July 2004 Medicare Bulletin - Tennessee Insert
Download a PDF copy
of this issue 
Table of Contents
- 2004 2nd Quarter MPFSDB Updated
- Alefacept Therapy - LCD Article
- Alefacept Therapy (L12842) - LCD
- Diagnostic Nasal/Sinus Endoscopy - LCD Article
- Diagnostice Nasal/Sinus Endoscopy (L12829) - LCD
- Lumbosacral Spine X-Rays (L6640) - LMRP Revison
- Nerve Conduction Studies (NCS) Electomyography (EMG) (L5789) - LMRP Revision
- Tennessee Mental Health Professional Shortage Areas
- Tennessee Health Professional Shortage Areas (HPSAs)
2004 2ND QUARTER MPFSDB UPDATED CALCULATIONS FOR TENNESSEE EFFECTIVE JULY 1, 2004
| CODE | PAR | NONPAR | LIMITING CHG | |
| G0321 | NONFAC/FAC | $441.16 | $419.10 | $481.97 |
| G0322 | NONFAC/FAC | $386.21 | $366.90 | $421.93 |
| G0329 | NONFAC/FAC | $8.18 | $7.77 | $8.94 |
| 31629 | NONFAC | $586.16 | $556.85 | $640.38 |
| 31629 | FACILITY | $205.09 | $194.84 | $224.06 |
| 61863 | NONFAC/FAC | $1,214.27 | $1,153.56 | $1,326.59 |
| 61867 | NONFAC/FAC | $1,885.30 | $1,791.04 | $2,059.70 |
| 78804 | NONFAC/FAC | $433.15 | $411.49 | $473.22 |
| 78804tc | NONFAC/FAC | $379.86 | $360.87 | $415.00 |
| 88358 | NONFAC/FAC | $58.63 | $55.70 | $64.05 |
| 8835826 | NONFAC/FAC | $52.33 | $49.71 | $57.17 |
| 88358tc | NONFAC/FAC | $6.30 | $5.99 | $6.88 |
| 95144 | NONFAC/FAC | $8.85 | $8.41 | $9.67 |
(04-0958)
TopLMRP for Lumbosacral Spine X-Rays (L6640) - Revision
Lumbosacral Spine X-Rays (L6640) - LMRP Revision
(04-0919)
LMRP for Nerve Conduction Studies (NCS) Electomyography (EMG) (L5789) - Revision
Nerve Conduction Studies (NCS) Electomyography (EMG) (L5789) - LMRP Revision
(04-0927)
Diagnostic Nasal/Sinus Endoscopy - LCD Article
Diagnostic nasal/sinus endoscopy uses a flexible or rigid fiberoptic telescope to thoroughly examine the paranasal sinus openings that drain into the nose. The anatomic region being studied extends from the nostrils to the posterior edge of the soft palate. The endoscope may have an angled view ranging from 0 to 70 degrees, depending upon the structures being examined. Nasal/sinus endoscopy also examines structures in the nasal cavity, such as the nasal septum, turbinates, and the floor of the nose. Diagnostic nasal endoscopy is sometimes performed prior to surgical sinusotomy or other corrective surgical procedures.
- Use CPT procedure code 31231 to report a diagnostic nasal endoscopy when studying the area extending from the nostril to the posterior edge of the soft palate.
- Do not use CPT procedure code 31231 to report a diagnostic endoscopy of the nasopharynx. CPT procedure code 92511 should be used when studying the area extending from the posterior edge of the soft palate to the nasopharyngeal wall, including the Eustachian tube openings.
- Nasal/sinus endoscopy is payable only in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), emergency room (23), skilled nursing facility (31), and ambulatory surgical center (physician service only)(24).
- Nasopharyngoscopy ( 92511) and cauterization or packing for nasal hemorrage ( 30901, 30903 or 30905) are not separately payable on the same day as a diagnostic nasal/sinus endoscopy when performed by the same physician (Correct Coding Initiative).
- When a surgical sinus endoscopy is reported, it includes a sinusotomy and a diagnostic endoscopy. Therefore, when both are performed at the same session by the same provider, only one sinus endoscopy code (the surgical sinus endoscopy service) is reported to encompass both of these services (Correct Coding Initiative).
- When billed with other surgeries on the same day, multiple surgery rules apply.
- Do not use the bilateral modifier 50 with this procedure. The code description indicates the procedure is for both bilateral and unilateral services.
- An evaluation and management (E&M) code is not separately payable on the same day as a diagnostic nasal/sinus endoscopy unless a separately identifiable service is provided and documented. In this case, it would be appropriate to attach modifier -25 to the E&M code.
- Anytime a diagnostic nasal/sinus endoscopy evaluation is performed, all areas are inspected, but a separate code should not be reported for each area visulized.
- Use ICD-9-CM diagnosis code V82.9 (special screening for other conditions, unspecified condition) when reporting a diagnostic nasal/sinus endoscopy in absence of signs, symptoms, or complaints.
For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier must provide the patient with an acceptable advance notice of Medicare’s possible denial of payment and a waiver of liability should thus be signed when a provider/supplier does not want to accept the financial responsibility of the service.
Coverage Topic
Diagnostic Tests and X-Rays
Coding Information
Bill Type Codes
999x
Not Applicable
Revenue Codes
99999
Not Applicable
CPT/HCPCS Codes
31231 NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)
Coding Table Information
There is no Coding Table Information for this policy.
Other Information
Other Comments
This Article was converted from an LMRP on 04/21/2004
Related Documents
LCD(s)
L12829 - Diagnostic Nasal/Sinus Endoscopy
(04-0934)
Diagnostic Nasal/Sinus Endoscopy (L12829) - LCD
Diagnostic Nasal/Sinus Endoscopy (L12829) - LCD
(04-0934)
Alefacept Therapy - LCD Article
Psoriasis is a chronic immune-mediated disease of the skin affecting an estimated 2% of the population. It has been treated with topical, photo and systemic therapies. The topical therapies include corticosteroids, anthralin and tars, calcipotriene, tazarotene and salicylic acid. Phototherapies have generally involved UVA or UVB, but now also includes laser therapy for localized lesions. Systemic therapies include use of drugs such as methotrexate, cyclosporine, retinoids and now alefacept. Some of the therapies are used in combination so as to minimize toxicities while maximizing response, or as rotational therapy.
Alefacept is a human fusion protein directed at T-cells expressing the CD2 antigen, preventing lymphocyte activation. These lymphocytes are involved in the inflammatory process in psoriatic lesions. The drug is administered intramuscularly or intravenously weekly for 12 weeks. Because alefacept may reduce circulating CD4+ and CD8+ T-lymphocytes, weekly CD4+ tests are required for monitoring while administering the drug. Alefacept has been approved by the FDA for treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy.
Alefacept is administered as an intramuscular injection of 15mg, or as an intravenous bolus injection of 7.5mg over five (5) seconds.
Psoriasis severity is categorized by body surface area (National Psoriasis Foundation) as:
- Mild: covers less than 2% of the body
- Moderate: covers 2-10% of the body
- Severe: covers more than 10% of the body
Psoriasis of the palms can be severe even though the percentage of the body surface area covered may be small.
- The guidelines of the Correct Coding Initiative supersede all coding instructions in this policy.
- The alefacept should be coded using the HCPCS code J0215 with a unit of services of one (1). Enter “Alefacept,” along with the dose of the drug and the route administered, into item #19 of the CMS-1500 form, or its electronic equivalent.
- Administration of the alefacept should be coded with CPT code 90782 (“Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular”) or 90784 (“Therapeutic, prophylactic or diagnostic injection (specify material injected); intravenous”).
- Administration codes will not be reimbursed if an E&M service is billed on the same day.
- An E&M service appropriate for the service performed in evaluating the patient, and consistent with the level of care provided, may be billed if it is a significant, separately identifiable service from the administration of the alefacept.
- Acceptable places of service for billing these services to the Part B Carrier are:
J0215, 90782(if no E&M service is billed), or 90784 (if no E&M service is billed) are payable in POS 11. These codes are not payable in POS 21 & 22.
- For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier must provide the patient with an acceptable advance notice of Medicare’s possible denial of payment. An advance beneficiary notice (ABN) should be signed when a provider/supplier does not want to accept financial responsibility for the service.
Coverage Topic
Prescription Drugs
Coding Information
Bill Type Codes
999x
Not Applicable
Revenue Codes
99999
Not Applicable
CPT/HCPCS Codes
J0215 INJECTION, ALEFACEPT, 0.5 MG
Coding Table Information
There is no Coding Table Information for this policy.
Other Information
Other Comments
This Article was converted from an LMRP on 04/21/2004
Related Documents
LCD(s)
L12842 - Alefacept Therapy
(04-0935)
Alefacept Therapy (L12842) - LCD
Alefacept Therapy (L12842) - LCD
(04-0935)
Tennessee Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
(04-1026)
Tennessee Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 Classified as a HPSA, effective March 1, 2001.
2 No longer classified as a HPSA, effective January 1, 2001.
3 No longer classified as a HPSA, effective July 1, 2001.
4 Classified as a HPSA, effective July 1, 2001.
5 Classified as a HPSA, effective September 1, 2001.
6 No longer classified as a HPSA, effective February 1, 2001.
7 Classified as a HPSA, effective December 1, 2001.
8 Classified as a HPSA, effective March 1, 2002.
9 No longer classified as a HPSA, effective March 1, 2002.
10 Classified as a HPSA, effective April 1, 2002.
11 Classified as a HPSA, effective June 1, 2002.
12 Classified as a HPSA, effective February 1, 2004.
(04-1077)
