Source: http://www.medicarepaymentandreimbursement.com/2011_10_01_archive.html
Timestamp: 2013-05-24 19:31:04
Document Index: 633233033

Matched Legal Cases: ['art\n93308', 'art\n93320', 'art\n93321', 'art\n93325', 'art\n164', 'art\n239', 'art\n746', 'art\n746', 'art\n759']

Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline, CPT Code Billing: October 2011
Initial preventive physical examination CPT G0402,...
Medicare IVR - some Facts for Medicare secondary c...
Transthoracic Echocardiography (TTE) CPT C8929, C8...
Transesophageal Echocardiography (TEE) CPT code 93...
CPT code 37202 - Transcatheter Therapy – Other Tha...
Thrombolytic Agents - CPT code 37195, 37201, 92975...
CPT - 53850, 53852, 55899 - Thermotherapies (Minim...
Therapy Services (PT, OT, SLP) CPT code list - 959...
CPT 61796, 61797, 61798 - Stereotactic Radiosurger...
Stereotactic Body Radiation Therapy - CPT code 773...
Special Electroencephalography (EEG) - CPT 95950, ...
Less than 30 minutes Not reported Not reported 30 – 74 minutes 99354 Not reported 75 – 104 minutes 99354 99355
Description & CPT-4 Code Initial hospital care and subsequent hospital care
Inpatient psychotherapy with E&M component 90822, 90829
Initial preventive physical examination CPT G0402, G0403, G0404, G0405
IVR Fact If the patient does not have an employer insurance plan that is primary to Medicare, the IVR will confirm this information. If the patient is covered under an employer insurance plan, the IVR will confirm the information and provide the effective date along with the employer insurance information. Medicare would be the secondary payer to the employer insurance plan. However, the IVR statement “Medicare primary” does not negate the fact that the patient could have joined an MA plan that replaces traditional Medicare benefits. When the beneficiary has coverage through an MA plan, this plan is a temporary replacement of his traditional Medicare coverage. When this occurs, the patient will receive a new health insurance card from the MA plan and the traditional Medicare card will become inactive until that plan coverage is terminated. This scenario can happen frequently and cause unnecessary claim denials because the provider’s office assumes without employer insurance and the IVR statement “Medicare Primary” that the claims should be filed to traditional Medicare. The provider should remain on the IVR and also obtain MA plan eligibility to have a complete picture of the patient’s health care coverage. In addition to using the IVR, providers can also verify patient eligibility and claim status through an online inquiry process. Medicare Secondary Payer (MSP) Providers are required to file claims to Medicare using billing information obtained from the beneficiary to whom the item or service is furnished. Section 1862(b)(6) of the Social Security Act requires all entities seeking payment for any item or service furnished to complete, on the basis of information obtained from the individual to whom the item or service is furnished, the portion of the claim relating to the availability of other health insurance. Any provider who bills Medicare for services rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those services. Asking Medicare beneficiaries or their representatives questions concerning the beneficiary’s MSP status may accomplish this determination. To conform to the law and regulations, the provider must verify MSP information prior to submitting a bill to Medicare. Verifying MSP information means confirming that the information furnished about the presence of another payer that may be primary to Medicare is correct, clear, and complete and that no changes have occurred. The role of Medicare as the secondary payer is similar to the coordination of benefits clause in private health insurance policies. By federal law, Medicare is secondary payer to a variety of government and private insurance benefit plans. Medicare should be viewed as the secondary payer when a beneficiary can reasonably be expected to receive medical benefits through one or more of the following means:  An Employer Group Health Plan (EGHP) for working aged beneficiaries.  A Large Group Health Plan (LGHP) for disabled beneficiaries.  Beneficiaries eligible for End Stage Renal Disease (ESRD).  Auto/medical/no-fault/liability insurance.  Veterans Affairs (VA).  A Workers’ Compensation plan.  The Federal Black Lung Program. Any conditional primary payment(s) made by Medicare for services related to an injury is subject to recovery. A conditional payment is a payment made by Medicare for Medicare-covered services where another payer is responsible for payment and the claim is not expected to be paid promptly (i.e., within 120 days from receipt of the claim). Medicare makes conditional payments to prevent the beneficiary from using his own money to pay the claim. However, Medicare has the right to recover any payments. This includes payments that should have been paid under:  Workers’ Compensation.  Liability.  Automobile, medical or no-fault insurance. Questions that might be asked during patient screening include:  Are you or your spouse currently working?  Are you currently receiving any type of employer insurance benefits where you work now?  Are you covered under group health care from a spouse, parent or guardian’s employer insurance plan? · Are you receiving any type of medical care that could/should be covered under another insurance (e.g., workers’ compensation claim or liability accident)?  Do you need treatment as a result of an accident/injury/illness where another person/party should be responsible? Additional questions that could also be asked:  Are you currently receiving benefits due to coal miner’s disease or through black lung benefits?  Are you receiving benefits through the United Mine Workers Association?  Is your injury/illness the result of a work-related accident?  Are these services related to an auto/no-fault/liability accident?  Are you a veteran and will this service be paid for by Veterans Affairs?  Have you changed from “traditional” Medicare benefits to a Medicare Advantage replacement plan? Each of these questions will help determine Medicare’s role as an insurance payer. Should Medicare process the claim as primary, as the secondary payer, or not at all due to another payer being responsible for the service(s)? Supplemental Insurance Benefits A patient may elect to purchase outside supplemental insurance or retain a secondary insurance plan through some type of retirement package from a previous employer. Both types of plans pay as a secondary or supplemental insurance plan to Medicare. In some instances Medicare claims can be automatically transferred to the supplemental insurance plan either by an automatic crossover process or a process in place for those insurance plans designated as a Medigap plan. Supplemental insurance plans may offer an automatic crossover for those entitled to benefits, which is done through the Coordination of Benefits Contractor (COBC). The supplemental insurance eligibility is loaded into the patient’s national profile, and during claims processing the claim is automatically forwarded to the supplemental insurance for processing. This allows the provider office to file one claim and receive claim processing information from two insurance plans. Medigap plans are privately purchased and are designed to supplement Medicare coverage as well. Some Medigap insurance plans offer the same automatic crossover benefits as supplemental insurance plans. If the Medigap insurance does not provide automatic claim transfer, the provider must indicate on each Medicare claim the patient’s Medigap insurance information in order for the processed claim to be sent to the Medigap plan. 0
TTE affords unique insight into cardiac structure and function. It is a non-invasive technique in which pulsed high-frequency sound waves are used to visualize the contours, movements and dimensions of cardiac structures. Ultra-high frequency sound waves are directed toward and reflected by cardiovascular structures. Reflected echoes are translated into electrical impulses for display on a monitor and for recording and storage on either videotape or digital recording.The most commonly utilized echocardiographic techniques are motion-mode (M-mode) and two-dimensional (2-D) echocardiography.M-mode echocardiography employs a single pencil-like beam ultrasound view of cardiac structures. This method is especially useful for precisely recording the motion and dimensions of intracardiac structures with respect to time.Two-dimensional echocardiography employs an ultrasound beam rapidly swept through an arc, producing a cross-sectional or fan-shaped view of cardiac structures. It defines the configuration and changing dimensions of the chambers, dynamic cyclic variation in myocardial thickness and the associated valvular motions throughout the cardiac cycle. This technique is useful for recording lateral motion and providing the correct spatial relationship between cardiac structures.Doppler examination is a valuable adjunct to a complete echocardiographic examination. The basic principle utilizes the changes in frequency when a transmitted ultrasound wave is reflected from a moving surface, allowing measurement of velocity of movement (i.e., blood flow). Doppler velocity recordings (with volumetric flow calculations) provide an integrated picture of cardiac structure, function and adaptation to both normal and abnormal physiology. The proximal great vessels and the pericardium can also be directly visualized.The rapid and non-invasive acquisition of this information has contributed to exponential application and to potential overutilization. This policy addresses the medically reasonable, necessary and appropriate application of TTE.Ventricular Function and CardiomyopathiesChanges in myocardial thickness (hypertrophy and thinning), derived parameters of contractility and in chamber volume and morphology can be quantified and charted over time by TTE. Cardiac responses to changes in volume, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional anomalies to a clinical presentation is facilitated. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. Absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to augment clinical assessments with TTE measurements at more-frequent-than-annual examinations.Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings are not well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of diastolic functional abnormalities.Hypertensive Cardiovascular DiseaseLeft Ventricular Hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. In individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of LVH. TTE (CPT code 93308) may assist the decision to treat and the formulation of a treatment program. Baseline TTE (CPT code 93308) and periodic serial assessment (no more frequently than annually) would be medically appropriate.Acute Myocardial Infarction and Coronary InsufficiencyTTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. Absent clinical deterioration or unclear examination findings, repeat assessment typically includes an evaluation at discharge. Convalescent evaluation at approximately six months and annually thereafter generally provides adequate supplemental data to a thoughtful clinical evaluation. The medical record should document the medical necessity of more frequent TTE assessment.The role for TTE in the emergency room assessment of individuals presenting with chest pain is in evolution. Absent supporting clinical findings of myocardial dysfunction, this application is considered investigational and will be subjected to medical necessity review.Exposure to Cardiotoxic Agents (Chemotherapeutic and External)Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. Baseline assessment, bimonthly during and at six months following therapy is generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent abrupt change in clinical signs and/or symptoms, annual assessment would be considered reasonably medically necessary.Cardiac Transplant and Rejection MonitoringTTE is an integral part of the cardiac donor selection and donor recipient matching process. Evaluation should focus on analysis of ventricular function and the integrity of valvular performance.TTE is also incorporated into the management of allograft recipients. Myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics and the late development of pericardial fluid may alert to a rejection episode. None of these findings has achieved diagnostic sensitivity or specificity. Typically, TTE is performed weekly for the first four to eight weeks following transplant with subsequent decremental frequency. Absent acute rejection episodes, approximately three TTE examinations are typically performed yearly in chronic transplant recipients.Native Valvular Heart DiseaseTTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of multi-valve pathologies can be quantified. Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist, especially interventions for mitral stenosis. Absent acute intervention or a discrete change in otherwise stable clinical signs and symptoms, TTE in chronic valvular disease is used to document course over time. Generally, it is not medically reasonable and necessary to repeat these examinations more frequently than annually.Prosthetic Heart Valves (Mechanical and Bioprostheses)TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile. Reassessment following convalescence (three to six months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate.Acute EndocarditisTTE can provide diagnostic information. Larger vegetations can be directly visualized. Valvular anatomy and ventricular function may also be directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Acutely, examination frequency is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be dictated by the residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves.Pericardial DiseaseA collage of TTE findings have been found to be reliable indices of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually reasonable and medically necessary. TTE is less reliable in the detection of chronic pericardial constriction. Current echocardiographic findings in constrictive pericarditis lack the necessary specificity and sensitivity to be reliable diagnostic aids.Aortic PathologyTTE can provide valuable information when acute or chronic aortic pathology is present. However, the posterior window of TEE , coupled with the more posterior position of the thoracic aorta has rendered TEE a more determinative study. Non-invasive TTE remains the study of choice for following chronic aortic pathology when images suitable for serial quantitation can be obtained.Congenital Heart DiseaseIn children and small adults, TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and non-invasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. When the disease process and therapy are stable, serial assessment by TTE requires contemporaneous medical necessity documentation if the frequency exceeds an annual evaluation.Suspected Cardiac Thrombi and Embolic SourcesTTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial interstices and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias, especially atrial fibrillation, cardiomyopathies and ventricular dysfunction), TTE usually provides adequate supplemental therapeutic decisional data. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus, and the finding of thrombus or vegetation does not establish a cardiac embolic source. Absent the definition of and serial assessment for regression of potentially embolic material, repeat examinations are not generally medically required to direct clinical decisions.Cardiac Tumors and MassesInfiltrative and ventricular tumors and masses can be visualized, their extent quantified and their hemodynamic consequences assessed by TTE. Right atrial space occupying masses are usually well visualized by TTE. TEE provides a more detailed view of the left atrium and is more sensitivein quantifying mass characteristics (solid, cystic, etc.), extensions and attachments. These acute pathologies are not typically followed serially.Critically Ill and Trauma PatientsThere is a role of echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion or a pericardial effusion may be confirmed.Pertubations of volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the exigencies of the clinical milieu.Ultrasonic equipment is increasingly more compact and portable. Certain highly portable (a.k.a. “hand-held”) scanners possess the same functional capabilities, hence, providing the same diagnostic value as traditional and larger “state of the art” instruments. Other scanners have limited capabilities in terms of providing a permanent record of the examination or reduced functional capability for performing a complete examination. Medicare will not cover studies performed in such a manner that the result constitutes a simple extension of the physical examination. To qualify for Medicare payment, a valid echocardiographic service must meet the following standards, regardless of the size of the instrument used to perform the study:Performed for an accepted clinical indication.
Bill Type CodesContractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85XBill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.Revenue CodesContractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.0480, 0483CPT/HCPCS Codes
C8929TTE w or wo fol w con, Doppler (OPPS)
C8930TTE w or w/o contr, cont ECG (OPPS)
93303©Echo transthoracic
93304©Echo transthoracic
93306©Tte w/doppler, complete
93307©Echo exam of heart
93308©Echo exam of heart
93320©Doppler echo exam, heart
93321©Doppler echo exam, heart
93325©Doppler color flow add-on
93350©Echo transthoracic
93351©Stress tte complete
ICD-9-CM Codes That Support Medical NecessityThe CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.Medicare is establishing the following limited coverage for CPT/HCPCS codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, C8929 and C8930:Covered for:
074.1Epidemic pleurodynia
074.20–074.23Coxsackie carditis
086.0Chagas’ disease with heart involvement
088.81Lyme disease
093.0Aneurysm of aorta specified as syphilitic
093.1Syphilitic aortitis
093.9Cardiovascular syphilis unspecified
098.83–098.85Gonococcal infection of other specified sites
112.81Candidal endocarditis
115.03–115.04Infection of Histoplasma capsulatum
115.13–115.14Infection of Histoplasma duboisii
130.3Myocarditis due to toxoplasmosis
164.1Malignant neoplasm of heart
164.8Malignant neoplasm of other parts of mediastinum
198.89Secondary malignant neoplasm of other specified sites
212.7Benign neoplasm of heart
239.89Neoplasm of unspecified nature of other specified sites
276.0–276.4Disorders of fluid, electrolyte and acid-base balance
276.50–276.52Volume depletion
276.69Other fluid overload
276.7–276.9Disorders of fluid, electrolyte, and acid-base balance
277.30Amyloidosis, unspecified
277.39Other amyloidosis
368.00Amblyopia unspecified
392.0Rheumatic chorea with heart involvement
394.0–394.2Disease of mitral valve
395.0–395.2Disease of aortic valve
398.90–398.91Other and unspecified rheumatic heart diseases
401.0–401.1Essential hypertension
401.9Unspecified essential hypertension
403.00–403.01Hypertensive chronic kidney disease, malignant
403.10–403.11Hypertensive chronic kidney disease, benign
403.90–403.91Hypertensive chronic kidney disease, unspecified
404.00–404.03Hypertensive heart and chronic kidney disease
405.09Other malignant secondary hypertension
405.19Other benign secondary hypertension
405.99Other unspecified secondary hypertension
410.50–410.52Acute myocardial infarction of other lateral
414.00–414.07Other forms of chronic ischemic heart disease
415.11–415.12Acute pulmonary heart disease
423.0–423.3Other diseases of pericardium
425.0–425.9Cardiomyopathy
426.0Atrioventricular block complete
426.10–426.13Atrioventricular block, other and unspecified
426.2–426.4Conduction disorders
426.50–426.54Bundle branch block, other and unspecified
426.6–426.7Conduction disorders
427.60–427.61Premature beats
427.69Other premature beats
427.81Sinoatrial node dysfunction
427.9Cardiac dysrhythmia unspecified
429.71Acquired cardiac septal defect
429.9Heart disease unspecified
434.00–434.01Cerebral thrombosis
434.10–434.11Cerebral embolism
434.90–434.91Cerebral artery occlusion
435.0–435.3Transient cerebral ischemias
435.8–435.9Transient cerebral ischemias
436Acute but ill-defined cerebrovascular disease
440.20–440.24Atherosclerosis of native arteries of the extremities
440.29Other atherosclerosis of native arteries of the extremities
441.00–441.03Dissection of aorta
441.1–441.7Aortic aneurysm and dissection
441.9Aortic aneurysm of unspecified site without rupture
444.21–444.22Arterial embolism and thrombosis of arteries of the extremities
446.1Acute febrile mucocutaneous lymph node syndrome (MLNS)
446.7Takayasu’s disease
458.0Orthostatic hypotension
518.4–518.5Other diseases of lung
634.60–634.62Abortion complicated by embolism
635.60–635.62Legally induced abortion complicated by embolism
636.60–636.62Illegal abortion complicated by embolism
637.60–637.62Legally unspecified type of abortion complicated by embolism
638.6Failed attempted abortion complicated by embolism
673.20–673.24Obstetrical blood-clot embolism
674.82Other complications of puerperium with delivery with postpartum complication
674.84Other complications of puerperium
710.0–710.1Diffuse diseases of connective tissues
746.00Congenital pulmonary valve anomaly unspecified
746.01–746.02Anomalies of pulmonary valve
746.81–746.85Other specified anomalies of heart
746.87Malposition of heart and cardiac apex
746.89Other specified congenital anomalies of heart
746.9Unspecified congenital anomaly of heart
759.3Situs inversus
780.60–780.62Fever
782.5Cyanosis
785.0–785.3Symptoms involving cardiovascular system
785.50–785.51Shock without mention of trauma
785.59Other shock without trauma
790.7Bacteremia
794.31Nonspecific abnormal electrocardiogram (ECG) (EKG)
807.4Flail chest
861.00–861.03Heart without mention of open wound into thorax
861.10–861.13Heart with open wound into thorax
901.0–901.2Injury to blood vessels of thorax
901.40–901.42Pulmonary blood vessels
922.1Contusion of chest wall
958.0–958.1Certain early complications of trauma
959.11–959.14Trunk, injury other and unspecified
959.19Other and unspecified injury of other sites of trunk
960.7Poisoning by antineoplastic antibiotics
962.0Poisoning by adrenal cortical steroids
963.1Poisoning by antineoplastic and immunosuppressive drugs
965.09Poisoning by other opiates and related narcotics
972.0–972.1Poisoning by agents primarily affecting the cardiovascular system
980.3Toxic effect of fusel oil
986Toxic effect of carbon monoxide
990Effects of radiation unspecified
994.0Effects of lightning
994.8Electrocution and nonfatal effects of electric current
995.1Angioneurotic edema not elsewhere classified
996.01Mechanical complication due to cardiac pacemaker (electrode)
996.02–996.04Mechanical complication of cardiac device, implant and graft
996.61Infection and inflammatory reaction due to cardiac device implant and graft
996.71Other complications due to heart valve prosthesis
998.0Postoperative shock not elsewhere classified
998.51Infected postoperative seroma
999.31Infection due to central venous catheter
999.4Anaphylactic shock due to serum not elsewhere classified
V59.8Donors of other specified organ or tissue
Medicare is establishing the following additional limited coverage for CPT/HCPCS codes 93303, 93304, 93306, 93307 and 93308:Covered for: