Sunday, March 19, 2017

CPT CODE 81406

CPT/HCPCS Codes


Group 1 Codes:

81406 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 7 (EG, ANALYSIS OF 11-25 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 26-50 EXONS, CYTOGENOMIC ARRAY ANALYSIS FOR NEOPLASIA)

Coverage Indications, Limitations, and/or Medical Necessity

Background:

This policy provides limited-coverage for molecular phenotyping of erythrocyte antigens performed on the human erythrocyte antigen HEA BeadChip™ (Immucor, Warren, NJ), a single nucleotide polymorphisms (SNP)-based microarray test. This high throughput molecular assay received FDA pre-market (PMA) approval in May, 2014 and is the only in vitro diagnostics (IVD) approved molecular test to characterize human red blood cell (RBC) antigens.

Many clinically significant antigens are encoded by alleles defined by SNPs. This assay identifies 35 antigens and 3 phenotypic variants across 11 blood groups (Rh, Kell, Duffy, Kidd, MNS, Lutheran, Dombrock, Landsteiner-Wiener, Diego, Colton and Scianna). Genomic DNA targets isolated from whole blood are amplified and fluorescent signals are interpreted by online software as specific alleles and probable antigen phenotype. This test does not evaluate patient antibody status.

For more than ten years, RBC genotyping has been applied mainly to mass screen donors in blood centers. American Rare Donor Program, a consortium of the American Red Cross and American Association of Blood Banks (AABB) accredited immunohematology reference laboratories have used molecular genotype information for several years to identify antigen negative blood units from donor for patients with antibodies. Blood centers also use molecular technology to genotype donors for certain antigens (eg, Dombrock) that are hard to ascertain because of antisera unavailability or weak potency.

Hemagglutination is the most common serologic method of determining a RBC phenotype. In this technique, the patient’s RBCs are tested with antisera specific for the antigens of interest. However, hemagglutination testing cannot be used if a patient has a positive direct antiglobulin test (DAT), or if direct agglutination typing sera is not available for the antigen. In addition, serologic phenotyping is invalid in the transfused patient who may have persistent donor RBCs in circulation. Because molecular genotyping is not subject to the limitations of serologic testing, it has become a useful tool in large hospital transfusion services.

As early as 1999, Legler et al demonstrated disparate molecular Rh phenotyping in 7 of 27 patients compared to serologic typing. Soon afterwards, Reid and others demonstrated that DNA from blood samples could be used to genotype patients who had recently been transfused. Castilho et al confirmed the unreliability of serologic testing when they showed that 6 of 40 molecular genotypes differed from serologic phenotypes in multiply transfused sickle cell anemia (SCA) patients, and in 9 of 10 alloimmunized thalassemic patients. A number of investigators have replicated these findings, most notably Bakanay et al when they demonstrated genotypic and phenotypic discrepancies in 19 of 37 multi-transfused patients in multiple alleles. The discrepancies aided in the selection of antigen-matched blood products and improved RBC survival, ultimately improving patient care. A recent case report by Wagner emphasizes the usefulness of molecular testing over serologic testing in chronically transfused patients.

In a prospective observational study, Klapper et al. used the HEA BeadChip™ to provide extended human erythrocyte antigen (xHEA) phenotyped donor units and recipient patient samples. xHEA-typed units were assigned to pending transfusion requests using a web-based inventory management system to simulate blood order processing at four hospital transfusion services. The fraction of requests filled (FF) in 3 of 4 sites was >95% when matching for ABO, D and known alloantibodies, with a FF of > 90% when additional matching for C, c, E, e, and K antigens. The most challenging requests came from the fourth site where the FF was 62 and 51% respectively, even with a limited donor pool.

In a prospective observational study by Da Costa et al, 21 of 35 sickle cell anemia (SCA) patients had discrepancies or mismatches, mainly in the Rh, Duffy, Jk and MNS blood groups, between the genotype profile and the serologically-matched blood unit for multiple antigens. These authors report that their genotype matching program resulted in elevated hemoglobin levels, increased time between transfusions and prevented the development of new alloantibodies.

Two recently published papers have shown the feasibility of routinely applying molecular blood banking techniques in a hospital transfusion service. Routine RBC testing has been implemented in a large tertiary care hospital in Los Angeles, CA to maximize efficient use of blood units. At a large hospital in Cleveland, OH, pre-transfusion molecular typing is performed on chronically transfused patients, patients with autoantibodies, multiple antibodies, when no antigen specific antibody is available for testing and to solve laboratory discrepancies. They authors note that the major benefit of molecular typing is its application for patients who cannot be typed by serology due to an unsuitable sample. Valid results can be obtained even when they have been transfused within a few days of testing or have been massively transfused.

Samples selected for molecular testing were based on an algorithm.


Indications:

Medicare will cover pre-transfusion molecular testing using an FDA approved platform for red cell genotyping for the following categories of patients.
Long term, frequent transfusions anticipated to prevent the development of alloantibodies (e.g. sickle cell anemia, thalassemia or other reason);
Autoantibodies or other serologic reactivity that impedes the exclusion of clinically significant alloantibodies (e.g. autoimmune hemolytic anemia, warm autoantibodies, patient recently transfused with a positive DAT, high-titer low avidity antibodies, other reactivity of no apparent cause);
Suspected antibody against an antigen for which typing sera is not available; and
Laboratory discrepancies on serologic typing (e.g. rare Rh D antigen variants).
Fetal red cell genotyping to evaluate hemolytic disease of the fetus/newborn (HDFN) in alloimmunized mothers.”

Medicare does not expect molecular testing to be performed on patients undergoing surgical procedures such as bypass or other cardiac procedures, hip or knee replacements or revisions, or patients with alloantibodies identifiable by serologic testing that are not expected to require long term frequent transfusions. The medical necessity for molecular RBC phenotying must be documented in the patient’s medical record.



Limitations:

Medicare does not expect molecular testing to be performed on patients undergoing surgical procedures such as bypass or other cardiac procedures, hip or knee replacements or revisions, or patients with alloantibodies identifiable by serologic testing that are not expected to require long term frequent transfusions.


Monday, March 13, 2017

CPT 15823, 67904 - Dermatochalasis, Blepharochalasis, Pseudoptosis

CPT/HCPCS Codes

Group 1 Codes:

15822 BLEPHAROPLASTY, UPPER EYELID;

15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID

67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)

67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)

67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)

67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH

67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH

67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA)

67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)

67909 REDUCTION OF OVERCORRECTION OF PTOSIS




Coverage Indications, Limitations, and/or Medical Necessity

Introductory Definitions

Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process.

Blepharochalasis: excess skin associated with chronic recurrent eyelid edema that physically stretches the skin.

Blepharoptosis: drooping of the upper eyelid related to the position of the eyelid margin with respect to the visual axis

Pseudoptosis (“false ptosis”): For the purposes of this policy, the specific circumstance where the eyelid margin is in an appropriate anatomic position with respect to the visual axis but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin so as to become a “pseudo” lid margin. [Note: other causes of pseudoptosis are not the subject of this policy unless specifically referenced.]

Brow ptosis: drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid that may cause mechanical blepharoptosis and/or dermatochalasis

Blepharoplasty: removal of eyelid skin, fat, and or muscle

Blepharoptosis repair: restoring the eyelid margin to its normal anatomic position.

Brow ptosis repair: restoring the eyebrow tissues to their normal anatomic position.

Upper Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair (Brow Lift)

Blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic (i.e., to enhance appearance).

For the purposes of this policy, these surgeries (either individually or in the minimum combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. Published literature correlates this amount of field restriction with a Margin Reflex Distance (see below) of 2.0 mm or less.

This policy is not intended to cover reconstructive surgery, which is done to improve function or approximate a normal appearance in circumstances of congenital defects, developmental abnormalities, trauma, infection, tumors, or diseases not specifically referenced as included. Examples of such surgeries are (but not limited to):

ectropion or entropion repairs.

repairs to address ocular exposure.

repairs to address difficulty fitting an ocular prosthesis

primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is debilitating for which all other treatments have failed or are contraindicated.

prompt repair of an accidental injury


Note, however, the fact that this policy excludes reconstructive surgery does not relieve the physician of the obligation to document in the medical record reasonable evidence defending the medical necessity of a given procedure, including but not limited to an appropriate patient complaint that would impact their ability to perform tasks of daily living (or, in the absence of a specific complaint, a statement that the repair is needed to prevent anticipated future damage to ocular structures), an appropriate physical exam delineating the anatomical issues to be addressed, appropriate supplemental testing, appropriate photographic documentation clearly demonstrating to a qualified third-party the anatomical issues to be addressed, and appropriate operative notes and consents.

Lower Eyelid Blepharoplasty
Lower eyelid blepharoplasty is almost never functional in nature and is considered a non-covered procedure under this policy. Appeals to this statement may be considered on a case-by-case basis.

Coverage when a Noncovered Procedure is Performed with a Covered Procedure
When a noncovered cosmetic surgical procedure is performed in the same operative session as a covered surgical procedure, benefits will be provided for the covered procedure only. For example, if dermatochalasis would be resolved sufficiently by brow ptosis repair alone, an upper lid blepharoplasty in addition would be considered cosmetic. Similarly, if a visual field deficit would be resolved sufficiently by upper lid blepharoplasty alone (for tissue hanging over the lid margin), a blepharoptosis repair in addition would be considered cosmetic.

Documentation Requirements

Reasonably complete information fulfilling the criteria in Section A (Patient Complaints and Physical Signs), and Section B (Photographs) as delineated below must be adequately documented in the patient’s medical records to demonstrate the reasonableness and necessity of the procedure(s) performed.

In general and where applicable, clinical notes, and physical findings rather than formal visual field testing, should support a decrease in the superior field of vision and/or peripheral vision. While they may be performed to demonstrate to the patient (if needed) the potential for improvement, or if required by the prevailing standard of care, this policy does not consider the visual field testing in documenting a procedure as reasonable and necessary. Exceptions may be considered on appeal (see below).

If two (or more) surgeries are planned, each must be individually documented. This may (sometimes, but not necessarily) require multiple sets of photographs.

The medical record should also clearly indicate a statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that the surgery will significantly improve functional status of the patient.

When requested documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, (i.e., illegible or incomplete) such services will be denied as not reasonable and necessary.

Section A. Patient Complaints and Physical Signs

A functional deficit or disturbance secondary to eyelid and/or brow abnormalities must be documented, such as interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or driving).

In addition, the documentation should show that the eye being considered for surgery has physical signs consistent with the functional deficit or abnormality.

For Blepharoptosis Repair

A margin reflex distance (MRD sometimes referred to as MRD1)) of 2.0 mm or less. The MRD is a measurement from the corneal light reflex to the upper eyelid margin (NOT any overhanging skin
that may be present causing pseudoptosis) with the brows relaxed, and

If applicable, the presence of Herring's effect (related to equal innervation to both upper eyelids) defending bilateral surgery when only the more ptotic eye clearly meets the MRD criteria (i.e., if lifting the more ptotic lid with tape or by instillation of phenylephrine drops into the superior fornix causes the less ptotic lid to drop downward and meet the strict criteria, the less ptotic lid is also a candidate for surgical correction.


For Upper Blepharoplasty and/or Brow Ptosis Repair:

Redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the “pseudo” margin produces a central "pseudo-MRD" of 2.0 mm or less, or

Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in corresponding gaze.


In the expected to be rare circumstance where a patient would fail the MRD criterion for a given surgery but the provider feels that visual field testing would, despite that fact, support performance of surgery for a functional reason, this can be considered on appeal.

If an anatomic abnormality of the eye (such as an eccentric or elongated pupil) makes the MRD either difficult to establish or meaningless for this purpose, it is expected the surgeon will include a statement outlining his or her rationale that an equivalent standard has been met.

Section B Photographs

Photographs are required to support upper eyelid surgery as reasonable and necessary.

The “physical signs” documented in Section A must be clearly represented in photographs of the structures of interest and the photographs must be of good quality and of sufficient size and detail as to make those structures easily recognizable.

The patient’s head and the camera must be in parallel planes, not tilted so as not to distort the appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent measurement of a MRD).

Unless medial/lateral gaze is required to demonstrate a specific deficit, photos should be with gaze in the primary position, looking straight ahead.

Oblique photos are only necessary if needed to better demonstrate a finding not clearly shown by other requested photos.

Digital or film photographs are acceptable, and may be submitted electronically where possible. Photographs must be identified with the beneficiary’s name and the date.

For Blepharoptosis Repair (CPT 67901 & 67902)

Photographs of both eyelids in the frontal (straight-ahead) position should demonstrate the MRD outlined in Section A. If the eyelid obstructs the pupil, there is a clear-cut indication for surgery. (For reference, the colored part of the eye is about 11 mm in diameter, so the distance between the light reflex and the lid would need to be about one fifth that distance or less for the MRD to be 2.0 mm or less.)

In the special case of documenting the need for bilateral surgery because of Herring’s law, two photos are needed:One showing both eyes of the patient at rest demonstrating the above MRD criterion in the more ptotic eye, and another showing both eyes of the patient with the more ptotic eyelid raised to a height restoring a normal visual field, resulting in increased ptosis (meeting the above MRD standard) in the less ptotic eye.


NOTE: Reviewers will assume the accepted average of 11 mm of corneal diameter to assess measurements in photographs. If a patient’s corneal diameter deviates from this by more than 0.5 mm, this should be clearly documented in the record so appropriate adjustments can be made. . Alternatively, an accurate millimeter rule can be taped along the brow, on the cheek, or elsewhere in the photo (approximately in the corneal plane) to facilitate such measurements.


For Upper Lid Blepharoplasty (CPT 15822 & 15823)

Photographs of the affected eyelid(s) in both frontal (straight ahead) and lateral (from the side) positions demonstrate the physical signs in Section A. Oblique photos are only necessary if needed to better demonstrate a finding not clearly shown by frontal and lateral photos.

For Brow Ptosis Repair (CPT 67900)

One frontal (straight ahead) photograph should document drooping of a brow or brows and the appropriate other criteria in Section A. If the goal of the procedure is improvement of dermatochalasis, a second photograph should document such improvement by manual elevation of brow(s). If a single frontal photograph that includes the brow(s) would render other structures too small to evaluate, additional (overlapping to the degree possible) photos should be taken of needed structures to ensure all required criteria can be reasonably demonstrated and evaluated.


NOTE: If both a blepharoplasty and a ptosis repair are planned, both must be individually documented. This may (sometimes, but not necessarily) require two sets of photographs: showing a pseudo-MRD of 2.0 mm or less secondary to the redundant skin (and its correction by taping), AND an MRD of 2.0 mm or less secondary to the blepharoptosis.



ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

H02.31 Blepharochalasis right upper eyelid
H02.34 Blepharochalasis left upper eyelid
H02.401 Unspecified ptosis of right eyelid
H02.402 Unspecified ptosis of left eyelid
H02.403 Unspecified ptosis of bilateral eyelids
H02.411 Mechanical ptosis of right eyelid
H02.412 Mechanical ptosis of left eyelid
H02.413 Mechanical ptosis of bilateral eyelids
H02.421 Myogenic ptosis of right eyelid
H02.422 Myogenic ptosis of left eyelid
H02.423 Myogenic ptosis of bilateral eyelids
H02.431 Paralytic ptosis of right eyelid
H02.432 Paralytic ptosis of left eyelid
H02.433 Paralytic ptosis of bilateral eyelids
H02.831 Dermatochalasis of right upper eyelid
H02.834 Dermatochalasis of left upper eyelid
Q10.0 Congenital ptosis

Tuesday, March 7, 2017

human Leukocyte Antigen procedure codes


Coverage Indications, Limitations, and/or Medical Necessity

Background

Human Leukocyte Antigen (HLA) typing is performed to assess compatibility of recipients and potential donors as a part of solid organ and hematopoietic stem cell/ bone marrow pre-transplant testing. HLA testing is also performed to identify HLA alleles and allele groups (antigen equivalents) associated with specific diseases and individualized responses to drug therapy (e.g., HLA-B*27 and ankylosing spondylitis and HLA-B57:01 and abacavir hypersensitivity), as well as other clinical uses. One or more HLA genes may be tested in specific clinical situations (e.g., HLA A, B, C,-DRB1, and DQB1 for kidney transplantation). Each HLA gene typically has multiple variant alleles or allele groups that can be identified by typing.

HLA antigens are divided into types: Class I (A, B, C) and Class II (DR, DP, DQ). The primary use for HLA testing is to match organ and tissue transplant recipients with compatible donors. Different kinds of transplants necessitate different levels of matching between donor and intended recipient. This may determine which HLA tests are performed and which HLA genes are tested for. HLA typing identifies the unique constellation of HLA antigens for an individual.

HLA typing using newer DNA technologies provides tests that are more robust, accurate and reliable in resolving allele-level differences in HLA genes that cannot be detected by serology. DNA tests can be performed using a variety of source materials (lymphocytes, whole blood, buccal swabs, biopsy samples, frozen tissue) and are less affected by viability and sample age. Several approaches to HLA typing are used, offering a range of typing resolution levels from low (antigen-level) to high (allele-level). Examples include, tests used to identify HLA types that rely on amplification of limited stretches of genomic DNA within the HLA genes. The genetic polymorphisms associated with the different HLA alleles are identified through hybridization with specific amplification primers: sequence-specific primer (SSP) or sequence specific oligonucleotide probes (SSO) or by direct sequencing-based typing (SBT).

PCR-SSO

Reverse SSO hybridization is used to determine HLA-A, -B, -C, -DR, -DQ and -DP locus types at an intermediate level of resolution, somewhat higher than serological testing. Tests of this type are used when low or intermediate resolution typing is required or as a screening test to identify potential donors or individuals who may later require higher resolution testing.

This technology is used for high volume testing and allows for relatively low-cost typing for bone marrow donor drives or other applications involving large sample numbers.

PCR-SSP

PCR-SSP is also used to determine HLA-DP and to determine, at a resolution similar to serological testing, HLA-A, -B, -C, -DR and DQ locus types. PCR-SSP is a very rapid test that can be performed in 3-4 hours from the time a sample is received. PCR-SSP is used for typing deceased organ donors when speed is an important consideration. PCR-SSP can also be used to provide higher resolution testing and may be employed to resolve alleles. In this technique, PCR primers are designed to anneal only to a specific set of alleles or to a single allele.

SBT

SBT provides the highest resolution HLA typing for HLA-A, -B, -C, -DR, -DQ and -DP locus alleles. SBT is used when the highest resolution typing is important as in donors and recipients of stem cell transplants or in examining disease associations.


Indications

The commercial availability does not ensure that a molecular diagnostic test is indicated for clinical application. Molecular diagnostic testing is a rapidly evolving science in which the significance of detecting specific mutations has yet to be clarified in many circumstances. Analytical and clinical validity as well as clinical utility are the responsibility of the provider, and all testing must meet standards of care.

For the purpose of this LCD, the Molecular Pathology Procedures for HLA typing will be considered medically and reasonable necessary when the following apply:

Transplantation:

Standard of care determination of HLA matching for solid organ transplant (donor/recipient). Solid organ transplant registries include both serological HLA testing (e.g. crossmatch) and genomic molecular DNA typing. Family members, or unrelated living donors or cadaveric donors who donate bone marrow or a solid organ are HLA tested pretransplant to determine compatibility with the potential recipients.

Standard of care identification of determination of HLA matching for hematopoietic stem cell/bone marrow transplantation. Allele-level typing will provide clinical guidance for the HLA-A,B,C Class I and DRB1, DQB1,DPB1, and DQA1 Class II loci in the average transplant program because it is well established that mismatches at certain HLA loci between donor-recipients are closely linked to the risk of graft versus host disease. Potential marrow donors may enroll with a national registry such as the United States National Marrow Donor Program or the Canadian Blood Services registry.

Disease Association:

Standard of care testing to diagnose certain HLA related diseases/conditions when the testing is supported by the clinical literature and is informative for the direct management of a patient bearing a certain allele(s). It is not expected that more than one test would be required in a given beneficiary’s lifetime. Possible covered indications when standard laboratory testing (tissue typing) is not adequate:

HLA-B*27 for the diagnosis of certain cases of symptomatic patients with presumed ankylosing spondylitis or related inflammatory disease. HLA-B*27 is covered for ankylosing spondylitis in cases where other methods of diagnosis would not be appropriate or have yielded inconclusive results (National Coverage Determination 190.1).

In the work-up of certain patients with an unclear diagnosis of celiac disease and gluten hypersensitivity usually related to ambiguous standard laboratory results and/or inconsistent biopsy results (e.g., HLA-DQ2 by HLA-DQB1*02 and of DQ8 by HLA-DQB1*0302).

Pharmacogenetics:

Standard of care testing to diagnose certain HLA related drug hypersensitivity reactions when the testing is supported by the clinical literature and is informative for the direct management of a patient bearing a certain allele(s) associated to fatal skin drug reactions (Stevens-Johnson syndrome and toxic epidermal necrolysis). It is not expected that more than one test would be required in a given beneficiary’s lifetime. Possible covered indications:

HLA –B*5701 when testing performed prior to the initiation of an abacavir-containing regime in the treatment of HIV Infection.

HLA-B*1502 when genotyping may be useful for risk stratification when the testing is performed prior to the initiation of carbamazepine therapy in the treatment of patients at high risk of having this allele. HLA-B*1502 occurs almost exclusively in patients with ancestry across broad areas of Asia, including South Asian Indians.

Identification of HLA compatible platelets for transfusion.


Limitations

The following will be considered noncovered as applicable due to statutory exclusion, lack of Medicare benefit, not reasonable and necessary, or not separately billable (a component of the service per NCCI regulations).

Tests considered screening in the absence of clinical signs and symptoms of disease (e.g., HLA-DQB1*06:02P as a positive/negative predictor for narcolepsy).

Tests that do not provide the clinician with actionable data (information that will improve patient outcomes and/or change physician care and treatment of the patient).

Tests that confirm a known diagnosis or known information (and no new data for decision making).

Tests to determine risk for developing a disease or condition.

Tests without diagnosis specific indications.

Tests performed to measure the quality of a process.

Tests for Quality Control/Quality Assurance (QC/QA), i.e., tests performed to ensure a tissue specimen matches the patient.

Tests assessing the risk of allopurinol hypersensitivity reactions (HLA-B*58:01P).



CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

81370 Hla i & ii typing lr

81371 Hla i & ii type verify lr

81372 Hla i typing complete lr

81373 Hla i typing 1 locus lr

81374 Hla i typing 1 antigen lr

81375 Hla ii typing ag equiv lr

81376 Hla ii typing 1 locus lr

81377 Hla ii type 1 ag equiv lr

81378 Hla i & ii typing hr

81379 Hla i typing complete hr

81380 Hla i typing 1 locus hr

81381 Hla i typing 1 allele hr

81382 Hla ii typing 1 loc hr

81383 Hla ii typing 1 allele hr





ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

T86.00 - T86.819 - Opens in a new window Unspecified complication of bone marrow transplant - Unspecified complication of lung transplant
T86.830 - T86.839 - Opens in a new window Bone graft rejection - Unspecified complication of bone graft
T86.850 - T86.99 - Opens in a new window Intestine transplant rejection - Other complications of unspecified transplanted organ and tissue
Z48.21 - Z48.298 - Opens in a new window Encounter for aftercare following heart transplant - Encounter for aftercare following other organ transplant
Z94.0 - Z94.9 - Opens in a new window Kidney transplant status - Transplanted organ and tissue status, unspecified
Z95.3 - Z95.4 - Opens in a new window Presence of xenogenic heart valve - Presence of other heart-valve replacement


Group 2 Paragraph: CPT Code 81374 for HLA-B*27 Testing

ICD-10 CODE DESCRIPTION
M08.1 Juvenile ankylosing spondylitis
M45.0 - M45.9 - Opens in a new window Ankylosing spondylitis of multiple sites in spine - Ankylosing spondylitis of unspecified sites in spine
M48.8X1 - M48.8X9 - Opens in a new window Other specified spondylopathies, occipito-atlanto-axial region - Other specified spondylopathies, site unspecified

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.

Popular Posts