August 2004 Medicare Bulletin - Tennessee Insert

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2004 Tennessee Ambulance Fee Schedule / Prevaling Rates
Endoluminal Radiofrequency or Laser System Ablation of Varicose Veins - LCD Article
Endoluminal Radiofrequency or Laser System Ablation of Varicose Veins - LCD Conversion
Independent Diagnostice Testing Facility (IDTF) (L6181) - LMRP Revision
Nerve Conduction Studies (NCS) Electomyography (EMG) (L5789) - LMRP Revision
Physical Therapy Services, Part B, Medicare (L11424) - LMRP Revision
Tennessee Mental Health Professional Shortage Areas
Tennessee Health Professional Shortage Areas (HPSAs)
Updated Surgical Add - On Code(s) Listing - Tennnessee

2004 TENNESSEE AMBULANCE FEE SCHEDULE / PREVAILING RATES

PROCEDURE	URBAN RATE	URBAN RATE JULY '04	RURAL RATE	RURAL RATE JULY '04	IIC
A0425	5.65	5.71	.00	5.76	~
A0426M2	196.46	198.43	196.46	200.39	169.97
A0426M4	196.46	198.43	196.46	200.39	154.35
A0427M2	311.06	314.17	311.06	317.28	242.87
A0427M4	311.06	314.17	311.06	317.28	211.42
A0428M2	163.72	165.35	163.72	166.99	138.66
A0428M4	163.72	165.35	163.72	166.99	136.16
A0429M2	261.95	264.57	261.95	267.19	192.85
A0429M4	261.95	264.57	261.95	267.19	137.87
A0430	2269.65	2269.65	3404.48	3404.48	2492.57
A0431	2638.81	2638.81	3958.21	3958.21	1490.20
A0432	286.51	289.37	286.51	292.24	~
A0433M2	450.22	454.72	450.22	459.23	242.87
A0433M4	450.22	454.72	450.22	459.23	211.42
A0434M2	532.08	537.40	532.08	542.72	242.87
A0434M4	532.08	537.40	532.08	542.72	211.42
A0435	6.78	6.78	10.17	10.17	32.00
A0436	18.07	18.07	27.11	27.11	32.00
Q3019	261.95	264.57	261.95	267.19	242.87
Q3020	163.72	165.35	163.72	166.99	169.97
A0382	~	~	~		2.42
A0384	~	~	~		2.26
A0392	~	~	~		9.15
A0394	~	~	~		4.43
A0396	~	~	~		12.11
A0398	~	~	~		2.42
A0422	~	~	~		26.33

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Endoluminal Radiofrequency or Laser System Ablation of Varicose Veins – LCD Article

Historically, varicose veins have been treated by conservative measures, or by sclerotherapy or ligation with or without stripping if conservative measures fail. Recently, endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been developed as alternatives to vein ligation and stripping. Both procedures are designed to damage the intimal wall of the vein, resulting in fibrosis and subsequent obliteration of the lumen of a segment of the vessel. ERFA is performed by means of a specially designed catheter inserted through a small incision in the distal thigh. This catheter is advanced nearly to the saphenofemoral junction, and high frequency radio waves (200 – 300 kHz) are delivered through the catheter electrode, causing direct heating of the vessel wall. This in turn causes the vein to collapse. The catheter is slowly withdrawn, closing the vein. The procedure with a laser device is similar. Laser serves as the energy source.

This policy addresses endoluminal radiofrequency and laser system ablation of varicose veins only. CIGNA Government Services will cover these procedures only when done with FDA approved devices, and these approved devices are used only for their specific FDA approved indications.

Any type of treatment – sclerotherapy, ligation with or without stripping, ERFA, or laser system ablation – of varicose veins for cosmetic reasons is not medically necessary, and not covered.

If both legs are treated, each leg should be reported on a separate line.
If both legs are treated during the same session, the –59 modifier should be used to indicate a separate procedure.
Only one service should be reported for either leg, regardless of how many veins are treated.
This procedure will have a professional and a technical component. The catheter and necessary supplies will be paid in the technical component. If performed in a physician’s office, the global fee will apply. It is assumed that the majority of procedures will be done in the office (POS 11) setting.

Providers should not submit any medical record documentation with the initial claim. Upon receipt of the claim, CIGNA Government Services will solicit additional documentation by means of an Additional Documentation Request (ADR) letter. Providers who qualify for the exception to bill on paper and elect to do so, should insert “ERFA” or “Laser Ablation of Varicose Veins” in Field 19 of Form CMS–1500. Electronic billers should enter “ERFA” or “Laser Ablation of Varicose Veins” in the NTE segment (notes and comment segment). This is the electronic equivalent for Field 19 of Form CMS–1500 in HIPAA compliant EDI claim transactions. (ANSI 4010A1)

Coverage Topic
Surgical Services

Coding Information

Bill Type Codes
999x
Not Applicable

Revenue Codes
99999
Not Applicable

CPT/HCPCS Codes

37799	UNLISTED PROCEDURE, VASCULAR SURGERY
76986	ULTRASONIC GUIDANCE, INTRAOPERATIVE
93965	NON–INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY)
93970	DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY
93971	DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY

Coding Table Information

There is no Coding Table Information for this policy.

Other Information

Other Comments
This Article was converted from an LMRP on 06/25/2004

Related Documents
LCD(s)
L12797 – Endoluminal Radiofrequency or Laser System Ablation of Varicose Veins

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Endoluminal Radiofrequency or Laser System Ablation of Varicose Veins (L12797) – LCD Conversion

Endoluminal Radiofrequency or Laser System Ablation of Varicose Veins (L12797) – LCD Conversion

(04-1079)

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Independent Diagnostic Testing Facility (IDTF) (L6181) – LMRP Revision

(04-1058)

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Nerve Conduction Studies (NCS) Electomyography (EMG) (L5789) - LMRP Revision

Nerve Conduction Studies (NCS) Electomyography (EMG) (L5789) LMRP Revision

(04-1044)

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Physical Therapy Services, Part B, Medicare (L11424) – LMRP Revision

(04-1081)

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Updated Surgical Add-On Code(s) Listing - Tennessee

Certain surgical procedure codes are add-on codes that are always billed with another service. These add-on codes have a ZZZ indicated in the post-operative period. Post-operative work is not included in the fee schedule payment for the ZZZ codes.

Listed below are the surgical add-on codes and their primary procedure codes. Payment will not be made for these add-on codes unless billed in addition to accompanying primary procedure.

CHART FOR ZZZ (ADD-ON) CODES

ZZZ ADD-ON CODE	PRIMARY CODE
G0184	67221
G0236	76090,76091, G0204, G0206
G0241	G0240
G0247	G0245-G0246
G0275	93508, 93510-93511, 93524, 93526-93529, 93531-93533, 93539-93541, 93543-93545
G0278	93508, 93510-93511, 93524, 93526-93529, 93531-93533, 93539-93541, 93543-93545
G0289	29873, 29875, 29880-29889
11001	11000
11101	11100
11201	11200
11732	11730
11922	11921
13102	13101
13122	13121
13133	13132
13153	13152
15001	15000
15101	15100
15121	15120
15201	15200
15221	15220
15241	15240
15261	15260
15343	15342
15351	15350
15401	15400
15787	15786
16036	16035
17003	17000
17310	17304-17307
19001	19000
19126	19125
19291	19290
19295	19102
19340	19140 - 19162 19180 - 19240 19316 - 19318 19357 19364 - 19369 19370 – 19371, 19380
20931	Codes 20930-20938 are reported in addition to codes for the definitive procedure(s) without modifier 51. Report only one bone graft code per operative session
20937	Codes 20930-20938 are reported in addition to codes for the definitive procedure(s) without modifier 51. Report only one bone graft code per operative session
20938	Codes 20930-20938 are reported in addition to codes for the definitive procedure(s) without modifier 51. Report only one bone graft code per operative session
22103	22100 – 22102
22116	22110 – 22112 22114
22216	22210 – 22214
22226	22220 – 22224
22328	22325 – 22327
22522	22520, 22521
22534	22532, 22533
22585	22554 - 22558
22614	22600 – 22612
22632	22630
22840	22325 – 22327 22548 – 22812
22842	22325 – 22327 22548 – 22812
22843	22325 – 22327 22548 – 22812
22844	22325 – 22327 22548 – 22812
22845	22325 – 22327 22548 – 22812
22846	22325 – 22327 22548 – 22812
22847	22325 – 22327 22548 – 22812
22848	22325 – 22327 22548 – 22812
22851	22325 – 22327 22548 – 22812
26125	26123
26861	26860
26863	26862
27358	27355 - 27357
27692	27690 - 27691
31632	31628
31633	31629
32501	32480 – 32484
33141	33400 – 33496, 33510 – 33536
33225	33206-33208, 33212-33214, 33216-33217, 33222, 33233-33235, 33240, 33249
33508	33510-33523
33517	33533 – 33536
33518	33533 – 33536
33519	33533 – 33536
33521	33533 – 33536
33522	33533 – 33536
33523	33533 – 33536
33530	33400 - 33496 33510 - 33536 33863
33572	33510 - 33516 33533 - 33536
33924	33470 – 33475 33600 – 33619 33684 – 33688 33692 – 33697 33735 – 33767 33770 – 33786 33918 – 33922
33961	33960
34808	34800, 34813, 34825, 34826
34813	34812
34826	34825
35390	35301
35400	35201 – 35381, 35585
35500	35501 – 35587
35572	33510-33523, 34502, 34520, 35001-35002, 35011-35022, 35102-35103, 35121-35152, 35231-35256, 35501-35587, 35879-35907
35600	33533 – 33536
35681	List separately in addition to primary procedure
35682	35501 – 35587
35683	35501 – 35587
35685	35656, 35666, 35671
35686	35556, 35566, 35571, 35583-35587, 35623, 35656, 35666, 35671
35697	33877
35700	35556 35566 35571 35583 - 35587 35656,35666 - 35671
36218	36216 or 36217
36248	36246 or 36247
37206	37205
37208	37207
37250	36215 – 36248, 37200 – 37208, 61624, 61626
37251	37250
38102	List separately in addition to primary procedure.
38746	List separately in addition to primary procedure.
38747	List separately in addition to primary procedure.
43635	43631 - 43634
44015	List separately in addition to primary procedure.
44121	44120
44128	44126 – 44127
44139	44140 – 44147
44203	44202
44955 and 47001	When done for indicated purpose at time of other major procedure (not as separate procedure)
44701	44140, 44145, 44150, 44604
47550	47600 – 47620
48400	43260 - 43272
49568	49560 - 49566
49905	List separately in addition to primary procedure.
56606	56605
58611	43020 - 43634 43638 - 44010 44020 - 44120 44125 - 44130 44140 - 44950 44960 - 47000 47010 - 48180 48500 - 49566 49570 - 49900 59510 - 59515
59525	59510 – 59515 59618 – 59622
60512	60500 - 60505
61316	61304, 61312-61313, 61322-61323, 61340, 61570-61571, 61680-61705
61517	61510, 61518
61609 61610	61607 - 61608
61611 61612	61605 - 61606
61795	61304-61692 61700-61711 63001-63091 22100-22328 22548-22851 61855 31254-31256, 31267, 31276, 31287-31288, 31290-31294
61864	61863
61868	61867
62148	62140-62147
62160	61107, 61210, 62220, 62223, 62225, 62230
63035	63020 - 63030
63043	63040
63044	63042
63048	63045 - 63047
63057	63055 - 63056
63066	63064
63076	63075
63078	63077
63082	63081
63086	63085
63088	63087
63091	63090
63103	63101, 63102
63308	63300 - 63307
64472	64470
64476	64475
64480	64479
64484	64483
64623	64622
64627	64626
64727	64702 - 64726
64778	64776
64783	64782
64787	64774 - 64786
64832	64831
64837	64834 - 64836
64859	64856 - 64857
64872	64831 – 64865
64874	64831 – 64872 64876
64876	64831 - 64865
64901	64885 - 64893
64902	64885, 64886, 64895 - 64898
66990	65820, 65875, 65920, 66985-66986, 67038-67040
67225	67221
67320	67311 – 67318
67331	67311 – 67318
67332	67311 – 67318
67334	67311 – 67318
67335	67311 - 67334
67340	67311 – 67320 67331 – 67334
69990	Surgical procedure not excluded in CPT-4 definition of 69990
74301	74300
75774	75600 – 75790, 36215 – 36248
75946	75945
75964	75962
75968	75966
75993	75992
75996	75995
75998	36555-36585
76085	76092, G0202
76125	Xray procedure where dye or Isotope is used
76802	76801
76810	76805
76812	76811
76937	36555-36585
78020	78018
78478	78460 – 78464, 78465
78480	78460 – 78465
78496	78472
87904	87903
88141	88142 - 88154, 88164 – 88167, 88174-88175, G0123, P3000
88155	88142 – 88145, 88150 – 88154, 88164 – 88167
88311 and 88312	List separately in addition to primary procedure.
90472	90471
90781	90780
92547	92541 – 92546
92973	92980, 92982
92974	92980, 92982, 92995, 93508
92978	During therapeutic intervention including imaging supervision, interpretation and report. List separately in addition to code for primary procedure.
92979	92978
92981	92980
92984	92980,92982,92995,G0290
92996	92980,92982,92995
92998	92997
93320	93303 – 93317 93350
93321	93303 – 93317 93350
93325	76825 – 76828 93303 – 93321 93350
93571	92980-92984, 92995-92996, 93508, 93539-93540, 93545, G0290
93572	93571
93609	93620, 93651 - 93652
93613	93620, 93651 – 93652
93621	93620
93622	93620
93623	93620 – 93622
93662	93621, 93622, 93651, 93652
95920	92585, 95925 – 95937, 95822, 95860 95861, 95867, 95868, 95900, 95904
95962	95961
95967	95966
95973	95972
95975	95974
96412	96410
96423	96422
96570	31641, 43228
96571	31641, 43228
97546	97545
99292	99291
99354	99201-99205, 99212-99215, 99241-99245
99355	99354
99356	99221-99223, 99231-99233 99251-99255, 99261-99263, 99301-99303, 99311-99313
99357	99356

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Tennessee Mental Health Professional Shortage Areas (HPSAs)

Designated Geographic Areas

COUNTY	AREA NAME/PARTS	RURAL/URBAN
Bedford	MHCA 19 Bedford	Rural
Benton	MHCA 21 Benton	Rural
Bledsoe	MHCA 12 Bledsoe	Rural
Bradley	MHCA 10 Bradley	Rural
Cannon	MHCA 9 Cannon	Rural
Carroll	MHCA 21 Carroll	Rural
Cheatham	Catchment Area 14 Cheatham	Rural
Chester	MHCA 24 Chester	Rural
Claiborne	MHCA 5 Claiborne	Rural
Clay	MHCA 9 Clay	Rural
Cocke	MHCA 5 Cocke	Rural
Coffee	MHCA 19 Coffee	Rural
Crockett	Catchment Area 22 Crockett	Rural
Cumberland	MHCA 9 Cumberland	Rural
Decatur	MHCA 24 Decatur	Rural
Dekalb	MHCA 9 Dekalb	Rural
Dickson	Catchment Area 14 Dickson	Rural
Dyer	Catchment Area 22 Dyer	Rural
Fayette	MHCA 25 Fayette	Rural
Fentress	MHCA 9 Fentress	Rural
Franklin	MHCA 19 Franklin	Rural
Gibson	MHCA 21 Gibson	Rural
Giles	MHCA 20 Giles	Rural
Grainger	MHCA 5 Grainger	Rural
Greene	MHCA 4 Greene	Rural
Grundy	MHCA 12 Grundy	Rural
Hamblen	MHCA 5 Hamblen	Rural
Hancock	MHCA 4 Hancock	Rural
Hardeman	MHCA 24 Hardeman	Rural
Hardin	MHCA 24 Hardin	Rural
Hawkins	MHCA 4	Rural
Haywood	Catchment Area 23 Haywood	Urban
Henderson	Catchment Area 23 Henderson	Urban
Henry	MHCA 21 Henry	Rural
Hickman	MHCA 20 Hickman	Rural
Houston	Catchment Area 14 Houston	Rural
Humphreys	Catchment Area 14 Humhreys	Rural
Jackson	MHCA 9 Jackson	Rural
Jefferson	MHCA 5 Jefferson	Rural
Lake	Catchment Area 22 Lake	Rural
Lauderdale	MHCA 25 Lauderdale	Rural
Lawerence	MHCA 20 Lawerence	Rural
Lewis	MHCA 20 Lewis	Rural
Lincoln	MHCA 19 Lincoln	Rural
McMinn	MHCA 10 McMinn	Rural
McNairy	MHCA 24 McNairy	Rural
Macon	MHCA 9 Macon	Rural
Madison	Catchment Area 23 Madison	Urban
Marion	MHCA 12 Marion	Rural
Marshall	MHCA 20 Marshall	Rural
Maury	MHCA 20 Maury	Rural
Meigs	MHCA 10 Meigs	Rural
Montgomery	Catchment Area 14 Montgomery	Rural
Moore	MHCA 19 Moore	Rural
Obion	Catchment Area 22 Obion	Rural
Overton	MHCA 9 Overton	Rural
Perry	MHCA 20 Perry	Rural
Pickett	MHCA 9 Pickett	Rural
Polk	MHCA 10 Polk	Rural
Putman	MHCA 9 Putman	Rural
Rhea	MHCA 12 Rhea	Rural
Robertson	Catchment Area 14 Robertson	Rural
Sequatchie	MHCA#12 Sequatchie	Rural
Smith	MHCA 9 Smith	Rural
Stewart	Catchment Area 14 Steware	Rural
Sumner	MHCA 31 Sumner	Urban
Tipton	MHCA 25 Tipton	Rural
Trousdale	MHCA 31 Trousdale	Urban
Union	MHCA 5 Union	Rural
Van Buren	MHCA 9 Van Buren	Rural
Warren	MHCA 9 Warren	Rural
Wayne	MHCA 20 Wayne	Rural
Weakley	Catchment Area 22 Weakley	Rural
White	MHCA 9 White	Rural
Wilson	MHCA 31 Wilson	Urban

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Tennessee Health Professional Shortage Areas (HPSAs)

Designated Geographic Areas

COUNTY	AREA NAME/PARTS	RURAL/URBAN
Anderson	Briceville - Lake City Lake City West City Division New River City Division Lake City East City Division	Urban
Bledsoe	Dayton/Pikeville/Decataur	Rural
Cheatham	All	Rural
Chester¹¹	All	Rural
Claiborne⁸	All	Rural
Crockett⁷	All	Rural
Decatur⁵	All	Rural
Dickson	Vanleer/Shiloh Vanleer CCD	Urban
Fayette	All	Rural
Giles¹²	All	Rural
Grainger⁹	All	Urban
Greene⁵	Baileyton Baileyton CCD Jearoldstown Division	Rural
Grundy	All	Rural
Hamilton	Middle Valley Soddy Daisy Division Middle Valley Division Sale Creek Division	Urban
Hancock	All	Rural
Hardeman	All	Rural
Hawkins	All	Urban
Haywood	All	Rural
Henderson⁹	All	Rural
Hickman	All	Rural
Jackson	All	Rural
Johnson	All	Rural
Knox	Mechanicsville - Census Tracts 1, 2, 3, 4, 5, 6, 7, 11, 12, 13, 14, 20, 28	Urban
Lake⁹	All	Rural
Lauderdale	All	Rural
Lincoln³	Cash Point - Blanche Cash Point/Blanche CCD	Rural
Macon	All	Rural
Madison	East Jackson - Census Tracts 5 and 8-12	Rural
Maury⁷	Fairview/Boston/Santa Fe/Santa Fe Division	Rural
Meigs	Dayton/Pikeville/Decatur	Rural
Montgomery	Vanleer/Shiloh Palmyra/Shiloh CCD	Urban
Moore	All	Rural
Morgan	All	Rural
Obion⁴	Hornbeak/Samburg Hornbeak/Samburg CCD Dixie Division Elbridge-Cloverdale Division	Rural
Perry¹	All	Rural
Pickett	All	Rural
Polk⁸	Benton/Parkville Benton Division Parkville Division	Rural
Rhea	Dayton/Pikeville/Decatur	Rural
Rutherford	Eagleville Eagleville CCD Bethesda/Eagleville	Urban
Unicoi	All	Urban
Union	All	Urban
Van Buren⁷	All	Rural
Wayne²	All	Rural
White⁶	All	Rural
Williamson⁵	Bethesda/Eagleville Bethesda Division/Fairview/Boston/Santa Fe/Fairview Division	Rural

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.

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