Noncovered Conditions

All other indications not specified under §35-10 (A) are not covered under the Medicare program. No program payment may be made for any conditions other than those listed in §35-10(A). No program payment may be made for HBO in the treatment of the following conditions:

  1. Cutaneous, decubitus, and stasis ulcers.
  2. Chronic peripheral vascular insufficiency.
  3. Anaerobic septicemia and infection other than clostridial.
  4. Skin burns (thermal).
  5. Senility.
  6. Myocardial infarction.
  7. Cardiogenic shock.
  8. Sickle cell anemia.
  9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.
  10. Acute or chronic cerebral vascular insufficiency.
  11. Hepatic necrosis.
  12. Aerobic septicemia.
  13. Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease).
  14. Tetanus.
  15. Systemic aerobic infection.
  16. Organ transplantation.
  17. Organ storage.
  18. Pulmonary emphysema.
  19. Exceptional blood loss anemia.
  20. Multiple Sclerosis.
  21. Arthritic Diseases.
  22. Acute cerebral edema.

[EM 2003-0302/CR 2388]

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Denial Messages for Coverage of Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Wounds of the Lower Extremities

This article is to inform providers of the denial messages for Hyperbaric Oxygen (HBO) Therapy. Please refer to 35-10 of the Coverage Issues Manual (CIM) regarding the policy for HBO therapy. In situations, where the claim is being denied on the basis that the condition does not meet our coverage requirements, one of the following MSN Messages will be used:

English: “Medicare does not pay for this item or service for this condition.” MSN Message 16.48

Spanish: “ Medicare no paga por este articulo o servicio para esta afeccion.”

- OR -

English: “This service is not covered prior to April 1, 2003.” MSN Message 16.51

Spanish: “Esta servicio no se cubre antes del 1 de abril de 2003.”

In situations, where upon medical review of the claim based upon the utilization policy, a determination is made that the service is not medically necessary, MSN message, 15.4 will be used.

English: “The information provided does not support the need for this service or item.”

Spanish: “La informacion proporcionada no confirma la necesidad para este servicio o articulo.”

Remittance Advice Notices

Carriers will use appropriate existing remittance advice and reason codes at the line level to express the specific reason when payment is denied for HBO therapy for the treatment of diabetic wounds of the lower extremities. If the services are are denied as furnished before April 1, 2003, existing ANSI X12-835 claim adjustment reason code 26 - “Expenses incurred prior to coverage” will be used at the line level.

[EM 2003-0301/CR 2388]

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Independent Therapists and DME Suppliers Billing for Therapy Services or Supplies That May Be Part of a Home Health Stay

Before you provide therapy services to a Medicare beneficiary, you need to be certain whether or not a home health episode of care exists for that beneficiary, and whether or not an actual home health discharge date exists. This article provides information that will help you determine whether Medicare will pay separately for your service or whether payment for the services is consolidated into Medicare's payment to a home health agency (HHA). Claims consolidated in the HHAs payment will continue to be denied and you will not receive payment! Medicare adjusts claims for services already consolidated into the HHAs payment and will recover your payment for these services. You will receive a remittance advice on any denied claim which will read as follows: reason code B15: Payment adjusted because this procedure/service is not paid separately, and remark code N70: Home health consolidated billing and payment applies.

To help you determine whether the beneficiary is in a home health episode of care, CMS will, in the future, make home health inquiry information available to you electronically, through the Eligibility Benefit Inquiry/Response 270/271 Transaction System. Until and unless you have access to this system, it is your responsibility to simply ask the beneficiary or his/her authorized representative if he/she is presently under a home health plan of care. Payment for the services denied by Medicare may be sought from the beneficiary, but you should advise them of their obligation for payment prior to delivering the service.

Remember, you are responsible for determining if the beneficiary you wish to serve is eligible to receive additional Medicare payment for your services. Services provided to a beneficiary who is not eligible to receive those services because they are already in a home health plan of care, are not payable. [2003-0227/CR 2619]

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Medicare Payments for Part B Mental Health Services

The Office of Inspector General (OIG) recently studied the appropriateness of Medicare Part B payments for mental health services and recommended that we promote provider awareness of the requirements for payment of these services. OIG reports can be accessed at http://www.oig.hhs.gov/oei/oeisearch.html. This article explains Medicare's guidelines for payment of Part B mental health services including qualification requirements for mental health providers; incident to services; reasonable and necessary services; reasonable expectation of improvement; general principles of medical record documentation; documentation guidelines for evaluation and management (E/M) services involving a general psychiatric examination or the single system psychiatric examination; and documentation guidelines for psychiatric diagnostic or evaluative interview procedures, psychiatric therapeutic procedures, central nervous system assessment, and health and behavior assessment.

Qualification Requirements for Mental Health Providers

Providers of mental health services must be qualified to perform the specific mental health services that are billed to Medicare. In order for services to be covered, mental health professionals must be working within their state Scope of Practice Act and licensed or certified to perform mental health services by the state in which the services are performed. Qualification requirements for mental health professionals are listed below.

Incident to Services

Certain nonphysician practitioners such as clinical psychologists, nurse practitioners, clinical nurse specialists, and physician assistants may have services furnished incident to their professional services. To the extent that they are licensed or authorized by the state to furnish mental health services, these practitioners could have others provide some services as an incident to overall mental health services. There is no national policy that specifies the qualifications for individuals who may furnish these incidental services. In the absence of national policy, contractors can implement local medical review policies that determine who can furnish mental health services incident to the professional services of these specific nonphysician practitioners. Therefore, inconsistencies may be found in policy in terms of billing and payment to nonphysician practitioners for incident to mental health services. The requirements found in the Medicare Carriers Manual Part 3, Chapter II, §2050.1 are also applicable to services furnished incident to the professional services of certain nonphysician practitioners.

Refer to the following requirements found on the American Psychological Association's (APA) Web site at http://www.apa.org/practice/medincident.html:

Reasonable and Necessary Services

Section 1862(a)(1)(A) of the Social Security Act states that all Medicare Part B services, including mental health services, must be "reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member." For every service billed, providers must indicate the specific sign, symptom, or patient complaint necessitating the service.

Partial hospitalization programs are structured to provide intensive psychiatric care through active treatment for patients who would otherwise require inpatient psychiatric care. These programs are used to prevent psychiatric hospitalization or shorten an inpatient stay and transition the patient to a less intensive level of care.

Reasonable Expectation of Improvement

Services must be for the purpose of diagnostic study or be reasonably expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization and improve or maintain level of functioning. The goal of a course of therapy is not necessarily restoration of the patient to the level of functioning exhibited prior to the onset of illness, although this may be appropriate for some patients. For many other psychiatric patients, particularly those with long-term, chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Where there is a reasonable expectation that a patient's condition would deteriorate, relapse further, or require hospitalization if treatment services are withdrawn, this criterion would be met.

General Principles of Medical Record Documentation

Medical record documentation is required to record pertinent facts, findings, and observations about a patient's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient, and is an important element contributing to high quality care. It also facilitates:

The general principles of medical record documentation for reporting of medical and surgical services for Medicare payments include the following, if applicable to the specific setting/encounter:

Documentation Guidelines for E/M Services Involving a General Psychiatric Examination or the Single System Psychiatric Examination

Documentation Guidelines for Psychiatric Diagnostic or Evaluative Interview Procedures, Psychiatric Therapeutic Procedures, Central Nervous System Assessment, and Health and Behavior Assessment

[EM 2003-0260/CR 2520; AB-03-037]

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Optical Coherence Biometry (OCB)

OCB is a method of measuring and calculating the intraocular lens power without using ultrasound and without touching the eye.

In the absence of National Policy and a Local Medical Review Policy, CIGNA Government Services will determine coverage case by case, based on Medicare's medical necessity and reasonableness criteria (similar to ophthalmic biometry by ultrasound echography, A-scan with intraocular lens power calculation).

Coding Instructions:

Effective January 1, 2002, a new CPT code 92136 was implemented for Optical Coherence Biometry (OCB). Services prior to this date were submitted under 92499 (unlisted ophthalmological service or procedure), with “Optical Coherence Biometry” in Item 19 of the CMS-1500 form or in the narrative of an electronic claim.

On or after January 1, 2002, when submitting claims for Optical Coherence Biometry (OCB), use CPT code 92136. Medicare will reimburse one technical and two professionals or one global with an additional professional per patient's lifetime. Append modifier RT or LT to indicate the eye.

Example:

When the test with technical and professional is performed on both eyes on same date:

Global Code Units   Components Code Units
92136RT 1 or 92136TC 1
9213626LT 1   9213626LT 1
      9213626RT 1

When the professional component is performed on one eye (left) and then at a later date to the other eye (right):

Global Code Units   Components Code Units
92136LT 1 or 92136TC 1
      9213626LT 1
Later Date:        
9213626RT 1      

NOTE: If you did not purchase the test, check item 20 “no” as this replaced modifier -WJ.

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Percutaneous Image-Guided Breast Biopsy - Coverage and Billing

This article summarizes the addition of §50-59 of the Coverage Issues Manual (CIM) regarding percutaneous image-guided breast biopsy. Refer to this section of the CIM for complete information regarding the policy.

Background

Percutaneous image-guided breast biopsy is a method of obtaining a breast biopsy through a percutaneous incision by employing image guidance systems. Image guidance systems may be either ultrasound or stereotactic.

Coverage

For services furnished on or after January 1, 2003, Medicare will cover percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for the following breast lesions:

Applicable CPT Codes for Percutaneous Image-Guided Breast Biopsy

19102 percutaneous needle core, using imaging guidance
19103 percutaneous automated vacuum assisted or rotating biopsy device, using imaging guidance
10022 fine needle aspiration; with imaging guidance

NOTE: For imagining guidance performed in conjunction with 19102, 19103 see codes 76095, 76096, 76360, 76393, and 76942. [EM 2003-0297/CR 2575]

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Global Surgery - Common Billing Errors Resulting in Denials

Much has been previously published about billing for services with respect to global surgery packages. This article is being written to alert the provider community to some of the common patterns repeatedly seen in these reviews that account for a delay of or incorrect reimbursement. The two most frequently seen problems are 1) billing for services out of sequence/lack of appropriate modifiers and 2) fragmented billing.

Billing for services out of sequence necessitates the use of modifiers to ensure payment. For example, many cases reviewed by the Hearings staff relate to services billed out of sequence that subsequently “hit” global surgery edits. There have been many instances where a service is denied by Batch Exceptions for being a component to a global package, the denial is upheld by Appeals and the provider has to take a case to the hearing level to receive payment he or she feels they duly deserve. It is not until this point that many providers recognize a modifier should have been appended to the service that has not yet been paid. Conversely, providers should not append just any modifier that will elicit payment. The medical record must firmly support the modifier used. The following are examples of common modifier misuse:

  1. Modifier 79 vs. 78 - although both of these modifiers will keep a claim from being denied due to hitting against the global period of a preceding procedure, these modifiers differ in their purpose and reimbursement. The 79 modifier indicates the patient is undergoing an unrelated operation during the global period of a preceding service. No reduction of payment is made for the second service. Reviewers are seeing this modifier being appended to services that do relate to the original service when the patient is actually returning to the OR for treatment of a complication. In cases such as these, modifier 78 would be the appropriate modifier. As established by the Centers for Medicaid & Medicare Services, those services with modifier 78 appended are reimbursed equal to the intraoperative procedure only. Providers who bill modifier 79 when modifier 78 should have been used are billing Medicare incorrectly.
  2. Modifier 76 vs. 78 - modifier 76 should be used if the same exact procedure was repeated on the same date of service as the original surgery. Some providers will use modifier 76 when a surgery is repeated within the global period of the original service. In this instance, modifier 78 should be used instead.
  3. Modifier 58 vs. 78 - modifier 58 is used when a surgery performed during the global period of a preceding procedure was actually planned/anticipated prospectively at the time of the original procedure, is more extensive than the original service, or for therapy following a diagnostic surgical procedure. There has been misuse of modifier 58 when modifier 78 should have been used instead because the beneficiary is returning to the OR during the global period due to complications.
  4. Modifier 24 on postoperative evaluation and management visit during global period of a preceding major surgery—modifier 24 has been incorrectly appended to evaluation and management visits within the global period of a major procedure. A major procedure has global period beginning the day before surgery continuing through 90 days after the surgery for any visits related to the recovery from the surgery. The use of modifier 24 must be sufficiently documented in the patient's medical record that the service was unrelated to the post-operative care of the procedure. Also, providers are reminded that preoperative, postoperative or same day services that fall within the global surgery period will be denied when billed by either the surgeon or a physician of the same specialty who is a member of the same group.
  5. Modifier 25 on an evaluation and management visit same date of service as a minor procedure - this modifier should be used only if a separately identifiable E&M service (above and beyond the usual pre- and postoperative services) is done the same day as a minor (0-10 days global period) surgical procedure.

Providers can refer to the January/February 2000 issue of the Medicare Bulletin for guidelines regarding modifier usage. Again, use of an incorrect modifier will delay payment of claims, as the determination of the appropriateness of a modifier by the medical review staff is a time consuming process. Providers should not append whatever modifier that will prompt payment. Reviewers will determine the appropriateness of the modifiers used and if the documentation in the medical record supports the services billed.

Fragmented billing is separately submitting charges for procedures performed the same date of service. Multiple surgeries performed the same date of service may take on a multiple procedure reduction as determined by the multiple procedure or endoscopy indicators established by the Centers for Medicaid and Medicare Services. Frequently, providers will submit a claim for a higher valued procedure after a lesser valued procedure has already been billed and paid. According to multiple procedure/endoscopy pricing, the reimbursement for the lesser value procedure would need to be adjusted to recoup the overpayment. To avoid this, providers should submit all procedures performed on the same date of service on the same CMS-1500 claim form.

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Global Period Modifiers

The Medicare Physician Fee Schedule Database (MPFSDB) provides the post-operative periods that apply to each procedure. Post-operative periods apply to some procedures that may not be considered surgical procedures. The payment rules for global surgery apply to codes with entries of 000, 010, 090, and YYY in the global period on the MPFSDB. Codes with 000 and 010 post-operative periods are either minor procedures or endoscopies; codes with a 090 post-operative period are major surgeries; codes with YYY are carrier-priced codes and the carrier determines the global period.

The Medicare approved amount for services subject to global surgery rules includes payment for services related to the procedure when billed by the surgeon or a physician in the same group as the surgeon with the same specialty. Services which are not related to the procedure must be documented with the appropriate modifier. The CMS instructions for use of the modifiers may differ from the CPT definition. Medicare guidelines in this article should be used when determining the appropriate modifier to document services during the global period of a procedure performed on a Medicare beneficiary.

The global period for a major procedure starts on the day before the procedure, includes the day of the procedure, and ends with the 90-day post operative period immediately following the procedure. The global period for a minor procedure with a 10-day post operative period includes the day the procedure was performed, and the 10-day post operative period immediately following the procedure. The global period for a minor procedure with a 000-day postoperative period includes the day of the procedure only.

When the carrier assigns a 000, 010, 090 global period to a procedure designated YYY, the global period rules are the same. The rules and modifiers for global surgery do not apply only to services by the surgeon. They also apply to services billed by members of the same group who have the same specialty and are providing services to the beneficiary.

A complete list of procedure codes and their global periods as identified in the MPFSDB can be requested from the Freedom of Information Unit in Tennessee by writing to:

Idaho North Carolina Tennessee
CIGNA Government Services CIGNA Government Services CIGNA Government Services
Freedom of Information Freedom of Information Freedom of Information
P.O. Box 22599 P.O. Box 671 P.O. Box 1465
Nashville, TN 37202 Nashville, TN 37202 Nashville, TN 37202

Global Surgery Modifiers for Evaluation & Management (E/M) Services

Modifier Description/Usage
22

Unusual procedural service

  • Surgeries for which services performed are significantly greater than usually required may be billed with the 22 modifier.
  • The 22 modifier is billed with the CPT code for the procedure performed.
  • Services billed with the 22 modifier must be sufficiently documented to support the service furnished was significantly greater than usually required (range of complexity, length, risk, and difficulty associated with each procedure). The supporting documentation must be submitted on a separate form and accompanied by a CMS-1500 claim form and operative notes.
  • Modifier 22 should not be routinely used on all surgical procedures.
  • Additional reimbursement can only be considered when the exceptional nature of the service(s) provided is adequately documented.
  • If an adequate explanation is not documented or received, the payment will be based on the regular Medicare fee schedule.
  • Nonparticipating physicians transmitting/submitting nonassigned claims need to monitor the remittance form and make adjustments or refunds as needed in order to meet the limiting charge requirements.
24

Unrelated E/M service during the post operative period

  • The physician may need to indicate that an unrelated E/M service was performed during the post-operative period.
  • The 24 modifier is billed with the appropriate level of E/M service.
  • Services submitted with the 24 modifier must be sufficiently documented in the patient's medical record that the visit was unrelated to the post-operative care of the procedure. An ICD-9 CM code that clearly indicates that the reason for the encounter was unrelated to post-operative care of the surgery may provide sufficient documentation.
  • The 24 modifier may be used when furnishing an E/M service that is exclusively for treatment of the underlying condition and not for post-operative care. This situation must be thoroughly documented. Apply modifier 24 to the unrelated E/M services beginning the day after a
    procedure.
  • The 24 modifier may not be used to document an unrelated E/M service the same day as a procedure.
25

Significant, separately identifiable E/M services on the same day of a minor procedure

  • The physician may need to indicate that on the same day of a minor procedure, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual pre-operative and post-operative care associated with the procedure or service that was performed.
  • The 25 modifier is billed with the appropriate level of E/M service.
  • When a significant, separately identifiable E/M service on the day of a minor procedure falls within the post-operative period of another unrelated procedure, both 24 and 25 modifiers are necessary to document the service as payable.
  • Modifier 25 should not be used on the E/M service when it is a new patient visit.
  • Carriers will monitor the use of modifier 25 and deny payment if billed incorrectly.
53

Discontinued procedure

  • A physician may start a surgical or diagnostic procedure and determine that due to extenuating circumstances, or those that threaten the well being of the patient, to discontinue the procedure.
  • Claims for procedures that are discontinued or attempted may be billed with the 53 modifier.
  • The 53 modifier is billed with the CPT code for the service furnished.
  • Services billed with 53 modifier are subject to carrier medical review and are priced by individual consideration. Additional documentation will be requested in order to process these claims.
57

E/M service resulting in the initial decision to perform major surgery

  • An E/M service on the day before or day of major surgery that results in the decision to perform the surgery is not included in the global surgery payment and may be billed separately. Apply modifier 57 to the appropriate E/M code.
  • The 57 modifier is not used in connection with minor procedures.
  • When an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another unrelated procedure, the E/M service must be billed with both the 24 and 57 modifiers.
  • Do not report modifier 57 with an E/M service if the surgery was preplanned or prescheduled.

Modifiers Used for Services Billed During a Global Period

The use of the following modifiers are related to services billed during a global period.

Modifier Description/Usage
54

Surgical care only

  • The surgeon identifies the surgical service with a 54 modifier when all or part of the postoperative care is relinquished to a physician who is not a member of the same group.
  • The 54 modifier is billed with the CPT codes that describe the service furnished.
  • The 54 modifier is used only with procedure codes that include 010 or 090 global period on the MPFSDB. Modifier 54 should not be appended to E/M services.
  • The CMS definition of the surgeon's portion of the 54 modifier includes reimbursement of all preoperative care, the intraoperative surgical service, and all hospital postoperative care. This definition of the 54 modifier differs from the CPT use of this modifier.
  • Transfer of care must be documented in the patient 's record.
55

Post-operative care

  • The surgeon who furnished a portion of the outpatient postoperative care and the physician who furnished the remaining postoperative management services bill with the 55 modifier.
  • The 55 modifier may be billed only for procedure codes with 010 or 090 global period on the MPFSDB. Modifier 55 should not be appended to E/M services.
  • The date of service for the procedure billed with modifier 55 should be the date of surgery.
  • Enter the “assumed” and “relinquished” dates in the narrative field of an electronic claim or in Item 19 of a paper claim. Report units of service as one.
  • Transfer of care must be documented in the patient's record.
  • The receiving physician cannot bill for any part of the postoperative care until he/she has provided at least one service.
  • Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.
58

Staged or related procedure during the post-operative period

  • Modifier 58 is used to permit payment for a surgical procedure during the postoperative period of another surgical procedure because the subsequent procedure:
    • Was planned prospectively at the time of the original procedure (we would expect to see documentation in the records); or
    • Was more extensive that the original procedure; or
    • Was for therapy following a diagnostic surgical procedure.
  • Modifier 58 is billed with the CPT code that best describes the subsequent procedure performed.
  • A new global period begins with each new procedure. Modifier 58 should only be used to document claims for services with 000, 010, 090, or YYY global period on the MPFSDB.
  • Modifier 58 is not used to report the treatment of a problem that requires a return to the operating room.
  • The existence of modifier 58 does not negate the global fee concept. Services which are included in CPT as multiple sessions or are otherwise defined as including multiple services or events may not be billed with the modifier (i.e., CPT codes 67141-67228).
78

Return to the operating room for a related procedure during the post-operative period

  • A physician may need to indicate that during the postoperative period, another procedure, requiring return to the operating room, was performed to treat complications.
  • The 78 modifier is billed with the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the unspecified procedure code in the correct series should be used.
  • The procedure code for the original procedure is not used except when the identical procedure is repeated for complications.
  • Reimbursement for modifier 78 is the intraoperative percentage only.
  • The 78 modifier may be used to document treatment of complications only. The CPT definition for this modifier does not limit its use to treatment for complications.
  • The 78 modifier may be used when the service is furnished in an operating room(OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. It includes a cardiac catheterization suite, a laser suite, or an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room,or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR).
79

Unrelated procedure during a post-operative period

  • the physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the postoperative care of the original procedure.
  • The 79 modifier is billed with the CPT code that describes the procedure performed.
  • Modifier 79 may be used with all procedure codes except those indicated as XXX on the MPFSDB.
  • The 79 modifier should be used only on services during the postoperative period starting with day after the procedure.
  • If the procedure is related to the original procedure performed, modifier 79 should not be billed. Modifier 78 should be billed.

Modifiers add information to the procedure code to enhance the Medicare claim pricing and processing. It is the billing provider's responsibility to include the appropriate modifiers on the claims when and where applicable. Inappropriate use and/or repeated omission of the appropriate modifiers may be interpreted as an attempt to defraud the Medicare program. Omission of a required modifier may result in the denial of the billed service and a request to rebill the service with the accurate information. The beneficiary may not be charged for these denied services.

When billing for multiple same, similar and repeat procedures on the same day, it is essential to include the appropriate modifier to prevent claim processing delays, denials as duplicates or billing errors. When these denials occur, the services should be rebilled with the appropriate information (modifier). If a review of the service is requested, the provider should submit medical necessity documentation (reports, description, reasons for repeating the procedure, etc.).

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Program Integrity Manual Update

The Program Integrity Manual (PIM) is available only on the Internet in HTML format. Notifications will be included in the Medicare Bulletin anytime there is an update to the PIM.

The Internet address for the PIM is: http://cms.hhs.gov/manuals/108_pim/pim83toc.asp.

Chapter Revised Sections New Sections Deleted Sections Description
3 4     Overview of Prepayment and Postpayment Review for MR Purposes
  4.1     Determinations Made During Prepayment and Postpayment MR
  4.1.1     Documentation Specifications for Areas Selected for Prepayment or Postpayment MR
  4.1.2     Additional Documentation Request (ADR) During Prepayment of Postpayment MR
  4.1.4     Handling Late Documentation
  4.2     Denials
  4.3     Documenting That a Claim Should Be Denied
  4.6     Spreading Workload Evenly
  4.8     Review That Involves Utilization Parameters
  5     Prepayment Review of claims for MR Purposes
      5.3 Documentation Specifications for Areas Selected for MR
      5.3.1 Laboratory Claims
      5.3.2 Documentation for Non Physician Claims
      5.3.3 Development of Claims for Additional Documentation
  6.1     Postpayment Review Case Selection
  6.2     Location of Postpayment Reviews
  6.3     Re-adjudication of Claims
  6.4     Calculation of the Correct Payment Amount and Subsequent Over/Under payment
  6.6     Provider(s) Rebuttal(s) of Findings
      7 Appeal of Denials

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Medical Review Frequently Asked Questions - Correction

The HCPCS code for digitization of mammography images was incorrectly printed as G0263 on page 21 of the April, 2003 Medicare Bulletin, in the “Medical Review Frequently Asked Questions.” The correct HCPCS code is G0236. We apologize for any inconvenience this may have caused.

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2nd Quarter 2003 Update to the Part B Not Otherwise Classified Drug Pricing File

Effective 04-01-2003
Include Name of Drug and Dosage Given in Block 19 (paper) or Narrative Field (EMC)

DRUG NAME DOSAGE 95% AWP Previous
Acyclovir Sodium (Zovirax) Covered if given IV for initial and recurrent mucosal and cutaneous HSV1 and HSV2 and varicella-zoster (shingles) in immunocompromised patients. ICD-9 Code(s) 052.0 - 054.9. 50 mg/ml  2.10 34.20 /  500 mg
Alefacept (Amevive) Covered DX = 696.1 7.5 mg 665.00  
Alefacept (Amevive) Covered DX = 696.1 15 mg 945.25  
Alemtuzumab (Campath) Effective 01/01/2003 new code J9010 per 10mg 30mg/3ml SDV 1,533.66 1533.66
Amikacin Sulfate (Amikin)   50 mg 3.22 15.44
Aztreonam (Azactam) 500 mg 8.94 8.94
Bacitracin 50,000 U 10.39 8.55
Bretylium Tosylate (Bretylol) 500 mg 24.12 12.08
Bumetadine (Bumex) 0.5 mg/2ml 1.33 1.46
Bupivacaine Hcl, 0.5%, 2 ml  (Considered part of other service(s)) 2 ml 0.23 0.23
Bupivacaine Hcl, 0.25%, 2 ml  (Considered part of other service(s)) 2 ml 0.15 N/A
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 76005, or 96530. When billed with other procedures, considered part of procedure performed. 0.25%/10ml 1.95 3.92
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 76005, or 96530. When billed with other procedures, considered part of procedure performed. 0.50%/10ml 2.21 3.92
Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 76005, or 96530. When billed with other procedures, considered part of procedure performed. 0.75%/10ml 2.48 3.92
Buprenorphine Hcl. (Buprenex) Effective 01/01/2003 new code J0592 per .1mg 0.3 mg 2.54 2.54
Butorphanol Tartrate IV/IM, (Stadol  IV/IM) Allowed separately when administered in the Dr.'s office and no surgical procedures are billed. 2 mg 7.11 6.82
Butorphanol Tartrate IV/IM, (Stadol  IV/IM) Allowed separately when administered in the Dr.'s office and no surgical procedures are billed. 20 mg 65.65 65.65
Calcium Chloride 100 mg/ml 0.14 0.08
*Caspofungin Acetate J9999 (Cancidas) Effective 01/01/2003 new code J0637 per 5 mg. Covered ICD-9 = 117.3 50 mg 342.00 342.00
*Caspofungin Acetate J9999 (Cancidas)  Effective 01/01/2003 new code J0637 per 5 mg.  Covered ICD-9 = 117.3 70 mg 440.56 440.56
Cefoperazone Sodium  (Cefobid) 1 gram 16.38 16.60
Cefotetan Disodium (Cefotan) 1 gram 10.60 10.60
Cimetidine Hcl.(Tagamet) Covered when given on same day as J0207, J1440, J1441, J2355, J2430, J2820, J3305, J3487, or Chemotherapy Drugs J9000-J9999. 150 mg 1.42 1.42
Cimetidine Hcl.(Tagamet) Covered when given on same day as J0207, J1440, J1441, J2355, J2430, J2820, J3305, J3487, or Chemotherapy Drugs J9000-J9999 300 mg 2.96 2.96
Clindamycin Phosphate (Cleocin) 300 mg 3.56 3.23
Cytarabine Liposome (Depocyt) J9999 Covered for ICD-9 198.4 10 mg 371.45 371.45
Darbepoetin Alpha (Aranesp) (For 2003 dates of service use code J0880 per 5mcg) 2002 dates of service use code J3490 Covered indications = (1)CRF/ESRD (585) with secondary DX of  285.21, 285.8, or 285.9. (2) Chemotherapy (V58.1) with secondary DX of 285.8 or 285.9.) per 1 mcg 4.74 4.74
Denileukin Difitox, Ontak (For 300 mcg, see J9160) 150 mcg 605.15 605.15
Diltiazem Hcl. (Cardizem IV) 5 mg 1.94 1.34
Dopamine Hcl. (Intropine, Dopostat) 40 mg 1.02 1.08
Doxycycline Hyclate 100 mg 14.01 17.95
Edrophonium Chloride (Tensilon) (Allow for ICD9-358.0) 10 mg 0.65 0.65
Enalaprilat (Vasotec IV) 1.25 mg 5.36 14.54
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office 500,000 IU/ 1ml 32.06 28.85
Ertapenem Sodium (Invanz) 1 gram 45.31 45.31
Esmolol Hcl. (Brevibloc) Covered when administered in the doctor office or ambulance. Covered  ICD-9 = 427.89 10 mg/ml 2.10 1.85
Estradiol Pellets Per Pellet Invoice Invoice
Ethracrynate Sodium (Edecrin Sodium) 50 mg 22.61 21.57
Etoposide Phosphate (Etopophus) J9999 covered diagnoses = 151.0-151.9, 155.0, 155.2, 160.0-160.9, 162.0-162.9, 170.0-171.9, 173.0-176.9, 182.0-183.9, 186.0-186.9, 188.0-189.9, 190.5, 191.0-191.9, 194.0-195.8, 200.00 to 207.01, 236.1. 100mg 117.93 117.93
Famotidine (Pepcid) Covered when given on same day as J0207, J1440, J1441, J2355, J2430, J2820, J3305, J3487, or Chemotherapy Drugs J9000 - J9999. 10 mg 0.40 1.24
Flumazenil (Mazicon, Romazicon) 0.1 mg/ml 2.39 1.92
Fulvestrant (Faslodex) J9999 Covered DX's 174.0 through 175.9. 50 mg 175.16 175.16
Gatifloxacin (Tequin) 200 mg 18.15 17.18
Glycopyrolate (Robinul) 0.2mg 0.11 0.06
Hetastarch Sodium Cl., 500 ml 500 ml 35.31 35.31
Inamrinone Lactate 5 mg 4.05 4.03
Ketamine Hcl. (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368 or 96530. 50 mg/ml 0.73 1.48
Ketorolac Tromethamine (See Code J1885 with instructions) 30 mg 6.03 6.03
Ketorolac Tromethamine (See Code J1885 with instructions) 60 mg 6.34 6.34
Labetalol Hcl (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses. 20 mg 1.00 2.28
Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 62310, 62311, 62318, 62319, 62368, 76005, or 96530. 2.5 mg/ml 0.31 0.31
Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't ta