(Medicare Claims Processing Manual)

 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   HCPCS code G9143 (to be carrier priced for claims with dates of service on and after August 3, 2009, that are processed prior to the January 2011 CLFS update.)   NOTE: This NCD does not determine coverage to identify CYP2C9 or VKORC1 alleles for other purposes beside warfarin responsiveness, nor does it determine national coverage to identify other alleles to predict warfarin responsiveness. These decisions are made at the local MAC level.   250.3  Payment Requirements  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  Beginning April 5, 2010, for claims with dates of service on and after August 3, 2009, the Medicare Shared System will track the number of times a beneficiary receives pharmacogenomic testing for warfarin response. When a claim is received for pharmacogeno mic testing for warfarin response, and the shared system has determined that the beneficiary has already received the test in his/her lifetime, it will generate a Medicare line-item denial and the Medicare contractor will provide the following messages to enforce the one- time limitation for the test:  Claim Adjustment Reason Code (CARC) 50  These are non -covered services because this is not deemed a medical necessity by the payer. This change to be effective April 1, 2010: These are non -covered services because this is not deemed a medical necessity by the payer.   NOTE: Refer to the 835 Healthcare Policy Identification Segment, if present.  Remittance Advice Remark Code (RARC) N362   The number of Days or Units of Service exceeds our acceptable maximum.   Group Code CO  Contractual Obligation   Medicare Summary Notice (MSN) 16.76   This service/item was not covered because you have exceeded the lifetime limit for getting this service/item. (Este servicio/artculo no fue cubierto porque usted ya se ha pasado del lmite permitido de por vida, para recibirlo.).  The Medicare shared system and the A/B MACs (B) will also ensure that pharmacogenomic testing for warfarin response is billed in accordance with clinical trial reporting requirements. In other words, the shared system and the A/B MACs (B) will return to provider/return as unprocessable lines for pharmacogenomic testing for warfarin response when said line is not billed with HCPCS modifier Q0 and ICD-10- CM diagnosis code if applicable, ICD -10-CM Z00.6 is not present as a secondary diagnosis. When the system or the A/B MAC (B) initiates the line - item return to provider or returns the claim as unprocessable, the Medicare contractor will respond with the following messages:  For a missing Q0 modifier: CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.   For a missing Z00.6 diagnosis code when a HCPCS Q0 modifier is reported with  HCPCS G9143:  CARC 16  - Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)  Remark Code M64 - Missing/incomplete/invalid other diagnosis.   For either a missing Q0 modifier and/or a missing ICD-10-CM Z00.6 diagnosis code:  Group Code CO- Contractual Obligation   MSN 16.77  This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.)  260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS) (Rev. 2105, Issued: 11- 24-10, Effective: 03-23-10, Implementation: 07-06-10)  260.1  Policy (Rev. 2105, Issued: 11- 24-10, Effective: 03-23-10, Implementation: 07-06-10)  The Centers for Medicare & Medicaid Services (CMS) received a request for national coverage of treatments for facial lipodystrophy syndrome (LDS) for human immunodeficiency virus (HIV)- infected Medicare beneficiaries.  Facial LDS is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks.  This fat loss can arise as a complication of HIV and/or highly active antiretroviral therapy.  Due to their appearance and stigma of the condition, patients with facial LDS may become depressed, socially isolated, and in some cases may stop their HIV treatments in an attempt to halt or reverse this complication.   Effective for claims with dates of service on and after March 23, 2010, dermal injections for facial LDS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration for this purpose, and then only in HIV- infected beneficiaries who manifest depression secondary to the physical stigmata of HIV treatment.  See Pub. 100-03, National Coverage Decision manual, section 250.5, for detailed policy information concerning treatment of LDS.  260.1.1  Hospital Billing Instructions  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  A - Hospital Outpatient Claims   For hospital outpatient claims, hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:   1. A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March 23, 2010,               NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014 HCPCS update.   2. A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,   3. If ICD -10-CM is applicable, ICD-10-CM diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 Lipodystrophy, not elsewhere classified       The applicable NCD is 250.5 Facial Lipodystrophy.  B - Outpatient Prospective Payment System (OPPS) Hospitals or Ambulatory Surgical Centers (ASCs):   For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026 and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800, instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.      NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014, HCPCS update.   C - Hospital Inpatient Claims   Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:   C. Discharge date on or after March 23,  2010,  D. If ICD -10-PCS is  applicable,    ICD-10-PCS procedure code 3E00XGC Introduction of Other Therapeutic Substance into Skin and Mucous Membrances, External Approach, or  E. If ICD -10-CM is  applicable on or after 10/01/2015,     ICD-10-CM diagnosis codes B20 Human Immunodeficiency Virus [HIV] disease and E88.1 Lipodystrophy not elsewhere classified.   A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractors policy.   260.2 Billing Instructions  (Rev. 2105, Issued: 11- 24-10, Effective: 03-23-10, Implementation: 07-06-10)  260.2.1  Hospital Billing Instructions  (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)  A - Hospital Outpatient Claims   For hospital outpatient claims, hospitals must bill covered d ermal injections for treatment of facial LDS by having all of the required elements on the claim:   A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March 23, 2010,   A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,    If ICD -9-CM is applicable,  ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Lipodystrophy) or,   If ICD-10-CM is applicable, ICD -10-CM diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 Lipodystrophy, not elsewhere classified   The applicable NCD is 250.5 Facial Lipodystrophy.  B - Outpatient Prospective Payment System (OPPS) Hospitals or Ambulatory Surgical Centers (ASCs):   For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026 and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800, instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.  C - Hospital Inpatient Claims   Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:    Discharge date on or after March 23, 2010,   If ICD -9-CM is applicable,    o ICD-9-CM procedure code 86.99 (other operations on skin and subcutaneous tissue, i.e., injection of filler material), or  o ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Lipodystrophy)   If ICD -10-PCS is applicable,    o ICD-10-PCS procedure code 3E00XGC Introduction of Other Therapeutic Substance into Skin and Mucous Membrances, External Approach, or   o ICD-10-CM diagnosis codes B20 Human Immundodeficiency Virus [HIV] disease and E88.1 Lipodystrophy not elsewhere classified.  A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractors policy.  260.2.2  Practitioner Billing Instructions  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  Practitioners must bill covered claims for dermal injections for treatment of facial LDS by having all of the required elements on the claim:  Performed in a non- facility setting :   A line with HCPCS codes Q2026 or Q2027 with a LIDOS on or after March 23, 2010,    NOTE : Q2027 is replaced with Q2028 effective 1/1/14 per the 2014 HCPCS update.   A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,   51 If ICD -10-CM applies, diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 (Lipodystrophy not elsewhere  classified). Both diagnoses are required on the claim.   NOTE: A diagnosis code for a comorbidity of depression may also be required for coverage based on the individual Medicare contractors policy.