(Medicare Claims Processing Manual)

30.1 - Billing Requirements for HBO Therapy for the Treatment of Diabetic Wounds of the Lower Extremities  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Hyperbaric Oxygen Therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Effective April 1, 2003, a National Coverage Decision expanded the use of HBO therapy to include coverage for the treatment of diabetic wounds of the lower extremities. For specific coverage criteria for HBO The rapy, refer to the National Coverage Determinations Manual, Chapter 1, section 20.29.  NOTE: Topical application of oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.    Billing Requirements for A/B MACs  (A)  Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS -1450.  a. Applicable Bill Types   The applicable hospital bill types are 11X, 13X and 85X.  b. Procedural Coding    99183  Physician attendance and supervision of hyperbaric oxygen therapy, per  session.    G0277  Hyperbaric oxygen under pressure, full body chamber, per 30 -minute  interval.   NOTE: Code G0277 is not available for use other than in a hospital outpatient department. In skilled nursing facilities (SNFs), HBO therapy is part of the SNF PPS payment for beneficiaries in covered Part A stays.   For hospital inpatients and critical access hospitals (CAHs) not electing Method I, HBO therapy is reported under revenue code 940 without any HCPCS code. For inpatient services, if ICD -10 is applicable, show ICD -10-PCS code 5A05121.  For CAHs electing Method I, HBO therapy is reported under revenue code 940 along with HCPCS code 99183.  c. Payment Requirements for A/B MACs  (A)  Payment is as follows:  A/B MAC (A) payment is allowed for HBO therapy for diabetic wounds of the lower extremities when performed as a physician service in a hospital outpatient setting and for inpatients. Payment is allowed for claims with valid diagnosis codes as shown above w ith dates of service on or after April 1, 2003. Those claims with invalid codes should be denied as not medically necessary.   For hospitals, payment will be based upon the Ambulatory Payment Classification (APC) or the inpatient Diagnosis Related Group (DRG). Deductible and coinsurance apply.   Payment to Critical Access Hospitals (electing Method I) is made under cost reimbursement. For Critical Access Hospitals electing Method II, the technical component is paid under cost reimbursement and the professional component is paid under the Physician Fee Schedule.   II. A/B MAC (B) Billing  Requirements   Claims for this service should be submitted using the ASC X12 837 professional claim format or Form CMS -1500.  The following HCPCS code applies:    99183  Physician attendance and supervision of hyperbaric oxygen therapy, per session.    G0277  Hyperbaric oxygen under pressure, full body chamber, per 30-minute  interval.    a. Payment Requirements for A/B MACs (B)   Payment and pricing information will occur through updates to the Medicare Physician Fee Schedule Database (MPFSDB). Pay for this service on the basis of the MPFSDB. Deductible and coinsurance apply. Claims from physicians or other practitioners where assignment was not taken, are subject to the Medicare limiting charge.   III. Medicare Summary Notices (MSNs)   Use the following MSN Messages where appropriate:   In situations where the claim is being denied on the basis that the condition does not meet our coverage requirements, use one of the following MSN Messages:   Medicare does not pay for this item or service for this condition. (MSN Message 16.48)   The Spanish version of the MSN message should read:   Medicare no paga por este articulo o servicio para esta afeccion.   In situations where, based on the above utilization policy, medical review of the claim results in a determination that the service is not medically necessary, use the following MSN message:   The information provided does not support the need for this service or item. (MSN Message 15.4)   The Spanish version of the MSN message should read:   La informacion proporcionada no confirma la necesidad para este servicio o articulo.   IV. Remittance Advice Notices   Use appropriate existing remittance advice remark codes and claim adjustment reason codes at the line level to express the specific reason if you deny payment for HBO therapy for the treatment of diabetic wounds of lower extremities.    30.2 Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)  (Rev.3921, Issued: 11-17 -17, Effective: 04 -03-17, 12 -18-17)  CMS considers topical oxygen therapy (TOT) to be a method whereby a local supply of oxygen is applied to a wound.  I. Billing Requirements for A/B MACs (A)  Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS -1450.  II.   Payment Requirements for A/B MACs (A)  As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors. NOTE:  Regardless of whether an A/B MAC (A) has made a determination to cover this service, there shall be no coverage for any separate or additional physicians professional services related to this procedure.   III.  Billing Requirements for A/B MACs (B)  As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors. NOTE:  Regardless of whether an A/B MAC (B) has made a determination to cover this service, there shall be no coverage for any separate or additional physicians professional services related to this procedure.   40  Sacral Nerve Stimulation  (Rev. 125, 03- 26-04)  A sacral nerve stimulator is a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire.  These impulses cause the bladder muscles to contract, which gives the patient ability to void more properly.  40.1  Coverage Requirements  (Rev. 125, 03- 26-04)  Effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency- frequency syndrome and urinary retention.  Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates.  Both the test and the permanent implantation are covered.   The following limitations for coverage apply to all indications:   o Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.   o Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) that are associated with secondary manifestations of the above three indications are excluded.   o Patient must have had a successful test stimulation in order to support subsequent implantation.  Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation.  Improvement is meas ured through voiding diaries.   o Patient must be able to demonstrate adequate ability to record voiding diary data such that  clinical results of the implant procedure can be properly evaluated.   40.2  Billing Requirements (Rev. 125, 03- 26-04)  40.2.1  Healthcare Common Procedural Coding System (HCPCS)  (Rev. 11789, Issued:01- 19-23, Effective Date: 02- 21-23, Implementation Date: 02- 21-23)   64561 -  Percutaneous implantation of neurostimulator electrodes; sacral   nerve (transforaminal placement)  64581 - Incision for implantation of neurostimulator electrodes; sacral nerve  (transforaminal placement)  64585 -  Revision or removal of peripheral neurostimulator electrodes  64590 - Incision and subcutaneous placement of peripheral   neurostimulator pulse generator or receiver, direct or inductive   coupling  64595 -  Revision or removal of peripheral neurostimulator pulse generator  or receiver  A4290 -  Sacral nerve stimulation test lead, each  C1767 -  Generator, neurostimulator (implantable)  C1778 -  Lead, neurostimulator (implantable)                        C1820 -  Generator, neurostimulator (implantable), with rechargeable  battery and charging system -  effective 01/01/20 for NCD230.18 with  CR11655  C1883 -  Adaptor/extension, pacing lead or neurostimulator lead  (implantable)  C1897 -  Lead, neurostimulator test kit (implantable)  E0752 -  Implantable neurostimulator electrodes, each  E0756 -  Implantable neurostimulator pulse generator    NOTE :  The "C" codes listed above are only applicable when billing under the hospital   outpatient prospective payment system (OPPS).  They should be reported in place of codes  A4290, E0752 and E0756.  40.2.2  Payment Requirements for Test Procedures (HCPCS Codes 64585, 64590 and 64595)  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  Payment is as follows:   Hospital outpatient departments  OPPS    Critical access hospital (CAH) -  Reasonable cost    Comprehensive outpatient rehabilitation facility -  Medicare physician fee schedule (MPFS)    Rural health clinics/federally qualified health centers (RHCs/FQHCs) - All inclusive rate, professional component only.  The technical component is outside the scope of the RHC/FQHC benefit.  Therefore, the provider of that technical service bills their A/B MAC (B) using the ASC X12 837 professional claim format or Form CMS -1500 and payment is made under the MPFS.  For provider -based RHCs/FQHCs payment for the technical component is made as indicated above based on the type of provider the RHC/FQHC is based with.   Deductible and coinsurance apply.   40.2.3  Payment Requirements for Device Codes A4290, E0752 and E0756 (Rev. 125, 03- 26-04)  Payment is made on a reasonable cost basis when these devices are implanted in a CAH.   40.2.4  Payment Requirements for Codes C1767, C1778, C1820, C1883 and C1897 (Rev. 11789, Issued:01- 19-23, Effective Date: 02- 21-23, Implementation Date: 02- 21-23)    Only hospital outpatient departments report these codes.  Payment is made under OPPS.   40.3  Bill Types (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  The applicable bill types for test stimulation procedures are 13X, 71X, 73X, 75X and 85X.   The RHCs and FQHCs bill you under bill type 71X and 73X for the professional component. The technical component is outside the scope of the RHC/FQHC benefit. The provider of that technical service bills their A/B MAC (B) using the ASC X12 837 professional claim format or the Form CMS -1500.   The technical component for a provider -based RHC/FQHC is typically furnished by the provider. The provider of that service bills you under bill type 13X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider number since t hese services are not covered as RHC/FQHC services.) Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for test stimulation procedures.   The applicable bill types for implantation procedures and devices are 11X, 13X, and 85X.   40.4  Revenue Codes  (Rev.10881; Issued: 08- 06-2021; Effective: 09- 07-2021; Implementation: 09- 07- 2021)