(Medicare Claims Processing Manual)

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)  The following messages are used by Medicare contractors when denying non- covered TIP services:    MSN: 21.11  This service was not covered by Medicare at the time you received it.    CARC:  96  Non-covered charge(s)   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/med/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  220.4 - Advance Beneficiary Notice (ABN)  (Rev. 1646, Issued: 12- 09-08, Effective: 09-29-08, Implementation: 01-05-09)  Providers are liable for charges if TIPS is used in 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 AB N.  230  Billing Wrong Surgical or Other Invasive Procedures Performed on a Patient, Surgical or Other Invasive Procedures Performed on the Wrong Body Part, and Surgical or Other Invasive Procedures Performed on the Wrong Patient  (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 Centers for Medicare & Medicaid Services (CMS) internally generated a request for a national coverage analysis (NCA) to establish national coverage determinations (NCDs) addressing Medicare coverage of Wrong Surgical or Other Invasive Procedures Performed on a Patient, Surgical or Other Invasive Procedures Performed on the Wrong Body Part, and Surgical or Other Invasive Procedures Performed on the Wrong Patient.  Information regarding these NCDs can be found in Publication (Pub.) 100-03, Chapter 1, sections 140.6, 140.7, and 140.8, respectively.  Inpatient Claims   Hospitals are required to bill two claims when a surgical error is reported and a covered service is also being reported:    One claim with covered service(s)/procedure(s) unrelated to the erroneous surgery(s) on a Type of Bill (TOB) 11X (with the exception of 110), and  The other claim with the non- covered service(s)/procedure(s) related to the erroneous surgery(s) on a TOB 110 (no- pay claim)   NOTE:   Both the covered and non- covered claim shall have a matching Statement Covers Period.  For discharges prior to October 1, 2009, the non-covered TOB 110 must indicate on the 837 institutional claim format, or in the Remarks field of the Form CMS1450 one of the applicable erroneous surgery(s) two- digit codes (entered exactly as specified below ):   For a wrong surgery on patient, enter the following: MX   For a surgery on a wrong body part, enter the following: MY   For a surgery on wrong patient, enter the following: MZ   For discharges on or after October 1, 2009, the non-covered TOB 110 must have one of the following diagnosis codes reported in diagnosis position 2-9, instead of billing the aforementioned two-digit codes in Remarks:  If ICD -9-CM Is Applicable   E876.5 - Performance of wrong operation (procedure) on correct patient (existing code)   E876.6 - Performance of operation (procedure) on patient not scheduled for surgery  E876.7- Performance of correct operation (procedure) on wrong side/body part  NOTE : The above codes shall not be reported in the External Cause of Injury (E- code) field.   If ICD -10-CM Is Applicable   Y65.51 Performance of wrong procedure (operation) on correct patient  Y65.52 Performance of procedure (operation) on patient not scheduled for surgery  Y65.53 Performance of correct procedure (operation) on wrong side of body parts Outpatient, Ambulatory Surgical Centers, and Practitioner Claims   Providers are required to append one of the following applicable HCPCS modifiers to all lines related to the erroneous surgery(s):   PA: Surgery Wrong Body Part   PB: Surgery Wrong Patient  PC: Wrong Surgery on Patient  All claims   Claim/Lines submitted with a surgical error will be denied/line -item denied using the following:  Medicare Summary Notice  23.17  Medicare wont cover these services because they are not considered medically necessary.  23.17  Medicare no cubrir estos servicios porque no son considerados necesarios por razones mdicas.   Claim Adjustment Reason Code  CARC 50  These are non -covered services because this is not deemed a medical necessity by the payer.  Group Code CO  Contractual Obligation   Beneficiary Liability   Generally, beneficiary liability notices such an Advance Beneficiary Notice of Non- coverage (ABN) or a Hospital Issued Notice of Non-coverage (HINN) is appropriate when a provider is furnishing an item or service that the provider reasonably believes Medicare will not cover on the basis of 1862(a)(1).  An ABN must include all of the elements described in Pub. 100-04, Claims Processing Manual (CPM), Ch. 30, 50.6.3, in order to be considered valid.  For example, the ABN must specifically describe the item o r service expected to be denied (e.g. a left leg amputation) and must include a cost estimate for the non -covered item or service.  Similarly, HINNs must specifically describe the item or service expected to be denied (e.g. a left leg amputation) and must include all of the elements described in the instructions found in the CPM Ch. 3,0 200. Thus, a provider cannot shift financial liability for the non-covered services to the beneficiary, unless the ABN or the HINN satisfies all of the applicable requirements in the CPM Ch. 30, 50.6.3 and 200, respectively.  Given these requirements, CMS cannot envision a scenario in which HINNs or ABNs could be validly delivered in these NCD cases.  However, an ABN or a HINN could be validly delivered prior to furnishing services related to the follow -up care for the non-covered surgical error that would not be considered a related service to the non -covered surgical error.   240  Special Instructions for Services with a Gender/Procedure Conflict  (Rev. 1877, Issued: 12- 18-09, Effective: 04-01-10, Implementation: 04-05-10)  Claims for some services for beneficiaries with transgender, ambiguous genitalia, and hermaphrodite issues, may inadvertently be denied due to sex related edits unless these services are billed properly.   The National Uniform Billing Committee (NUBC) has approved condition code 45 (Ambiguous Gender Category) as a result of the increasing number of claims received that are denied due to sex/diagnosis and sex/procedure edits.  This claim level condition code should be used by institutional providers to identify these unique claims and alerts the fiscal intermediary that the gender/procedure or gender/diagnosis conflict is not an error allowing the sex related edits to be by- passed.   The KX modifier ( Requirements specified in the medical policy have been met ) is now a multipurpose informational modifier and will also be used identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses.  Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries.  Therefore, if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an error and will allow the claim to continue with normal processing.  240.1 - Billing Instructions for Institutional Providers  (Rev. 1877, Issued: 12- 18-09, Effective: 04-01-10, Implementation: 04-05-10)  Institutional providers are to report condition code 45 on any inpatient or outpatient claim related to transgender, ambiguous genitalia, or hermaphrodite issues.  240.2  Billing Instructions for Physicians and Non -Physician Practitioners  (Rev. 1877, Issued: 12- 18-09, Effective: 04 -01-10, Implementation: 04- 05-10)  The KX modifier is to be billed on the detail line only with the procedure code(s) that is gender specific for transgender, ambiguous genitalia, and hermaphrodite  beneficiaries.  (NOTE:  The KX modifier is a multipurpose informational modifier, and may also be used in conjunction with other medical policies.)   250  Pharmacogenomic Testing for Warfarin Response  (Rev. 1889, Issued:  01- 08-10; Effective Date:  08 -03-09; Implementation Date:  04- 05-10)  250.1  Coverage Requirements  (Rev. 1889, Issued:  01- 08-10; Effective Date:  08 -03-09; Implementation Date:  04- 05-10)  Effective August 3, 2009, pharmacogenomic testing to predict warfarin responsiveness is covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin; i.e., have not been previously tested for CYP2C9 or V KORC1 alleles; and have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and only then in the context of a prospective, randomized, controlled clinical study when that study meets certain criteria a s outlined in Pub 100- 03, section 90.1, of the NCD Manual.   NOTE:   A new temporary HCPCS Level II code effective August 3, 2009, G9143, warfarin responsiveness testing by genetic technique using any method, any number of specimen(s), was developed to enable implementation of CED for this purpose.  250.2  Billing Requirements  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Institutional clinical trial claims for pharmacogenomic testing for warfarin response are identified through the presence of all of the following elements:    Value Code D4 and 8- digit clinical trial number (when present on the claim) -  Refer to Transmittal 310, Change Request 5790, dated January 18, 2008;    ICD-10 diagnosis code Z00.6 (secondary) -  Refer to Transmittal 310, Change Request 5790, dated January 18, 2008; and Z79.01 (primary);    Condition Code 30 -  Refer to Transmittal 310, Change Request 5790, dated January 18, 2008;    HCPCS modifier Q0: outpatient claims only -  Refer to Transmittal 1418, Change Request 5805, dated January 18, 2008;  and,   HCPCS code G9143 (mandatory with the April 2010 Integrated Outpatient Code Editor (IOCE) and the January 2011 Clinical Laboratory Fee Schedule (CLFS) updates. Prior to these times, any trials should bill FIs for this test as they currently do absent these instructions, and the FIs should process and pay those claims  accordingly.)   Practitioner clinical trial claims for pharmacogenomic testing for warfarin response are identified through the presence of all of the following elements:          ICD-10-diagnosis code  Z00.6 (secondary), and ICD -10 diagnosis code Z79.01 (primary) MCS edit 031L70.7;   8-digit clinical trial number(when present on the claim);   HCPCS modifier Q0; and, MCS edit 031L