(Medicare Claims Processing Manual)

Coverage policy can be found in Pub. 100- 03, Medicare National Coverage Determinations Manual, Chapter 1, section 190.11 PT/INR. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp    60.6  Carrier Claims Requirements  (Rev. 1562, Issued: 07- 25-08, Effective: 03-19-08, Implementation: 08-25-08)  Note this test is not covered as durable medical equipment. Therefore, claims submitted to DMERCs will not be paid. It is covered under the physician fee schedule.  Also note that the cost of the device and supplies is included in the payment for G0249 and therefore not separately billed to Medicare.  G0249 continues to include materials for 4 tests.  Additionally, G0250 continues to mean per 4 tests and should be billed no more frequently than once every 4 weeks.   60.7  Carrier Payment Requirements  (Rev. 1562, Issued: 07- 25-08, Effective: 03-19-08, Implementation: 08-25-08)  Payment and pricing information will be in the Medicare Physician Fee Schedule Database (MPFSDB).  Pay for INR on the basis of the MPFS.  Deductible and coinsurance apply.  60.8  Carrier and Intermediary General Claims Processing Instructions  (Rev. 216, 06-25-04)  60.8.1  Remittance Advice Notices  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD -10)  Use appropriate existing remittance advice reason and remark codes at the line level to express the specific reason for denying payment for PT/INR:  Remittance Advice Remark Code N386, This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at http://www.cms. hhs.gov/mcd/search.asp.  If you do not have Web access, you may contact the contractor to request a copy of the NCD.  If denying services furnished after July 1, 2002, use ASC X 12-835 claim adjustment reason code 50, These are non-covered services because this is not deemed a medical necessity by the payer.   60.8.2 - Medicare Summary Notice (MSN) Messages (Rev. 1562, Issued: 07- 25-08, Effective: 03-19-08, Implementation: 08-25-08)  If denying services furnished after July 1, 2002, use MSN message:  The following policies [190.11] were used when we made this decision. (MSN Message 15.20)  60.12 - Coverage for PET Scans for Dementia and Neurodegenerative Diseases  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  Effective for dates of service on or after September 15, 2004, Medicare will cover FDG PET scans for a differential diagnosis of fronto- temporal dementia (FTD) and Alzheimer's disease OR; its use in a CMS -approved practical clinical trial focused on the ut ility of FDG -PET in the diagnosis or treatment of dementing neurodegenerative diseases.  Refer to Pub. 100-03, NCD Manual, section 220.6.13, for complete coverage conditions and clinical trial requirements and section 60.15 of this manual for claims processing information.  A.  A/B MAC (A and B) Billing Requirements for PET Scan Claims for FDG -PET for the Differential Diagnosis of Fronto- temporal Dementia and Alzheimers Disease:   CPT Code for PET Scans for Dementia and Neurodegenerative Diseases   Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for dementia and neurodegenerative diseases for services performed on or after January 28, 2005.  Diagnosis Codes for PET Scans for Dementia and Neurodegenerative Diseases   The contractor shall ensure one of the following appropriate diagnosis codes is present on claims for PET Scans for AD:     ICD -10-CM is applicable, ICD -10 codes are:  F03.90, F03.90 plus F05, G30.9, G31.01, G31.9, R41.2 or R41.3  Medicare contractors shall deny claims when submitted with an appropriate CPT code from section 60.3.1 and with a diagnosis code other than the range of codes listed above.  Medicare contractors shall instruct providers to issue an Advanced Beneficiary Notice to beneficiaries advising them of potential financial liability prior to delivering the service if one of the appropriate diagnosis codes will not be present on the claim.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR (if claim is received with a GA modifier) otherwise CO  CARC: 11  RARC: N/A  MSN: 16.48  Provider Documentation Required with the PET Scan Claim  Medicare contractors shall inform providers to ensure the conditions mentioned in the NCD Manual, section 220.6.13, have been met.  The information must also be maintained in the beneficiary's medical record:   - Date of onset of symptoms; - Diagnosis of clinical syndrome (normal aging, mild cognitive impairment or MCI: mild, moderate, or severe dementia); - Mini mental status exam (MMSE) or similar test score;  - Presumptive cause (possible, probably, uncertain AD); - Any neuropsychological testing performed; - Results of any structural imaging (MRI, CT) performed; - Relevant laboratory tests (B12, thyroid hormone); and, - Number and name of prescribed medications.   B. Billing Requirements for Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease:   Effective for claims with dates of service on and after September 27, 2013, Medicare will only allow coverage with evidence development (CED) for Positron Emission Tomography (PET) beta amyloid (also referred to as amyloid -beta (A)) imaging (HCPCS A9586) or (HCPCS Q9982) or (HCPCS Q9983) (one PET A scan per patient).   Note: Please note that effective January 1, 2014 the following code A9599 will be updated in the IOCE and HCPCS update. This code will be contractor priced.      Note: Please note that effective January 1, 2018 the following code A9599 is end- date.   Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes  Effective for dates of service on or after September 27, 2013, contractors shall return as unprocessable/return to provider claims for PET A imaging, through CED during a clinical trial, not containing the following:   Condition code 30, and value code D4 (FI only)  Modifier Q0 as appropriate  CD-10 dx code Z00.6 (in either the primary/secondary position)   A PET HCPCS code (78811 or78814)   At least, one Dx code from the table below,    And one of these additional diagnoses is required in addition to Z00.6   F03.90  Unspecified dementia without behavioral disturbance  F03.91  Unspecified dementia with behavioral disturbance  F01.50  Vascular dementia without behavioral disturbance  F01.51  Vascular dementia with behavioral disturbance  F02.80  Dementia in other diseases classified elsewhere without behavioral disturbance  F02.81  Dementia in other diseases classified elsewhere with behavioral disturbance  G31.01  Pick's disease  G31.09  Other frontotemporal dementia  G31.85  Corticobasal degeneration  G31.83  Dementia with Lewy bodies  G31.84  Mild cognitive impairment, so stated  R41.1  Anterograde amnesia  R41.2  Retrograde amnesia  R41.3  Other amnesia (amnesia NOS, memory loss NOS)   and  A HCPCS code A9586 or Q9982 or Q9983)    Contractors shall return as unprocessable claims for PET A imaging using the following messages:   -Claim Adjustment Reason Code 4  the procedure code is inconsistent with the modifier used or a required modifier is missing.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   Remittance Advice Remark Code N519 -  Invalid combination of HCPCS modifiers. Contractors shall line -item deny claims for PET A , HCPCS code A9586 or Q9982 or Q9983, where a previous PET A, HCPCS code A9586 or Q9982 or Q9983 is paid in history using the following messages:    CARC 149: Lifetime benefit maximum has been reached for this service/benefit  category.    RARC N587: Policy benefits have been exhausted.    MSN 20.12: This service was denied because Medicare only covers this service once a lifetime.    Spanish Version: Este servicio fue negado porque Medicare slo cubre este servicio una vez en la  vida.    Group Code: PR, if a claim is received with a GA modifier    Group Code: CO, if a claim is received with a GZ  modifier   66 - National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage Plans                                           (Rev. 10229, Issued: 07- 21-20 Effective: 10 -01-20, Implementation: 10- 05-20)  CMS is streamlining the editing for MA plans claims when it is determined that  certain services are being disallowed on MA plans that are considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Original fee -for-service Medicare will pay for services obtained by beneficiaries enrolled in Medicare Advantage (MA) plans in this circumstance.   Consistent with 1862 (t)(2) of the Social Security Act, Medicare Administrative Contractors will pay for identified significant cost services for Medicare beneficiaries enrolled in MA plans. In addition 42 CFR 422.109, the Medicare payment for the services or benefit is made directly by the A/B MAC to the provider furnishing the service or benefit in accordance with original Medicare payment, rules, methods, and requirements .    Beneficiaries are liable for any applicable coinsurance amounts.  Cost for NCD services legislative changes in benefits for which CMS A/B MACs will not make payment and are the responsibility of the M+C organization are:   I. Services necessary to diagnose a condition covered by the NCD or legislative changes in benefits;  II. Most services furnished as follow up care to the NCD services or legislative changes in benefits;  III. Any services that is already a Medicare- covered service and included in the annual M+C capitation rate or previously, adjusted payments; and IV. Any services, including costs of the NCD service or legislative change  in benefits, to the extent the M+C organization is already obligated to cover it as an additional benefit under 42CFR 422.312 or supplemental benefit under 42 CFR 422.102.    66.1  Institutional Billing for National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage                                   (Rev. 10229, Issued: 07- 21-20 Effective: 10 -01-20, Implementation: 10- 05-20)                                                                                       A. Institutional Inpatient Billing for National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage.  The Medicare contractors shall allow Condition Code (CC) 78 on any inpatient institutional claims for Medicare Advantage beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under  section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Any current editing that doesnt allow this shall be updated to allow this scenario, unless there has been previous instructions excluding certain conditions.  Note: Condition Code 78 = Newly covered Medicare service for which an HMO doesn't pay.  B. Institutional Outpatient Billing for National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage  The Medicare contractors shall allow Condition Code (CC) 78 on any outpatient institutional claims for Medicare Advantage beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost unde r section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Any current editing that doesnt allow this shall be updated to allow this scenario, unless there has been previous instructions excluding certain conditions. Note:  Condition Code 78 = Newly covered Medicare service for which an HMO doesn't pay.