(Medicare Claims Processing Manual)

  CWF shall display the number of counseling sessions remaining for G0443 PROF on all CWF provider query screens (HUQA, HIQA, HIQH, ELGA, ELGB, ELGH).    CWF shall display the remaining PROF services counting DOWN from four (4) for the HCPCS code G0443 on the MBD/NGD extract file.    CWF shall calculate a next eligible date for G0442 PROF and G0443 PROF for a given beneficiary.     The calculation shall include all applicable factors including beneficiary Part B entitlement status, beneficiary claims history and utilization rules.    When there is no next eligible date, the CWF provider query screens shall display an 8- position alpha code in the date field to indicate why there is not a next eligible date.    Any change to beneficiary master data or claims data that would result in a change to any next eligible date shall result in an update to the beneficiarys next eligible date.   NOTE:  If G0442 is not paid, the beneficiary is not eligible for G0443.    CWF shall create a utility to remove previously posted G0442 TECH for the AUX file.    CWF shall remove G0442/G0443 TECH from editing, MBD, NGD, Provider Inquiry screens and all other applicable areas (i.e., HICR) previously done under CR 7633.  Frequency Requirements   When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.  Additionally, CWF shall create an edit to allow alcohol misuse br ief behavioral counseling, HCPCS G0443, no more than 4 times in a 12- month period. CWF shall also count four alcohol misuse counseling sessions HCPCS G0443 in the same 12 -month period used for G0442 counting from the date the G0442 screening session was bi lled.  When applying frequency limitations to G0442 screening on the same date of service as G0443 counseling, CWF shall allow both a claim for the professional service and a claim for a facility fee.  CWF shall identify the following institutional claims as facility fee claims for screening services: TOB 13X, TOB 85X when the revenue code is not 096X, 097X, or 098X.  CWF shall identify all other claims as professional service claims for screening services (professional claims, and institutional claims with TOB 71 X, 77X, and 85X when the revenue code is 096X, 097X, or 098X).  NOTE: This does not apply to RHCs and FQHCs.   190  Billing Requirements for Extracorporeal Photopheresis  (Rev. 3050, Issued: 08- 22-14, Effective: 09 -23-14, ICD -10: Upon Implementation of ICD -10, Implementation: 09 -23-14, ICD -10: Upon Implementation of ICD- 10)  Effective for dates of services on and after December 19, 2006, Medicare has expanded coverage for extracorporeal photopheresis for patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppresive drug treatment and patients with chronic graft versus host disease whose disease is refractory to standard immunosuppresive drug treatment. (See the National Coverage Determinations (NCD) Manual, Pub. 100 -03, Chapter 1, part 2, section 110.4, for complete coverage guidelines .)   Effective for claims with dates of service on or after April 30, 2012, the Centers for Medicare & Medicaid Services has expanded coverage for extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome ( BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study that meets specific requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following lung a llograft transplantation. Fur ther coverage criteria is outlined in Pub. 100- 03, Chapter 1, part 2, section 110.4 of the NCD Manual.  190.1  Applicable Intermediary Bill Types  (Rev. 1206; Issued:  03- 16-07; Effective:  December 19, 2006; Implementation:  04- 02-07)  11X, 13X, or 85X   190.2  Healthcare Common Procedural Coding System (HCPCS), Applicable Diagnosis Codes and Procedure Code  (Rev.10881; Issued: 08-06-2021; Effective: 09- 07-2021; Implementation: 09-07- 2021)   The following HCPCS procedure code is used for billing extracorporeal photopheresis:   36522 - Photopheresis, extracorporeal      Effective for claims with dates of service on or after Oct 1, 2015, the following are the applicable ICD-10-CM procedure codes for the new expanded coverage:   6A650ZZ Phototherapy, Circulatory, Single  6A651ZZ Phototherapy, Circulatory, Multiple   NOTE: Contractors shall edit for an appropriate oncological and autoimmune disorder diagnosis for payment of extracorporeal photopheresis according to the NCD.  Effective for claims with dates of service on or after Oct 1, 2015, in addition to HCPCS 36522, the following ICD-10-CM codes are applicable for extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study as outlined in above sections 190 and 190.2 Healthcare Common Procedural Coding System (HCPCS) codes, and applicable diagnosis codes as below::   A reference listing of ICD -10-CM coding and descriptions is listed below:  CUTANEOUS T -CELL LYMPHOMA   C84.01  Mycosis fungoides, lymph nodes of head, face, and neck  C84.02  Mycosis fungoides, intrathoracic lymph nodes  C84.03  Mycosis fungoides, intra -abdominal lymph nodes  C84.04  Mycosis fungoides, lymph nodes of axilla and upper limb  C84.05  Mycosis fungoides, lymph nodes of inguinal region and lower limb  C84.06  Mycosis fungoides, intrapelvic lymph nodes  C84.07  Mycosis fungoides, spleen  C84.08  Mycosis fungoides, lymph nodes of multiple sites  C84.09  Mycosis fungoides, extranodal and solid organ sites  C84.11  Szary disease, lymph nodes of head, face, and neck  C84.12  Szary disease, intrathoracic lymph nodes  C84.13  Szary disease, intra -abdominal lymph nodes  C84.14  Szary disease, lymph nodes of axilla and upper limb  C84.15  Szary disease, lymph nodes of inguinal region and lower limb C84.16  Szary disease, intrapelvic lymph nodes  C84.17  Szary disease, spleen  C84.18  Szary disease, lymph nodes of multiple sites  C84.19  Sezary disease, extranodal/solid organ sites  C84.A0  Cutaneous T -cell lymphoma, unspecified, unspecified site  C84.A1  Cutaneous T -cell lymphoma, unspecified lymph nodes of head, face, and neck  C84.A2  Cutaneous T -cell lymphoma, unspecified, intrathoracic lymph nodes  C84.A3  Cutaneous T -cell lymphoma, unspecified, intra -abdominal lymph nodes  C84.A4  Cutaneous T -cell lymphoma, unspecified, lymph nodes of axilla and upper limb  C84.A5  Cutaneous T -cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb  C84.A6  Cutaneous T -cell lymphoma, unspecified, intrapelvic lymph nodes  C84.A7  Cutaneous T -cell lymphoma, unspecified, spleen  C84.A8  Cutaneous T -cell lymphoma, unspecified, lymph nodes of multiple sites  C84.A9  Cutaneous T -cell lymphoma, unspecified, extranodal and solid organ sites   ACUTE CARDIAC ALLOGRAFT REJECTION/GRAFT -VERSUS -HOST -DISEASE   D89.811  Chronic graft -versus -host disease  D89.812  Acute on chronic graft -versus -host disease  D89.813  Graft -versus -host disease, unspecified  T86.01  Bone marrow transplant rejection  T86.02  Bone marrow transplant failure  T86.03  Bone marrow transplant infection  T86.21  Heart transplant rejection  T86.22  Heart transplant failure  T86.23  Heart transplant infection  T86.290  Cardiac allograft vasculopathy  T86.31  Heart -lung transplant rejection  T86.32  Heart -lung transplant failure  T86.33  Heart -lung transplant infection  T86.5  Complications of stem cell transplant  Z94.3  Heart and lungs transplant status  Z94.81  Bone marrow transplant status   BOS (CED/TRIAL ONLY)   J42 Unspecified chronic bronchitis  J44.0  Chronic obstructive pulmonary disease with (acute) lower respiratory infection  J44.1  Chronic obstructive pulmonary disease with (acute) exacerbation  J44.9  Chronic obstructive pulmonary disease, unspecified  T86.810  Lung transplant rejection  T86.811  Lung transplant failure  T86.812  Lung transplant infection  T86.818  Other complications of lung transplant  T86.819  Unspecified complication of lung transplant  Z94.2  Lung transplant status  Z00.6  Encounter for examination for normal comparison and control in clinical research program   190.3  Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RAs) and Claim Adjustment Reason Code  (Rev.10881; Issued: 08-06-2021; Effective: 09- 07-2021; Implementation: 09-07- 2021)   Contractors shall continue to use the appropriate existing messages that they have in place when denying claims submitted that do not meet the Medicare coverage criteria for extracorporeal photopheresis.  Medicare coverage for extracorporeal photopheresis is restricted to the inpatient or outpatient hospital settings specifically for BOS, and not for the other covered diagnosis (including chronic graft versus host disease) which remain covered in the hospital inpatient, hospital outpatient, and non- facility (physician -directed clinic or office settings) settings.   Contractors shall deny claims for extracorporeal photopheresis for BOS when the service is not rendered to an inpatient or outpatient of a hospital, including critical access hospitals using the following codes:    Claim Adjustment Reason Code (CARC) 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.    CARC 171  Payment is denied when performed/billed by this type of provider in this type of facility. NOTE : Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if  present.    Medicare Summary Notice 16.2 -  This service cannot be paid when provided in this location/facility." Spanish translation: "Este servicio no se puede pagar cuando es suministrado en esta sitio/facilidad. (Include either MSN 36.1 or 36.2 dependent on liability.)    Remittance Advice Remark Code (RARC) N428  Not covered when performed in this place of service. (A/MACs only)   B. Group Code CO (Contractual Obligations) or PR (Patient Responsibility)  dependent  on liability.   Contractors shall return to provider/ return as unprocessable claims for BOS containing HCPCS procedure code 36522 along with one of the  allowable ICD -10 codes if the claim is missing diagnosis code Z00.6 (as primary/secondary diagnosis, institutional only), condition code 30 (institutional claims only), clinical trial modifier Q0/Q1, and value code D4 with an 8- digit clinical trial identifier number (A/MACs only). Use the following messages:   When diagnosis code Z00.6 is missing, use:   CARC 16 Claim/service lacks information or has submission/billing error(s). and   RARC M76, Missing/incomplete/invalid diagnosis or condition.   When Condition Code 30 is missing, use CARC 16 and   RARC M44  Missing/incomplete/invalid condition code.   When Clinical Trial modifier Q0/Q1 is missing, use CARC 16 and   RARC N822, Missing procedure modifier(s).