(Medicare Claims Processing Manual)

 66986 -  Exchange of intraocular lens   In addition, physicians inserting a P -C IOL or A -C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL. Medicare will make payment for the lens based on reasonable cost for a conventional IOL.  Place of Service (PO S) = 11.   Effective for dates of service on and after January 1, 2006, physician, hospitals and ASCs may also bill the non-covered charges related to the P -C function of the IOL using HCPCS code V2788.  Effective for dates of service on and after January 22, 2007 through January 1, 2008, non- covered charges related to A -C function of the IOL can be billed using HCPCS code V2788. The type of service indicator for the non -covered billed charges is Q.  (The type of service is applied by the Medicare carrier and not the provider).  Effective for A -C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 rather than V2788 to report any additional charges that accrue.   When denying the non- payable charges submitted with V2787 or V2788, contractors shall use an appropriate Medical Summary Notice (MSN) such as 16.10 (Medicare does not pay for this item or service) and an appropriate claim adjustment reason code such as 96 (non- covered charges) for claims submitted with the non-payable charges.   Hospitals and physicians may use the proper CPT code(s) to bill Medicare for evaluation and management services usually associated with services following cataract extraction surgery, if appropriate.    A - Applicable Bill Types    The hospital applicable bill types are 12X, 13X, 83X and 85X.    B - Other Special Requirements for Hospitals   Hospitals shall continue to pay CAHs method 2 claims under current payment methodologies for conditional IOLs.   120.3 - Provider Notification Requirements  (Rev. 1228; Issued:  04- 27-07; Effective:  01 -22-07; Implementation:  05 -29-07)  When a beneficiary requests insertion of a P -C or A -C IOL instead of a conventional IOL following removal of a cataract:    Prior to the procedure to remove a cataractous lens and insert a P -C or A -C lens, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment or other subsequent treatments related to the  P-C or A -C functionality of the IOL.    The P -C or A -C functionality of a P -C or A -C IOL does not fall into a Medicare benefit category, and, therefore, is not covered.  Therefore, the facility and physician are not required to provide an Advanced Beneficiary Notice to beneficiaries who request a P -C or A -C IOL.    Although not required, CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to clearly identify the non- payable aspects of a P -C or A -C IOL insertion.  This notice may be found in English at http:\\cms.hhs.gov/medicare/bni/20007_English.pdf   Spanish language at:   http://cms.hhs.gov/medicare/bni/20007_Spanish.pdf .  120.4 - Beneficiary Liability  (Rev. 1228; Issued:  04-27- 07; Effective:  01 -22-07; Implementation:  05 -29-07)  When a beneficiary requests insertion of a P -C or A -C IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the beneficiary is responsible for payment of facility and physician charges for services and supplies attributable to the P -C or A -C functionality of the P- C or A -C IOL:    In determining the beneficiary's liability, the facility and  physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P -C or A -C IOL that exceed the work and resources attributable to insertion of a conventional IOL.   The physician and the facility may not charge for cataract extraction with insertion of a P- C or A -C IOL unless the beneficiary requests this service.   o The physician and the facility may not require the beneficiary to request a P- C or A -C IOL as a condition of performing a cataract extraction with IOL insertion.  130 - External Counterpulsation (ECP) Therapy  (Rev. 898, Issued:  03- 31-06; Effective/Implementation Dates:  03 -31-06)  Commonly referred to as enhanced external counterpulsation, is a non- invasive outpatient treatment for coronary artery disease refractory medical and/or surgical therapy.  Effective for dates of service July 1, 1999, and after, Medicare will cover ECP when its use is in patients with stable angina (Class III or Class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass, becaus e:   Their condition is inoperable, or at high risk of operative complications or post- operative failure;    Their coronary anatomy is not readily amenable to such procedures; or   They have co -morbid states that create excessive risk.   (Refer to Publication 100-03, section 20.20 for further coverage criteria.)  130.1 - Billing and Payment Requirements  (Rev. 12109; Issued:06-29- 23; Effective: 10 -02-23; Implementation: 10-02-23)   Effective for dates of service on or after January 1, 2000, use HCPCS code G0166 (External counterpulsation, per session) to report ECP services. The codes for external cardiac assist (92971), ECG rhythm strip and report (93040 or 93041), pulse oximetry (94760 or 94761) and plethysmography (93922 or 93923) or other monitoring tests for examining the effects of this treatment are not clinically necessary with this service and should not be paid on the same day, unless they occur in a clinical setting not connected with the delivery of the ECP. Daily evaluation and management service, e.g., 99201-  99205, 99211- 99215, 99217- 99220, 99241-99245, and G0463 cannot be billed with the ECP treatments. Any evaluation and management service must be justified with adequate documentation of the medical necessity of the visit. Deductible and coinsurance apply.   Note: Please note that effective December 31, 2020 evaluation and management service code 99201 is end-dated. Effective December 31, 2022 codes 99217,99218,99219,99220 and 99241 are end dated.  For Part A, remove CPT codes 99202- 99215, 99242- 99245 and repl ace with G0463 (the OPPS equivalent of E/M codes) effective retroactive to 10/1/2015.     130.2 - Special Intermediary Billing and Payment Requirements  (Rev. 898, Issued:  03- 31-06; Effective/Implementation Dates:  03 -31-06)  Payment is made to hospitals for the facility costs it incurs under Part B on a reasonable cost basis.  Payment is also made to PPS -exempt hospitals for the facility costs it incurs on a reasonable cost basis.  Deductible and coinsurance apply.   Applicable bill types are 12X, 13X, 83X or 85X.   140 - Cardiac Rehabilitation (CR) Programs, Intensive Cardiac Rehabilitation (ICR) Programs, and Pulmonary Rehabilitation (PR) Programs On or After January 1, 2024 (Rev. 12497; Issued: 02- 08-24; Effective: 01 -01-24; Implementation: 03 -12-24)  Cardiac rehabilitation (CR) means a physician or nonphysician practitioner supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Intensive cardiac rehabilitation (ICR) progra m means a physician or nonphysician practitioner supervised program that furnishes CR and has shown, in peer -reviewed published research, that it improves patients cardiovascular disease through specific outcome measurements described in 42 CFR 410.49(c). Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social Security Act (the Act).    Effective January 1, 2024, Medicare Part B pays for CR/ICR if specific criteria are met by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is administered, and the physician a dministering the program.   Pulmonary rehabilitation (PR) means a physician or nonphysician practitioner supervised program for chronic obstructive pulmonary disease (COPD) and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Act.   Effective January 1, 2024, Medicare Part B pays for PR if specific criteria are met by the Medicare beneficiary, the PR program itself, the setting in which it is administered, and the physician administering the program, as outlined below.  140.1  CR Program Services Furnished On or Before December 31, 2009  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)   Medicare covers CR exercise programs for patients who meet the following criteria:    Have a documented diagnosis of acute myocardial infarction (MI) within the preceding 12 months; or   Have had coronary bypass surgery; or,   Have stable angina pectoris; or,  Have had heart valve repair/replacement; or,   Have had percutaneous transluminal coronary angioplasty (PTCA) or coronary  stenting; or,  Have had a heart or heart -lung transplant.   Effective for dates of services on or after March 22, 2006, services provided in connection with a CR exercise program may be considered reasonable and necessary for up to 36 sessions. Patients generally receive 2 to 3 sessions per week for 12 to 18 weeks. The contractor has discretion to cover CR beyond 18 weeks. Coverage must not exc eed a total of 72 sessions for 36 weeks.  CR programs shall be performed incident to physicians services in outpatient hospitals, or outpatient settings such as clinics or offices. Follow the policies for services incident to the services of a physician as they apply in each setting. For example, see Pub. 100-02, Chapter 6, 2.4.1, and Pub. 100-02, Chapter 15, 60.1. (Refer to Publication 100-03, 20.10 for further coverage guidelines.)  140.1.1 - Coding Requirements for Cardiac Rehabilitation Services Furnished On or Before Dec. 31, 2009  (Rev. 12497; Issued: 02-08- 24; Effective: 01 -01-24; Implementation: 03-12-24)  The following are the applicable Healthcare Common Procedure Coding System (HCPCS) codes:   93797 - Physician or other qualified health care professional  services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session); and  93798 - Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session). Note: The above HCPCS descriptors are effective January 1, 2013.   Effective for dates of service on or after January 1, 2008, and before January 1, 2010, providers and practitioners may report more than one unit of CPT code 93797 or 97398 for a date of service if more than one CR session lasting at least 1 hour each is provided on the same day. In order to report more than one session for a given date of service, each session must last a minimum of 60 minutes. For example, if the CR provided on a given day total 1 hour and 50 minutes, then only one session should be billed to report the CR provided on that day.  140.2  Cardiac Rehabilitation Program Services Effective for Dates of Service On or After January 1, 2024  (Rev. 12497; Issued: 02-08- 24; Effective: 01 -01-24; Implementation: 03-12-24)