(Medicare Claims Processing Manual)

Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without diagnosis code V70.7 (ICD-10 Z00.6) as unprocessable:   CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).   RARC M76: Missing/incomplete/invalid diagnosis or condition   RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   Group Code  Contractual Obligation (CO): Beginning January 2, 2020, contractors shall no longer report Group Code CO on remittances for claims billed without ICD -10 dx Z00.6 and returned as unprocessable.  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/articulo no fue cubierto porque no estaba incluido como parte de un ensavo clinic/studio calificado.  Beginning January 2, 2020, contractors shall no longer report MSN 16.77 on remittances for claims billed without ICD-10 diagnosis Z00.6 and returned as unprocessable.  Professional Claims 8 -digit ClinicalTrials.gov Identifier Number   For claims with dates of service on or after July 1, 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with the numeric, 8- digit clinicaltrials.gov identifier number preceded by the two alpha characters CT when placed in Field 19 of paper Form CMS-1500, or when entered without the CT prefix in the electronic 837P in Loop 2300REF02(REF01=P4). Claim lines billed without an 8- digit clinicaltrials.gov identifier number shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without an 8-digit clinicaltrials.gov identifier number as unprocessable:   CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).   RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number for FDA -approved clinical trial services.   RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   NOTE: Clinicaltrials.gov identifier numbers for TAVR are listed on our website:  (http://www.cms.gov/Medicare/Coverage/Coverage- with-Evidence-Development/Transcatheter -Aortic -Valve -Replacement -TAVR -.html)   290.3 - Claims Processing Requirements for TAVR Services on Inpatient Hospital Claims (Rev. 10179, Issued: 06 -10-20, Effective: 06-21-19, Implementation: 06-12-20)  Inpatient hospitals shall bill for TAVR on an 11X TOB effective for discharges on or after May 1, 2012. Refer to Section 69 of this chapter for further guidance on billing under CED.  Inpatient hospital discharges for TAVR shall be covered when billed with:    ICD -9 V70.7 through September 30, 2015, ICD -10 Z00.6 for dates of service on or after October 1, 2015. and Condition Code 30.    An 8- digit clinicaltrials.gov identifier number listed on the CMS website (effective July 1, 2013)   Inpatient hospital discharges for TAVR shall be rejected when billed without:    ICD -9 V70.7 through September 30, 2015, ICD -10 Z00.6 for dates of service on or after October 1, 2015, and Condition Code 30.    An 8- digit clinicaltrials.gov identifier number listed on the CMS website (effective July 1, 2013)   Claims billed by hospitals not participating in the trial/registry shall be rejected with the following messages:   CARC 50: These are non -covered services because this is not deemed a medical necessity by the payer.   RARC 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.   Group Code:Contractual Obligation (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.   290.4 - Claims Processing Requirements for TAVR Services for Medicare Advantage (MA) Plan Participants  (Rev. 3898, Issued: 10- 27-17; Effective: 04 -01- 15, Implementation: 04- 02-18)  MA plans are responsible for payment of TAVR services for MA plan participants.  Medicare coverage for TAVR is not included under section 310.1 of the NCD Manual (Routine Costs in Clinical Trials).   300  Billing Requirements for Ocular Photodynamic Therapy (OPT) with Verteporfin  (Rev. 2728, Issued: 06- 14-13-Effective: 04 -03-13, Implementation: 07- 16-13)  Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic diseases; specifically, for age -related macular degeneration (AMD), a common eye disease among the elderly. OPT involves the infusion of an intravenous photosensitizing drug calle d Verteporfin, followed by exposure to a laser. For complete Medical coverage guidelines, see National Coverage Determinations (NCD) Manual (Pub 100- 03)  80.2 through 80.3.1.   300.1 - Coding Requirements for OPT with Verteporfin  (Rev. 2728, Issued: 06- 14-13, Effective: 04 -03-13, Implementation: 07- 16-13)  The following are applicable Current Procedural Terminology (CPT) codes for OPT with Verteporfin:   67221 - Destruction of localized lesion of choroid (e.g. choroidal neovascularization); photodynamic therapy (includes intravenous infusion)   67225-  Destruction of localized lesion of choroid (e.g. choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment)   The following are applicable Healthcare Common Procedure Coding System (HCPCS) code for OPT with Verteporfin:   J3396-  Injection, Verteporfin, 0.1 mg  300.2 - Claims Processing Requirements for OPT with Verteporfin Services on Professional Claims and Outpatient Facility Claims  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  OPT with Verteporfin is a covered service when billed with the below ICD -10-CM codes      Nationally Covered ICD -10-CM codes    H35.3210 Exudative age -related macular degeneration, right eye, stage unspecified  H35.3211 Exudative age -related macular degeneration, right eye, with active choroidal neovascularization  H35.3212 Exudative age -related macular degeneration, right eye, with inactive choroidal neovascularization  H35.3213 Exudative age -related macular degeneration, right eye, with inactive scar  H35.3220 Exudative age -related macular degeneration, left eye, stage unspecified  H35.3221 Exudative age -related macular degeneration, left eye, with active choroidal neovascularization  H35.3222 Exudative age -related macular degeneration, left eye, with inactive choroidal neovascularization  H35.3223 Exudative age -related macular degeneration, left eye, with inactive scar  H35.3230 Exudative age -related macular degeneration, bilateral, stage unspecified  H35.3231 Exudative age -related macular degeneration, bilateral, with active choroidal neovascularization  H35.3232 Exudative age -related macular degeneration, bilateral, with inactive choroidal neovascularization  H35.3233 Exudative age -related macular degeneration, bilateral, with inactive scar    ICD- 10- Codes for OPT with Verteporfin for other ocular indications are eligible for local coverage determinations through individual contractor discretion.    B39.4  Histocapsulati, unspecified   (Translates to combination of both B39.4 & H32)  B39.5  Histoplasmosis duboisii   (Requires H32 coverage)  B39.9  Histoplasmosis, unspecified   (Requires H32 coverage)  H32 Chorioretinal disorders in diseases classified elsewhere   (Requires B39.4 coverage)  H44.2A1  Degenerative myopia with choroidal neovascularization, right eye  H44.2A2  Degenerative myopia with choroidal neovascularization, left eye  H44.2A3  Degenerative myopia with choroidal neovascularization, bilateral eye  H44.2B1  Degenerative myopia with macular hole, right eye  H44.2B2  Degenerative myopia with macular hole, left eye  H44.2B3  Degenerative myopia with macular hole, bilateral eye  H44.2C1  Degenerative myopia with retinal detachment, right eye  H44.2C2  Degenerative myopia with retinal detachment, left eye  H44.2C3  Degenerative myopia with retinal detachment, bilateral eye H44.2D1  Degenerative myopia with foveoschisis, right eye  H44.2D2  Degenerative myopia with foveoschisis, left eye  H44.2D3  Degenerative myopia with foveoschisis, bilateral eye  H44.2E1  Degenerative myopia with other maculopathy, right eye  H44.2E2  Degenerative myopia with other maculopathy, left eye  H44.2E3  Degenerative myopia with other maculopathy, bilateral eye H44.21  Degenerative Myopia, right eye  H44.22  Degenerative Myopia, left eye  H44.23  Degenerative Myopia, bilateral  H35.711  Central serous chorioretinopathy, right eye  H35.712  Central serous chorioretinopathy, left eye  H35.713  Central serous chorioretinopathy, bilateral   Coverage is denied when billed with the below Nationally Non- Covered ICD -10-CM codes   Nationally Non -Covered ICD -10-CM codes: