(Medicare Claims Processing Manual)

Effective January 1, 2000, the replacement code (CPT 69990) for modifier - 20 - microsurgical techniques requiring the use of operating microscopes may be paid separately only when submitted with CPT codes:  61304 through 61546  61550 through 61711 62010 through 62100  63081 through 63308 63704 through 63710  64831 64834 through 64836 64840 through 64858 64861 through 64871 64885 through 64891 64905 through 64907. 20.4.6 - Payment Due to Unusual Circumstances (Modifiers -22 and  -52) (Rev. 1, 10- 01-03) B3-15028  The fees for services represent the average work effort and practice expenses required to provide a service.  For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service.  Thus, A/B MACs (B) may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.  20.4.7  Technical Component Payment Reduction for X- Rays and Other Imaging Services  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18) Several provisions provide for a payment reduction to the technical component (and the technical component of the global fee) for X -rays and imaging services under certain circumstances.  Please see Chapter 13, Section 20.2 of this publication for more information.   20.5 - No Adjustments in Fee Schedule Amounts  (Rev. 1, 10- 01-03) B3-15054 A/B MACs (B) may not make adjustments in fee schedule amounts provided by CMS for:   Inherent reasonableness;   Comparability;  Multiple visits to nursing homes (i.e., when more than one patient is seen during the same trip);  Refractions -  If A/B MACs (B) receive a claim for a service that also indicates that a refraction was done, A/B MACs (B) do not reduce payment for the service.  The CMS has already made the reduction in the fee for refractions provided to A/B MACs (B);   HCPCS alpha -numeric modifiers AT (acute treatment), ET (emergency treatment), LT (left side of body), RT (right side of body), and SF (second opinion ordered by PRO);   CPT modifiers - 23 (unusual anesthesia), -32 (mandated services), - 47 (anesthesia by surgeon), - 76 (repeat procedure by same physician), and - 90 (reference laboratory); and   A/B MAC (B) -unique local modifiers (HCPCS Level 3 modifiers beginning with the letters w through z).   20.6- Update Factor for Fee Schedule Services  (Rev. 2464, Issued: 05 -04-12, Effective: 10 -01-11-MCS/10 -01-12-VMS, Implementation: 10-03-11-MCS, VMS Analysis and Design /10- 01-12-VMS implementation)   The CMS provides updates to the MPFSDB and other fee schedules annually or as otherwise necessary.  C laims processing A/B MACs (B) must maintain at least five full calendar years of fee schedules and related pricing data (i.e., the current and four prior calendar years) , regardless of the number of updates or pricing periods within those five years.   20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board  (Rev. 1, 10- 01-03) B3-15064 The delegation of authority, under which the Railroad Retirement Board (RRB) administers the Supplementary Medical Insurance Benefits Program for qualified railroad retirement beneficiaries, requires that:  The Railroad Retirement Board shall take such action as may be necessary to assure that payments made for services by the A/B MACs (A) it selects will conform as closely as possible to the payment made for comparable services in the same locality by an A/B  MAC (A) acting for CMS.  The purpose of this comparability of payment is to reduce to the extent possible disparities between the payments made by the A/B MAC (B) under the RRB delegation and the payments made by the regular A/B MACs (B) for services or items furnished by the same  physicians, including provider -based physicians, or suppliers.  For all services paid for under the physician fee schedule, A/B MACs (B) under the RRB delegation pay based on the same fee schedule amount used by the A/B MAC (B).  20.8 - Payment for Teleradiology Physician Services Purchased by the Indian Health Service (IHS) Providers and Physicians  (Rev. 1643, Issued: 12- 05-08, Effective: 01 -01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract with non- IHS physicians or practitioners for teleradiology interpretations services.  These services may be paid using either contractual reassignment or purchased test methodologies.  See Chapter 19, 120 of this manual for further information.  30 - Correct Coding Policy (Rev. 1, 10- 01-03) B3-15068 The Correct Coding Initiative was developed to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.  Refer to Chapter 23 for additional information on the initiative. The principles for the correct coding policy are:   The service represents the standard of care in accomplishing the overall procedure;   The service is necessary to successfully accomplish the comprehensive procedure.  Failure to perform the service may compromise the success of the procedure; and   The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.   For a detailed description of the correct coding policy, refer to http://www.cms.gov/Outreach-and-Education/Medicare -Learning -Network -MLN/MLNProducts/downloads/How -To-Use-NCCI -Tools.pdf .  The CMS as well as many third party payers have adopted the HCPCS/CPT coding system for use by physicians and others to describe services rendered.  The system contains three levels of codes.  Level I contains the American Medical Associations Current Pro cedural Terminology (CPT) numeric codes.  Level II contains alpha -numeric codes primarily for items and services not included in CPT.  Level III contains A/B MAC (B) specific codes that are not included in either Level I or Level II.  For a list of CPT and  HCPCS codes refer to the CMS Web site.   The following general coding policies encompass coding principles that are to be applied in the review of Medicare claims.  They are the basis for the correct coding edits that are installed in the claims processing systems effective January 1, 1996. A. Coding Based on Standards of Medical/Surgical Practice  All services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code.  Many of these generic activities are common to virtually all procedures and, on other occasions, some are integral to only a certain group of procedures, but are still essential to accomplish these particular procedures.  Accordingly, it is inappropriate to separately report these services based on standard medical and surgical principles.  Because many services are unique to individual CPT coding sections, the rationale for rebundling is described in that particular section of the detailed coding narratives that are transmitted to A/B MACs (B) periodically.  B. CPT Procedure Code Definition  The format of the CPT manual includes descriptions of procedures, which are, in order to conserve space, not listed in their entirety for all procedures.  The partial description is indented under the main entry.  The main entry then encompasses the portion of the description preceding the semicolon.  The main entry applies to and is a part of all indented entries, which follow with their codes.  In the course of other procedure descriptions, the code definition specifies other procedures that are included in this comprehensive code.  In addition, a code description may define a rebundling relationship where one code is a part of another based on t he language used in the descriptor.  C. CPT Coding Manual Instruction/Guideline  Each of the six major subsections include guidelines that are unique to that section.  These directions are not all inclusive of nor limited to, definitions of terms, modifiers, unlisted procedures or services, special or written reports, details about reporting separate, and multiple or starred procedures and qualifying circumstances. D. Coding Services Supplemental to Principal Procedure (Add -On Codes) Code  Generally, these are identified with the statement list separately in addition to code for primary procedure in parentheses, and other times the supplemental code is used only with certain primary codes, which are parenthetically identified.  The reason for these CPT codes is to enable physicians and others to separately identify a service that is performed in certain situations as an additional service.  Incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy) are not separately billed.  E. Separate Procedures  The narrative for many CPT codes includes a parenthetical statement that the procedure represents a separate procedure.  The inclusion of this statement indicates that the procedure, while possible to perform separately, is generally included in a more comprehensive procedure, and the service is not to be billed when a related, more comprehensive, service is performed.  The separate procedure designation is used with codes in the surgery (CPT codes 10000- 69999), radiology (CPT codes 70000- 79999), and medicine (CPT codes 90000- 99199) sections.  When a related procedure from the same section, subsection, category, or subcategory is performed, a code with the designation of separate procedure is not to be billed with the primary procedure.  F. Designation of Sex  Many procedure codes have a sex designation within their narrative.  These codes are not billed with codes having an opposite sex designation because this would reflect a conflict in sex classification either by the definition of the code descriptions themselves, or by the fact that the performance of these procedures on the same beneficiary would be anatomically impossible.   G. Family of Codes   In a family of codes, there are two or more component codes that are not billed separately because they are included in a more comprehensive code as members of the code family.  Comprehensive codes include certain services that are separately identifiable by other component codes.  The component codes as members of the comprehensive code family represent parts of the procedure that should not be listed separately when the complete procedure is done.  However, the component codes are considered individually if performed independently of the complete procedure and if not all the services listed in the comprehensive codes were rendered to make up the total service.  H. Most Extensive Procedures   When procedures are performed together that are basically the same or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is bundled into the more extensive procedure.  I. Sequential Procedures  An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach.  There may be separate CPT codes describing each service.  The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service.  These procedures are considered sequential procedures.  Only the CPT code for one of the services, generally the more invasive service, should be billed.  J. With/Without Procedures