(Medicare Claims Processing Manual)

 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).    When Clinical Trial Number is missing, use CARC 16 and   RARC MA50, Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.   When Value Code D4 is missing, use CARC 16 and   RARC M49, Missing/incomplete/invalid value code(s) or amount(s).   190.4  Advance Beneficiary Notice and Hospital Issued Notice of Noncoverage Information  (Rev. 1206; Issued:  03- 16-07; Effective:  December 19, 2006; Implementation:  04- 02-07)  If this service is not reasonable and necessary under 1862(a)(1)(A) of the Act (falls outside the scope of the revised NCD found in Pub. 100- 03, chapter 1, section 110.4), contractors shall advise physicians and/or hospital outpatient departments, including critical access hospitals (CAHs), that they will be held liable for charges unless the physician and/or hospital has the beneficiary sign an Advance Beneficiary Notice in advance of providing the service.   If this service is provided to a hospital inpatient, including CAHs, for a reason unrelated to the admission (outside of the bundled payment) contractors shall advise hospitals billing for inpatient services that they will be held liable for charges unless  the hospital has the beneficiary sign a Hospital Issued Notice of Noncoverage letter 11 in advance of providing the service.   200 - Billing Requirements for Vagus Nerve Stimulation (VNS)  (Rev. 1271, Issued:  06- 22-07; Effective:  05- 04-07; Implementation:  07 -23-07) 200.1 - General  (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  VNS is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve.  Electrical signals are sent from the battery -powered gen erator to the vagus nerve via the lead.  These signals are in turn sent to the brain.  FDA approved VNS for treatment of refractory epilepsy in 1999.  Further coverage guidelines can be found in the National Coverage Determination Manual (Publication 100- 03), Chapter 1, Section 160.18.  Since the HCPCS codes for VNS can also be used for other indications, contractors must determine if the service being billed are for VNS and make a determination to pay or deny.  CMS guidance on payment is listed below.  200.2 - ICD-10 Diagnosis Codes for Vagus Nerve Stimulation  (Covered  since  DOS  on and after  July 1, 1999)  (Rev. 12435, Issued:12- 28-23, Effective:01 -29-24, Implementation:01- 29-24)  One of the following diagnosis codes must be reported as appropriate, when  billing  for Vagus  Nerve Stimulation:   If ICD- 10-CM is applicable:   G40.011 Localization- related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with  status  epileptic    G40.019 Localization- related (focal) (partial) idiopathic epilepsy and  epileptic  syndromes  with seizures  of localized  onset, intractable,  without  status  epilepticus    G40.111 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic syndromes with simple partial seizures, intractable, with status  epilepticus    G40.119 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic  syndromes  with simple  partial  seizures,  intractable,  without  status  epilepticus    G40.211 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic  syndromes  with complex partial  seizures,  intractable,  with status  epilepticus    G40.219 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic syndromes with complex partial seizures, intractable, without status  epilepticus    G40.833 Dravet  syndrome, intractable,  with  status  epilepticus     G40.834 Dravet  syndrome, intractable,  without  status  epilepticus    G40.C11 Lafora progressive myoclonus epilepsy, intractable, with status epilepticus    G40.C19 Lafora progressive myoclonus epilepsy, intractable, without status epilepticus       200.3 - Carrier/MAC Billing Requirements (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  Effective for services performed on or after July 1, 1999, contractors are accepting claims submitted for vagus nerve stimulation for epilepsy and recurrent seizures.   Effective for services performed on or after July 1, 1999, CMS determined that vagus nerve stimulation is not reasonable and necessary for all other types of seizures which are refractory and for whom surgery is not recommended or for whom surgery has fail ed.  Effective for services performed on or after May 4, 2007, contractors will deny claims submitted for vagus nerve stimulation for resistant depression.  Contractors need to update their local coverage determination policy to include this new NCD determination.  There is no coverage for vagus nerve stimulation for patient with resistant depression.   200.4 - Fiscal Intermediary Billing Requirements  (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  Effective for services performed on or after July 1, 1999, contractors are accepting claims submitted for vagus nerve stimulation for epilepsy and recurrent seizures.   Effective for services performed on or after July 1, 1999, CMS determined that vagus nerve stimulation is not reasonable and necessary for all other types of seizures which are refractory and for whom surgery is not recommended or for whom surgery has fail ed.  Effective for services performed on or after May 4, 2007, contractors will reject claims submitted for vagus nerve stimulation for resistant depression.   200.5 - Medicare Summary Notice (MSN), Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Messages (Rev.11035, Issued:10 -13-21, Effective:  11-17-21; Implementation:  11-17-21)   The following messages are used by Medicare contractors when denying non - covered  VNS services:   MSN:  16.10 Medicare  does  not pay for this  item or  service."   CARC: 50 These are non -covered services because this is not deemed a medical  necessity by the payer."   The following  RARC messages  can be used  depending  on liability:   M27 Alert: The patient has been relieved of liability of payment of these  items and services under the limitation of liability provision of the law.  You, the provider, are ultimately liable for the patient's waived charges,  including any charges for coinsurance, since the  items or  services  were not  reasonable and necessary or constituted custodial care, and you knew or  could reasonably have been expected to know, that they were not covered. You may appeal this determination.  You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive  this notice. You must make  the request  through this  office.   Or  M38 Alert: The patient is liable for the charges for this service as you  informed  the patient  in writing  before  the service  was furnished that we  would  not pay for it, and the patient agreed to  pay. Contractors  will also  include  group code  CO (contractual  obligation)  or PR (patient  responsibility)  depending on liability.   200.6 - Advance Beneficiary Notice and HINN Information  (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  Physicians are liable for non -covered VNS procedures unless they issue an appropriate advance beneficiary notice (ABN).  T he following language should be included in the ABN:   Items or Service Section:  Vagas Nerve Stimulation.   Because Section:  As specified in section 160.18 of Pub.100- 03, Medicare National Coverage Determination Manual, Medicare will not pay for this procedure as it is not a reasonable and necessary treatment for (select either your type of seizure disorder or resistant depression.)   Note that the ABN is the appropriate notice for Part B services and is valid whether the language above is inserted or not.  210 - Billing Requirements for Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea (OSA)  (Rev.)   220 - Billing Requirements for Thermal Intradiscal Procedures (TIPs)  (Rev. 1646, Issued: 12- 09-08, Effective: 09 -29-08, Implementation: 01- 05-09)  220.1 - General  (Rev. 1646, Issued: 12- 09-08, Effective: 09 -29-08, Implementation: 01- 05-09)  Effective for services on or after September 29, 2008, the Center for Medicare & Medicaid Services (CMS) made the decision that Thermal Intradiscal Procedures (TIPS) are not reasonable and necessary for the treatment of low back pain. Therefore, TIPs are non-covered.  Refer to Pub.100- 03, Medicare National Coverage Determination (NCD) Manual Chapter 1, Part 2, Section 150.11, for further information on the NCD.  220.2 - Contractors, A/B Medicare Administrative Contractors (MACs)  (Rev. 1646, Issued: 12- 09-08, Effective: 09 -29-08, Implementation: 01- 05-09)  The following Healthcare Common Procedure Coding System (HCPCS) codes will be nationally non- covered by Medicare effective for dates of service on and after September 29, 2008:   22526: Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level   22527:  Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels   0062T:  Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; single level  0063T:  Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; one or more additional levels  NOTE:   The change to add the non-covered indicator for the above HCPCS codes will be part of the January 2009 Medicare Physician Fee Schedule Update.  The change to the status indicator to non-cover the above HCPCS will be part of the January Integrated Outpati ent Code Editor (IOCE) update.  Claims submitted with the non -covered HCPCS codes on or after September 29, 2008, will be denied by Medicare contractors. 220.3 - Medicare Summary Notice (MSN), Claim Adjustment Reason Code (CARC), and Remittance Advice Remark Code (RARC)  (Rev. 1646, Issued: 12- 09-08, Effective: 09-29-08, Implementation: 01-05-09)