MNB-2001-11, November/December 2001

Policy Updates

This section includes updates to local medical review policies that were published in earlier issues of The Medicare News Brief. These updates may include both corrections to policies as originally published and/or expansions of coverage.

Notice: Critical Care Services
The local medical review policy on Critical Care Services (EM002E00) that was published in The Medicare News Brief, MNB-NY-2000-8, September 2000 issue, page 40, will be fully implemented in the month of December 2001. Providers should be aware that they may be asked to submit records for services rendered to patients that exceed a threshold established by the carrier.

Cardiovascular Nuclear Medicine - CV004E00
Published: MNB-NY-2001-5, May 2001, Page 33

This policy is expanded to include additional ICD-9-CM codes to the "ICD-9-CM Codes That Support Medical Necessity" section of the policy.

Under Group 1, for ICD-9-CM Diagnosis Codes That Support Medical Necessity for Perfusion with or without Functional Studies, CPT codes 78460, 78461, 78464, 78465, 78472, 78473, 78478, 78480, 78481, 78483, 78494, and 78496, the following ICD-9-CM codes are added:

Under group 2, for ICD-9-CM Diagnosis Codes That Support Medical Necessity for Cardiac Blood Pool Studies, CPT codes 78472, 78473, 78478, 78480, 78481, 78483, 78494, and 78496, the following ICD-9-CM codes are added:

Cardiac Electrophysiology Services (EPS) (CV007E00)

The following are the correct ICD-9-CM codes payable for CPT codes 93620, 93621, 93622, 93623, 93624, 93631, 93640, 93641, 93642, 93650, 93651, and 93652.

This revision is effective 7/11/2001.

Diagnostic Cardiac Catheterization - CV013E00
Published:    MNB-NY-2001-10, October 2001, page 28

Coding Guideline # 9 was inadvertently omitted from the version printed in last month's issue.

Coding Guideline #9 states: "Cardiac output codes (93561 and 93562) are to be coded for hemodynamic monitoring only and should be used on days subsequent to Swan-Ganz catheterization. They should be used only when there is clear documentation that the physician performed these services."

As a result of this addition to the Coding Guideline section, the Coding Guideline published in the October issue as #9 now becomes Coding Guideline #10 while Coding Guideline published as #10 now becomes Coding Guideline #11.

Carboplatin (Paraplatin, Paraplatin AQ) Drug #98
Published:    MNB-95-2, February 1995, page 12
Updated:      MNB-96-6, 97-1, 97-7, 97-10, 98-9

Addition to ICD-9-CM Codes That Support Medical Necessity (effective for dates of service on or after 09/06/2001):

Docetaxel (Taxotere®) Ydrug#21
Published:    MNB-98-8, October 1998, page 29
Updated:      MNB-NY-2000-2, February/March 2000, page 20
Updated:      MNB-NY-2001-6, June 2001, page 31

Additions to ICD-9-CM Codes That Support Medical Necessity:

Irinotecan Hydrochloride (Camptosar) Ydrug#20

Additions to Off-labeled Indications (effective July 1, 2001):
150.0-150.9    Malignant neoplasm of esophagus
151.0-151.9    Malignant neoplasm of stomach

General Ophthalmological Services (Ymed 30)
Published:    MNB-99-1, January 1999, page 6
Updated:      MNB-99-3, April 1999, page 31

Coding Guidelines and Limitations:
Places of service 12 (home), 32 (nursing facility), and 33 (custodial care facility) are added as covered places of service for CPT codes 92002, 92012, 92004, and 92014, effective 12/30/2001.

Ground Ambulance Services (AM001E01)
Published: MNB-NY-2001-9, September 2001, page 104

Other Indications/Limitations - Transportation to a physician's office - correction:
Situation #2 - For inpatients of a hospital or SNF, the cost of transporting the patient for medically necessary diagnostic or therapeutic services is less than the cost of bringing diagnostic or therapeutic services to the patient.

Coding Guideline #11 - Effective for dates of service on or after January 14, 2002, mileage codes A0380 and A0390 must be submitted with origin and destination modifiers. Any claim which is received without these modifiers appended to the mileage codes will be returned as unprocessable.

Coding Guideline #21 - The reference to HIPAA screens is removed. Ambulance suppliers should utilize the ambulance certification record when submitting electronic claims.

Coding Guideline #22 - For Paper claims, the PCR does not have to accompany claims, but must be available in the patient's record for review.

ICD-9-CM Codes That Support Medical Necessity - Corrected codes:

ICD-9-CM Codes That Support Medical Necessity - Additions:

Indications #1 - Scheduled services - Clarification:
If the ambulance supplier is unable to obtain an order from the patient's physician, a signed certification may be obtain from a PA, NP, CNS, RN, or discharge planner who is employed by the facility where the patient is being treated, and who has knowledge of the patient's condition at the time of transport.

Physician Certification Form:
Suppliers have the option to use the Physician Certification form (Appendix B) as published in The Medicare News Brief, MNB-NY-2001-9, September 2001 issue, page 124 or a certification of their own design. However, the certification must verify that the stated condition(s) of the patient would render transportation by other means as medically contraindicated.

Mental Health Services (PS001E00)
Published: MNB-NY-2001-5, May 2001, page 49
Updated: MNB-NY-2001-6, June 2001, page 35
MNB-NY-2001-8, August 2001, page 19

Section III: Psychotherapy Services:
Addition to Coding Guideline #1:
Place of service 32 (nursing facility) should be included as a payable place of service for the covered practitioners.

Section IV: Pharmacologic Management of Psychiatric Illness (90862, M0064)
Reminder:
Code 90862 is subject to the Outpatient Mental Health Treatment Limitation, except when the patient is being treated for Alzheimer's Disease or Senile Dementia.

Extended Ophthalmoscopy (OP006E00)
Published:    MNB-NY-2001-5, May 2001, page 41
Updated:      MNB-NY-2001-9, September 2001, page 28

Coding Guidelines:
Place of service 32 (nursing facility) is added as a covered place of service for CPT codes 92225 and 92226, effective 12/30/2001.

Lipid Profile/Cholesterol Testing (LB007E00)
Published:    MNB-NY-2001-10, October 2001, page 55

This policy is revised to include the following ICD-9-CM codes that were inadvertently omitted from the policy:

Drug Screening (LB006E00)
Published: MNB-NY-2001-10, October 2001, page 46

Several statements were inadvertently left out of the policy when finalized and published. These additions are printed below. They do not represent any changes to the interpretation of the policy.

Indications:

• In the treatment of mental illness or psychiatric disorders:

-	where there is a history of actual or suspected drug abuse
-	where there is an untoward or unexpected response to psychiatric medication or unexpected changes in personality or presentation and drug abuse is suspected
-	in investigation of the differential diagnosis of anxiety, mood, psychotic personality, adjustment and sleep disorders.

Coding Guidelines:

IMPORTANT
Radiological Examination of the Chest (RD005E00)

The local medical review policy originally published in the May 2000 issue of The Medicare News Brief, will be fully implemented in December 2001. Providers may become aware of new edits and changes in claims processing based on the implementation of this policy. However, please be assured that the policy has not been changed or revised beyond that which was previously published in the above listed issues of The Medicare News Brief.

The Medicare appeals process should be utilized to appeal claims not initially approved. Please be sure that all documentation requirements are fully met when filing these appeals.

Laryngoscopy - YSurg#28
Published:    MNB-97-13, December 1997, page 39

This policy is expanded to include the nursing home (POS 32) as an acceptable place of service for CPT code 31575.

Diagnostic Nasal/Sinus Endoscopy - EN001E00
Published:    MNB-NY-2000-6, July 2000, page 49
                       MNB-99-9, December 1999, page 56

Please note that the above listed policy, republished in this issue, is being expanded to include the nursing home, place of service 32, as a payable place of service for CPT code 31231.

Computerized Axial Tomography (CT/CAT Scans) - RD003E00
Published:    MNB-99-9, December 1999, page 20
Update:         MNB-NY-2001-5, May 2001, page 24
Revised:        MNB-NY-2001-9, September 2001, page 60

This policy is expanded to add the following ICD-9-CM codes in the "ICD-9-CM Codes That Support Medical Necessity" section of the policy.

For 72192-72194 and 74150-74170 same day - (CT Scans of Abdomen/Pelvis on the Same Day.)

789.1    (Hepatomegaly)

For CPT 76375 - Coronal sagittal, multiplanar, oblique, 3-Dimensional and/or holographic reconstruction of computerized tomography, magnetic resonance imaging, or other topographic modality

In addition, the following ICD-9-CM code will become truncated and will be terminated as of 12/31/2001:

Under the "ICD-9-CM Codes That Support Medical Necessity" section of the policy for CPT codes 70450 - 70470 (Computerized axial tomography, head or brain) ICD-9-CM 772.1 is terminated as of 12/31/2001.

For dates of service on or after 10/31/2001, please use the following ICD-9-CM codes instead: 772.10 - 772.14

Vestibular Function Testing/Audiologic Services (AU001G03)

This policy is revised to reflect changes under the following sections:

CPT/HCPCS Codes:
Added 92561 and new code 92586 (effective January 1, 2001). Also changed the description of CPT code 92585.

Non-Covered Tests include the following:
92596 was added to this section.

ICD-9-CM Codes That Support Medical Necessity:

• The list of payable diagnoses for codes 92542 through 92547 now includes code 92541.
• Effective April 1, 2001, diagnosis codes 333.0-333.7, 333.81-333.99, 340, 341.0-341.9, 377.30-377.39, 388.12, 388.5, 780.4, and 781.0 were added to the list of payable diagnoses for procedure codes 92585 and 92586.

Coding Guidelines:

Magnetic Resonance Imaging (MRI) - YRad#10

The following CPT codes have been added to this policy for dates of service on or after January 1, 2001:

70542, 70543, 71551, 71552, 72195, 72197, 73218, 73219, 73222, 73223, 73718, 73719, 73722, 73723, 74182, 74183

In addition, please note that the narrative descriptions of the following codes have been changed for dates of service on or after January 1, 2001:

70336, 71550, 72196, 73220, 73221, 73720, 73721, 74181

The new CPT codes are added to the listings for the appropriate anatomical sites as follows:

MRI ABDOMEN - 74182 & 74183 were added
MRI CHEST -71551 & 71552 were added
MRI LOWER EXTREMITY - 73722 & 73723 were added.
MRI ANY JOINT, UPPER EXTREMITY - 73222 & 73223 were added.
MRI LOWER EXTREMITY - 73718 & 73719 were added.
MRI ORBIT FACE/NECK - 70542 & 70543 were added.
MRI PELVIS - 72195 & 72197 were added,
MRI UPPER EXTREMITY, OTHER THAN JOINT - 73218 & 73219 were added.

Mammography/Breast Echography(Sonography)/Breast MRI/Ductography (RD001E00)

The Centers for Medicare and Medicaid (CMS) has updated the Screening Mammography and Diagnostic Mammography policy for dates of service on or after January 1, 2002.

Changes include:

• Payment for screening mammography will be made as a physician service under the Medicare Physician Fee Schedule (MPFS). The payment limitation for screening mammography no longer applies for claims with dates of service on or after January 1, 2002.
• Diagnostic mammography and screening mammography performed on the same day for the same beneficiary can both be paid.
• Two new codes, CPT code 76085 and HCPCS code G0236, have been created.
• Three HCPCS codes, G0203, G0205, and G0207 have been deleted.
• A new modifier, GG, has been added and will be used with the diagnostic code to show that the screening test has turned into an additional diagnostic test.

Specific Codes used with mammography claims on or after January 1, 2002 are listed below. (CPT codes and G codes will be paid under the Medicare Physician Fee Schedule.)

ICD-9-CM codes for diagnostic mammography will vary according to diagnosis.

Deleted mammography codes as of January 1, 2002:

Electrocardiogram (ECG or EKG) - YMDT#01R5

This policy is revised to add the following code to the "ICD-9-CM Codes That Support Medical Necessity" section, sub-section ‘C' of the policy.

794.31 - Abnormal electrocardiogram [ECG][EKG]

This revision is effective December 30, 2001

Computer Corneal Topography (OP007W00)
Published:    MNB-NY-2001-10, October 2001, page 25

ICD-9-CM Codes That Support Medical Necessity-Correction:

ICD-9-CM code 996.51 (Mechanical complications due to corneal graft) was inadvertently omitted from the published revision and should be included in covered diagnoses for this policy.

Pulmonary Function Testing - PU002E01

This policy is revised to expand the following ICD-9-CM codes:

The effective date is January 1, 2001.

© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.