Tuesday, January 17, 2017

CPT code 81225, 81227, 81355

CPT/HCPCS Codes

Group 1 Codes:

81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17)

Group 2 Codes:

81226 CYP2D6 (CYTOCHROME P450, FAMILY 2, SUBFAMILY D, POLYPEPTIDE 6) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)

Group 3 Paragraph: Non-Covered Codes - CYP2C9 and VKORC1 will be covered in accordance with NCD 90.1 and should be reported with HCPCS code G9143 warfarin responsiveness testing.

Group 3 Codes:

81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6)

81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG, WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, -1639G>A, C.173+1000C>T)


Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This policy limits CYP2C19 and CYP2D6 genetic testing to defined indications. All other testing for CYP2C19 and CYP2D6 is non-covered until definitive clinical utility is established to justify coverage.

CYP2C19 Genotyping

Background on CYP2C19 Testing

The CYP450 gene superfamily is composed of many isoenzymes that are involved in the metabolism of about 75% of commonly prescribed drugs. CYP2C19 metabolizes 15% of all currently used drugs, whereas CYP2D6 enzymes metabolize approximately 20-25%, and CYP2C9 metabolizes approximately 10%.

Genetic alterations or “polymorphisms” are common in these isoenzymes, with more than 30 polymorphisms identified in CYP2C19. These polymorphisms can lead to differences in individual drug response secondary to variation in metabolism.

CYP2C19 phenotypes include poor, intermediate, extensive and ultra-rapid metabolizers. The frequency of the various metabolizer phenotypes has been estimated as follows:
2-15% - poor metabolizers

18-45% - intermediate metabolizers

35-50% - extensive metabolizers

5-30% - ultra-rapid metabolizers

The genotypic rates vary by ethnicity. Approximately 2% of whites, 4% of blacks and 14% of Chinese are poor CYP2C19 metabolizers.

Pharmacogenetic testing has been proposed to predict individual response to a variety of CYP2C19-metabolized drugs including clopidogrel, proton pump inhibitors, and tricyclic antidepressants, among others. In certain scenarios, an individual patient may benefit from genetic testing in determining dosage and likely response to specific medications.

Clopidogrel bisulfate (Plavix) is a widely prescribed medication to/for:
Prevent blood clots in patients with acute coronary syndrome (ACS);

Other cardiovascular (CV) disease-related events;

Undergoing percutaneous coronary intervention

Clopidogrel response varies significantly due to genetic and acquired factors including obesity, smoking and noncompliance. Patients with poor response to clopidogrel may experience recurrent CV event or thrombotic events while taking clopidogrel. They are at greater risk for major adverse CV events such as heart attack, stroke and death. These individuals are typically poor to intermediate metabolizers of clopidogrel due to the presence of the associated CYP2C19 polymorphisms. These individuals should be given an alternate treatment strategy (Plavix PI). As such, the clinical utility of CYP2C19 genotyping has been supported with net benefits on improving health outcomes for individuals with ACS who are undergoing percutaneous coronary interventions (PCI). There is insufficient evidence of clinical utility of CYP2C19 genotyping for individuals considering clopidogrel therapy for other indications, such as medical management of ACS without PCI, stroke, or peripheral artery disease.

With regards to CYP2C19 testing for antidepressant treatment, recent evidence has suggested genetic testing prior to initiating certain tricyclic antidepressants, namely amitriptyline, due to the effects of the genotype on drug efficacy and safety. Use of this information to determine dosing has been proposed to improve clinical outcomes and reduce the failure rate of initial treatment. However, the Clinical Pharmacogenetics Implementation Consortium did not have enough evidence to make a strong recommendation for dose modification based on genotype, and a moderate recommendation was given based on data outside of randomized trials. Additionally, even with genotype information, a suggestion is given to start patients on low dose, gradually increasing to avoid adverse side effects. Consequently, genotyping is not needed with this approach.

Proton pump inhibitors are used to treat several gastric acid-related conditions including duodenal ulcer, gastric ulcer and gastroesophageal reflux disease. Proton pump inhibitors can also be used to treat Helicobactor pylori. Several proton pump inhibitors are metabolized by CYP2C19. However, there is insufficient data to warrant CYP2C19 genotyping to determine health outcomes or adverse drug reactions in treatment with proton pump inhibitors.

With regards to Serotonin reuptake inhibitors, there is insufficient evidence to support CYP2C19 genotyping to determine medical management for the treatment of obsessive compulsive disorder at this time.

Covered Indications
In summary, genetic testing of the CYP2C19 gene is considered medically necessary for patients with ACS undergoing PCI who are initiating or reinitiating Clopidogrel (Plavix) therapy.

Non-covered Indications
Genetic testing for the CYP2C19 gene is considered investigational at this time for the following medications including but not limited to:
Amitriptyline

Clopidogrel for indications other than above

Proton pump inhibitors

Selective serotonin reuptake inhibitors

Warfarin

CYP2D6 Genotyping

Background on CYP2D6 Testing

Genetic alterations or “polymorphisms” are common in these isoenzymes, with more than 100 polymorphisms identified in CYP2D6. These polymorphisms can lead to differences in individual drug response secondary to variation in metabolism.

CYP2D6 phenotypes include poor, intermediate, extensive and ultra-rapid metabolizers. The frequency of the poor metabolizer phenotype varies by ethnicity with 7-10% in Caucasians, 1.9-7.3% in African- Americans, and = 1% in most Asian populations studied. The extensive metabolizer phenotype, observed in 50% of Caucasians, is the most common in this population. Genetic variation, as well as drug-drug interactions, can influence the classification of CYP2D6 metabolism into one of the above phenotypes. In addition, chronic dosing of a CYP2D6 drug can inhibit its own metabolism over time as the concentration of the drug approaches a steady state.

Pharmacogenetic testing has been proposed to predict individual response to a variety of CYP2D6-metabolized drugs including tamoxifen, antidepressants, opioid analgesics, and tetrabenzine for chorea, among others. In certain scenarios, an individual patient may benefit from this genetic testing in determining dosage and likely response to specific medications.

Tamoxifen

Available evidence fails to support direct evidence of clinical utility for testing of CYP2D6 in treatment with tamoxifen. Tamoxifen metabolism and the causes for resistance are complex rather than the result of a single polymorphism.

Antidepressants

In regards to CYP2D6 testing for antidepressant treatment, there was insufficient evidence in the past to support testing to determine treatment. More recently, evidence has supported the use of genetic testing prior to initiating certain tricyclic antidepressants due to the effects of genotype on drug efficacy and safety. Use of this information to determine dosing can improve clinical outcomes and reduce the failure rate of initial treatment. However, there is insufficient evidence for CYP2D6 genotyping for individuals considering antipsychotic medications or other antidepressants with CYP2D6 as a metabolizing enzyme.

Codeine

In addition, the role of CYP2D6 genotyping has been evaluated for use in opioid analgesic drug therapy, specifically codeine analgesia. The efficacy and toxicity, including severe or life- threatening toxicity after normal doses of codeine has been linked to an individual’s CYP2D6 genotype. However, genotyping would indicate avoidance of codeine due to risk of adverse events in only 1-2% of the populations, and there is considerable variation in the degree of severity of adverse events, with most not classified as serious. Furthermore, codeine is widely used without genotyping. At this time, there is insufficient evidence to support clinical utility of genotyping for management of codeine therapy.

Tetrabenazine for treatment of Huntington’s disease
The dosing of tetrabenazine is based, in part, on CYP2D6 genotyping. However, a recent study suggests that the necessity to genotype may need to be reconsidered. The Xenazine® manufacture package insert indicates that poor metabolizers of CYP2D6 should not exceed a maximum does of 50 mg/day.

Drugs for Alzheimer’s Disease

Galantamine is an antidementia drug used in the treatment of Alzheimer’s disease. Studies have been performed that reveal the CYP2D6 genotype significantly influences galantamine concentrations in blood. Still other studies have revealed that urinary assays for CYP2D6 phenotype are technically feasible. At this time, the association between phenotype and drug responsiveness remains unknown. It has been suggested that confirmation studies in larger populations are necessary to establish evidence regarding individuals most likely to benefit from galantamine, including information on treatment efficacy and tolerability.

Donepezil (Aricept) is a drugs used to treat an Alzheimer’s disease. Some studies have reported an influence of the CYP2D6 on the response to treatment with this drug. Other studies suggest that therapy based on CYP2D6 genotype is unlikely to be beneficial for treating Alzheimer’s disease patients in routine clinical practice. Additional studies are needed to determine the efficacy and utility of CYP2D6 genotyping in those patients who are treated with donepezil.

Covered Indications

In summary, genetic testing of the CYP2D6 gene is considered medically necessary to guide medical treatment and/or dosing for individuals for whom initial therapy is planned with:
Amitriptyline or nortriptyline for treatment of depressive disorders

Tetrabenazine doses greater than 50 mg/day or re-initiation of therapy with doses greater than 50 mg/day.

Non-covered Indications

There is insufficient evidence to demonstrate that genetic testing for the CYP2D6 gene improves clinical outcomes. Consequently, genetic testing for the CYP2D6 gene is considered investigational including but not limited to the following medications:
Antidepressants other than those listed above

Antipsychotics

Codeine

Donepezil

Galantamine

Tamoxifen

CYP2C9 Genotyping

Background on CYP2C9 Testing

CYP2C9 metabolizes approximately 10-15% of all currently used drugs. Genetic alternations or “polymorphisms” are common in these isoenzymes, with 57 polymorphisms identified in CYP2C9, which can lead to differences in individual drug response secondary to variation in metabolism.

Pharmacogenetic testing has been proposed to predict individual response to a variety of CYP2C9-metabolized drugs including celecoxib, fluorbiprofen, fluvoxamine and warfarin, among others. In certain scenarios, an individual patient may benefit from this genetic testing in determining dosage and likely response to specific medications. However, there is insufficient evidence to support CYP2C9 genotyping to determine medical management and alter outcomes at this time.

Individuals with low enzyme activity for CYP2C9 substrates are at risk of adverse drug reactions. However, pharmacogenetic testing for individuals being treated with drugs, such as warfarin, may experience little or no benefit from testing. This is, in part, because the CYP2C9 genotype accounts for only part of the variability in drug sensitivity.




Warfarin

While there is extensive literature regarding warfarin and the CYP2C9 genotype, the clinical utility of such testing remains unproven at this time. In fact, pharmacogenetic testing for warfarin treatment has been recommended against by the American College of Medical Genetics and the American College of Chest Physicians. These guidelines suggest that genetic testing for warfarin metabolism is not medically necessary, and evidence of clinical utility remains to be proven. Obstacles for determining clinical utility have been reviewed with suggestions for researchers in this area.




Celecoxib

In addition, limited information is available regarding celecoxib metabolism in individuals with CYP2C9 polymorphisms. More trials are needed to determine clinical utility and appropriateness of pharmacogenetic testing in this population.




Covered Indications

Effective August 3, 2009, the Centers for Medicare & Medicaid Services (CMS) believes that the available evidence supports that coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act (the Act) is appropriate for pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness by any method, and is therefore covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin who:
Have not been previously tested for CYP2C9 or VKORC1 alleles; and

Have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and

Are enrolled in a prospective, randomized, controlled clinical study when that study meets the following standards.

Non-covered Indications

All other coverage for genetic testing for the CYP2C9 gene is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to:

Celecoxib

Fluorbiprofen

Flovoxamine

VKORC1 Genotyping

Background on VKORC1 Testing

The vitamin K epoxide reductase complex subunit 1, encoded by the gene VKORC1, is critical in the vitamin K pathway for coagulation. Warfarin therapy targets VKORC1 to reduce clotting risk.

Variation in response to warfarin therapy has been linked to genetic variations. Retrospective study of European-American patients undergoing long term warfarin therapy identified 5 major haplotypes that were most predictive of approximately 25% of variance in warfarin dose. These are classified into A: low dose haplotype and B: high dose haplotype. This was validated in two European-American populations. Average maintenance dose for A/A haplotypes was approximately 2.7 mg per day; 4.9 mg per day for A/B, and 6.2 mg per day for B/B (p<0 .001="" p="">
Review by the American College of Medical Genetics (2008) confirmed the analytic validity of testing VKORC1 and confirmed that there is sufficient evidence to support association with final therapeutic dose of warfarin. However, safe warfarin dosing requires careful monitoring and there is insufficient evidence available to support routine VKORC1 genotyping for determination of final dosing. Further studies in prospective clinical trials are needed to determine clinical utility.

Clinical Pharmacogenetics Implementation Consortium guidelines recommend that pharmacogenetic algorithms be used to determine ideal dosing, and recommend including VKORC1 genotyping when available. However the evidence from randomized prospective trials is limited, and impact on clinical outcomes is not yet known, limiting the ability to recommend that genotyping be performed for initial warfarin prescribing.

Prospective study of 30 healthy subjects assessed for warfarin dosing with daily INR measurements determined that VKORC1 (p=0.02) variant carriers require lower cumulative doses of warfarin to achieve INR = 2.0. Participants who carried variants in both CYP2C9 and VKORC1 required fewer days to achieve INR = 2.0 that wild type subjects (p=0.01) resulting in an estimated genetic contribution to dose variability of 62%.

Meta-analysis of CYP2C9 and VKORC1 genotypes influence the risk of hemorrhagic complications in warfarin treated patients and increase the risk for over-coagulation and hemorrhagic complications with CYP2C9*3 carriers. No significant association was noted between VKORC1 genotypes and hemorrhagic complications.

Randomized controlled study assessing 109 adult patients and the influence of VKORC1 genotyping data on clinical outcomes of initial warfarin dosing was performed. Primary endpoints included time in therapeutic range over 90 days and number of anticoagulation visits. Hospitalizations, emergency visits, time to reach therapeutic dose, INR >4, hemorrhagic events, thrombotic events and mortality were secondary endpoints. No difference in the primary endpoints was noted between patients who received initial dosing by clinical and genotype information as compared to those whose initial dosing was determined by clinical information alone. No statistical difference was noted between either group in secondary events, however fewer of these events were noted among patients whose dosing included genotypic data.

Covered Indications
Effective August 3, 2009, the Centers for Medicare & Medicaid Services (CMS) believes that the available evidence supports that coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act (the Act) is appropriate for pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness by any method, and is therefore covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin who:
Have not been previously tested for CYP2C9 or VKORC1 alleles; and

Have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and

Are enrolled in a prospective, randomized, controlled clinical study when that study meets the standards as outlined in NCD 90.1 - Pharmacogenomic Testing to Predict Warfarin Responsiveness.

Non-covered Indications
Genetic testing for the VKORC1 gene is considered investigational at this time for all other medications.


Bill Type Codes:

Contractors 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.
N/A




Revenue Codes:

Contractors 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.

N/A




ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: 81225


ICD-10 CODE DESCRIPTION

I20.0 Unstable angina

I20.1 Angina pectoris with documented spasm

I20.8 Other forms of angina pectoris

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I21.29 ST elevation (STEMI) myocardial infarction involving other sites

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site

I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I24.0 Acute coronary thrombosis not resulting in myocardial infarction

I24.1 Dressler's syndrome

I24.8 Other forms of acute ischemic heart disease

I24.9 Acute ischemic heart disease, unspecified

I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris

I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris

I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris

I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris

I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina

I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina

Saturday, January 7, 2017

cpt code 00840 -Anesthesia for Intraperitoneal procedures

cpt code and Description

00840 Anesthesia for Intraperitoneal procedures in lower abdomen including laparoscopy

Billing Guide

 Base units - 6 (Additional time may be billed in 15 minute increments = 1 unit)


00126, 00170, 00840, 00851, or 01961, Certified Registered Nurses Anesthetist (CRNA) during tympanotomy, intraoral procedures, lower abdominal surgery, tubal ligation, or cesarean deliveries: When modifier QX is used on claims with procedure codes 00126, 00170, 00840, 00851, or 01961, the services will be reimbursed at 40% of the West Virginia state Medicaid physician fee schedule


Explanation of Updates

Section 292.440 has been revised to correct errors in billing instructions effective October 13, 2003. Information that is no longer applicable to this program has been deleted. This section of the manual has been reformatted for clarification and readability. Information has been added to notify providers that anesthesia procedure codes with a base of 4 or less are eligible to be billed with a second modifier, 22, referencing surgical field avoidance.

Information previously included in Section 292.440, part A has been moved to an added part of this section, part C. The information in part C has been revised to delete national CPT procedure code 00840 as an appropriate crosswalk for local code Z9940. Locally assigned procedure code Z9940 is the correct procedure code when billing anesthesia services for abdominal hysterectomy.

The description for Z9940 has been changed to “anesthesia for abdominal hysterectomy.” Information previously included in part B of section 292.440 has been moved to an added part of this section, part D. Information in part D has been revised to delete procedure code 00855 and add procedure codes 01962 and 01963 as replacement codes.

Section 292.447 includes minor changes to the example of a completed claim for clarification. Section 292.730 includes information regarding the billing of professional and technical components for covered laboratory and radiology services and use of new modifiers, TC for the technical component and 26 for the professional component.

Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes have already been incorporated.

00840 Required to name each procedure done on females only, by surgeon in “Procedures, Services or Supplies” column.


ASA Codes Associated with CPT Codes That May Require Prior Authorization

00402 Anesthesia for reconstructive breast procedures (reduction, augmentation, muscle flaps)
00580 Anesthesia for heart transplant or heart-lung transplant
00796 Liver transplant (recipient)
00840 Anesthesia for intraperitoneal procedures in lower abdomen (hysterectomy and sterilization)
00846 Anesthesia for radical hysterectomy
00848 Anesthesia for pelvic exenteration

Wednesday, January 4, 2017

CPT code 00170 - Anesthesia intraoral procedures

Use CPT code 00170 to bill general anesthesia

The Health Insurance Portability and Accountability Act of 1996 mandates that all professional anesthesia services performed on or after Sept. 1, 2002, be reported with CPT-4 anesthesia procedure codes (range *00100-*01999) and national modifiers.

The correct code to report general anesthesia for dental services under the medical program is:

Procedure Code Explanation

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

The medical criteria for the procedure are:

• Children under age four (i.e., through the end of their third year) are approved based on age alone.

• Older patients require a total of six or more teeth extractions, restorations or other procedures performed in two or more quadrants of the mouth, and one of the following:

 – High-risk medical condition that does not permit the  procedure to be performed safely under local anesthesia

 – Infection that does not allow the use of local anesthesia

 – Extensive orofacial and/or dental trauma for which  treatment under local anesthesia would be ineffective  or compromised


Billing Guide

00126, 00170, 01961  - Certified Registered Nurses Anesthetist (CRNA) during tympanotomy, intraoral procedures, or cesarean deliveries: When modifiers QK or QY are used on claims with procedure codes 00126, 00170, or 01961, the services will be reimbursed at 60% of the West Virginia state Medicaid physician fee schedule.

00126, 00170, 00840, 00851, or 01961,- Certified Registered Nurses Anesthetist (CRNA) during tympanotomy, intraoral procedures, lower abdominal surgery, tubal ligation, or cesarean deliveries: When modifier QX is used on claims with procedure codes 00126, 00170, 00840, 00851, or 01961, the services will be reimbursed at 40% of the West Virginia state Medicaid physician fee schedule.

CRNA Services and Modifier Combinations

Modifiers QZ and U1 must be submitted when a CRNA has personally performed the anesthesia services, is not medically directed by the anesthesiologist, and is directed by the surgeon. Modifiers QX and U2 must be submitted by a CRNA who provided services under the medical direction of an anesthesiologist.

Monitored Anesthesia Care

Anesthesiologists or CRNAs may use modifier QS to report monitored anesthesia care.

The QS modifier is an informational modifier, and must be billed with any combination of pricing modifiers for reimbursement.

30.2.4.4 Dental General Anesthesia Procedure code 00170 with modifier U3 should be used when billing for the appropriate reimbursement of dental general anesthesia.

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

General Modifiers Can use with CPT code 00170

The following anesthesia modifiers must be used for anesthesia services: - AA Anesthesia services personally performed by the anesthesiologist. The modifier “AA” may be used if a teaching anesthesiologist is continuously involved in one procedure with one resident or with one student certified registered nurse anesthetist. The teaching anesthesiologist must document in the medical records that he or she was present during all critical portions of the procedure including induction and emergence.

- AD Medical supervision by a physician: more than four concurrent anesthesia procedures;
- QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals;
- QX CRNA with medical direction by a physician or anesthesia assistant with medical direction by an anesthesiologist;
- QY Medical direction of one CRNA by an anesthesiologist; and
- QZ CRNA without medical direction by physician.

Note: Anesthesiologist assistants may use the modifier “QX” for services provided under the medical direction of an anesthesiologist if they are employed by a physician or in an independent practice. An anesthesiologist may use the “QY” modifier if he/she provides medical direction to an anesthesiologist assistant.

When it is medically necessary to provide general anesthesia services for extensive restorative dental procedures or for a covered oral surgery procedure for which there is not a surgical code, the anesthesia services must use code 00170 modified by the appropriate anesthesia modifier.

For the reimbursement of anesthesia services the provider must use the anesthesia code that best describes the anesthesia procedure performed modified by the appropriate anesthesia modifier, and report the total anesthesia time in minutes.

Surgical CPT codes that include the administration of anesthesia in the description of that CPT code will only be reimbursed when an anesthesia CPT code in the range 00100-01999 is also coded on the claim. Certain CPT codes will not be reimbursed by CareSource because it is not considered to be a surgery or incident to another surgery.

Friday, December 2, 2016

Pediatric anesthesia service CPT 99143, 99144 AND 99145

Pediatric Moderate (Conscious) Sedation

Effective January 1, 2006, Procedure  codes 99141 and 99142 were deleted and have been replaced with Procedure  codes 99143 (Moderate sedation services…provided by the same physician performing the diagnostic or therapeutic service…requiring the presence of an independent trained observer to assist in the monitoring of the patient’s…under 5 years of age, first 30 minutes intra-service time), 99144 (…age 5 years or older, first 30 minutes intra-service time), and add-on code 99145 (…each additional 15 minutes intra-service time).

• Claims for moderate sedation should be submitted hard copy indicating the medical necessity for the procedure. Documentation should also reflect pre- and post-sedation clinical evaluation of the patient.

• Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999).

• Moderate sedation is restricted to recipients from birth to age 13. (Exceptions to the age restriction will be made for children who are severely developmentally disableddocumentation attached must support this condition. No claims will be considered for recipients twenty-one years of age or older)

• Moderate sedation includes the following services (which are not to be reported/billed separately):

* *  Assessment of the patient (not included in intraservice time);

* *  Establishment of IV access and fluids to maintain patency, when performed;

* *  Administration of agent(s);

* *  Maintenance of sedation;

* *  Monitoring of oxygen saturation, heart rate and blood pressure; and

* *  Recovery (not included in intraservice time)

• Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.

• Louisiana Medicaid has adopted Procedure  guidelines for procedures that include moderate sedation as an inherent part of providing the procedure. Louisiana Medicaid does not reimburse when a second physician other than the health care professional performing the diagnostic or therapeutic service provides the sedation. Claims paid inappropriately are subject to recoupment.

Additional Anesthesia Information

• CRNAs must place the name of their supervising doctor in Item 17 of the CMS 1500 or 837P claim form.

• Anesthesia time begins when the provider begins to prepare the patient for induction and ends with the termination of the administration of anesthesia.

• Time spent in pre- or postoperative care may not be included in the total anesthesia time.

• A surgeon who performs a surgical procedure will not also be reimbursed for the administration of anesthesia for the procedure.

• A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-anesthesia examination/evaluation, and another may fulfill other criteria. The medical record must indicate the services provided and must identify the provider who rendered the service. A single claim must be submitted showing one member as the performing provider for all services rendered. In other words, the billing of these services separately will not be reimbursed.

• Anesthesia for arteriograms, cardiac catheterizations, CT scans, angioplasties and/or MRIs should be billed with the appropriate code from the Radiological Procedures subheading in the Anesthesia section of Procedure .



• Procedure  code 00952 (Anesthesia for vaginal procedures…; hysteroscopy and/or hysterosalpingography) pends to Medical Review and must be submitted hardcopy with the anesthesia record attached.

When billed for anesthesia administered during a hysterosalpingogram, Procedure  code 58340, the documentation attached must indicate:

* *  medical necessity for anesthesia (diagnosis of mental retardation, hysteria, and/or musculoskeletal deformities
that would cause procedural difficulty) and

* *  that the hysterosalpingogram (HSG) meets the criteria for that procedure (see the Medical Review section-Billing
Information)

• Anesthesia for dental restoration should be billed under Procedure  anesthesia code 00170 with the appropriate modifier, minutes and most specific diagnosis code. Reimbursement is formula-based, with no additional payment being made for a biopsy. A provider does not have to perform a biopsy to bill this code.

• Anesthesia for multiple surgical procedures in the same anesthesia session must be billed on one claim line using the most appropriate anesthesia code with the total anesthesia time spent reported in Item 24G on the claim form.

The only secondary procedures that are not to be billed in this manner are tubal ligations and hysterectomies.

• Anesthesia claims with a total anesthesia time less than 10 minutes or greater than 224 minutes must be submitted hard copy with the appropriate anesthesia graph attached.

• Anesthesia claims for multiple but separate operative services performed on the same recipient on the same date of service must be submitted hard copy, with a cover letter indicating the above. The anesthesia graphs from the surgical procedures should be included and the claim with attachments should be submitted to Unisys at the address below.

• When anesthesia claims deny with error codes 749 (delivery billed after hysterectomy was done) or 917 (lifetime limits for this service have been exceeded), a new claim must be submitted to Unisys at the address below with a cover letter describing the situation.

Thursday, November 24, 2016

Anesthesia and CRNA Services in a Critical Access Hospital (CAH)



Payment for CRNA Pass-Through Services


If a CAH that meets the criteria for a pass-through exemption is interested in selecting the Method II option, it can choose this option for all outpatient professionals except the CRNA’s and still retain the approved CRNAs exemption for both inpatient and outpatient professional services of CRNAs. The CAH, with an approved exemption, can choose to give up its exemption for both inpatient and outpatient professional services of CRNAs in order to include its CRNA outpatient professional services along with those of all other professional services under the Method II option. By choosing to include the CRNAs under the Method II for outpatient services, it loses its CRNA pass-through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to bill the A/B MAC (B) for the CRNA inpatient professional services.

All A/B MAC (A) payments for CRNA services are subject to cost settlement.

If a CAH that meets the criteria for a pass-through exemption is not interested in selecting the Method II option, the CAH can still receive the CRNA pass-through under the Standard Option (Method I). Below are the billing requirements for Method

Provider Billing Requirements for Method I

TOBs = 85X and 11X

Revenue Code 037X for CRNA technical services

Revenue Code 0964 for Professional services

HCPCS Code for services the CRNA is legally authorized to perform in the state in which the services are furnished

Units = Anesthesia (if applicable)

Reimbursement

Revenue Code 37X, CRNA technical service = Cost Reimbursement

Revenue Code 0964, CRNA professional service = Cost Reimbursement for both inpatient and outpatient

Deductible and coinsurance apply.

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass-through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.


 Payment for Anesthesia Services by a CRNA (Method II CAH only)


Provider Billing Requirements for Method II Receiving the CRNA Pass-Through

TOB = 85X

Revenue Code 037X = CRNA technical service

Revenue Code 0964 = CRNA professional service

HCPCS Code = for services the CRNA is legally authorized to perform in the state in which the services are furnished

Units = Anesthesia (if applicable)

Reimbursement

Revenue Code 037X, CRNA technical service = cost reimbursement

Revenue Code 0964, CRNA professional service = cost reimbursement

Deductible and coinsurance apply.

Provider Billing Requirements for Method II CRNA - Gave up Pass-Through Exemption (or never had exemption)

TOB = 85X

Revenue Code = 037X for CRNA technical service

Revenue Code = 0964 for CRNA professional service

Reimbursement - For dates of service on or after July 1, 2007

Revenue Code 037X for CRNA technical service = cost reimbursement

Revenue Code 0964 for CRNA professional service = based on 100 percent of the allowed amount when not medically directed or
50 percent of the allowed amount when medically directed.

Providers bill a “QZ” modifier for non-medically directed CRNA services. Deductible and coinsurance apply.

How to calculate payment for anesthesia claims based on the formula - For dates of service on or after July 1, 2007

Identify anesthesia claims by HCPCS code range from 00100 through 01999


Non-medically directed CRNA

(Sum of base units plus time (anesthesia time divided by 15)) times conversion factor minus (deductible and coinsurance) times 1.15

Medically directed CRNA

(Sum of base units plus time (anesthesia time divided by 15)) times conversion factor times medically directed reduction (50 %) minus (deductible and coinsurance) times 1.15

Reimbursement - For dates of service prior to July 1, 2007

Revenue Code 037X for CRNA technical service = cost reimbursement

Revenue Code 0964 for CRNA professional service = 115% times 80% (not medically directed) or 115% times 50% (medically directed) of allowed amount (Use Anesthesia formula) for outpatient CRNA professional services.

Providers a “QZ” modifier for non-medically directed CRNA services. Deductible and coinsurance apply.

How to calculate payment for anesthesia claims based on the formula - For dates of service prior to July 1, 2007

Add the anesthesia code base unit and time units. The time units are calculated by dividing actual anesthesia time (Units field on the UB92) by 15. Multiply the sum of base and time units by the locality specific anesthesia conversion factor (file name below).

The Medicare program pays the CRNA 80% of this allowable charge when not medically directed. Deductible and coinsurance apply.

If the CRNA is medically directed, pay 50% of the allowable charge. Deductible and coinsurance apply.


Base Formula

Number of minutes divided by 15, plus the base units = Sum of base units and time Sum of base units and time times the conversion factor = allowed amount


Source

Number of minutes = Number of units on the claim (Units field of the UB04) Base Units = Anesthesia HCPCS

Conversion Factor = File - MU00.@BF12390.MPFS.CYXX.ANES.V1023

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass-through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.


 CAH Outpatient Services Part B Deductible and Coinsurance

Payment for outpatient services of a CAH is subject to applicable Medicare Part B deductible and coinsurance amounts unless waived based on statute.

For information on the application of deductible and coinsurance for screening and preventive services, see chapter 18 of Pub. 100-04, Medicare Claims Processing Manual.

Payments for clinical diagnostic laboratory tests furnished to CAH outpatients on or after November 29, 1999, are made on a reasonable cost basis with no beneficiary cost-sharing - no coinsurance, deductible, copayment, or any other cost-sharing.

Tuesday, November 15, 2016

CPT code 00640, 01935, 01936 and 01991, 01992

Procedure code and Description

00640 (Investigational)  ANESTHESIA FOR MANIPULATION OF THE SPINE OR FOR CLOSED PROCEDURES ON THE CERVICAL, THORACIC OR LUMBAR SPINE

01935 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; DIAGNOSTIC

01936 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; THERAPEUTIC

01991 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); OTHER THAN THE PRONE POSITION

01992 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); PRONE POSITION

Additional Information

Monitored anesthesia (as defined by CPT codes 01991, 01992, 01935 and 01936) is considered not medically necessary when provided in conjunction with all of the Epidural Injections defined in this policy. Denials for anesthesia services will be reviewed only on appeal with supportive medical necessity documentation.

For additional information relating to medical policy regarding this service, please review the CareSource Medical Policy titled “Pain Management Interventional Procedures Policy”


Anesthesia Services  Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. 


Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure code plus modifier codes. Surgery codes are not appropriate unless the anesthesiologist or Qualified Nonphysician Anesthetist is performing the surgical procedure.

An anesthesiologist, Qualified Nonphysician Anesthetist or an Anesthesia Assistant (AA) can provide anesthesia services. The anesthesiologist and the Qualified Nonphysician Anesthetist can bill separately for anesthesia services they personally perform. In cases of medical direction, both the anesthesiologist and the Qualified Nonphysician Anesthetist would bill Medicare for their component of the procedure. Each provider should use the appropriate anesthesia modifi er.

Note: If the surgery is non-covered, the anesthesia is also non-covered. Anesthesia procedure codes are organized as follows:



Area of the Body Head Neck Thorax (chest wall and shoulder girdle) Intrathoracic Spine and Spinal Cord Upper Abdomen Lower Abdomen Perineum Pelvis (except hip) Upper Leg (except knee) Knee and Popliteal Area Lower Leg (below knee, including ankle and foot) Shoulder and Axilla Upper Arm and Elbow Forearm, Wrist and Hand Radiological Procedure Burn Excisions or Debridement Obstetric

Other Procedure CPT Code Range

00100-00222

00300-00352

00400-00474

00500-00580

00600-00670

00700-00797

00800-00882

00902-00952

01112-01190

01200-01274

01320-01444

01462-01522

01610-01682

01710-01782

01810-01860

01916-01936

01951-01953

01958-01969

01990-01999


Description of Procedure or Service

Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (usually general anesthesia or moderate sedation).

Background

Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft-tissue adhesions with less force than would be required to overcome patient resistance or apprehension. 

MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions, such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to treat (reduce) fractures (e.g., vertebral, long bones) and dislocations. MUA has been proposed as a treatment modality for acute and chronic pain conditions, particularly of the spinal region, when standard care, including manipulation, and other conservative measures have been unsuccessful. MUA of the spine has been used in various forms since the 1930s. Complications from general anesthesia and forceful long-lever, high-amplitude nonspecific manipulation procedures resulted in decreased use of the procedure in favor of other therapies. MUA was modified and revived in the 1990s. This revival is attributed to increased interest in spinal manipulative therapy and the advent of safer, shorter-acting anesthesia agents used for conscious sedation.

MUA of the spine is described as follows: after sedation is achieved, a series of mobilization, stretching, and traction procedures to the spine and lower extremities is performed and may include passive stretching of the gluteal and hamstring muscles with straight-leg raise, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After the stretching and traction procedures, spinal manipulative therapy (SMT) is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand while the upper torso and lower extremities are stabilized. SMT may also be applied to the thoracolumbar or cervical area if considered necessary to address the low back pain.

The MUA takes 15–20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term analgesic control. Some practitioners  recommend performing the procedure on 3 consecutive days for best results. Care after MUA may include 4–8 weeks of active rehabilitation with manual therapy including SMT and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar
zygapophyseal and/or sacroiliac joints under fluoroscopic guidance (MUJA) and after epidural  injection of corticosteroid and local anesthetic (MUESI). Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. Together, these may be referred to as medicine-assisted manipulation.

This policy does NOT address the treatment of vertebral fractures or dislocations by spinal MUA. This policy does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.


When Spinal Anesthesia Under Anesthesia is not covered

• Spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain.

• Spinal manipulation and manipulation of other joints under anesthesia involving serial  treatment sessions are considered investigational.

• Manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain.

Policy Guidelines

Scientific evidence regarding spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is limited to observational case series and nonrandomized comparative studies. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking. Evidence is insufficient to determine whether MUA improves health outcomes.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 22505, 00640

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.



Coding

The five character codes included in the Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines are obtained from Current Procedural Terminology (CPT®) copyright 2012 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physician.

The responsibility for the content of Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines is with Blue Cross and Blue Shield of Louisiana and no endorsement by the AMA is intended or should be implied.

The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Any use of CPT outside of Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms.Applicable FARS/DFARS apply.

CPT is a registered trademark of the American Medical Association. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

CPT   - 00640, 22505, 23655, 24300, 27275
HCPCS - No codes
ICD-9 - Diagnosis All diagnoses
ICD-9 - Procedure No codes

MEDICAL POLICY AND/OR PROCEDURE

7.01.084 Spinal Manipulation Under Anesthesia

ACTIONS, COMMENTS AND REPORTING GUIDELINES

Under Policy Guidelines, added updated 2014 rationale statement. Report service with Category I CPT® codes 00640 and 22505.

CPT codes not covered for indications listed in the CPB:

00640 Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine

Policy Guideline

A pre-anesthesia evaluation by the anesthesiologist when surgery is canceled may be covered at the level of care rendered (e.g., brief or limited visit) as a hospital or office visit. A pre-anesthesia evaluation by the anesthesiologist when the procedure is delayed is not eligible for coverage as a separate procedure. It is an integral part of the subsequent anesthesia services.

If anesthesiologists are in a group practice, one physician member may provide the preanesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. The medical record must indicate the services furnished and identify the physicians who furnished them. However, only one member of the group is eligible to bill for the entire anesthesia service.

If an organ or tissue transplant is eligible for payment, the anesthesia services for harvesting the organ or tissue from a cadaver donor is also covered (maintaining respiration, oxygenation, etc.). Harvesting of organs or tissue requires careful maintenance of the donors to retain organ viability. However, only base relative value and time units are only allowed, with no additional modifying units.

Standby anesthesia services are not eligible for payment even when required by the facility in which the patient is to have surgery.

When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure should be reported. The time reported is the combined total for all procedures.

If circumstances warrant two anesthesiologists, documentation should be submitted with the claim. A base value of five units plus time will be allowed for the second anesthesiologist.


The following revised/reactivated 2016 CPT/HCPCS codes require prior approval, or for New England Health Plan members a referral authorization, beginning with services on January 1, 2016:

95972 S3870 00635 01935 01936 01991 01992 0200T 0201T 20974 22840 22851 E0747 E0748


Additional Information

Monitored anesthesia (as defined by CPT codes 01991, 01992, 01935 and 01936) is considered not medically necessary when provided in conjunction with all of the Epidural Injections defined in this policy. Denials for anesthesia services will be reviewed only on appeal with supportive medical necessity documentation.

For additional information relating to medical policy regarding this service, please review the CareSource Medical Policy titled “Pain Management Interventional Procedures Policy”.


• Codes are listed from head to toe (00100-01860)

– Modifiers are imperative to identify anesthesia provider(s) and type

• Anesthesia for Radiological Procedures (01916-01936)

– Cardiac cath (01920), interventional radiology (01924-01926), percutaneous image guided spinal procedures (01935-01936)

• Anesthesia for Burn Excisions and Debridement (01951-01953)

– Must be familiar with Total Body Surface Area (TBSA) measurements
– Less than 4% - 01951
– Between 4%-9% - 01952
– Each additional 9% (or part thereof) - +01953

• Anesthesia for Obstetrics (01958-01969)

– Read carefully to select accurate code (vaginal, C-section, hysterectomy, abortion, etc.)

Policy: American Society of Anesthesiologist (ASA) codes

Blue Cross accepts the CPT (ASA), 00100-01999 codes, for anesthesia services billed on the 837P claim format. Blue Cross does not accept, thus will deny, surgical codes submitted with anesthesia modifiers. All services for the same operative session should be submitted on the same claim.

ASA codes are restricted to anesthesiologists and CRNAs.

Time Designation/Submission

Anesthesia time should be indicated on the 837P claim format in the unit(s) field of the 837P record. Anesthesia time begins when the anesthesiologist or CRNA begins to prepare the patient for the induction of anesthesia in the operating room, or an equivalent area, and ends when they are no longer in personal attendance. Anesthesia time should be coded as minutes in the units of service field. (One unit equals one minute.)

Modifier use

Modifiers are required to identify the practitioner (anesthesiologist or CRNA), the circumstance (full or part-time), medical direction and if appropriate, patient physical status.

The HCPCS full or part-time modifiers (AA, AD, QK, QS, QX, QZ and QY) should be listed in the first modifier position. The anesthesia modifiers should only be reported with the CPT anesthesia codes 00100-01999. Other services (such as nerve blocks), may be performed by an anesthesiologist or CRNA, but should not be submitted with an anesthesia modifier.

Full-time:

• Use modifier AA for full-time physician (anesthesiologist) services.
• Modifier QZ would be used for full-time CRNA services. Part-time:
• Use modifier -AD or -QK for the medical direction provided by a physician (part-time services).
• Use modifier -QY for part-time medical direction of one CRNA by an anesthesiologist.
• Use modifier -QX for medically directed CRNA services (part time).
• Modifier -QS would be used for part-time monitored anesthesia care.

Physical Status

Six levels are currently recognized for patient physical status that may be used to distinguish various levels of complexity of the anesthesia service provided. These modifiers are reported in the second modifier position, on the same line as the anesthesia service code. Additional reimbursement may be made based on the patient physical status.

Qualifying Circumstances

In accordance with CPT, the following circumstances are recognized for submission of risk. These codes must be billed on a separate line from the anesthesia service. However, qualifying circumstance codes billed without an ASA service on the same claim will be rejected. The corresponding eligible base units that may be allowed are listed below.

Anesthesia risk factors will be priced independently of the anesthesia line for easier posting of payments to accounts and greater accuracy of payments.

Anesthesia Reporting for Multiple Surgery

Code anesthesia services associated with multiple or bilateral surgical procedures performed during the same operative session with the single anesthesia code that has the highest base unit value. If multiple ASA codes are submitted for the same operative session, the lower valued ASA code(s) will be denied.

Monitored Anesthesia Care

Monitored anesthesia care (MAC) refers to instances in which an anesthesiologist has been called on to provide specific anesthesia services to a particular patient undergoing a planned procedure. In this case, the physician performs a preanesthetic examination, is physically present in the operating suite, monitors the patient’s condition, makes medical judgments regarding the patient’s anesthesia needs, and is prepared to furnish anesthesia service as necessary.

For those circumstances under which such care is medically necessary and requested by the performing surgeon, Blue Cross will allow submission for MAC the same as for any other anesthesia service.

Use modifier -QS for monitored anesthesia services

Radiology Anesthesia services - Includes CPT codes 01916 - 01936


Issues

1. Is CPT Code 01992 the appropriate anesthesia code for the disputed services?

2. What is the total allowable for the disputed services ?

3. Is the requestor entitled to reimbursement ?

Findings

1. The insurance carrier denied CPT Code 01992 based on incorrect coding and substantiates this in their position statement claiming that this code is “anesthesia block in the prone position.” CPT Code 01992 is correctly defined as “Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position” [emphasis added]. Review of the submitted documentation finds that the primary procedure, performed by a different health care provider, was placement of therapeutic spinal cord electrode arrays, which is accomplished via injection. Therefore, CPT Code 01992 is found to be the appropriate anesthesia code for the disputed services.

2. 28 Texas Administrative Code §134.203(b)(1) states, in pertinent part, “for coding, billing reporting, and reimbursement of professional medical services, Texas Workers’ Compensation system participants shall apply the following: (1) Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; … and other payment policies in effect on the date a service is provided…” Chapter 12 of the Medicare Claims Processing Manual 140.3 (effective 1/1/13) states,

“For services furnished on or after January 1, 1996, the fee schedule for anesthesia services furnished by qualified nonphysician anesthetists is the least of 80 percent of:

* The actual charge;

* The applicable locality anesthesia conversion factor multiplied by the sum of allowable base and time units.”

The base unit reported by Medicare for 2014 is 5. The requestor reported 38 minutes of monitored anesthesia time. Chapter 12 of the Medicare Claims Processing Manual 50(G) states, “For anesthesia services furnished on or after January 1, 1994, the A/B MAC computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal place.” 38 minutes divided by 15 minutes, rounded to one decimal place is 2.5 time units. 28 Texas Administrative Code §134.203 (c) defines the conversion factor to be used in place of the Medicare conversion factor. The Division of Workers’ Compensation conversion factor for anesthesia with dates of service 1/1/14-12/31/14, as reported by the commissioner, is $55.75.

Base units (5) added to time units (2.5) then multiplied by the conversion factor ($55.75) equals $418.13. As the services were provided by a qualified nonphysician anesthetist (CRNA), the total allowable is calculated at 80 %, which is $334.51

3. Because the insurance carrier’s denial reasons were not supported, the requestor is entitled to reimbursement. The requestor is seeking reimbursement of $800.00. The total allowable is $334.51. Therefore, the recommended amount is $334.51.

Conclusion

For the reasons stated above, the Division finds that the requestor has established that additional reimbursement is due. As a result, the amount ordered is $334.51.


Wednesday, November 9, 2016

CPT code 62270, 62272, 62273

Lumbar puncture Procedure code and Description

62270 T Spinal puncture, lumbar, diagnostic 0206 $373 $204

62272 T Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) 0206 $373 $204

62273 T Injection, epidural, of blood or clot patch 0207 $672 $368

What is a Lumbar Puncture?

Fluoroscopy is a special form of X-ray that produces real-time video images, as opposed to pictures on film, making it possible to see internal organs and joints in motion. A lumbar puncture (also called a spinal tap) is a fluoroscopic procedure used to collect and look at the cerebrospinal fluid (CSF) surrounding the brain and spinal cord.


A lumbar puncture can help diagnose serious infections, such as

• Meningitis;

• Other disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis;

• Cancers of the brain or spinal cord.

Sometimes doctors use lumbar puncture to inject anesthetic medications or chemotherapy drugs into the cerebrospinal fluid.

Other names for a lumbar puncture (an LP):
• Spinal tap
• Spinal puncture
• Thecal puncture (thecal sac is a membrane of dura mater that surrounds the spinal cord and the cauda equina)
• Rachiocentesis (prefix “rachio-” indicating “spine”)

Other spinal punctures or punctures to obtain cerebral spinal fluid (CSF):

• Ventricular puncture (this is a puncture into a lateral ventricle of the brain)
• Cisternal puncture (this is a cervical vertebral puncture into the  cisterna at the base of the brain)


Spinal Injection Procedures that May Be Done Without Fluoroscopy Interlaminar epidural steroid injections may be performed without fluoroscopy if performed at a certified or accredited facility by a provider with privileges to perform the procedure at that facility. The provider must decide whether to use fluoroscopy based on sound medical practice. To be payable, these spinal injections must include a facility place of service code and documentation that the procedure was performed at a certified or accredited facility. Procedure  Code 62310 62311 62318 62319

Spinal Injection Procedures that Don’t Require Fluoroscopy Procedure  Code 62270 62272 62273

CPT 62273 - injection, epidural, of blood or clot patch; a comprehensive code, includes the following component codes:

• 36000 introduction of needle or intracatheter, vein
• 36140 introduction of needle or intracatheter, extremity artery
• 36410 venipuncture, child over age 3 years or adult, necessitating physician’s skill
• 62310 injection, single, epidural or subarachnoid; cervical or thoracic
• 62311 injection, single; epidural, lumbar sacral (caudal)
• 64479 transforaminal epidural; cervical or thoracic, single level
• 64483 transforaminal epidural; lumbar or sacral, single level
• 69990 use of operating microscope
• 76000-76003 fluoroscopy codes
• G0001 routine venipuncture for collection of specimen(s)


Code 62273 has been revised by deleting the specific reference to the lumbar region of the spine, because an ongoing cerebrospinal fluid leak can occur at any level of the spinal column. This revision clarifies that the epidural injection of blood or blood clot is not limited to the lumbar region.

Codes 62274 to 62279 have been deleted to eliminate overlapping procedures, accommodate placement of new combinations of procedures and substances (eg, injection of local anesthetic and steroid), designate types of administration, and specific spinal anatomy. Cross-references appear in the 2000 CPT book in the Spine and Spinal Cord Section to direct clinicians to the appropriate new injection procedure codes.

Anesthesia Service Codes not an all-inclusive list

Procedure  Code - 00100 to 00936, 00940 to 01999, 62273, 99100 to 99150

HCPCS Code - D9220, D9221 (D-codes only covered for oral surgery)

Anesthesia Modifiers *not an all-inclusive list. See Modifier policy for a complete list Modifiers must be billed with anesthesia procedure codes to indicate whether the procedure was personally performed, medically directed or medically supervised.

Service will deny:

* When billed without appropriate modifier for provider’s specialty

* When modifier is not billed in the appropriate modifier position.

* When billed with invalid modifier combinations. (see incorrect modifier billing  combination grid below)

* If not billed in accordance with standard coding/billing guidelines and Neighborhood’s policies


Image Guidance: 77003 Fluoroscopy Image Guidance: Guidance: 77003 Fluoroscopy Fluoroscopy * Spine and Spinal Cord: Injection, Drainage, or Aspiration Procedure  Section Guidelines

– Injection of contrast during fluoroscopic guidance and localization is an inclusive component in 62263, 62264, 66267, 62270-62273, 62280-62282, 62310- 62319.



A second issue relates to the reimbursement schedule. Most of the interventional procedures are grouped into Group II, diagnostic and therapeutic procedures with therapeutic procedures being reimbwsed at 7 5o/o of the applicable group rates of $130.00 and other diagnostic procedures at $168.00.

The following procedures are either listed in Group II C or D:

Procedure  62273 - injection, epidural, ofblood or clot patch

Procedure  62281 - injection/infusion of neurolytic substance, with or without other therapeutic substance; epidural, cervical or thoracic

Procedure  62282 - injection/infusion of neurolytic substance, with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Procedure  6231,0 - injection, single, not including neurolytic substances, with or without contrast, of diagnostic or'therapeutic substances; epidural or subarachnoid; cervical or thoracic

Procedure  62311 - - injection, single, not including neurolytic substances, with or without contrast, of diagnostic or therapeutic substances; epidural or subarachnoid; lumbar, sacral (caudal)


Billing Fluorscopic Guidance In Conjunctions with Facet Joint Injections 

Since fluoroscopic guidance is required to perform paravertebral facet joint and paravertebral facet joint nerve with destruction by neurolytic agent or sacroiliac joint injections, code 77003 should be additionally reported in conjunction with codes 64470- 64476, 64479-64484 and 64622-64627; and in certain circumstance, with code 27096.

Subsequent CPT Assistant articles in the January and February 2000 issues repeated the critical language “code 77003 should be additionally reported” when fluoroscopic guidance and localization is performed in conjunction with the epidural, subarachnoid, transforaminal, facet joint and paravertebral facet joint injections.

The Director of CPT Information and Education Services confirmed that “…from a CPT coding perspective code 77003 should be separately reported in addition to codes 62270-62273, 62280-62282, 62310-62319, and 64470-64484.”

Failure to report the fluoroscopic guidance code may result in the recoupment of claims for facet injections.

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