(Medicare Claims Processing Manual)

General policies for post implant services.   The services of a speech -language pathologist may be covered for SLP services provided after implantation of auditory devices.  For example, a speech-language pathologist may provide evaluation and treatment of speech, language, cognition, voice, and auditory processing using code 92506 and 92507.  Use 92626 and 92627 for auditory (aural) rehabilitation evaluation following cochlear implantation or for other hearing impairments.  For diagnostic testing of cochlear implants, audiologists use codes 92601, 92602, 92603 and 92604.  These services may not be provided by speech-language pathologists or others, with the exception of physicians and NPPs who may personally provide the servi ces that are within their scope of practice.   30.4 - Cardiovascular System (Codes 92950 -93799)  (Rev. 979, Issued: 06-09-06, Effective: 07-10-06, Implementation: 07-10-06)  A. Echocardiography Contrast Agents Effective October 1, 2000, physicians may separately bill for contrast agents used in echocardiography.  Physicians should use HCPCS Code A9700 (Supply of Injectable Contrast Material for Use in Echocardiography, per study).  The type of service code is 9.  This code will be A/B MAC (B) -priced.  B. Electronic Analyses of Implantable Cardioverter- defibrillators and Pacemakers  The CPT codes 93731, 93734, 93741 and 93743 are used to report electronic analyses of single or dual chamber pacemakers and single or dual chamber implantable cardioverter-defibrillators.  In the office, a physician uses a device called a programmer to obt ain information about the status and performance of the device and to evaluate the patients cardiac rhythm and response to the implanted device. Advances in information technology now enable physicians to evaluate patients with implanted cardiac devices without requiring the patient to be present in the physicians office.  Using a manufacturers specific monitor/transmitter, a patient can send complete device data and specific cardiac data to a distant receiving station or secure Internet server.  The electronic analysis of cardiac device data that is remotely obtained provides immediate and long- term data on the device and clinical data on the pat ients cardiac functioning equivalent to that obtained during an in-office evaluation.  Physicians should report the electronic analysis of an implanted cardiac device using remotely obtained data as described above with CPT code 93731, 93734, 93741 or 93743, depending on the type of cardiac device implanted in the patient.  30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions  (Rev. 968. Issued:  05 -26-06; Effective/Implementation Dates:  06 -26-06)  A. General  Codes for Chemotherapy administration and nonchemotherapy injections and infusions include the following three categories of codes in the American Medical Associations Current Procedural Terminology (CPT):  1. Hydration;  2. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy); and  3. Chemotherapy administration. Physician work related to hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of nonphysician clinical staff.  B. Hydration  The hydration codes are used to report a hydration IV infusion which consists of a pre -packaged fluid and /or electrolytes (e.g. normal saline, D5- 1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion of drugs or other substances. C. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy)  A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs.  The fluid used to administer the drug (s) is incidental hydration and is not separately payable.  If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable:  1. Use of local anesthesia;  2. IV start;  3. Access to indwelling IV, subcutaneous catheter or port;  4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.  Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service.  If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or nonchemotherapy injection and infusion service.  For an evaluation and management service provided on the same day, a different diagnosis is not required.  The CPT 2006 includes a parenthetical remark immediately following CPT code 90772 (Therapeutic, prophylactic or diagnostic injection; (specify substance or drug); subcutaneous or intramuscular.)  It states, Do not report 90772 for injections given without  direct supervision.  To report, use 99211.  This coding guideline does not apply to Medicare patients.  If the RN, LPN or other auxiliary personnel furnishes the injection in the office and the physician is not present in the office to meet the supervision requirement, which is one of the requirements for coverage of an incident to service, then the injection is not covered.  The physician would also not report 99211 as this would not be covered as an incident to service.  D. Chemotherapy Administration  Chemotherapy administration codes apply to parenteral administration of non- radionuclide anti-neoplastic drugs; and also to anti -neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto -immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers.  The following drugs are commonly considered to fall under the category of monoclonal antibodies:  inf liximab, rituximab, alemtuzumb, gemtuzumab, and trastuzumab.  Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate.  The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes.  A/B MACs (B) may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare.  The administration of anti -anemia drugs and anti -emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration.  If performed to facilitate the chemotherapy infusion or injection, the following services and items are included and are not separately billable:  1. Use of local anesthesia;  2. IV access;  3. Access to indwelling IV, subcutaneous catheter or port;  4. Flush at conclusion of infusion;  5. Standard tubing, syringes and supplies; and  6. Preparation of chemotherapy agent(s).  Payment for the above is included in the payment for the chemotherapy administration service.  If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy code.  For an evaluation and management service provided on the sam e day, a different diagnosis is not required.  E. Coding Rules for Chemotherapy Administration and Nonchemotherapy Injections and Infusion Services  Instruct physicians to follow the CPT coding instructions to report chemotherapy administration and nonchemotherapy injections and infusion services with the exception listed in subsection C for CPT code 90772.  The physician should be aware of the followi ng specific rules.  When administering multiple infusions, injections or combinations, the physician should report only one initial service code unless protocol requires that two separate IV sites must be used.  The initial code is the code that best describes the key or pr imary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur.  If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code should be reported.  For example, the first IV push given subsequent to an initial one -hour infusion is reported using a subsequent IV push code.  If more than one initial service code is billed per day, the A/B MAC (B) shall deny the second initial service code unless the patient has to come back for a separately identifiable service on the same day or has two IV lines per protocol.  For these separately identifiable services, instruct the physician to report with modifier 59.  The CPT includes a code for a concurrent infusion in addition to an intravenous infusion for therapy, prophylaxis or diagnosis.  Allow only one concurrent infusion per patient per encounter.  Do not allow payment for the concurrent infusion billed with modifier 59 unless it is provided during a second encounter on the same day with the patient and is documented in the medical record.  For chemotherapy administration and therapeutic, prophylactic and diagnostic injections and infusions, an intravenous or intra -arterial push is defined as:   1.) an injection in which the healthcare professional is continuously present to administer the substance/drug and observe the patient; or 2.) an infusion of 15 minutes or less. The physician may report the infusion code for each additional hour only if the infusion interval is greater than 30 minutes beyond the 1 hour increment.  For example if the patient receives an infusion of  a single drug that lasts 1 hour and 45 minutes,  the physician would report the initial code up to 1 hour and the add- on code for the additional 45 minutes. Several chemotherapy administration and nonchemotherapy injection and infusion service codes have the following parenthetical descriptor included as a part of the CPT code, List separately in addition to code for primary procedure.  Each of these codes has a physician fee schedule indicator of ZZZ meaning this service is allowed if billed with another chemotherapy administration or nonchemotherapy injection and infusion service code.  Do not interpret this parenthetical descriptor to mean that the add- on code can be billed only if it is listed with another drug administration primary code.  For example, code 90761 will be ordinarily billed with code 90760.  However, there may be instanc es when only the add- on code, 90761, is billed because an initial code from another section in the drug administration codes, instead of 90760, is billed as the primary code. Pay for code 96523, Irrigation of implanted venous access device for drug delivery systems, if it is the only service provided that day.  If there is a visit or other chemotherapy administration or nonchemotherapy injection or infusion service provided o n the same day, payment for 96523 is included in the payment for the other service.  F. Chemotherapy Administration (or Nonchemotherapy Injection and Infusion) and Evaluation and Management Services Furnished on the Same Day  For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code.  Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005.  Physicians providing a chemotherapy  administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with 30.6.6 using modifier 25.  The A/B MACs (B) pay for evaluation and management services provided on the same day as the chemotherapy  administration services or a nonchemotherapy injection or infusion service if the evaluation and management service meets the requirements of section 30.6.6  even though the underlying codes do not have global periods.  If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required.  In 2005, the Medicare physician fee schedule status database indicators for therapeutic and diagnostic injections were changed from T to A.  Thus, beginning in 2005, the policy on evaluation and management services, other than 99211, that is applicable to a chemotherapy or a nonchemotherapy injection or infusion service applies equally to these codes.  30.6 - Evaluation and Management Service Codes - General (Codes 9920 2 - 99499)  (Rev.  11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  30.6.1 - Selection of Level of Evaluation and Management Service  (Rev .11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A.  General Rules   Advise physicians to generally use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management (E/M) services.  Medicare has created Medicare- specific codes that must be used to report prolonged E/M services and E/M visit c omplexity add- on services.