(Medicare Claims Processing Manual)

Coverage is denied when billed with the below Nationally Non- Covered ICD -10-CM codes   Nationally Non -Covered ICD -10-CM codes:   H35.30  Unspecified macular degeneration  H35.3110 Nonexudative age-related macular degeneration, right eye, stage unspecified  H35.3111 Nonexudative age -related macular degeneration, right eye, early dry stage  H35.3112 Nonexudative age -related macular degeneration, right eye, intermediate dry stage  H35.3113 Nonexudative age -related macular degeneration, right eye, advanced atrophic without subfoveal involvement  H35.3114 Nonexudative age -related macular degeneration, right eye, advanced atrophic with subfoveal involvement  H35.3120 Nonexudative age -related macular degeneration, left eye, stage unspecified  H35.3121 Nonexudative age -related macular degeneration, left eye, early dry stage  H35.3122 Nonexudative age -related macular degeneration, left eye, intermediate dry stage  H35.3123 Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement  H35.3124 Nonexudative age -related macular degeneration, left eye, advanced atrophic with subfoveal involvement  H35.3130 Nonexudative age -related macular degeneration, bilateral, stage unspecified  H35.3131 Nonexudative age -related macular degeneration, bilateral, early dry stage  H35.3132 Nonexudative age -related macular degeneration, bilateral, intermediate dry stage  H35.3133 Nonexudative age -related macular degeneration, bilateral, advanced atrophic without subfoveal involvement  H35.3134 Nonexudative age -related macular degeneration, bilateral, advanced atrophic with subfoveal involvement    Payment for OPT service (CPT code 67221/67225) must be billed on the same claim as the drug (J3396) for the same date of service.   Claims for OPT with Verteporfin for dates of service prior to April 3, 2013 are covered at the initial visit as determined by a fluorescein angiogram (FA) CPT code 92235 . Subsequent follow -up visits also require a FA prior to treatment.   For claims with dates of service on or after April 3, 2013, contractors shall accept and process claims for subsequent follow -up visits with either a FA, CPT code 92235, or optical coherence tomography (OCT), CPT codes 92133 or 92134, prior to treatment.   Regardless of the date of service of the claim, the FA or OCT is not required to be submitted on the claim for OPT and can be maintained in the patients file for audit purposes.   300.3 - Claims Processing Requirements for OPT with Verteporfin Services on Inpatient Facility Claims  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Inpatient facilities shall report ICD -10-CM codes H35.3210- H35.3233 (Exudative Age -related Macular Degeneration) and ICD -10-PCS codes 085E3ZZ (Destruction of Right Retina, Percutaneous Approach) and 085F3ZZ (Destruction of Left Retina, Percutaneous Approac h)   300.4 - Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages (Rev. 2728, Issued: 06- 14-13, Effective: 04 -03-13, Implementation: 07- 16-13)  The following message shall be used to notify beneficiaries and providers of denial situations that may occur:   MSN 14.9: Medicare cannot pay for this service for the diagnosis shown on the claim.  (English version) or Medicare no puede pagar por este servicio debido al diagnostic indicado en la reclamacion. (Spanish Version)   Claims Adjustment Reason Code B22:  This payment is adjusted based on the diagnosis.   310 - Transesophageal Doppler Used for Cardiac Monitoring  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  Effective May 17, 2007, Transesophageal Doppler used for cardiac monitoring is covered for ventilated patients in the ICU and operative patients with a need for intra -operative fluid optimization was deemed reasonable and necessary.  See National Coverage Determinations Manual (Pub. 100- 03) 220.5, for complete coverage guidelines.   A new Healthcare Common Procedure Coding System (HCPCS) code, G9157, Transesophageal Doppler used for cardiac monitoring, will be made effective for use for dates of service on or after January 1, 2013.   310.1 - Coding Requirements for T ransesophageal Doppler Cardiac Monitoring  Furnished Before January 1, 2013  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  Prior to January 1, 2013, the applicable HCPCS code for Transesophageal Doppler cardiac monitoring is:   HCPCS 76999 (billed with modifier - 26) when performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization.   If globally billed using code 76999, it shall be returned as unprocessable to the provider using a claim adjustment reason code (CARC) such as:    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), if present.   HCPCS 76999 (billed with modifier - TC) shall be denied when performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization with a message such as:    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), if present.    RARC M77: Missing/incomplete/invalid place of service.   MSN 17.9: Medicare (Part A/Part B) pays for this service. The provider must bill the correct Medicare contractor. (English version) or Este servicio es pagado por Medicare (Parte A/Parte B). El proveedor debe enviar la facture al contratista de Medicare correcto.(Spanish version).  HCPCS 76999 (billed globally or with - 26 or - TC) when performed in an ASC setting for operative patients with a need for intra -operative fluid optimization, ultrasound diagnostic procedures are covered when performed by an entity  other than the ASC.  310.2 - Coding Requirements for T ransesophageal Doppler Cardiac Monitoring  Furnished On or After January 1, 2013  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  After January 1, 2013, the applicable HCPCS code for Transesophageal Doppler cardiac monitoring is:   HCPCS G9157 : Transesophageal Doppler used for cardiac monitoring  Contractors shall allow HCPCS G9157 to be billed when services are provided in POS 21 for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization.   Contractors shall deny HCPCS 76999 when billed for Esophageal Doppler for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization using the following messages:    CARC 189: Not otherwise classified or unlisted procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.    RARC M20: Missing/incomplete/invalid HCPCS.    MSN 16.13: The code(s) your provider used is/are not valid for the date of service billed. (English version) or El/los cdigo(s) que us su proveedor no es/son vlido(s) en la fecha de servicio facturada. (Spanish version).    Group Code: Contractual Obligation (CO)   310.3 - Correct Place of Service (POS) Code for T ransesophageal Doppler Cardiac Monitoring  Services on Professional Claims  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  Contractors shall pay for T ransesophageal Doppler cardiac monitoring , G9157, only when services are provided at POS 21.  Contractors shall deny HCPCS G9157 when billed globally in any POS other than 21 for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization using the following messages:   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), if present.   MSN 16.2:   This service cannot be paid when provided in this location/facility.  Group Code: CO   320 - Artificial Hearts and Related Devices  (Rev.10837; Issued: 06- 11-21; Effective: 12 -01-20; Implementation: 07 -27-21)  Effective for claims with dates of service on or after December 1, 2020, as a result of a reconsideration of National Coverage Determination (NCD) 20.9 of the Medicare NCD Manual, coverage determinations for artificial hearts and related devices shall be m ade by the Medicare Administrative Contractors.    320.1  Coding Requirements for Artificial Hearts Furnished Before May 1, 2008 (Rev. 3054, Issued: 08- 29-14, Effective: 10 -30- 13, Implementation: 09 -30-14)  Effective for discharges before May 1, 2008, Medicare does not cover the use of artificial hearts, either as a permanent replacement for a human heart or as a temporary life-support system until a human heart becomes available for transplant (often referred to a "bridge to transplant").   320.2  Coding Requirements for Artificial Hearts Furnished On or After May 1, 2008 (Rev. 3054, Issued: 08- 29-14, Effective: 10-30- 13, Implementation: 09-30-14)   Effective for discharges on or after May 1, 2008, the use of artificial hearts will be covered by Medicare under Coverage with Evidence Development (CED) when beneficiaries are enrolled in a clinical study that meets all of the criteria listed in IOM Pub. 100- 03, Medicare NCD Manual, section 20.9.  Claims Coding