(Medicare Claims Processing Manual)

380.1 -  Leadless Pacemaker Coding and Billing Requirements for Professional   Claims   380.1.1 -  Leadless Pacemaker Place of Service Restrictions   380.1.2 -  Leadless Pacemaker Modifier   380.1.3 -  Leadless Pacemaker Additional Claim Billing Information  380.2 -  Leadless Pacemaker Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Medicare Summary Notice (MSN) Messages  390  Supervised exercise therapy (SET) of Symptomatic Peripheral Artery Disease   390.1 -  General Billing Requirements   390.2 -  Coding Requirements for SET   390.3 -  Special Billing Requirements for Institutional Claims    390.4 -  Common Working File (CWF) Requirements  390.5 -  Applicable Medicare Summary Notice (MSN), Remittance Advice Remark Codes (RARC) and Claim Adjustment Reason Code (CARC) Messaging  400 -  Chimeric Antigen Receptor (CAR) T - cell Therapy   400.1 -  Coverage Requirements  400.2 -  Billing Requirements  400.2.1-  A/B Medicare Administrative Contractor (MAC) (A) Bill Types  400.2.2 -  A/B MAC (A) Revenue Codes  400.2.3 -  A/B MAC Billing Healthcare Common Procedural Coding System (HCPCS) Codes     400.2.3.1  A/B MAC (B) Places of Service (POS)  400.2.4 -  A/B MAC Diagnosis Requirements  400.2.5  Billing Information for Professional Claims  400.3 -  Payment Requirements  400.4 -  Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs),Group Codes, and Medicare Summary Notice (MSN) Messages  400.5 -  Claims Editing  410 -  Acupuncture for Chronic Low Back Pain (cLBP)  410.1 -  Coverage Requirements  410.2 -  Claims Processing General Information  410.3 -  Institutional Claims Bill Type and Revenue Coding Information  410.4  Messaging  410.5  Common Working File (CWF) Editing  411  Home Infusion Therapy Services  411.1  Policy   411.2  Coverage Requirements  411.3  Home Infusion Drugs: Healthcare Common Procedural Coding System (HCPCS) Drug Codes   411.4  Billing and Payment Requirements  411.5  Return as Un -Processable, Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages  411.6  CWF and MCS Editing Requirements      10 - Diagnostic Blood Pressure Monitoring  (Rev. 109, 02-27-04)  10.1 - Ambulatory Blood Pressure Monitoring (ABPM) Billing Requirements  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  A. Coding Applicable to A/B MACs (A and B)   Effective April 1, 2002, a National Coverage Decision was made to allow for Medicare coverage of ABPM for those beneficiaries with suspected "white coat hypertension" (WCH). ABPM involves the use of a non-invasive device, which is used to measure blood pressure in 24-hour cycles. These 24- hour measurements are stored in the device and are later interpreted by a physician. Suspected "WCH" is defined as: (1) Clinic/office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; (2) At least two documented separate blood pressure measurements taken outside the clinic/office which are < 140/ 90 mm Hg; and (3) No evidence of end -organ damage. ABPM is not covered for any other uses. Coverage policy can be found in Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 20.19. ( http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).  The ABPM must be performed for at least 24 hours to meet coverage criteria. Payment is not allowed for institutionalized beneficiaries, such as those receiving Medicare covered skilled nursing in a facility. In the rare circumstance that ABPM needs to be performed more than once for a beneficiary, the qualifying criteria described above must be met for each subsequent ABPM test.   Effective dates for applicable Common Procedure Coding System (HCPCS) codes for ABPM for suspected WCH and their covered effective dates are as follows:   HCPCS  Definition  Effective Date  93784 ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report. 04/01/2002 93786 ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only. 04/01/2002 93788 ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report. 01/01/2004    HCPCS  Definition  Effective Date  93790  ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; physician review with interpretation and report. 04/01/2002   In addition, one of the following diagnosis codes must be present:    Diagnosis  Code  Description  If ICD -10-CM is applicable  R03.0  Elevated blood pressure reading without diagnosis of hypertension   B. A/B MAC (A) Billing Instructions   The applicable types of bills acceptable when billing for ABPM services are 13X, 23X, 71X, 73X, 75X, and 85X. Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B MACs (A). The A/B MACs (A) pay for hospital outpatient ABPM services billed on a 13X type of bill with HCPCS 93786 and/or 93788 as follows: (1) Outpatient Prospective Payment System (OPPS) hospitals pay based on the Ambulatory Payment Classification (APC); (2) non- OPPS hospitals (Indian H ealth Services Hospitals, Hospitals that provide Part B services only, and hospitals located in American Samoa, Guam, Saipan and the Virgin Islands) pay based on reasonable cost, except for Maryland Hospitals which are paid based on a percentage of cost. E ffective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for ABPM.   The A/B MACs (A) pay for comprehensive outpatient rehabilitation facility (CORF) ABPM services billed on a 75x type of bill with HCPCS code 93786 and/or 93788 based on the Medicare Physician Fee Schedule (MPFS) amount for that HCPCS code.  The A/B MACs (A) pay for ABPM services for critical access hospitals (CAHs) billed on a 85x type of bill as follows: (1) for CAHs that elected the Standard Method and billed HCPCS code 93786 and/or 93788, pay based on reasonable cost for that HCPCS code; and (2) for CAHs that elected the Optional Method and billed any combination of HCPCS codes 93786, 93788 and 93790 pay based on reasonable cost for HCPCS 93786 and 93788 and pay 115% of the MPFS amount for HCPCS 93790.  The A/B MACs (A) pay for ABPM services for skilled nursing facility (SNF) outpatients billed on a 23x type of bill with HCPCS code 93786 and/or 93788, based on the MPFS.  The A/B MACs (A) accept independent and provider -based rural health clinic (RHC) bills for visits under the all -inclusive rate when the RHC bills on a 71x type of bill with revenue code 052x for providing the professional component of ABPM services. The A/ B MACs  (A) should not make a separate payment to a RHC for the professional component of ABPM services in addition to the all -inclusive rate. RHCs are not required to use ABPM HCPCS codes for professional services covered under the all -inclusive rate.   The A/B MACs (A) accept free- standing and provider -based federally qualified health center (FQHC) bills for visits under the all- inclusive rate when the FQHC bills on a 73x type of bill with revenue code 052x for providing the professional component of ABP M services.   The A/B MACs (A) should not make a separate payment to a FQHC for the professional component of ABPM services in addition to the all -inclusive rate. FQHCs are not required to use ABPM HCPCS codes for professional services covered under the all -inclusive ra te.  The A/B MACs (A) pay provider -based RHCs/FQHCs for the technical component of ABPM services when billed under the base providers number using the above requirements for that particular base provider type, i.e., a OPPS hospital based RHC would be paid for the ABPM technical component services under the OPPS using the APC for code 93786 and/or 93788 when billed on a 13x type of bill.  Independent and free -standing RHC/FQHC practitioners are only paid for providing the technical component of ABPM services when billed to the A/B MAC (B) following the MACs instructions.   A/B MAC (B)  Claims   A/B MACs (B) pay for ABPM services billed with ICD -10-CM diagnosis code R03.0 (if ICD-10 is applicable) and HCPCS codes 93784 or for any combination of 93786, 93788 and 93790, based on the MPFS for the specific HCPCS code billed.   Coinsurance and Deductible   The A/B MACs (A and B) shall apply coinsurance and deductible to payments for ABPM services except for services billed to the A/B MAC (A) by FQHCs. For FQHCs only co - insurance applies.    11 - Wound Treatments  (Rev 124a, 03-19-04)  11.1 - Electrical Stimulation  (Rev. 371, Issued 11-19- 04, Effective: 04 -01-05, Implementation: 04-04-05)  A.  Coding Applicable to Carriers & Fiscal Intermediaries (FIs)   Effective April 1, 2003, a National Coverage Decision was made to allow for Medicare coverage of Electrical Stimulation for the treatment of certain types of wounds.  The type of wounds covered are chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers.  All other uses of electrical stimulation for the treatment of wounds are not covered by Medicare.  Electrical stimulation will not be covered as an initial treatment modality.   The use of electrical stimulation will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing. If electrical stimulation is being used, wounds must be evaluated periodically by the treating physician but no less than every 30 days by a physician. Continued treatment with electrical stimulation is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.  Additionally, electrical stimulation must be discontinued when the wound demonstrates a 100% epithelialzed wound bed.  Coverage policy can be found in Pub. 100- 03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.1 (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)  The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:   HCPCS  Definition  Effective Date  G0281 Electrical Stimulation, (unattended), to one or more areas for chronic Stage III and 04/01/2003 HCPCS  Definition  Effective Date  Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.   Medicare will not cover the device used for the electrical stimulation for the treatment of wounds.  However, Medicare will cover the service. Unsupervised home use of electrical stimulation will not be covered.   B.  FI Billing Instructions   The applicable types of bills acceptable when billing for electrical stimulation services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X.  Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to FIs .  FIs pay for electrical stimulation services under the Medicare Physician Fee Schedule for a hospital, Comprehensive Outpatient Rehabilitation Facility (CORF), Outpatient Rehabilitation Facility (ORF), Outpatient Physical Therapy (OPT) and Skilled Nursing Facility (SNF).