Issue 2006-03, March 2006

LCD and Article Revisions for March 2006

Apligraf ® (Graftskin) - L523
Under the “CMS National Coverage Policy” section, added numbers 7 and 8:

• Change Request (CR) 4236, dated December 16, 2005. January 2006 Non-Outpatient Prospective Payment System Code Editor (Non-OPPS OCE) Specifications.
• Change Request (CR) 4238, dated December 16, 2005. January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications.

This section was also updated in the article.

Under the “CPT/HCPCS Codes” section, removed the following terminated codes:

15342 Application of bilaminate skin substitute/neodermis; initial 25 sq. cms
15343 Application of bilaminate skin substitute/neodermis; each additional 25 sq. cms
C1305 Graftskin, per 44 square centimeters

Under this section, added the following replacement codes:

15340 Application of bi-laminate skin substitute/neodermis; 25 sq. cm
15341 Each additional 25 sq. cm (list separately in addition to code for primary procedure)

J7340 Dermal and epidermal tissue of human origin, with or without bio-engineered or processed elements, with metabolically active elements, per square centimeter

This section was also updated in the article.

Under the “ICD-9-CM Codes That Support Medical Necessity” section, added numbers 4 and 5 with the appropriate ICD-9-CM codes for each number:

• For Venous Stasis Ulcer (VSU):
• For Diabetic Foot Ulcer (DFU):

Article Revisions:
Under the “Coding Guidelines” section, added numbers 8 and 9:

• The CPT codes 15342 and 15343, and the HCPCS code C1305 have been terminated effective December 31, 2005.
• The CPT codes 15340 and 15341, and the HCPCS code J7340 are effective for services performed on or after January 1, 2006.

Breast Imaging - Mammography/Breast Echography (Sonography/Breast MRI Ductography) - L481
LCD Revisions:

Under the “CMS National Coverage Policy” section, added number 10:

• Change Request (CR) 4243, dated February 1, 2006. Use of 12X Type of Bill (TOB) for Billing Screening Mammography, Screening Pelvic Examinations and Screening Pap Smears.

Under the “Bill Type Codes” section, added the following code:

12X Hospital Ancillary

Under the “CPT/HCPCS Codes” section, removed the following terminated code:

76085 Digitization of film radiographic images with computer analysis for lesion
detection and further physician review for interpretation, screening mammography (list separately in addition to code for primary procedure) for computer aided detection. This code is an add-on code and must be used in conjunction with the primary codes.

This section has also been updated in the article.

Under the “ICD-9-CM Codes That Support Medical Necessity” section, the Notes section at the end of the listing has been removed:

Notes:
* See the “Limitations” section of this policy for information on the use of this diagnosis.
** Onlyusewith GG modifier, when starting as screening mammogram.
*** See the “Limitations” section of this policy for information on the use of this diagnosis code.
**** May be reported only until clinical stability has been established
***** To be reported only after mammography and focal findings

Also, under this section, added the following

Notes at the end of the section titled, “For diagnostic mammography and screening mammography that converts to diagnostic mammography, on or after 01/01/2002:”

Note: * See the “Limitations” section of this LCD for information concerning this diagnosis.

** Use ICD-9-CM code 611.8 for hematoma
*** ICD-9-CM codes V10.89 and V45.83 may be reported only until clinical stability has been established
**** See “Coding Guidelines” section of the article for billing instructions

Added the following Notes at the end of the section titled, “For breast echography/sonography and breast MRI:”

Note: * See the “Limitations” section of this LCD for information concerning this diagnosis.

** ICD-9-CM codes 610.1 - 610.4, 610.8, 610.9, 611.2 - 611.6, 611.8, and 611.9 should be reported only after mammography and focal findings

Article Revisions:
Under the “Coding Guidelines” section, added number 33 and 34:

• Use ICD-9-CM code V76.12 only with GG modifier when starting as a screening mammography.
• Effective July 1, 2006, type of bill 12X is to be used in place of type of bill 13X for the billing of screening mammography when provided to hospital inpatients under Part B.

Cyclophosphamide (Cytoxan) - L602
LCD Revisions:
Under the “CMS National Coverage Policy” section, added numbers 8 and 9:

• Change Request (CR) 4236, dated December 16, 2005. January 2006 Non-Outpatient Prospective Payment System Code Editor (Non-OPPS OCE) Specifications
• Change Request (CR) 4238, dated December 16, 2005. January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications

This section was also updated in the article.

Under the “CPT/HCPCS Codes” section, removed the following terminated codes:

C9420 Cyclophosphamide, injection - brand name
C9421 Cyclophosphamide, lyophilized - brand name

This section was also updated in the article.

Article Revisions:

Under the “Coding Guidelines” section, added number 6:

• The HCPCS codes C9420 and C9421 have been terminated effective December 31, 2005.

Hyaluronate Polymers - L671
Under the “CMS National Coverage Policy” section, added numbers 6 and 7:

• Change Request (CR) 4236, dated December 16, 2005. January 2006 Non-Outpatient Prospective Payment System Code Editor (Non-OPPS OCE) Specifications
• Change Request (CR) 4238, dated December 16, 2005. January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications

This section has also been updated in the article.

Under the “CPT/HCPCS Codes” section, removed the following terminated code:

C9413 Sodium Hyaluronate, per 20 to 25 mg dose, for intra-articular injection, brand name

Also, under this section, added the following code:

J7320 Hylan, G-F 20, 16 mg, for intra-articular injection

This section has also been updated in the article.

Article Revisions:
Under the “Coding Guidelines” section, added numbers 16 and 17:

• The HCPCS code C9413 was terminated effective December 31, 2005.
• Hylan G-F 20 has always been mentioned in the “Indications” section as coverable; therefore, the HCPCS code J7320 should have been included in the LCD.

Intravenous Immune Globulin (IVIG) - L699
LCD Revisions:
Under the “CMS National Coverage Policy” section, added numbers 11 and 12:

• Change Request (CR) 4236, dated December 16, 2005. January 2006 Non-Outpatient Prospective Payment System Code Editor (Non-OPPS OCE) Specifications
• Change Request (CR) 4238, dated December 16, 2005. January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications

This section was also updated in the article.

Under the “CPT/HCPCS Codes” section, removed the following terminated codes:

Q9941 Injection, immune globulin, intravenous, lyophilized, 1g
Q9942 Injection, immune globulin, intravenous, lyophilized, 10g
Q9943 Injection, immune globulin, intravenous, non-lyophilized, 1g
Q9944 Injection, immune globulin, intravenous, non-lyophilized, 10g

Also under this section, added the following new codes:

J1566Injection, immune globulin, intravenous, lyophilized (e.g., powder), 500 mg
J1567 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), 500 mg

This section was also updated in the article.

Article Revisions:
Under the “Coding Guidelines” section, added numbers 13 and 14:

• The HCPCS codes Q9941 - Q9944 have been terminated effective December 31, 2005.
• The HCPCS codes J1566 and J1567 are effective for services performed on or after January 1, 2006.

Outpatient Psychiatric Services - L541
LCD Revisions:
Under the “CMS National Coverage Policy” section, added numbers 22 and 23:

• Change Request (CR) 4236, dated December 16, 2005. January 2006 Non-Outpatient Prospective Payment System Code Editor (Non-OPPS OCE) Specifications
• Change Request (CR) 4238, dated December 16, 2005. January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications

This section was also updated in the article.

Under the “CPT/HCPCS Codes” section, removed the following terminated codes:

96100 Psychological testing (includes psycho-diagnostic assessment of personality, psychopathology, emotionally, intellectual abilities e.g., WAIS-R, Rorschach, MMPI) with interpretation and report, per hour

96115 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention memory, visual spatial abilities, language functions, planning), with interpretation and report, per hour

96117 Neurobehavioral testing battery (e.g., Halstead-Reitan, Luria, WAIS-R) with interpretation and report, per hour

Also under this section, added the following codes:

96101 Psychological testing (includes psycho-diagnostic assessment of emotionally, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing report

96102 Psychological testing includes psycho-diagnostic assessment of emotionally, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face

96103 Psychological testing (includes psycho-diagnostic assessment of emotionally, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), administered by a computer, with qualified health care professional interpretation and report

96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing report

96118 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing report

96119 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face

96120 Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report

This section was also updated in the article.

Article Revisions:

Under the “Coding Guidelines” section, added numbers 11 and 12:

• The CPT codes 96100, 96115 and 96117 have been terminated effective December 31, 2005.

• The CPT codes 96101 - 96103, 96116 and 96118 - 96120 are effective for services performed on or after January 1, 2006.

Oxaliplatin (Eloxatin™ ) - L17584
LCD Revisions:
Under the “CMS National Coverage Policy” section, added numbers 5, 6, 7, and 8:

• Change Request (CR) 3742, dated June 17, 2005. This CR refers to coverage of colorectal anti-cancer drugs included in clinical trials.

• CMS Manual, Publication 100-3 (National Coverage Determinations), Chapter 1, Part 2, section 110.17. Anti-cancer Chemotherapy for Colorectal Cancer

• Change Request (CR) 4236, dated December 16, 2005. January 2006 Non-Outpatient Prospective Payment System Code Editor (Non-OPPS OCE) Specifications

• Change Request (CR) 4238, dated December 16, 2005. January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications

This section was also updated in the article.

Under the “Indications” section, removed the following subtitle:

FDA Labeled Indications:

Also, under this section, added numbers 5, 6, and 7:

• Effective 12/01/2005, oxaliplatin is covered in adjuvant therapy for Stage II colorectal cancer.
• Effective 12/01/2005, coverage of oxaliplatin is extended to include patients with metastatic (Stage IV) colorectal cancer.
• Effective May 1, 2005, oxaliplatin is covered for the off-labeled indication of patients with malignant neoplasm of the stomach.

Under the “CPT/HCPCS Codes” section, removed the following terminated code:

C9205 Oxaliplatin, injection, per 5 mg

This section was also updated in the article.

Under the “Sources of Information and Basis for Decision:” section, added numbers 7 and 8:

• Thierry Andre´, M.D., Corrado Boni, M.D., Larnia Mounedji-Boudiaf, M.D., Matilde Navarro, M.D., Josep Tabernero, M.D., Tamas Hickish, M.D., Clare Topharn, M.D., Marta Zaninelli, M.D., Philip Clingan, M.D., John Bridgewater, M.D., Isabelle Tabah-Fisch, M.D., Airnery de Gramont, M.D., for the Multi-center International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjunvant Treatment of Colon Cancer (MOSAIC) Investigators. Volume 350:2343-2351, June 3, 2004, Number 23.
  
• www.nci.nih.gov/cancertopics/pdq/treatment/colon/healthprofessional/page7

Article Revisions:

Under the “Coding Guidelines” section, added numbers 12, 13, and 14:

• Providers treating patients whose primary malignancy has been previously excised or eradicated from its site and for whom there is no further treatment directed at that site can report ICD-9-CM codes for personal history of malignant neoplasm to indicate the former site of the malignancy now being treated.
• The HCPCS code C9205 has been terminated effective December 31, 2005.
• The new indications (numbers 5 and 6 in the LCD) are effective for services performed on or after 12/01/2005.