February 2005 Medicare Bulletin - Tennessee Insert
Posted February 2, 2005
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Table of Contents
- 2005 Tennessee Ambulance Fee Schedule / Prevailing Rates
- Azacitidine for Injectable Suspension (Vidaza TM) (L18069) - LCD
- Azacitidine for Injectable Suspension (Vidaza TM) - LCD Comment/Response Document
- Tennessee Health Professional Shortage Areas
- Tennessee Mental Health Professional Shortage Areas
- Virtual Colonoscopy (CT Colonography) (L18631) - LCD
Top
2005 TENNESSEE AMBULANCE FEE SCHEDULE / PREVAILING RATES
PROCEDURE |
URBAN RATE |
RURAL RATE |
IIC |
| A0425 | 5.90 | 5.96 | |
| A0426M2 | 203.43 | 205.45 | 175.58 |
| A0426M4 | 203.43 | 205.45 | 159.44 |
| A0427M2 | 322.10 | 325.29 | 250.88 |
| A0427M4 | 322.10 | 325.29 | 218.40 |
| A0428M2 | 169.53 | 171.20 | 143.24 |
| A0428M4 | 169.53 | 171.20 | 140.65 |
| A0429M2 | 271.24 | 273.93 | 199.21 |
| A0429M4 | 271.24 | 273.93 | 142.42 |
| A0430 | 2332.21 | 3498.32 | 2574.82 |
| A0431 | 2711.54 | 4067.30 | 1539.38 |
| A0432 | 296.67 | 299.61 | |
| A0433M2 | 466.20 | 470.81 | 250.88 |
| A0433M4 | 466.20 | 470.81 | 218.40 |
| A0434M2 | 550.96 | 556.41 | 250.88 |
| A0434M4 | 550.96 | 556.41 | 218.40 |
| A0435 | 7.00 | 10.50 | 33.06 |
| A0436 | 18.67 | 28.01 | 33.06 |
| Q3019 | 271.24 | 273.93 | 218.40 |
| Q3020 | 169.53 | 171.20 | 159.44 |
| A0382 | 2.50 | ||
| A0384 | 2.33 | ||
| A0392 | 9.45 | ||
| A0394 | 4.58 | ||
| A0396 | 12.51 | ||
| A0398 | 2.50 | ||
| A0422 | 27.20 |
Azacitidine for Injectable Suspension (Vidaza TM) (L18069) - LCD
Azacitidine for Injectable Suspension (Vidaza TM) (L18069) - LCD
Azacitidine for Injectable Suspension (Vidaza TM) - LCD Comment/Response Document
| Policy Title: | Azacitidine for Injectable Suspension (Vidaza TM) |
| Open Forum Presentation: | October 12, 2004 |
| CAC Meeting Presentation: | October 19, 2004 |
| End of Comment Period: | November 12, 2004 |
| Start of Notice Period: | December 15, 2004 |
| Policy Effective Date: | January 30, 2005 |
Comment: The criteria defining adequate response to therapy are too stringent and would limit access to care for patients who would still benefit even at a lower level of response.
Response: Adequate response was redefined as monolineage or bilineage response with 50% restoration of the initial deficit to a lower level of normal in either red blood cells, neutrophils/ANC, or platelets, or a decrease in transfusion requirement to less than 50% of baseline.
Comment: Some patients may require more than four cycles of therapy to achieve a response.
Response: This was increased to six cycles.
Comment: CPT code 205.10 does not specifically describe chronic myelomonocytic leukemia and should be eliminated from the policy.
Response: This code will be removed from the policy. ICD-9 coding will be limited to ICD-9 code 238.7 which represents the myelodysplastic syndrome and its manifestations, and chronic myelomonocytic leukemia is one of them.
Comment: ICD-9 code 205.0, acute myeloid leukemia, should be added to the ICD-9 codes that support medical necessity.
Response: Currently, the threshold of evidence for this has not been reached. This indication is neither FDA approved nor Compendia supported.
Comment: Frequently, the administration must be divided into two doses. Therefore, two administration codes should be reimbursed.
Response: This is not a topic of medical reasonableness and necessity and, therefore, outside the scope of an LCD. It is being addressed here for completeness. Reimbursement for two injections will be considered pending CMS’ final instructions on drug administration and coding changes for 2005 as they relate to the Medicare Modernization Act (MMA).
Comment: This agent should be used only by physicians with expertise and experience in the medical treatment of neoplastic disease.
Response: This provision will be added to the policy.
Virtual Colonoscopy (CT Colonography) (L18631) - LCD
Virtual Colonoscopy (CT Colonography) (L18631) - LCD
Virtual Colonoscopy (CT Colonography) - LCD Comment/Response Document
| Policy Title: | Virtual Colonoscopy (CT Colonography) |
| Open Forum Presentation: | October 12, 2004 |
| CAC Meeting Presentation: | October 19, 2004 |
| End of Comment Period: | November 12, 2004 |
| Start of Notice Period: | December 15, 2004 |
| Policy Effective Date: | January 30, 2005 |
Comment: “Obstruction” or “obstructing” lesion should be replaced with the more specific term “obstructing neoplasm.”
Response: We agree; this was done.
Comment: CT colonography should be reimbursable following incomplete colonoscopy if the reason for the colonoscopy is other than an obstructing neoplasm.
Response: At this point and time, there is not enough evidence in reputable peer reviewed literature to support this. A double contrast barium enema is the standard of practice in these circumstances. This policy will be subject to reconsideration and revision, once the evidence is available
Comment: As the policy allows CT colonography only for neoplastic lesions, when and how is this diagnosis to be made to allow it immediately after a failed colonoscopy and to avoid a second preparation for the patient? Will a high level of suspicion by the colonoscopist suffice?
Response: It is correct that the primary focus of this policy are malignant neoplasms. However, we understand that also certain benign lesions, such as large lipomas, etc., can cause high grade obstruction resulting in surgery where the surgeon needs additional information about the anatomy proximal to the obstructions. In these rare situations, CIGNA Government Services will allow reimbursement for CT colonography following incomplete colonoscopy if the reason for the colonoscopy turns out to be a benign neoplasm causing high grade obstruction.
Comment: In case of incomplete colonoscopy because of colonic redundancy, benign narrowing or benign changes in the sigmoid colon that make it difficult to pass the colonoscope, double contrast barium enema is the appropriate test.
Response: We agree with the exception noted in the above response.
Comment: Is CT evaluation of the liver and other abdominal structures during the same session reimbursable?
Response: Given documented medical necessity, the policy does not exclude this. This is primarily a pricing issue, and an appropriate algorithm will be applied.
Tennessee Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
Tennessee Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
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.
