Draft Article - Billing and Coding: Cervical Fusion (DA59634)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, 180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cervical Fusion DL39773. Refer to the draft LCD DL39773 Cervical Fusion for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable American Medical Association (AMA) CPTManual to assist with proper reporting of these services.Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.This LCD applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).General Guidelines for Claims Submitted to Part A or Part B MAC:Procedure codes may be subject to NCCI edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.ModifierWhen to Use ModifierGAWaiver of Liability StatementIssued as Required by PayerPolicy, Individual CaseReport when you issue a mandatory Advance Beneficiary Notice (ABN) for a service as required and keep it on file. You dont need to submit a copy of the ABN, but you must make it available on request. Use the GA modifier when both covered and non-covered services appear on an ABN-related claim.GXNotice of Liability Issued,Voluntary Under Payer PolicyReport when you issue a voluntary ABN for a service we never cover because its statutorily excluded or isnt a Medicare benefit. Use this modifier combined with modifier GY.GYNotice of Liability Not Issued,Not Required Under PayerPolicyReport Medicare statutorily excludes the item or service, or the item or service doesnt meet the definition of a Medicare benefit. Use this modifier combined with modifier GX.GZExpect Item or ServiceDenied as Not Reasonableand NecessaryReport when you expect well deny payment of the item or service because its medically unnecessary and you didnt issue an ABN.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The operative note should include the procedure performed and any associated/additional procedures performed at the same time.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s)Use of BiologicalsThere are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.