MIR-2006-8A, August 2006

LCD and Article Revisions for August 2006  

Audiologic/Vestibular Function Tests - L685
LCD Revisions:
Under the “Indications” section, updated number 1 from:

1. Vestibular function tests and/or diagnostic audiometric tests (including hearing and balance assessment services) are covered as “other diagnostic tests,” when testing is for the purpose of obtaining information necessary for the physician’s diagnostic evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. The payment for these services is determined by the reason the tests were performed, rather than the diagnosis or the patient’s condition.

To show the following:

1. Vestibular function tests and/or diagnostic audiometric tests are covered when testing is for the purpose of determining the appropriate medical or surgical treatment for disorders of the auditory, balance and other neural systems.

Also, under this section, updated number 2 from:

2. For conductive hearing loss, hearing should be retested after medical or surgical treatment. For sensorineural hearing loss, the audiologist or physician will recommend when repeat testing should be done. Since hearing may change or fluctuate, it is important to detect this as early as possible to prevent further loss and to obtain medical treatment, if needed.

To show the following:

2. For conductive hearing loss, hearing should be retested after medical or surgical treatment or observation for resolution of a medical problem. For sensorineural hearing loss, the audiologist or physician will determine when reasonable and necessary follow-up testing should be done. However, billing for any testing assumes that the provider has a reasonable expectation that the patient will require medical or surgical treatment. Repeat testing for expected age-related hearing loss, either as follow-up or to screen for hearing aids, is not covered.

Under the “ICD-9-CM Codes That Support Medical Necessity” section, added the following codes to the section for the CPT codes 92557 and 92567:

387.1 Otosclerosis involving oval window, obliterative
388.40 Abnormal auditory perception, unspecified
389.02 Conductive hearing loss, tympanic membrane
784.5 Other speech disturbance

Also under this section, removed the asterisk (*) note from each CPT code section, put it at the very end of this section, and updated the asterisk (*) note from:

* Tests for the ICD-9-CM diagnosis codes indicated with an asterisk (*) are covered only for an INITIAL evaluation of a hearing problem.

To show the following:

* Tests for the ICD-9-CM codes indicated with an asterisk (*) are covered only for an INITIAL evaluation of a hearing problem and for subsequent evaluation when the medical necessity is clearly documented in the patient’s medical record. 

Article Revisions
Under the “Coding Guidelines section, added numbers 18 - 21:

18. Physical therapists and occupational therapists can perform the procedure 92548 (Computerized dynamic posturography). Claims should be submitted using the revenue code 471.
19. Outpatient Rehabilitation Facilities (ORF) and Comprehensive Outpatient Rehabilitation Facilities (CORF) cannot bill for services requiring revenue code 471.
20. The following ICD-9-CM codes (indicated with an asterisk * in the LCD) are covered only for an INITIAL evaluation of a hearing problem and for subsequent evaluation when the medical necessity is clearly documented in the patient’s medical record: 388.2, 389.10, 389.11, 389.12, 389.14, 389.18, 389.2
21. The following ICD-9-CM codes have been included in the section for CPT codes 92557 and 92567 and are effective for services performed on or after August 1, 2006: 387.1, 388.40, 389.02, and 784.5

Breast Imaging - Mammography/Breast Echography (Sonography/Breast MRI Ductography) - L481
LCD Revision:
Under the “CPT/HCPCS Codes” section, added CPT codes 76093 and 76094. These codes were not deleted effective October 1, 2001; however, they are not paid under the Outpatient Prospective Payment System (OPPS) and cannot be billed with bill types 12X, 13X, or 14X.

This section was also updated in the article.

Article Revision:

Under the “Coding Guidelines” section, updated numbers 19 and 20 from:

19. The CPT codes 76093 and 76094 are no longer billable to Medicare Part A, effective October 1, 2001.
20. The HCPCS codes C8903, C8904, C8905, C8906, C8907, and C8908 are effective for dates of service on or after October 1, 2001.

To show the following:

19. The CPT codes 76093 and 76094 are not paid under the Outpatient Prospective Payment System (OPPS) effective October 1, 2001.
20. The HCPCS codes C8903, C8904, C8905, C8906, C8907, and C8908 are effective for dates of service on or after October 1, 2001. These codes are paid under the Outpatient Prospective Payment System (OPPS).

Also under this section, removed number 36, as it is the same as number 34:

36. Effective 07/01/2006, 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.

Number 37 is now number 36.

CT Colonography (Virtual Colonoscopy) - L17586
LCD Revisions:

Under the “Indications” section, updated the paragraph from:

CT colonography is only indicated in those patients in whom an instrument colonoscopy of the entire colon is incomplete due an obstructing lesion resulting in an inability to pass the colonoscope proximally.

To show the following:

1. CT colonography is only indicated in those patients in whom an instrument colonoscopy of the entire colon is incomplete due to an obstructing lesion resulting in an inability to pass the colonoscope proximally. Failure to advance the colonoscope may be secondary to an obstructing neoplasm, spasms, redundant colon, diverticulitis, extrinsic compression or aberrant anatomy/scarring from prior surgery.

Under the “Limitations” section, numbered the paragraphs 1 - 3.

Article Revisions:
Under the “Coding Guidelines” section, added number 7 as follows:

7. The updated “Indication” (in the LCD) is effective from 09/17/2004. The appropriate ICD-9-CM codes have been included in this policy since 09/17/2004.

Hyaluronate Polymers - L671
LCD Revisions:

Under the “Indications and Limitations of Coverage and/or Medical Necessity” section, updated the first paragraph from:

Hyaluronic acid is a natural constituent of synovial fluid and cartilage. The function of hyaluronic acid is to maintain structural and functional characteristics of extracellular matrix and fluids. It may also play a role in the interactions of local immune cells. The federal Food and Drug Administration (FDA) has approved two materials, sodium hyaluronate (Hyalgan TM) and hylan G-G-20 (Synvisc TM). These two materials are composed of various fractions of hyaluronate, for the treatment of pain associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics such as acetaminophen.

To show the following:
Hyaluronic acid is a natural constituent of synovial fluid and cartilage. The function of hyaluronic acid is to maintain structural and functional characteristics of extracellular matrix and fluids. It may also play a role in the interactions of local immune cells. There are currently several products composed of various fractions of hyaluronate approved by the Food and Drug Administration (FDA) for pain associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics such as acetaminophen. This LCD defines coverage criteria for the injection of the knee with either sodium hyaluronate or hylan G-F 20 polymers.

The following sentence has been removed from this section. The information was added to the first paragraph:

This policy defines coverage criteria for the injection of the knee with either Hyalgan TM or Synvisc TM.

Under the “Indications” section, letters D and F have been moved to the “Limitations” section as numbers 1 and 2:

1. Contraindications to injection of hyaluronate products include (but not limited to):
   1. active inflammatory joint disease or synovitis affecting the knees (e.g., crystal synovitis, rheumatoid arthritis);
   2. presence of infection of the target joint or skin surrounding the proposed site of injection; and
   3. known hypersensitivity to hyaluronic acid preparations.
2. A repeat series of injections for patients who have responded to the first series may be given individual consideration by Medicare for coverage under the following circumstances:
   1. The medical record objectively documents significant improvement in pain and function;
   2. The medical record documents significant reduction in the doses of non-steroidal anti-inflammatory drugs;
   3. At least six months have elapsed since the prior series of injections

Also, under this section, letter E has been moved to the “Utilization Guidelines” section, as number 1:

1. Frequency of injections:
   1. Sodium hyaluronate is typically injected as a series of five weekly injections;
   2. Hylan G-F-20 is typically injected as a series of three weekly injections;

Rituximab - L2175

LCD Revisions:

Under the “Indications and Limitations of Coverage and/or Medical Necessity” section, added letter F:

6. Rituximab is Food and Drug Administration (FDA) approved for the treatment of rheumatoid arthritis, when used in combination with methotrexate.

Under the “ICD-9-CM Codes That Support Medical Necessity” section, added the following code:

714.0 Rheumatoid arthritis

Article Revisions:

Under the “Coding Guidelines” section, added number 7:

7. Based on an LCD Reconsideration request, the covered indication for rheumatoid arthritis (diagnosis code 714.0) has been added effective for services performed on or after February 28, 2006.