(Medicare Claims Processing Manual)

Applicable Revenue Codes   The applicable revenue code is 940, except for hospitals.  This service can be performed in other revenue centers such as a clinic (510) for hospitals.  Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.   80.5 - Applicable Revenue Codes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)   The applicable revenue code is 940, except for hospitals.  This service can be performed in other revenue centers such as a clinic (510) for hospitals.  Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.   80.6 - Editing Instructions for A/B MACs (A)  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Edit 1  - Implement diagnosis to procedure code edits to allow payment only for the LOPS codes, G0245, G0246, and G0247 when submitted with one of the following ICD-10-CM diagnosis codes   If ICD -10-CM is applicable:   ICD-10-CM ICD-10 DX Description  E08.40  Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified               E08.42  Diabetes mellitus due to underlying condition with diabetic polyneuropathy               E09.40  Drug or chemical induced diabetes mellitus with neurological complications with diabetic n               E09.42  Drug or chemical induced diabetes mellitus with neurological complications with diabetic p                E10.40  Type 1 diabetes mellitus with diabetic neuropathy, unspecified           E10.41  Type 1 diabetes mellitus with diabetic mononeuropathy           E10.42  Type 1 diabetes mellitus with diabetic polyneuropathy           E10.43  Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy           E10.44  Type 1 diabetes mellitus with diabetic amyotrophy           E10.49  Type 1 diabetes mellitus with other diabetic neurological complication           E10.610  Type 1 diabetes mellitus with diabetic neuropathic arthropathy              E11.40  Type 2 diabetes mellitus with diabetic neuropathy, unspecified         E11.41  Type 2 diabetes mellitus with diabetic mononeuropathy       E11.42  Type 2 diabetes mellitus with diabetic polyneuropathy         E11.43  Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy         E11.44  Type 2 diabetes mellitus with diabetic amyotrophy   E11.49  Type 2 diabetes mellitus with other diabetic neurological complication        E11.610  Type 2 diabetes mellitus with diabetic neuropathic arthropathy  E13.40  Other specified diabetes mellitus with diabetic neuropathy, unspecified  E13.41  Other specified diabetes mellitus with diabetic mononeuropathy         E13.42  Other specified diabetes mellitus with diabetic polyneuropathy         E13.43  Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy         E13.44  Other specified diabetes mellitus with diabetic amyotrophy         E13.49  Other specified diabetes mellitus with other diabetic neurological complication         E13.610  Other specified diabetes mellitus with diabetic neuropathic arthropathy         Deny these services when submitted without one of the appropriate diagnoses. Use the same messages you currently use for procedure to diagnosis code denials. Edit 2   Deny G0247 if it is not submitted on the same claim as G0245 or G0246. Use MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.  Use RA claim adjustment reason code 107 - The related or qualifying claim/service was not identified on this claim. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  80.7 - CWF General Information  (Rev. 4203, Issued: 01- 18-19, Effective: 02-19-19, Implementation: 02-19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Though G0245 and G0246 have no technical or professional components, for these codes, CWF will post institutional claims with type of bill 13X as technical, and professional claims as professional.  For bill type 85X with revenue code 940, CWF will post as technical.  For 85X bill type with revenue code 98X, (Method II), CWF will post as technical and professional.  This will allow both the facility and professional service payments to be approved by CWF for payment when the code and date of service match.  Therefore, should a claim be received with the same code and same date of service for the same beneficiary, the second claim submitted will not be rejected as a duplicate.   Due to the billing and payment methodology of Rural Health Clinics - bill type 71X and Federally Qualified Health Centers - bill type 73X, CWF will post these claims as usual, which will correctly allow claims from these entities that are billed on institu tional claims to reject as duplicates when the HCPCS code, date of service, and Medicare beneficiary identifier are an exact match with a claim billed on a professional claim.   Medicare contractors must react to these duplicate claims as they currently do for any other duplicates.  80.8 - CWF Utilization Edits  (Rev. 1742, Issued: 05- 22-09, Effective: 06-08-09, Implementation: 06-08-09)  Edit 1  - Should CWF receive a claim from an FI for G0245 or G0246 and a second claim from a contractor for either G0245 or G0246 (or vice versa) and they are different dates of service and less than 6 months apart, the second claim will reject.  CWF will edit to  allow G0245 or G0246 to be paid no more than every 6 months for a particular beneficiary, regardless of who furnished the service.  If G0245 has been paid, regardless of whether it was posted as a facility or professional claim, it must be 6 months before  G0245 can be paid again or G0246 can be paid.  If G0246 has been paid, regardless of whether it was posted as a facility or professional claim, it must be 6 months before G0246 can be paid again or G0245 can be paid.  CWF will not impose limits on how man y times each code can be paid for a beneficiary as long as there has been 6 months between each service.   The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation.  Based on the CWF reject code, the contractors and FIs must deny the claims and return the following messages:  MSN 18.4 -- This service is being denied because it has not been __ months since your last examination of this kind (NOTE :  Insert 6 as the appropriate number of months.)  RA claim adjustment reason code 96  Non -covered charges, along with remark code M86  Service denied because payment already made for same/similar procedure within set time frame.   Edit 2   The CWF will edit to allow G0247 to pay only if either G0245 or G0246 has been submitted and accepted as payable on the same date of service.  CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation.  Based on this reject code, contractors and FIs will deny the claims and return the following m essages:   MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.   RA claim adjustment reason code 107  The related or qualifying claim/service was not identified on this claim.   Edit 3   Once a beneficiarys condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services.  Those services would be considered to be included in the regular exams and treatments afforded to the beneficiary on a routine basis.  The physician or provider must then just bill the routine foot care codes, per Pub 100-02, Chapter 15, 290.  The CWF will edit to reject LOPS codes G0245, G0246, and/or G0247 when on the beneficiarys record it shows that one of the following routine foot care codes were billed and paid within the prior 6 months: 11055, 11056, 11057, 11719, 11720, and/or 11721.  The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation.  Based on the CWF reject code, the contractors and FIs must deny the claims and return the following messages:  MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.   The RA claim adjustment reason code 96  Non -covered charges, along with remark code M86  Service denied because payment already made for same/similar procedure within set time frame.   90 - Stem Cell Transplantation  (Rev.12533; Issued: 03 -07-24 Effective: 04 -08-24; Implementation:04 -08-24)   A. General   Stem cell transplantation is a process in which stem cells are harvested  from  either  a patients  (autologous) or donors (allogeneic)  bone marrow  or peripheral blood for intravenous infusion.  Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses. See Pub. 100-03, National Coverage Determinations Manual, section 110.23, for a complete description of covered and noncovered conditions. For Part A hospital inpatient claims processing instructions, refer to Pub. 100-04, chapter 3, section 90. The following sections contain claims processing instructions for all other claims.   B. Nationally Covered  Indications  C. Allogeneic  Hematopoietic Stem  Cell Transplantation (HSCT)   ICD- 10-PCS  Procedure  Codes   30230G2  Transfusion  of Allogeneic  Related  Bone  Marrow  into Peripheral  Vein,  Open  Approach  30230G3  Transfusion of Allogeneic Unrelated Bone Marrow into Peripheral  Vein,  Open Approach  30233U2  Transfusion of Allogeneic Related T -cell Depleted Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach  30233U3  Transfusion of Allogeneic Unrelated T -cell Depleted Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach  30230Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Peripheral  Vein, Open Approach  30230Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Peripheral  Vein, Open Approach  30233G2  Transfusion  of Allogeneic  Related  Bone  Marrow  into Peripheral  Vein,  Percutaneous  Approach  30233G3  Transfusion of Allogeneic Unrelated Bone Marrow into Peripheral  Vein,  Percutaneous Approach  30243U2  Transfusion of Allogeneic Related T -cell Depleted Hematopoietic Stem Cells into Central Vein, Percutaneous Approach  30243U3  Percutaneous Approach  30233Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Peripheral  Vein, Percutaneous Approach  30233Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Peripheral  Vein, Percutaneous Approach  30240G2  Transfusion of Allogeneic Related Bone Marrow into Central Vein,  Open  Approach  30240G3  Transfusion of Allogeneic Unrelated Bone Marrow into Central Vein,  Open  Approach  30240Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Central  Vein, Open Approach  30240Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Central  Vein, Open Approach  30243G2  Transfusion of Allogeneic Related Bone Marrow into Central Vein,  Percutaneous  Approach  30243G3  Transfusion of Allogeneic Unrelated Bone Marrow into Central Vein,  Percutaneous  Approach  30243Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Central  Vein, Percutaneous Approach  30243Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Central  Vein, Percutaneous Approach   HCPCS  Code  38240   See below  table  for ICD-10-DX Codes: