Friday, August 6, 2010

CPT 90870 , 01967 - Electroconvulsive Therapy - Add-On Codes of Anesthesia

Electroconvulsive Therapy (ECT) – 90870

Electroconvulsive Therapy (ECT) is used in the treatment of depression and related disorders and other severe psychiatric conditions.

When a psychiatrist administers the anesthesia for the ECT procedure, no separate payment is made for the anesthesia service.

Add-On Codes for Anesthesia

Anesthesia add-on codes are priced differently than multiple anesthesia codes. Only the base unit(s) of the add-on code will be allowed. All anesthesia time should be reported with the primary anesthesia code. See exception below in the obstetrical area.

Add-on codes for anesthesia involving burn excisions or debridement and obstetrical anesthesia are:

01952© Anesth, burn 4-9 percent – primary code
01953© Anesth, burn each 9 percent – add-on code
01967© Anesth, analg vag delivery – primary code
01968© Anes/analg cs deliver add-on – add-on code
01969© Anesth/analg cs hyst add-on – add-on code

The add-on codes should be billed in addition to the primary anesthesia code. For example, in the burn area, anesthesia time should be reported with code 01952. Anesthesia time would not be reported with the add-on code 01953. One unit (not time) per additional 9 percent total body surface area or part thereof should be reported with code 01953. This would be reported in the Days/Units field (Item 24g) on the CMS-1500 form or electronic equivalent.

There is an exception for obstetrical anesthesia. Therefore, Medicare requires for the obstetrical add-on codes, that the anesthesia time be separately reported with each of the primary and the add-on codes based on the amount of time appropriately associated with either code. Both the base unit and the time units for the primary and the add-on obstetrical anesthesia codes are recognized.

Billing and Coding Guidelines


1. The outpatient mental health limitation appears in 42 CFR 410.155 and applies to this ECT policy and applies to outpatient treatment services when an individual is not an inpatient of a hospital. It is applied based on both the procedure and the diagnosis code.

2. ICD-9 codes must be reported to the highest level of specificity for the date of service.

3. Screening tests, in the absence of signs and symptoms of illness should be billed with "V" codes for a screening denial.

4. Separate payment is not allowed for the psychiatrist’s performance of the anesthesia service associated with the electroconvulsive therapy if the psychiatrist performs the electroconvulsive therapy.

5. Effective for dates of service on or after January 1, 1994 if anesthesia is given by the same physician who is performing the therapy, the anesthesia would be included in the therapy service.

Separate payment for anesthesia service to psychiatrists who provide electroconvulsive therapy will no longer be allowed. The RVUs for CPT 90870 have been increased to include payment for anesthesia when performed by the Psychiatrist (Medicare Matters November 2002).


6. Facility billing of 90870 and 00104 on the same date of service is a bundled service in the APC 0320. Under the OPPS, packaged services are items and services that are considered to be an integral part of another service that is paid under the OPPS. No separate payment is made for packaged services, because the cost of these items and services is included in the APC payment for the service of which they are an integral part. It is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged (CMS Publication, Medicare Claims Processing Manual, 100-04, Chapter 4, Section 10.4).



Coding Guidelines Part B

1. ICD-9 codes must be reported to the highest level of specificity for the date of service.

2. Screening tests, in the absence of signs and symptoms of illness should be billed with "V" codes for a screening denial.

3. Physician Billing:

a. Code 90870 is limited to use by physicians (MD/DO) only.

b. Separate payment is not allowed for the psychiatrist’s performance of the anesthesia service associated with the electroconvulsive therapy if the psychiatrist performs the electroconvulsive therapy. The RVUs for CPT 90870 have been increased to include payment for anesthesia when performed by the Psychiatrist.

Coding Guidelines Part A 


1. The outpatient mental health limitation appears in 42 CFR 410.155 and applies to this ECT policy and applies to outpatient treatment services when an individual is not an inpatient of a hospital. It is applied based on both the procedure and the diagnosis code.

2. ICD-9 codes must be reported to the highest level of specificity for the date of service.

3. Screening tests, in the absence of signs and symptoms of illness should be billed with "V" codes for a screening denial.

4. Separate payment is not allowed for the psychiatrist’s performance of the anesthesia service associated with the electroconvulsive therapy if the psychiatrist performs the electroconvulsive therapy.

5. Effective for dates of service on or after January 1, 1994 if anesthesia is given by the same physician who is performing the therapy, the anesthesia would be included in the therapy service. Separate payment for anesthesia service to psychiatrists who provide electroconvulsive therapy will no longer be allowed. The RVUs for CPT 90870 have been increased to include payment for anesthesia when performed by the Psychiatrist (Medicare Matters November 2002).

6. Facility billing of 90870 and 00104 on the same date of service is a bundled service in the APC 0320. Under the OPPS, packaged services are items and services that are considered to be an integral part of another service that is paid under the OPPS. No separate payment is made for packaged services, because the cost of these items and services is included in the APC payment for the service of which they are an integral part. It is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged (CMS Publication, Medicare Claims Processing Manual, 100-04, Chapter 4, Section 10.4).

7. IPFs receive an additional payment for each ECT treatment furnished during the IPF stay…..The ECT base rate is adjusted by the wage index and any applicable COLA factor. An IPF must report revenue code 0901 along with the number of units of ECT on the claim.

The units should reflect the number of ECT treatments provided to the patient during the IPF stay. In addition, IPFs must include the ICD-9-CM procedure code for ECT (94.27) in the procedure code field and use the date of the last ECT treatment the patient received during their IPF stay. It is important to note that since ECT treatment is a specialized procedure, not all providers are equipped to provide the treatment. Therefore, many patients who need ECT treatment during their IPF stay must be referred to other providers to receive the ECT treatments, and then return to the IPF.

In accordance with 42 CFR 412.404(d)(3), in these cases where the IPF is not able to furnish necessary treatment directly, the IPF would furnish ECT under arrangements with another provider. While a patient is an inpatient of the IPF, the IPF is responsible for all services furnished, including those furnished under arrangements by another provider. As a result, the IPF claim for these cases should reflect the services furnished under arrangements by other providers (CMS Publication, 100-04, Medicare Claims Processing Manual, Chapter 3, 190.7.3 and CR 6077).

8. When a hospital provides electroconvulsive therapy (ECT) on the same day as partial hospitalization services, both the ECT and partial hospitalization services should be reported on the same hospital claim. In this instance, the claim should contain condition code 41. As noted above, report charges for all services and supplies associated with the ECT service, which were furnished on the same date(s) on the same claim (CMS Publication, Medicare Claims Processing Manual, 100-04, Chapter 4, Section 170).

9. When billing for services in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier. To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

a. GA: Waiver of Liability statement on file. Use for patients who do not meet the covered indications and limitations of the LCD and for who an ABN is on file. ABN does not have to be submitted but must be made available upon request.

b. GZ: Waiver of liability statement on file. Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN.

c. GY: item or service is statutorily excluded or does not meet the definition of any


Issue - Purpose 

This memorandum recommends that the Centers for Medicare & Medicaid Services (CMS) consider the appropriateness of one of the two current procedural terminology (CPT) codes for electroconvulsive therapy (ECT). Currently, ECT can be billed under 90870, Single Seizure; or 90871, Multiple Seizures, per day. However, the National Institutes of Health (NIH) 1985 Consensus Conference Statement on ECT, as well as more current research, indicates that the administration of multiple seizures is not clinically recommended.

Background

Electroconvulsive therapy is a treatment for severe mental illness in which a brief application of electric stimulus is used to produce a generalized seizure. Electrodes connected to an ECT machine are attached to the scalp of a patient who has received general anesthesia and a muscle relaxant.

The ECT treatments are generally given on an every-other-day basis for 2 to 3 weeks. Seizure lengths of duration of greater than 20 seconds per treatment (as assessed by motor activity, not electroencephalogram seizure activity) are considered adequate for therapeutic purposes. According to the NIH 1985 Consensus Development Conference Statement on ECT, “...The number of treatments in a course of therapy varies. Six to twelve treatments are usually effective....”

The March 14, 2001, Journal of the American Medical Association states that ECT is “...an effective and safe treatment for severe major depression...(it) may also be seriously considered as treatment for patients with acute mania, and for patients with schizophrenia who have not responded to adequate antipsychotic medications....”

Medicare allowed charges for ECT in 1998, 1999, and 2000 were $13.3 million; $13.6 million; and $13.6 million, respectively. The total allowed services were 154, 995 (1998); 153,193 (1999); and 153,000 (2000).

Issue - Medical Literature Does Not Support Use of CPT 90871 

According to the American Medical Association’s CPT Assistant newsletter, Summer 1992, two CPT codes are available for billing Medicare for ECT services: Code 90870, single seizure, and Code 90871, multiple seizures, per day. (Note that multiple seizures is also known as multiple monitored ECT (MMECT)).

Medicare allowed charges for CPT 90871 during 1998, 1999 and 2000 were $473,000; $464,513; and $435,000, respectively. The total allowed services were 3,855 (1998); 3,788 (1999); and 3,585 (2000). The average allowed charge for CPT 90871 in 2000 was $121.00; for CPT 90870 it was $88.00.

The NIH 1985 Consensus Development Conference Statement on ECT states that “...Multiplemonitored ECT (several seizures during a single treatment session) has not been demonstrated to be sufficiently effective to be recommended...” Notwithstanding this statement, CPT 90871 is being reimbursed by Medicare, as noted above, at the rate of about $500,000 per year.

In 1997, we sought an opinion from a carrier medical director, who is also a psychiatrist, about Medicare ECT data. He advised us as follows: “...the use of 90871, multiple seizures in one day, should show a very small utilization...The technique of purposely inducing multiple seizures to increase the therapeutic benefit is rarely done, and is apparently only supported by anecdotal reports....”

This carrier medical director believes that the frequent use of 90871 could be caused by practitioner confusion. He states: “...in the ordinary course of administering ECT, or in order for the treatment to be effective, the seizure needs to last more than 20 seconds. If the seizure is of shorter duration, the seizure needs to be repeated until a seizure of sufficient duration is achieved. This should be coded as 90870...”

Because the NIH Consensus Development Conference Statement on ECT was issued over 15 years ago, we recently asked the National Institute of Mental Health (NIMH) for their opinion on the use of Code 90871 (MMECT).

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