(Medicare Claims Processing Manual)

Contractors shall not pay separately for routine costs associated with PROVENGE, HCPCS Q2043, except for the cost of administration. (Q2043 is all -inclusive and represents all routine costs except for its cost of administration).   280.5 - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs), and Group Codes (Rev. 2394, Issued: 01- 25-12, Effective: 06 -30-11 for -(claims with dates of service on or after 07 -01- 11 processed on or after July 02- 12, Implementation: 07- 02-12)  Contractors shall use the following messages when denying claims for the on- label indication for PROVENGE, HCPCS Q2043, submitted without ICD -9-CM diagnosis code 185 and at least one diagnosis code from the ICD -9 table in Section 280.2 above:   MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.  Spanish Version -  Medicare no puede pagar por este servicio debido al diagnstico indicado en la reclamacin.   RARC 167 -  This (these) diagnosis (es) are not covered. Note: Refer to the 835 Healthcare Policy Identification segment (loop 2110 Service Payment Information REF), if present.   Group Code  CO (Contractual Obligation)   Contractors shall use the following messages when denying claims for the off -label indication for PROVENGE, HCPCS Q2043, submitted without ICD -9-CM diagnosis code 233.4:   MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.  Spanish Version -  Medicare no puede pagar por este servicio debido al diagnstico indicado en la reclamacin.   RARC 167 -  This (these) diagnosis (es) are not covered. Note: Refer to the 835 Healthcare Policy Identification segment (loop 2110 Service Payment Information REF), if present.   Group Code  CO (Contractual Obligation)   For claims with dates of service on or after July 1, 2012, processed on or after July 2, 2012, when denying claims for PROVENGE, HCPCS Q2043 that exceed three (3) services in a patients lifetime, contractors shall use the following messages:  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   RARC N362 -  The number of Days or Units of Service exceeds our acceptable maximum.  CARC 149 -  Lifetime benefit maximum has been reached for this service/benefit category.  Group Code  CO ( Contractual Obligation)       290  Transcatheter Aortic Valve Replacement (TAVR)  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)  Transcatheter aortic valve replacement (TAVR -  also known as TAVI or transcatheter aortic valve implantation) is used in the treatment of aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the aortic valve.   The most recent reconsideration of the TAVR policy is effective for claims with dates of service on and after June 21, 2019. It makes changes to the criteria for the heart team and the hospital, and to the trial outcomes and the registry questions/criteria . Please see Publication 100-03, National Coverage Determination Manual Part 1, section 20.32, for complete national policy criteria.   HISTORICAL NOTE: CR 7897, Transmittal (TR) 2552, issued September 24, 2012, implemented the initial NCD for TAVR, effective May 1, 2012. CR 8168, TR 2628, issued January 7, 2013, implemented replacement coding to TAVR effective January 1, 2013. CR 8255, TR  2737, issued July 11, 2013, implemented clinical trial number reporting effective July 1, 2013. CR 8537, TR 2827, issued November 29, 2013, implemented replacement CPT coding effective January 1, 2013.   290.1  Coding Requirements for TAVR Furnished on or After May 1, 2012, through December 31, 2012  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)  The following are the applicable Current Procedural Terminology (CPT) codes for TAVR:   0256T: Implantation of catheter -delivered prosthetic aortic heart valve; endovascular approach   0257T: Implantation of catheter -delivered prosthetic aortic heart valve; open thoracic approach (eg, transapical, transventricular)   0258T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter -delivered aortic valve replacement; without cardiopulmonary bypass   0259T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter -delivered aortic valve replacement; with cardiopulmonary bypass   The following are the International Classification of Diseases (ICD) -9 procedure codes applicable for TAVR:   35.05: Endovascular replacement of aortic valve  35.06: Transapical replacement of aortic valve   The following are the ICD -10 procedure codes applicable for TAVR:   35.05: 02RF37Z, 02RF38Z. 02RF3JZ, 02RF3KZ  35.06: 02RF37H, 02RF38H, 02RF3JH, 02RF3KH   290.1.1 - Coding Requirements for TAVR Services Furnished on or After January 1, 2013  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)  Beginning January 1, 2013, the following are the applicable CPT codes for TAVR:   33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach   33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral approach   33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach   33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach   33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (e.g., median sternotomy, mediastinotomy)   0381T Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical approach (e.g., left thoracotomy)   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014, shall instead use permanent CPT code 33366.   290.2 - Claims Processing Requirements for TAVR Services on Professional Claims (Rev. 10179, Issued: 06 -10-20, Effective: 06-21-19, Implementation: 06-12-20)  Place of Service (POS) Professional Claims   Effective for claims with dates of service on and after May 1, 2012, place of service (POS) code 21 shall be used for TAVR services. All other POS codes shall be denied.   The following messages shall be used when Medicare contractors deny TAVR claims for POS:   Claim Adjustment Reason Code (CARC) 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), i f present.   Remittance advice remark code (RARC) N428: Not covered when performed in this place of service. Beginning January 2, 2020, contractors shall no longer report RARC N428 for claims denied for invalid POS.  Medicare Summary Notice (MSN) 21.25: This service was denied because Medicare only covers this service in certain settings.   Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   Professional Claims Modifier -62   For TAVR claims with dates of service on or after July 1, 2013, contractors shall pay claim lines with 33361, 33362, 33363, 33364, 33365 & 0318T only when billed with modifier -62. Claim lines billed without modifier -62 shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without modifier -62 as unprocessable:   CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N29: Missing documentation/orders/notes/summary/report/chart. Beginning January 2, 2020, contractors shall no longer report RARC N29 on remittance for claims billed without modifier -62 and returned as unprocessable.  RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   Professional Claims Modifier - Q0   For claims with dates of service on or after January 1 , 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with modifier-Q0. Claim lines billed without modifier -Q0 shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014, shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without modifier -Q0 as unprocessable:   CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N29: Missing documentation/orders/notes/summary/report/chart. Beginning January 2, 2020, contractors shall no longer report RARC N29 on remittance for claims billed without modifier Q0 and returned as unprocessable.  RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   Diagnosis Coding  For claims with dates of service  on or after July 1, 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with diagnosis code V70.7 (ICD-10 Z00.6). Claim lines billed without diagnosis code V70.7 (ICD-10  Z00.6) shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without diagnosis code V70.7 (ICD-10 Z00.6) as unprocessable:   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).   RARC M76: Missing/incomplete/invalid diagnosis or condition   RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.