(Medicare Claims Processing Manual)

- Effective for dates of service on or after January 18, 2017, contractors shall return claims as unprocessable with the procedure codes listed in 10117- 04.2 billed without ICD -10 Z00.6 and use the following messages:     CARC 16 -  Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the N CPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC M76 -  Missing/incomplete/invalid diagnosis or condition.  - Effective for claims with dates of service on or after January 18, 2017, contractors shall return claims as unprocessable  that are billed with the Q0 modifier and do not contain the 8- digit clinical trial identifier in item 23 of the CMS -1500 form or the electronic equivalent.  Use the following messages:    CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)   RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.   Group Code  Contractual Obligation (CO).   390 - Supervised exercise therapy (SET) Symptomatic Peripheral Artery Disease  (Rev. 4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)  Effective for claims with dates of service on or after May 25, 2017, the Centers for Medicare and Medicaid Services (CMS) will cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease ( PAD).  Up to 36 sessions over a 12 week period are covered if all of the following components of a SET program are met:     The SET program must:   consist of sessions lasting 30- 60 minutes comprising a therapeutic exercise -training program for PAD in patients with claudication;  be conducted in a physicians office;   be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and    be under the direct supervision of a physician (as defined in 1861(r)(1)) of the Social Security Act (the Act)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) of (the Act) who must be trained in both ba sic and advanced life support techniques.   Beneficiaries must have a face- to-face visit with the physician responsible for PAD treatment to obtain the referral for SET.   At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.  SET is non -covered for beneficiaries with absolute contraindications to exercise as determined by their primary attending physician. .       Please refer to the National Coverage Determinations Manual (Publication 100 -03, Section 20.35) for more information.   390.1  General Billing Requirements   (Rev. 4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)  Effective for claims with date of services on or after May 25, 2017, contractors shall pay claims for SET for beneficiaries with IC for the treatment of symptomatic PAD, with a referral from the physician responsible for PAD treatment.    Medicare Administrative Contractors (MACs) have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time.  Contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the services that documentation is on file verifying that further treatment beyond the 36 sessions of SET over a 12 week period meets the requirements of the medical policy.   390.2  Coding Requirements for SET  (Rev. 4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)    CPT 93668   Under Peripheral Arterial Disease Rehabilitation    ICD-10 Codes   I70.211  right leg   I70.212  left leg   I70.213  bilateral legs   I70.218  other extremity   I70.311  right leg   I70.312  left leg   I70.313  bilateral legs   I70.318  other extremity    I70.611  right leg   I70.612  left leg   I70.613  bilateral legs   I70.618  other extremity   I70.711  right leg   I70.712  left leg   I70.713  bilateral legs   I70.718  other extremity    390.3 Special Billing Requirements for Institutional Claims  (Rev.4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)  Contractors shall pay claims for SET services containing CPT code 93668 on Types of Bill (TOBs) 13X under OPPS and 85X based on reasonable cost.   Contractors shall pay claims for SET services containing CPT 93668 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or the submitted charge.   390.4 Common Working File (CWF) Requirements  (Rev.4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07 -02-18)  CWF shall create a new edit for CPT 93668 to reject claims when a beneficiary has reached 36 SET sessions within 84 days after the date of the first SET session and the KX modifier is not included on the claim or to reject any SET session provided after 84 days from the date of the first session and the KX modifier is not included on the claim.  CWF shall determine the remaining SET sessions.   The CWF determination, to parallel claims processing, shall include all applicable factors including:    Beneficiary entitlement status   Beneficiary claims history   Utilization rules  CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation.   CWF shall display the remaining SET sessions on all CWF provider query screens.   The Multi -Carrier System Desktop Tool (MCSDT) shall display the remaining SET sessions in a format equivalent to the CWF HIMR screen(s).   390.5 Applicable Medicare Summary Notice (MSN), Remittance Advice Remark Codes and Claim Adjustment Reason Code Messaging  (Rev.4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)   Contractors shall deny claims for SET when services are provided on other than TOBs 13X and 85X using the following messages:  MSN 15.20: The following policies NCD 20.35 were used when we made this  decision.   Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.  (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call  1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.    Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1800- 633-4227).   Claim Adjustment Reason Code (CARC) 58:   Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.   Remittance advice remark code (RARC) N386:  This decision was based on a National Coverage Determination (NCD) 20.35. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www. cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Contractors deny/reject claim lines for CPT 93668 without one of the diagnosis codes listed in 390.2 and use the following messages:    MSN 15.20: The following policies NCD 20.35 were used when we made this  decision.   Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.   (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call  1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.  Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1800- 633-4227).   CARC 167  This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N386  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at  www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.   Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file.    Contractors shall use Group CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Contractors shall reject claims with CPT 93668 which exceed 36 sessions within 84 days from the date of the first session when the KX modifier is not included on the claim line OR any SET session provided after 84 days from the date of the first session an d the KX modifier is not included on the claim and use the following messages:   96- Non -covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.)   Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    N640 Exceeds number/frequency approved/allowed within time period.     Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line -item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).     Contractors shall deny/reject claim lines with CPT 93668 when sessions have reached 73 sessions using the following messages:  MSN 15.20: The following policies NCD 20.35 were used when we made this decision.     Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.   (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call  1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.