(Medicare Claims Processing Manual)

Group Code CO   MSN 15.060 - The information provided does not support the need for this many services or items within this period of time.   Spanish Version - (La informacin proporcionada no confirma la necesidad de estos servicios o artculos en este periodo de tiempo.)  -- Contractors shall reject claims for allogeneic CAR T -cell therapy ICD -10-PCS codes XW033G7 and XW043G7 and autologous CAR T -cell therapy ICD -10-PCS codes XW033C7 and XW043C7 when not billed for clinical trials under NCD 310.1 with the NCT number for the specific trial, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after October 1, 2021, using the following messages:   CARC 55: Procedure/treatment/drug is deemed experimental/investigational by the payor.  Group Code: CO  MSN 16.77  This service/item was not covered because it was not provided as part of a qualifying trial/study.   Spanish Version  (Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.)   In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.   400.5 - Claims Editing (Rev. 11721; Issued: 11-28-22; Effective: 01 -01-23; Implementation: 01-03-23)  A. Fee- For-Service Medicare   Medicare edits CAR T -cell therapy claims based on requirements found in NCD 110.24.   B. Beneficiaries enrolled in Medicare Advantage (MA) plans   Effective for clams with dates of service on and after August 7, 2019, CMS determined that the NCD requiring coverage of CAR T -cell therapy for cancer is a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. As a result, for CYs 2019 (beginning August 7, 2019) and 2020 only, original fee- for-service Medicare will pay for CAR T- cell therapy for cancer obtained by beneficiaries enrolled in Medicare Advantage (MA) plans when the coverage criteria outlined in the NCD are met. Plans should account for CAR T- cell therapy for cancer items and services in their contract year 2021 bids.   Consistent with 1862 (t)(2) of the Act, MACs will pay for CAR T- cell therapy for cancer for Medicare beneficiaries enrolled in MA plans in CYs 2019 (beginning August 7, 2019) and 2020.  410  Acupuncture for Chronic Low Back Pain (cLBP)  (Rev.  10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06 -24 - 20 - A/B MACs; 10 -05-20- SSM Edits; 01 - 04-21 - BR 13 CWF only)  Acupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or needling, or other non-needling techniques focused on these points.    410.1 - Coverage Requirements  (Rev.  10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06 -24 - 20 - A/B MACs; 10 -05-20- SSM Edits; 01 - 04-21 - BR 13 CWF only)  Effective for services on or after January 21, 2020, the Centers for Medicare & Medicaid Services ( CMS) will cover acupuncture for chronic low back pain (cLBP) under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:   For the purpose of this decision, cLBP is defined as:  o Lasting 12 weeks or longer; o nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);  o not associated with surgery; and o not associated with pregnancy.  An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Example: If the 1st service is performed on March 21, 2020, the next service beginning a new year cannot be performed until March 1, 2021. This means 11 full months must pass from the date of the 1st service before eligibility begins again.  All types of acupuncture including dry needling for any condition other than cLBP are non- covered by Medicare.   410.2  Claims Processing General Information  (Rev.  10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06 -24 - 20 - A/B MACs; 10 -05-20- SSM Edits; 01 - 04-21 - BR 13 CWF only)  Effective for claims with dates of service (DOS) on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported with CPT codes 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under National Coverage Determ ination (NCD) 30.3.3 no more than 20 times per annum.  NOTE: If the 1st service is performed on March 21, 2020, the next service beginning a new year cannot be performed until March 1, 2021, 11 full months following the 1st service.   The attached includes the International Classification of Diseases (ICD) -10 diagnosis codes are applicable and must be reported for acupuncture for cLBP services:   Contractors shall accept and process acupuncture for cLBP claims with the - KX modifier  for the 13th through 20th service per annum.   NOTE: The 1st through 12th service over a 90- day period do not require the KX modifier. There is a 20 service maximum per annum for this benefit.   NOTE: By applying the - KX modifier to the claim, the therapy provider is confirming that the additional services are medically necessary as justified by appropriate documentation in the medical record.    410.3  Institutional Claims Bill Type and Revenue Coding Information  (Rev.  10337, Issued: 08- 027-20, Effective: 01 -21-20, Implementation:  06-24 - 20 - A/B MACs; 10 -05-20-SSM Edits; 01 - 04-21 - BR 13 CWF only)   Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported on institutional claims on types of bill (TOBs) 12X, 13X, 71X, 77X, and 85X (and revenue codes not equal to 096X, 097X, and 098X for CAH Method I).    Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported with Revenue Code 0940 on institutional claims.  Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported on institutional claims on TOB 12X, 71X, 77X 85X CAH Method II with revenue codes 096X, 097X, and 098X.  410.4  Messaging (Rev.  10337, Issued: 08- 027-20, Effective: 01 -21-20, Implementation:  06-24 - 20 - A/B MACs; 10 -05-20-SSM Edits; 01 - 04-21 - BR 13 CWF only)   Effective for claims with DOS on or after January 21, 2020, contractors shall reject/deny claims that do not contain the appropriate diagnosis/procedure coding noted in section 410.2 and use these messages:   Claim Adjustment Reason Code (CARC) 50 -  These are non -covered services because this is not deemed a 'medical necessity' by the payer.   Remittance Advice Remark Code (RARC) M64   Missing/incomplete/invalid other diagnosis.  Group Code CO (Contractual Obligations) or PR (Patient Responsibility) dependent on liability.  MSN 15.20 -  The following polices were used when we made this decision: NCD 30.3.3.  Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 30.3.3.  NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  In addition to the codes noted in section 410.2, contractors shall afford appeal rights to all denied parties.   Contractors shall return to provider/return as unprocessable claims for acupuncture for cLBP for services 13 through 20 per annum without the - KX modifier and use these messages:   CARC 4 -  The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N657 -  This should be billed with the appropriate code for these services.  Group Code CO    Contractors shall reject/deny more than 20 claims per annum for acupuncture  for cLBP and use the following messages:   CARC 96 -  Non -covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segme nt (loop 2110 Service Payment Information REF), if present.   RARC N640 -  Exceeds number/frequency approved/allowed within time period.  Group Code -  CO (Contractual Obligation)   MSN 15.20 -  The following polices were used when we made this decision: NCD 30.3.3.   Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 30.3.3.   MSN 15.19: We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage -database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doc tor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare -coverage -database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.   NOTE: Due to system requirements, the Fiscal Intermediary Shared System has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  410.5  Common Working File (CWF) FISS, and Multi- Carrier System (MCS) Editing (Rev.  10337, Issued: 08- 027-20, Effective: 01 -21-20, Implementation:  06-24 - 20 - A/B MACs; 10 -05-20-SSM Edits; 01 - 04-21 - BR 13 CWF only)   The Common Working File (CWF) shall create a new reject for claims with DOS on and after January 21, 2020, for claims received on or after October 5, 2020, to not allow payment for more than 20 acupuncture for cLBP claims per annum.  For acupuncture for cLBP claims CWF, FISS and the Multi -Carrier System (MCS) shall apply appropriate updates to the Next Eligibility Date file for DOS on or after January 21, 2020.   NOTE : Appropriate updates include modifications to HUQA, and Extract Records on the Next Generation Desktop (NGD) and the Medicare Beneficiary Database (MBD) for next eligible date and services remaining.   CWF shall count 11 full months starting with the month of a beneficiarys 1st acupuncture for cLBP service. EX: If 1st date of service is October 15, 2020, the next eligible date beginning a new year would be October 1, 2021.  NOTE: A new cLBP auxiliary (AUX) file will be created and HIMR will be updated to post the previous acupuncture for cLBP HCPCS 97810, 97811, 97813, 97814, 20560, or 20561.