November 2004 Medicare Bulletin - Tennessee Insert

Posted November 3, 2004

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2005 ICD-9 Code Udpate
Local Coverage Determinations (LCDs) - Formerly Local Medical Review Policies (LMRPs)
Tennessee Health Professional Shortage Areas
Tennessee Mental Health Professional Shortage Areas
Tennessee Updated Surgical Add-On Code(s) Listing

Local Coverage Determinations (LCDs) – Formerly Local Medical Review Policies (LMRPs)

A “Local Coverage Determination” (LCD), as established by section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary).

The final rule establishing LCDs was published 11/07/2003. Effective 12/07/2003, CMS’s contractors began issuing LCDs instead of LMRPs. Additionally, over the next 2 years contractors will convert all existing LMRPs into LCDs. Until the conversion is complete the term LCD will refer to both stand-alone LCDs and the “reasonable and necessary” provisions of an LMRP. For a listing of LCDs/LMRPs, you may access these on the Internet at: http://www.cignamedicare.com/medicare_dynamic/clickwrap/clickwrap.asp?url=tnpolicies

LCD Reconsideration Process
Contractors who have the task of developing LCDs shall have an LCD Reconsideration Process in accordance with the following instructions.

Purpose:
The LCD Reconsideration Process is a mechanism by which interested parties can request a revision to an LCD.

Background:
The LCD Reconsideration Process is available only for final LCDs. The whole LCD or any provision of the LCD may be reconsidered. Section 522 of The Benefits Improvement and Protection Act (BIPA), created the term “local coverage determination” (LCD). Until the conversion of all existing LMRPs into LCDs is complete, the term LCD refers to both:

Reasonable and necessary provisions of an LMRP; and
An LCD that contains only reasonable and necessary language.

Valid LCD Reconsideration Request Requirements

LCD reconsideration requests will be considered from:

Beneficiaries residing or receiving care in CIGNA’s jurisdiction;
Providers doing business in CIGNA’s jurisdiction;
Any interested party doing business in CIGNA’s jurisdiction.

CIGNA will only accept reconsideration requests for LCDs published in final form. Requests will not be accepted for other documents including:

National Coverage Decisions (NCD);
Coverage provisions in interpretive manuals;
Draft LCDs;
Template LCDs, unless or until they are adopted by CIGNA;
Retired LCDs;
Individual claim determinations;
Bulletins, articles, training materials; and
Any instance in which no LCD exists, i.e., requests for development of an LCD.

If modification of the LCD would conflict with an NCD, the request would not be valid. For these requests, CIGNA suggests that the requestor review the NCD reconsideration process according to the CMS Manual System, Pub 100-8, Medicare Program Integrity, Chapter 13, Section 13.1.1, (http://www.cms.hhs.gov/manuals/).

Requests shall be submitted in writing, and must identify the language that the requestor wants added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD’s content or basis. Copies of published evidence must be included.

The level of evidence required for LCD reconsideration is the same as that required for new LCD development. (PIM Chapter 13, Section 13.7.1)

There are several ways you can send CIGNA your LCD Reconsideration requests:

By U.S. Postal Service:

Eugene J. Winter, M.D.
Carrier Medical Director
CIGNA Government Services
Two Vantage Way
Nashville, TN 37228

By e-mail: eugene.winter@cigna.com

By fax: 615.782.4480

Within 30 days of the day the request is received, CIGNA will determine if the request is valid or invalid. Any request for LCD reconsideration that, in the judgment of CIGNA, does not meet the criteria described above, is invalid.
If the request is valid:

Within 90 days of the day the request was received, CIGNA will make a final LCD reconsideration decision on the valid request and notify the requestor of the decision with CIGNA’s rationale. Decision options include retiring the policy, no revision, revision to a more restrictive policy, or revision to a less restrictive policy.
If the decision is to revise the LCD, CIGNA will follow the normal process for LCD development.

CIGNA will consolidate valid requests, if similar requests are received.

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2005 ICD-9 Code Update

Numerous CIGNA Local Medical Review Policies/Local Coverage Determinations (LMRPs/LCDs) have been revised to reflect the ICD-9 Code updates for 2005. Only the changes that meet the medical necessity criteria of the respective policies were incorporated.

Those may include:
Removal of ICD-9 “root” codes as a result of code expansions to additional digits.

Changes in code descriptions
Changes to the ICD-9 coding system became effective on October 1, 2004. To view these policies, go to the CIGNA Government Services website at http://www.cignamedicare.com/partb/lmrp_lcd/tn/index.html

Chest X-Ray (L6097) LMRP Revision
Debridement of Ulcers and Wounds (L6082) - LCD Revision
Diagnostic and Therapeutic Esophagogastroduodenoscopy (EGD) (L6167) - LMRP Revision
Diagnostic Nasal/Sinus Endoscopy (L12829) - LCD Revision
Electrocardiogram (L6416) - LMRP Revision
Imaging of the Brain: MRI (L6121) - LMRP Revision
Measurement of Bone Density (L5803) - LMRP Revision
Monitored Anesthesia Care (MAC) (L6665) - LMRP Revision
Nerve Conduction Studies (NCS) Electomyography (EMG) L5789) - LMRP Revision
Pelvic Echography (L6067) - LMRP Revision
Physical Therapy Services, Part B, Medicare (L11424) - LMRP Revision
Psychiatry and Psychology Services (L6224) - LMRP Revision
Select Anesthesia Services (Ocular and Oral Procedures (l6267) - LMRP Revision
Syphilis Test (L6381) - LMRP Revision

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Updated Surgical Add-On Code(s) Listing

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
76082	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 – 2232 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, 35566, 35556
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	34800-34805, 34825, 34830, 34832, 35081-35103
35700	35556 35566 35571 35583 - 35587 35656,35666 - 35671
36218	36216 or 36217
36248	36246 or 36247
37206	37205
37208	37207
Added/Updated 37250	Added/Updated 36215 – 36248, 37200 – 37208, 61624, 61626, 34800-34826
37251	37250, 34800-34826
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 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
Added/Updated 76937	Added/Updated 36555-36585, 36481, 36000, 36012, 36245, 36005, 36620, 36011, 36500
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/Bledsoe	Rural
Cheatham	All	Rural
Chester³	All	Rural
Claiborne¹	All	Rural
Crockett	All	Rural
Decatur	All	Rural
Dickson	Vanleer/Shiloh Vanleer CCD	Urban
Fayette	All	Urban
Giles⁴	All	Rural
Grainger²	All	Urban
Greene	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
Henderson²	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
Lake²	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
Maury	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
Obion	Hornbeak/Samburg Hornbeak/Samburg CCD Dixie Division Elbridge-Cloverdale Division	Rural
Perry	All	Rural
Pickett	All	Rural
Polk¹	Benton/Parkville Benton Division Parkville Division	Rural
Rhea	Dayton/Pikeville/Decatur/Rhea	Rural
Rutherford	Eagleville Eagleville CCD Bethesda/Eagleville	Urban
Unicoi	All	Urban
Union	All	Urban
Van Buren	All	Rural
Williamson	Bethesda/Eagleville Bethesda Division/Fairview/Boston/Santa Fe/Fairview Division /Boston Division	Rural

¹ Classified as a HPSA, effective March 1, 2002.
² No longer classified as a HPSA, effective March 1, 2002.
³ Classified as a HPSA, effective June 1, 2002.
⁴ Classified as a HPSA, effective February 1, 2004.

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