(Medicare Claims Processing Manual)

Under Part B, providers must bill HCPCS procedure code 37799. If above ICD -10-CM is applicable.    NOTE: ICD-  codes are subject to modification. Providers must always ensure they are  using the latest and most appropriate codes.   170 - Billing Requirements for Lumbar Artificial Disc Replacement  (Rev. 992, Issued: 06- 23-06, Effective: 05 -16-06, Implementation: Carriers 07- 17-06/FIs 10- 01-06)  170.1 - General  (Rev. 1340, Issued: 09- 21-07, Effective: 08 -14-07, Implementation: 10- 01-07)  Effective for services performed from May 16, 2006 through August 13, 2007, the Centers for Medicare & Medicaid Services (CMS) made the decision that lumbar artificial disc replacement (LADR) with the ChariteTM lumbar artificial disc is non -covered for Medicare beneficiaries over 60 years of age.  See Pub. 100-03, Medicare National Coverage Determinations Manual, section 150.10, for more information about the non-covered determination.   Effective for services performed on or after  August 14, 2007, CMS made the decision that LADR with any lumbar artificial disc is non -covered for Medicare beneficiaries over 60 years of age, (i.e., on or after a beneficiarys 61st birthday).  For Medicare beneficiaries 60 years of age and younger, there is no national coverage determination for LADR, leaving such determinations to continue to be made by the local contractors.   170.2 - Carrier Billing Requirements  (Rev. 11902; Issued:03- 16-23; Effective: 04 -17-23; Implementation: 04 -17-23)  Effective for services performed on or after  May 16, 2006 through December 31, 2006, carriers shall deny claims, for Medicare beneficiaries over 60 years of age, submitted with the following Category III Codes:    0091T  Single interspace, lumbar; and   0092T  Each additional interspace (List separately in addition to code for primary procedure.)  Effective for services performed on or after  January 1, 2007 through August 13, 2007, for Medicare beneficiaries over 60 years of age, LADR with the ChariteTM lumbar artificial disc, carriers shall deny claims submitted with the following codes:    22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace    0163T  Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace. NOTE: Effective December 31, 2022, code 0163T is end dated.    Carriers shall continue to follow their normal claims processing criteria for IDEs for LADR performed with an implant eligible under the IDE criteria.   For dates of service May 16, 2006 through August 13, 2007, Medicare coverage under the investigational device exemption (IDE) for LADR with a disc other than the ChariteTM lumbar disc in eligible clinical trials is not impacted.  Effective for services performed on or after  August 14, 2007, carriers shall deny claims for LADR surgery, for Medicare beneficiaries over 60 years of age, (i.e., on or after a beneficiarys 61st birthday) submitted with the following codes:    22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace   0163T     Total disc arthroplasty (artificial disc), anterior approach, including                  discectomy to prepare interspace (other than for decompression), lumbar, each    additional interspace NOTE: Effective December 31, 2022, code 0163T is end   dated.   22860 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar. Effective 01/01/23  170.3 - A/B MAC (A)  Billing Requirements  (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 A/B MAC (A) will pay for LADR when approved under the IDE/clinical trial criteria only when submitted with ICD -9-CM procedure code 84.65 if ICD -9 is applicable,  with condition code 30 and if ICD -9-CM is applicable , ICD-9-CM diagnosis code V70.7  when submitted on type of bill (TOB) 11X from May 16, 2006 through August 13, 2007.  Special Billing instructions:  For services performed on TOB 11X in critical access hospitals (CAH), the payment will be 101% of reasonable cost.   For services performed on TOB 11X Indian Health Services (IHS) inpatient hospitals will pay under the inpatient prospective payment system (IPPS) based on the DRG.  For services performed on TOB 11X, IHS CAHs will pay under 101% facility specific per diem rate.   NOTE:   The ICD -9-CM procedure code 84.65 is not payable for beneficiaries over 60 years of age, with the ChariteTM lumbar artificial disc, which is the only one that is FDA approved for any diagnosis.  If a different manufactures disc is used in an approved clinical trials or is an approved IDE, then condition code 30 and ICD-9-CM diagnosis code V70.7 must be on the claim for it to be payable.   Effective for discharges on or after August 14, 2007, CMS has found that LADR is not reasonable and necessary for the Medicare population over 60 years of age.  Therefore, LADR is non- covered for Medicare beneficiaries over 60 years of age as identified in section 150.10, of Pub.100- 03, the NCD Manual.  A/B MACS (A) shall deny claims with ICD -9-CM procedure code 84.65 for Medicare beneficiaries over 60 years of age.   For Medicare beneficiaries 60 years of age and younger, there is no NCD, leaving such determinations to continue to be made by the local contractors.   170.4  Reasons for Denial and Medicare Summary Notice (MSN), Claim Adjustment Reason Code Messages, and Remittance Advice Remark Code  (Rev. 1340, Issued: 09- 21-07, Effective: 08 -14-07, Implementation: 10- 01-07)  Contractors shall use the following messages when denying claims for Medicare beneficiaries over 60 years of age (i.e. on or after a beneficiarys 61st birthday).  21.24 This service is not covered for patients over age 60.    Este servicio no est cubierto en pacientes mayores de 60 aos.   Use an appropriate Claim Adjustment Reason Code:   96 "Non -covered charge(s)."   Use an appropriate Remittance Advice Remark Code:   N386  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp.  If you do not have Web access, you may contact the contractor to request a copy of the NCD.   170.5 - Advance Beneficiary Notice (ABN) and Hospital Issued Notice of Noncoverage (HINN) Information  (Rev. 1340, Issued: 09- 21-07, Effective: 08 -14-07, Implementation: 10- 01-07)  Providers must be advised that the provider is liable for charges if the lumbar artificial disc replacement is used in the surgery, unless the beneficiary was informed that he/she would be financially responsible prior to performance of the procedure.  To avoid this liability the provider should have the beneficiary sign an ABN.  The HINN model language should be adapted to this situation in the sections addressing description of the care at issue if the surgery is performed on an inpatient basis. Unless the beneficiary was informed prior to the admission that he/ she would be fina ncially liable for the admission, the provider is liable.  To avoid this liability the provider must issue a HINN. Other content requirements of a HINN still apply. Use the HINN letter most appropriate to the overall situation.   180  Cryosurgery of the Prostate Gland  (Rev. 1111, Issued: 11- 09-06, Effective: 04 -01-07, Implementation: 04- 02-07)  Cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CAP), destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the prostate gland.  180.1 - Coverage Requirements  (Rev. 1111, Issued: 11- 09-06, Effective: 04 -01-07, Implementation: 04- 02-07)  Medicare covers cryosurgery of the prostate gland effective for claims with dates of service on or after July 1, 1999.  The coverage is for:   1. Primary treatment of patients with clinically localized prostate cancer, Stages T1  T3 (diagnosis code is 185  malignant neoplasm of prostate).   2. Salvage therapy (effective for claims with dates of service on or after July 1, 2001 for patients:   a. Having recurrent, localized prostate cancer;   b. Failing a trial of radiation therapy as their primary treatment; and   c. Meeting one of these conditions:  State T2B or below; Gleason score less than 9 or; PSA less than 8 ng/ml.  180.2 - Billing Requirements (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)  Claims for cryosurgery for the prostate gland are to be submitted on the ASC X12 837, or, in exceptional circumstances, on a hard copy Form CMS  1450.  This procedure can be rendered in an inpatient or outpatient hospital setting (types of bill (TOBs) 11x  13x, 83x, and 85x).  The A/B MAC (A) will look for the following when processing claims with cryosurgery services:   If ICD -9-CM is applicable, ICD-9 CM diagnosis code 185 or    If ICD -10-CM is applicable, ICD-10 CM diagnosis code C61 must be on all cryosurgical claims;   For outpatient claims HCPCS 55873 and revenue codes 0360, 0361, or 0369 Cryosurgery ablation of localized prostate cancer, stages T1 - T3 (includes ultrasonic guidance for interstitial cryosurgery probe placement, postoperative irrigations and aspiration of sloughing tissue included) must be on all outpatient claims; and    For inpatient claims correct procedure codes are:   o If ICD -9-CM is applicable, ICD-9-CM procedure code 60.62 (perineal prostatectomy- the definition includes cryoablation of prostate, cryostatectomy of prostate, and radical cryosurgical ablation of prostate)   o If ICD -10 is applicable,ICD-10-PCS procedure code 0V500ZZ (Destruction of Prostate, Open Approach), or 0V503ZZ (Destruction of Prostate, Percutaneous Approach), or 0V504ZZ (Destruction of Prostate, Percutaneous Endoscopic Approach).  180.3  Payment Requirements  (Rev. 1111, Issued: 11- 09-06, Effective: 04-01-07, Implementation: 04-02-07)  This service may be paid as a primary treatment for patients with clinically localized prostate cancer, Stages T1  T3.  The ultrasonic guidance associated with this procedure will not be paid for separately, but is bundled into the payment for the surgical procedure.  When one provider has furnished the cryosurgical ablation and another the ultrasonic guidance, the provider of the ultrasonic guidance must seek compensation from the provider of the cryosurgical ablation.