National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MLN Matters Number: MM5608
Related Change Request (CR) #: 5608
Related CR Release Date: September 12, 2007
Effective Date: May 22, 2007
Related CR Transmittal #: R76NCD
Implementation Date: September 28, 2007

Provider Types Affected
Physicians and other providers who bill Medicare carriers, fiscal intermediaries (FI), and Medicare Administrative Contractors (MAC) for ultrasound diagnostic procedures  

What Providers Need to Know
CR 5608, from which this article is taken, announces that effective on and after May 22, 2007, the Centers for Medicare & Medicaid Services (CMS) will allow payment for the monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the intensive care unit (ICU) and for operative patients with a need for intraoperative fluid optimization.

Make sure that your billing staffs are aware of this change in the National Coverage Determinations (NCD) Manual, Chapter 1 (Coverage Determinations), Section 220.5 (Ultrasound Diagnostic Procedures) to allow coverage for this procedure.

Background
CR 5608, from which this article is taken, announces:

• Effective for claims with dates of service on and after May 22, 2007, CMS has determined that esophageal Doppler monitoring of cardiac output for ventilated patients in the ICU and for operative patients with a need for intra-operative fluid optimization is reasonable and necessary; and
• The previous national noncoverage of cardiac output Doppler monitoring is therefore removed.

Specifically, in CR 5608, CMS amends the Medicare NCD Manual, Chapter 1 (Coverage Determinations), Section 220.5 (Ultrasound Diagnostic Procedures), by adding: “Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative patients with a need for intraoperative fluid optimization” to Category I (covered procedures), and deleting “Monitoring of cardiac output (Doppler)” from Category II (noncovered procedures).

Notes:
There is no specific CPT code for this service. CPT code 76999 is for unlisted ultrasound procedures.

When performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for ultrasound diagnostic procedures, the professional services only are separately payable when billed using CPT code 76999 with the modifier -26 to show professional component.

Such services, when globally billed in a hospital setting with code 76999, will be returned as unprocessable to the provider with a reason code such as 58 denoting “Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.”

When such services are billed in a hospital setting as technical services with the code 76999-TC, Medicare will deny the services with the 58 reason code and an M77 remark code to show “Missing/Incomplete/Invalid place of service.”

When performed in an ambulatory surgery center (ASC), ultrasound diagnostic procedures are covered when performed by an entity other than the ASC if globally billed using code 76999, or the technical and professional components may be separately billed using codes 76999-TC and 76999-26, respectively.

Ultrasound diagnostic procedures professional services billed using codes 76999, 76999-TC, and 76999-26 are carrier-priced.

Medicare contractors will not search their files to identify and adjust claims processed prior to the implementation of this change, which are for services rendered on or after May 22, 2007. However, they will adjust such claims when you bring the claims to their attention.  

Additional Information
You can find more information about the coverage of esophageal Doppler monitoring of cardiac output by going to CR 5608, located at http://www.cms.hhs.gov/Transmittals/downloads/R76NCD.pdf on the CMS Web site.

You will find the amended Medicare NCD Manual, Chapter 1 (Coverage Determinations), Section 220.05 (Ultrasound Diagnostic Procedures), as an attachment to that CR.

If you have any questions, please contact your carrier, FI, or MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

Additional Information Provided by National Government Services

The consensus of medical directors across all National Government Services contracts is:

• the only billable professional service is the insertion of the esophageal probe;
• use of the technology for continuous monitoring is not separately billable, as once the probe is inserted, the hospital staff (nurses, technicians) take the readings; and the results are provided in a machine printed format;
• there is no separate "interpretation"; rather the results are used by the providers in the medical-decision-making component of E&M services;
• the service is not separately billable when provided during anesthesia by the anesthesiologist providing anesthesia care.