CO-197 -Precertification/authorization/notification absent.

Some of the  carriers request to obtaining prior authorization from them before the serivce/surgery.  This may be required for certain specific procedures or may even be for all procedures.  So these are carrier specific and procedure specific.  Please note that it is the responsibility of the Physician/Surgeon and not the patient to obtain the authorization# from the carrier.

When you get a denial from the carrier for this reason, first we need to check the system if any note/alert entry has been made for the patient for the DOS concerned and for the procedure in question. Always verify the entire notes/document since we might have already have it in systme. If we have the PreCerfication/Prior Authization document was scanned or uploaded in the PMS then w ehave to update that and resubmit the claim as corrected claim. But make sure todouble comfirm that it should be for the respective DOS and its valid for the DOS. If a valid auth# is found indicate the same else mention the source file name and pg# of the original file along with the PCP’s name and phone#.

Then call the PCP to get the Authorization, once we received then update and submit the claim for reimbursement.


DUPLICATE 

DENIAL CODE WITH DESCRIPTION:
18 - Duplicate claim/service.

Reason for Denial 

Insurance received the same claim more than one time.
Actions for Denial
Check the system whether the claims has been already paid/denied if  yes ignore the denial or follow the below one.
Check the denial history and resubmission history if we submitted the claim more than once without any changes (same dos, procedure, diagnosis code and doctor.)  please resubmit the claims with necessary changes as corrected claim.
If no payment or denial in the claim, we have to get the original claim status through calling or Online
To avoid this denial in the future

If any correction like append modifier/ICD changes/corrected Referring physician/obtained Auth/Referral/Changes in Units/Changes in Billed Amount we have update the claim as “CORRECTED CLAIM” in software. (CMS 1500-CLAIM NOTE Tab)

REMARK CODES & REASON:

N20 - Service not payable with other service rendered on the same date.

N347 - Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

M86 - Service denied because payment already made for same/similar procedure within set time frame

If we received   “Duplicate” denial with the above remark codes, we have to check the below check points.


Need to check if this same procedure/service was rendered/paid to another provider.
Need to submit with appropriate modifier (76/77) after confirmation with Coding Team. Even for EKG 93010 we get Duplicate denial, since we are billing repeatedly this code with combination of 93010-without modifier, 93010 -59,9310-59&76, 93010-76 (Based on EKG document performed timing) same DOS - Cardiology specialist.

Procedure  88175 - Cytopath c/v auto fluid redo


Category Inclusions Cost


Supplies Liquid based Pap test Stains and Fixatives Preparation Liquid based pap processor for automated screening, personnel, disposal of waste Evaluation Cytotechnologist and support salaries, pathologists salary Indirect Expenses Client service, record keeping, reports, liability, training, storage, occupancy and institutional overhead Total

88155 Cytopathology, slides, cervical or vaginal definitive hormonal evaluation


88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

88165 With manual screening and rescreening under physician supervision

Coding Guidelines

1. Determine if the test is screening or diagnostic.

2. Choose the code that best describes the method of testing, i.e. Thin Prep, Bethesda, or other.

Summary Procedure  section for cervicovaginal cytology (c/v): 88150-88154- c/v, conventional smear, “other” (non-Bethesda) reporting system 88164-88167- c/v, conventional smear, Bethesda reporting system 88142-88143- c/v, liquid-based cytology, any reporting system 88174-88175- c/v, liquid-based cytology, computer-assisted screening, any reporting system

3. Use procedure code 88199 only to indicate the service was provided with a system that is considered investigational. When services are provided by a method that is not FDA-approved, the entire service is considered non-covered.

a. Liquid based monolayer cell preparation technique is considered “investigational” when provided with systems that have not received FDA approval.

b. Do not list the pap test procedure code. List the description of the service “Investigational - (name of system,)”, in Box 19 of the HCFA 1500 form or on an attachment. This information is placed in the Narrative Record (HA0 record) for EMC submitters.

4. Liquid based prep services are no longer paid in addition to a Pap smear performed by another method, instead, they are available as another method of performing the test.


Cervical Cancer Screening Procedure Codes 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175 HCPCS G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB Rev Codes 0923 HPV Procedure Codes

87620-87622 LOINC Codes

21440-3, 30167-1, 38372-9, 49896-4, 59420-0 Women 21-64 years of age with one or more Pap tests within the last 3 years OR for women 30-64 years of age, a cervical cytology and human papillomavirus (HPV) co-testing with in the last 5 years. Notation of Pap test located in progress notes MUST  include the lab results in order to meet NCQA® requirements.

Cervical cytology and human papillomavirus test must be completed four or less days apart in order to qualify for every 5 years testing.


Code Code Type Description: Pap test

88141  Cytopathology, cervical or vaginal, interpretation by physician

88142  Cytopathology, cervical or vaginal, manual screening under physician supervision

88143 Cytopathology, cervical or vaginal, manual screening and rescreening under physician supervision

88147 Cytopathology smears, cervical or vagina, screening by automated system under physician supervision

88148 Cytopathology smears, cervical or vagina, screening by automated system with manual rescreening under physician supervision

88150 Cytopathology, slides, cervical or vaginal, manual screening, under physician supervision

88152 Cytopathology, slides, cervical or vaginal, manual screening and computer assisted rescreening, under physician supervision

88153 Cytopathology, slides, cervical or vaginal, manual screening and rescreening under physician supervision

88154 Cytopathology, slides, cervical or vaginal manual screening, computer assisted rescreening, under physician supervision

88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation

88164 Cytopathology, slides, cervical or vaginal, manual screening, under physician supervision

88165 Cytopathology, slides, cervical or vaginal, manual screening and rescreening, under physician supervision

88166 Cytopathology, slides, cervical or vaginal, manual screening and computer assisted rescreening, under physician supervision

88167 Cytopathology, slides, cervical or vaginal, manual screening and computer assisted rescreening using cell selection, under physician supervision

88174 Cytopathology, cervical or vaginal collected in preservation fluid, automated thin layer preparation, screening by auto system, under phys super

88175 Cytopathology, cervical or vaginal collected in preservation fluid, screening by automated system, and manual rescreening, under physician super

G0123 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, screening by cytotechnologist under physician supervision

G0124 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, requiring physician interpretation

G0141 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, with manual rescreening, requiring physician interpretation

G0143 Screening Cytopathology, cervical or vaginal, auto thin layer preparation, with manual screening/ rescreening by cytotechnologist, under phys super

G0144 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, with screening by automated system, under physician supervision

G0145 Screening Cytopathology, cervical or vaginal, automated thin layer prep, with screening by auto system w manual rescreening under phys super

G0147  Screening Cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

G0148 Screening Cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening

P3000 Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision

P3001 Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician

Q0091 Screening Papanicolaou smear, obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

Edit procedure code Guidelines

88141+ (Cytopathology, cervical or vaginal {any reporting system}; requiring interpretation by physician {list separately in addition to code for technical service), 88142 (Cytopathology, cervical or vaginal {any reporting system}, collected in preservation fluid, automated thin layer preparation; manual screening under physician supervision) 88143 (Cytopathology, cervical or vaginal {any reporting system; with manual screening and rescreening under physician supervision), 88147 (Cytopathology, smears, cervical or vaginal; screening by automated system under physician supervision), 88148 (Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision), 88150 (Cytopathology, slides, cervical or vaginal; manual screening under physician supervision), 88152 (Cytopathology, slides, cervical or vaginal; with manual screening and computerassisted rescreening under physician supervision), 88153 (Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision), 88154 (Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision), 88155+ (Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation {e.g., maturation index, karyopyknotic index, estrogenic index} {List separately in addition to code(s) for other technical and interpretation services}), 88164 (Cytopathology, slides, cervical or vaginal  {the Bethesda System}; manual screening under physician supervision), 88165 (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and rescreening under physician supervision), 88166 (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer assisted rescreening under physician supervision), 88167 (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer-assisted rescreening using cell selection and review with physician supervision), 88174 (Cytopathology, cervical or vaginal
{any reporting system}, collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision) and 88175 (Cytopathology, cervical or vaginal {any reporting system}, collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision) bundles with 99201-99215, 99241-99245, 99304-99316, 99318, 99324-99337, 99341-99350, 99381-99397 and 99450-99456 (Outpatient services, nursing facility services, domiciliary/rest home/boarding home or custodial care services, home services, preventive medicine services and special evaluation and management services).

MEDICAL APPEALS

Medical Appeals are clinical in nature and involve adverse benefit determinations of not medically necessary or investigational. All other Appeals are considered Administrative Appeals and are handled by the Administrative Appeals and Grievance Department. The process and contact information for this department is located elsewhere in this document.

We recognize that disputes may arise between members (member’s provider) and Blue Cross regarding covered services. An appeal is a written request from the member or authorized representative to change a prior decision that Blue Cross has made about covered services. Examples of issues that qualify as appeals include denied authorizations, claims based on adverse determinations of medical necessity or investigational denials, and be nefit determinations. A rescission of coverage is also eligible for an appeal.

The Member has the right to appoint an authorized representative to speak on their behalf in their Appeals. An authorized representative is a person to whom the Member has given written consent to represent the Member in an internal or external review of a denial. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.

The Member, their authorized representative, or a Provider authorized to act on the Member’s behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Requests submitted to Us after one hundred eighty (180) days of Our initial determination will not be considered.

Member appeals processes vary due to variations in state and federal laws. We will apply the law that governs the benefits purchased by the member or the member’s employer. In some instances this is state law, and in others, it is federal law. The member’s contract or certificate describes the appeals processes applicable to the member. We will follow the language in the member’s contract or certificate, should there be any variance between that language and what is printed below.

Due to variations between federal and state laws, appeals for ERISA members are handled differently from non-ERISA member appeals. There are some plans that are not governed by either the state laws or the ERISA laws. Examples are some plans for whom we provide administrative services only and the Federal Employee Program. For these members, we will follow the appeals processes stated in their member contracts. The majority of appeals should fall within the ERISA or non-ERISA (state) processes. If members are unsure which process applies to them, they should contact their employer, Plan Administrator, Plan Sponsor or Blue Cross at 1-800-599-2583 or 225-291-5370. Members and providers are encouraged to provide Blue Cross with all available information and documentation at the time of the appeal request to help Us completely evaluate the appeal.


Louisiana laws apply to individual contracts of insurance, employer insurance plans that are not governed by ERISA, and non-federal government insurance plans. Blue Cross generally refers to these processes  as “Non-ERISA” processes. We will follow internal and external laws set out in La. R.S. 22:2391 et seq. and applicable regulations for these types of plans. We will follow the appeal rules for ERISA plans as set out in 29 CFR 2560 et seq. If the laws that affect appeals for any type of plan change, we will revise our process to maintain compliance.

We will investigate the Member’s concerns. If we change Our original decision at the first level, We will process the Member’s Claim and notify the Member and all appropriate Providers. If the original determination on the Member’s Claim is upheld, We will notify the Member and all appropriate Providers of the decision. Notice of the Administrative Appeal decision will be sent in writing within thirty (30) calendar days of our receipt of the member’s request; unless it is mutually agreed that an extension of the time is warranted.

Both federal and state Medical Appeals processes include two levels of review; an internal level and an external level.

The internal level of review will be conducted by Persons not involved in previous decisions regarding the member’s claim will decide all Appeals. A physician or other health care professional; in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review and who is not subordinate to any previous decision-maker on the member’s claim, will review medical necessity appeals.

External level of review can be requested by the member, their authorized representative, or a provider authorized to act on the member’s behalf, who must submit a written request to Appeal within one hundred twenty (120) days following the member’s receipt of an internal appeal adverse benefit determination. Request submitted to us after one hundred twenty (120) days of Our internal appeal determination will not be considered. Please note that for those plans subject to Louisiana state law, the External Review request form provided with an internal appeal denial notice MUST be signed by the member and returned with any request for External Review.

The external level of review will be conducted by a non-affiliated Independent Review Organization (IRO). We will provide the IRO all pertinent information necessary to conduct the Appeal. The IRO decision will be considered a final and binding decision on both the Member and Us.

The external review will be completed within forty-five (45) days of Our receipt of the request, and the IRO will notify the Member or their authorized representative and all appropriate Providers of its decision.

Expedited Medical appeals requests are available in cases where review of an Adverse Determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the member may experience pain that cannot be adequately controlled while awaiting a standard internal appeal decision. In these cases, we will make a decision no later than seventy-two (72) hours of our receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal.


An Expedited Appeal is a request concerning an Admission, availability of care, continued stay, or health care service for a covered person who is requesting Emergency services or has received Emergency services, but has not been discharged from a facility. Expedited Appeals are not provided for review of services previously rendered. An Expedited Appeal shall be made available to, and may be initiated by the covered person; the covered person’s authorized representative, or the Provider acting on behalf of the covered person.

Standard Administrative Appeal

 First Level Administrative Process

Administrative Appeals involve contractual issues other than Medical Necessity or Investigational denials and those denials that do not require medical judgment.

If the Member is not satisfied with Our denial of services, the Member, their authorized representative, or a Provider acting on their behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Appeals should be submitted in writing to:

Medical Benefits:
Blue Cross and Blue Shield of Louisiana
Appeals and Grievance Unit
P. O. Box 98045
Baton Rouge, LA 70898-9045


Pediatric Dental Care Benefits: (applicable to Non-Grandfathered Individual and Small Group ONLY)
Blue Cross and Blue Shield of Louisiana
Dental Customer Service
P. O. Box 69420
Harrisburg, PA 17106-9420


Pediatric Vision Care Benefits: (applicable to Non-Grandfathered Individual and Small Group ONLY)
Blue Cross and Blue Shield of Louisiana
c/o Davis Vision
P. O. Box 791
Latham, NY 12110


Note: Requests submitted to Blue Cross after one hundred eighty (180) days of the denial will not be considered.

We will investigate the Member’s concerns. If We change Our original decision at the Appeal level, We will process the Member’s Claim and notify the Member and all appropriate Providers, in writing, of the first level Appeal decision. If the Member’s Claim is denied on Appeal, We will notify the Member and all appropriate Providers, in writing, of Our decision within thirty (30) calendar days of the Member’s  request; unless We mutually agree that an extension of the time is warranted. At that time, We will inform the Member of the right to begin the second level Appeal process, if applicable.

Second Level Administrative Process (If Applicable)

Within sixty (60) calendar days of the date of Our first level Appeal decision, a Member who is not satisfied with the decision may initiate, with assistance from the Customer Service Unit, if necessary, the second level of Appeal process. Requests submitted to Us after sixty (60) days of the denial will not be considered.

A Member Appeals Committee not involved in any previous denial will review all second level Appeals. The Committee’s decision is final and binding as to any administrative Appeal and will be mailed to the Member within five (5) days of the Committee meeting.

 Standard Medical Appeal

Internal Process

Medical Appeals involving a denial or partial denial based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational. If the Member is not satisfied with Our denial of services, the Member, their authorized representative, or a Provider acting on their behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Appeals should be submitted in writing to or fax to:

Blue Cross and Blue Shield of Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837


HMO Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837


Note: Requests submitted to Blue Cross after one hundred eighty (180) days of the denial will not be  considered.

We will investigate the member’s concerns. All Appeals of Medical Necessity denials will be reviewed by a physician or other health care professional in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review. If our initial denial is overturned on the Member’s Medical Necessity Appeal, We will process the claim and will notify the Member and all appropriate Providers, in writing, of the Internal Appeal decision. If our initial denial is upheld, We  will notify the Member and all appropriate Providers, in writing, of our decision and advise the Member of their right to request an External Appeal. The decision will be mailed within thirty (30) days of the member’s request, unless the member or their authorized representative and We mutually agree that an extension of the time is warranted. At that time, We will inform the member of their right to begin the External Appeal process if the claim meets the criteria.


External Process

If the Member still disagrees with our determination on their Claim following the internal review process, the Member or their authorized representative may request an External Appeal conducted by a non-affiliated Independent Review Organization (IRO). The Member must send their written request for an external Appeal, within one hundred twenty (120) days* of receipt of the Internal Appeal decision.The Member must grant permission  for the request of an External Review by completing and submitting at the time of External Appeal request the form "I want to ask for an External Appeal." Any external review requested without the required form will not be considered.

Blue Cross and Blue Shield of Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837

HMO Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax 225-298-1837

We will provide the IRO all pertinent information necessary to conduct the Appeal. The IRO decision will be considered a final and binding decision on both the Member and Us. The external review will be completed within forty-five (45) days of Our receipt of the request and the IRO will notify the Member or their authorized representative and all appropriate Providers of its decision.

* Requests submitted to us after one hundred twenty (120) days of receipt of the internal Appeal decision will not be considered.


Expedited Appeals

Internal Process

We provide an Expedited Appeal process for review of an Adverse Determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the Member may experience pain that cannot be adequately controlled while awaiting a standard Internal Appeal decision.


The Expedited Appeal process allows for expedited appeal decisions no later than seventy-two (72) hours of our receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal.

An Expedited Appeal is a request for immediate review of an initial non-certification determination concerning an admission, availability of care, continued stay, or health care service for a covered person or his authorized representative who is requesting emergency services or has received emergency services but has not been discharged from a facility or if waiting for the standard appeal 30 day process could seriously jeopardize the member’s life, health or ability to regain maximum function or in the treating physician’s opinion, the patient would be subjected to severe pain without care or treatment.   Expedited Appeals are not provided for services previously rendered.

Blue Cross and Blue Shield of Louisiana, Inc.
Expedited Appeal - Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837


HMO Louisiana, Inc.
Expedited Appeal - Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022

In any case where the Expedited Internal Appeal process does not resolve a difference of opinion between Us and the covered person or the Provider acting on behalf of the covered person, the Appeal may be elevated to an Expedited External Appeal.


External Process

An Expedited External Appeal of an adverse decision is available when requested by the Member, their authorized representative or a provider acting on behalf of a member.

An Expedited External Appeal is a request for immediate review of an initial non-certification determination concerning an admission, availability of care, continued stay, or health care service for a covered person or his authorized representative who is requesting emergency services or has received emergency services but has not been discharged from a facility or if waiting for the standard Appeal 30 day process could seriously jeopardize the member’s life, health or ability to regain maximum function or in the treating physician’s opinion, the patient would be subjected to severe pain without care or treatment.

Expedited External Appeals are not provided for review of services previously rendered. An Expedited External Appeal is also available if the Adverse Determination involves a denial of coverage based on a determination that the recommended or requested health care service or
treatment is deemed Investigational; and the covered person’s treating Physician certifies in writing  that the recommended or requested health care service or treatment that is the subject of the Adverse Determination would be significantly less effective if not promptly initiated. The request may be simultaneously filed with a request for an expedited internal review, since the Independent Review Organization assigned to conduct the expedited external review will determine whether the request is eligible for an external review at the time of receipt.


We will forward all pertinent information for Expedited External Appeal requests to the IRO so the review may be completed within seventy-two (72) hours of receipt.

All external review decisions are binding on Us and You for purposes of determining coverage under a health Contract. This Appeals process shall constitute Your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary, except to the extent that other remedies are available under state or federal law.


Please Note:

Although submission of additional information is not required at the time an appeal request is requested, an explanation and/or supporting documentation for an appeal is recommended.


Dispute Resolution

Blue Cross has established a general dispute resolution process to resolve any problems and disputes concerning Blue Cross’ right of offset or recoupment. To initiate the general dispute resolution process, providers should send a written notice with a brief description of their dispute to:


Blue Cross and Blue Shield of Louisiana
Provider Dispute
P.O. Box 98021
Baton Rouge, LA 70898-9021

Within sixty (60) calendar days of our receipt of the provider’s notice, Blue Cross and the provider will assign appropriate staff members who are to arrange to discuss and seek resolution of the dispute, consistent with the terms of the provider’s agreement with Blue Cross. Any and all dispute resolution procedures are to be conducted only between Blue Cross and the provider and shall not include any Blue Cross or HMO Louisiana member unless such involvement is necessary to the resolution of the dispute. Blue Cross, in its sole discretion, will determine if the member’s involvement is necessary to the resolution of the dispute.


If Blue Cross and the provider are unable to reach resolution within the initial sixty (60) day period, then management from both Blue Cross and the provider, who were not involved in the initial discussion, will have an additional thirty (30) days to resolve the dispute. This time period may be extended by mutual agreement between Blue Cross and the provider. Blue Cross and the provider, as mutually agreed, may include a mediator in such discussions. Blue Cross and the provider shall share the costs of the mediation equally. In any event, if additional meetings are held and no resolution of the dispute is reached within sixty (60) days from the initial meeting, Blue Cross and the provider shall elect binding arbitration as described in the Arbitration section below in order to resolve the dispute. Blue Cross or the provider’s failure to participate in the arbitration proceedings means that they have accepted the other’s demands. If resolution of the dispute occurs, Blue Cross and the provider shall express the resolution in written form or amend the provider’s agreement to include the resolution, if appropriate.

 Billing for Autologous Blood (Including Salvaged Blood) and Directed Donor Blood


In general, when autologous (predeposited or obtained through intra- or postoperative salvage) or directed-donor transfusion is performed, OPPS providers should bill for the transfusion service and the number of units of the appropriate HCPCS code that describes the blood product. Payment for the product is intended to cover the costs associated with providing the autologous or directed donor blood product service (e.g., collection, processing, transportation, and storage). OPPS providers should bill the transfusion service and the blood product HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.

When an autologous blood product is collected but not transfused, OPPS providers should bill Procedure  86890 (autologous blood or component, collection, processing, and storage; predeposited) or 86891(autologous blood or component, collection, processing, and storage; intra- or postoperative salvage) and the number of units collected but not transfused. Procedure  86890 and 86891 are intended to provide payment for the additional resources needed to provide these services, which are not captured when a blood product HCPCS code is not billed. Because billing 86890 or 86891 is only indicated when autologous blood is collected but not transfused, the OPPS provider should bill 86890 or 86891 on the date when the OPPS provider is certain the blood will not be transfused (i.e., date of a procedure or date of outpatient discharge), rather than on the date of the product’s collection or receipt from the supplier.

When a directed donor blood product is collected but not transfused to the initial targeted recipient or to any other patient, refer to the section 231.7 titled “Billing for Unused Blood.”



Billing for Split Unit of Blood


HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split and some portion of the unit is transfused to one patient and the other portions are transfused to other patients or to the same patient at other times. When a patient receives a transfusion of a split unit of blood or blood product, OPPS providers should bill P9011 for the blood product transfused, as well as Procedure  86985 (Splitting, blood products) for each splitting procedure performed to prepare the blood product for a specific patient.

Providers should bill split units of packed red cells and whole blood using Revenue Code 389 (Other blood), and should not use Revenue Codes 381 (Packed red cells) or 382 (Whole blood). Providers should bill split units of other blood products using the applicable revenue codes for the blood product type, such as 383 (Plasma) or 384 (Platelets), rather than 389. Reporting revenue codes according to these specifications will ensure the Medicare beneficiary's blood deductible is applied correctly.

EXAMPLE: OPPS provider splits off a 100cc aliquot from a 250 cc unit of leukocyte-reduced red blood cells for a transfusion to Patient X. The hospital then splits off an 80cc aliquot of the remaining unit for a transfusion to Patient Y. At a later time, the remaining 70cc from the unit is transfused to Patient Z.

In billing for the services for Patient X and Patient Y, the OPPS provider should report the charges by billing P9011 and 86985 in addition to the Procedure  code for the transfusion service, because a specific splitting service was required to prepare a split unit for transfusion to each of those patients. However, the OPPS provider should report only P9011 and the Procedure  code for the transfusion service for Patient Z because no additional splitting was necessary to prepare the split unit for transfusion to Patient Z. The OPPS provider should bill Revenue Code 0389 for each split unit of the leukocyte-reduced red blood cells that was transfused.


Billing for Irradiation of Blood Products

In situations where a beneficiary receives a medically reasonable and necessary transfusion of an irradiated blood product, an OPPS provider may bill the specific HCPCS code which describes the irradiated product, if a specific code exists, in addition to the Procedure  code for the transfusion. If a specific HCPCS code for the irradiated blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with Procedure  code 86945 (irradiation of blood product, each unit).

EXAMPLE: If an OPPS provider transfuses the product described by P9040 (red blood cells, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill an additional Procedure  code for irradiation of the blood product since charges for irradiation should be included in the charge for P9040.



 Billing for Frozen and Thawed Blood and Blood Products


In situations where a beneficiary receives a transfusion of frozen blood or a blood product which has been frozen and thawed for the patient prior to the transfusion, an OPPS provider may bill the specific HCPCS code which describes the frozen and thawed product, if a specific code exists, in addition to the Procedure  code for the transfusion.. If a specific HCPCS code for the frozen and thawed blood or blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with Procedure  codes for freezing and/or thawing services that are not reflected in the blood product HCPCS code.

EXAMPLE: If an OPPS provider transfuses the product described by P9057 (red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill additional Procedure  codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for P9057.

If a blood product has been frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion of the blood product, the OPPS provider may bill the patient for the Procedure  code that describes the freezing and/or thawing services specifically provided for the patient. Similar to billing for autologous blood collection when blood is not transfused, the OPPS provider should bill the freezing and/or thawing services on the date when the OPPS provider is certain the blood product will not be transfused (e.g., date of a procedure or date of outpatient discharge), rather than on the date of the freezing and/or thawing services.

The following chart of blood and blood products indicates whether providers should bill separately for freezing and thawing using the available Procedure  codes.



HCPCS/Procedure                Short Descriptor             Billing of Freezing/Thawing

P9010

Whole blood for transfusion

Freezing and thawing are separately billable

P9011

Blood split unit

Freezing and thawing are separately billable

P9012

Cryoprecipitate each unit

Freezing and thawing codes not separately billable

P9016

RBC leukocytes reduced

Alternative P-code for frozen/thawed product available

P9017

Plasma 1 donor frz w/in 8 hr

Freezing and thawing codes not separately billable

P9019

Platelets, each unit

Freezing and thawing are separately billable

P9020

Plaelet rich plasma unit

Freezing and thawing are separately billable

P9021

Red blood cells unit

Alternative P-code for frozen/thawed product available

P9022

Washed red blood cells unit

Freezing and thawing are separately billable

P9023

Frozen plasma, pooled, sd

Freezing and thawing codes not separately billable

P9031

Platelets leukocytes reduced

Freezing and thawing are separately billable

P9032

Platelets, irradiated

Freezing and thawing are separately billable

P9033

Platelets leukoreduced irrad

Freezing and thawing are separately billable

P9034

Platelets, pheresis

Freezing and thawing are separately billable

P9035

Platelet pheres leukoreduced

Freezing and thawing are separately billable

P9036

Platelet pheresis irradiated

Freezing and thawing are separately billable

P9037

Plate pheres leukoredu irrad

Freezing and thawing are separately billable

P9038

RBC irradiated

Freezing and thawing are separately billable

P9039

RBC deglycerolized

Freezing and thawing codes not separately billable

P9040

RBC leukoreduced irradiated

Alternative P-code for frozen/thawed product available

P9043

Plasma protein fract,5%,50ml

Concept not applicable

P9044

Cryoprecipitate reduced plasma

Freezing and thawing codes not separately billable

P9048

Plasmaprotein fract,5%,250ml

Concept not applicable

P9050

Granulocytes, pheresis unit

Concept not applicable

P9051

Blood, l/r, cmv-neg

Freezing and thawing are separately billable

P9052

Platelets, hla-m, l/r, unit

Freezing and thawing are separately billable

P9053

Plt, pher, l/r cmv-neg, irr

Freezing and thawing are separately billable

P9054

Blood, l/r, froz/degly/wash

Freezing and thawing codes not separately billable

P9055

Plt, aph/pher, l/r, cmv-neg

Freezing and thawing are separately billable

P9056

Blood, l/r, irradiated

Freezing and thawing are separately billable

P9057

RBC, frz/deg/wsh, l/r, irrad

Freezing and thawing codes not separately billable

P9058

RBC, l/r, cmv-neg, irrad

Freezing and thawing are separately billable


P9059

Plasma, frz between 8-24hour

Freezing and thawing codes not separately billable

P9060

Fr frz plasma donor retested

Freezing and thawing codes not separately billable



To report charges for transfusion services, OPPS providers should bill the appropriate Procedure  code for the specific transfusion service provided under Revenue Code 391 (Blood Administration). Transfusion services codes are billed on a per service basis, and not by the number of units of blood product transfused. For payment, a blood product HCPCS code is required when billing a transfusion service code. A transfusion APC will be paid to the OPPS provider for transfusing blood products once per day, regardless of the number of units or different types of blood products transfused.


 Billing for Pheresis and Apheresis Services


Apheresis/pheresis services are billed on a per visit basis and not on a per unit basis. OPPS providers should report the charge for an Evaluation and Management (E&M) visit only if there is a separately identifiable E&M service performed which extends beyond the evaluation and management portion of a typical apheresis/pheresis service. If the OPPS provider is billing an E&M visit code in addition to the apheresis/pheresis service, it may be appropriate to use the HCPCS modifier -25.


 Billing for Autologous Stem Cell Transplants

The hospital bills and shows all charges for autologous stem cell harvesting, processing, and transplant procedures based on the status of the patient (i.e., inpatient or outpatient) when the services are furnished. It shows charges for the actual transplant, described by the appropriate ICD procedure or Procedure  codes in Revenue Center 0362 (Operating Room Services; Organ Transplant, Other than Kidney) or another appropriate cost center.

The Procedure  codes describing autologous stem cell harvesting procedures may be billed and are separately payable under the Outpatient Prospective Payment System (OPPS) when provided in the hospital outpatient setting of care. Autologous harvesting procedures are distinct from the acquisition services described in Pub. 100-04, Chapter 3, §90.3.1 and §231.11 of this chapter for allogeneic stem cell transplants, which include services provided when stem cells are obtained from a donor and not from the patient undergoing the stem cell transplant.

The Procedure  codes describing autologous stem cell processing procedures also may be billed and are separately payable under the OPPS when provided to hospital outpatients.

Appeals as the Member’s Authorized Representative: Appeals that you can make as the member’s authorized representative according to the terms of the member’s contract are claims for which the member is financially responsible. When you act as the member’s authorized representative, you are not separately entitled to any appeals pursuant to this Contracting Provider Agreement.


 Appeals Pursuant to Contracting Provider’s Agreement

First Level: Written notification of disagreement highlighting specific points for reconsideration of a claim denied not medically necessary shall be provided to BCBSKS within 60 days from the date of the retrospective review determination. This notice shall be considered an initial appeal and be forwarded with all pertinent medical records to BCBSKS Customer Service. Medical records submitted with the request for initial appeal will be referred to the appropriate consultant and a determination will be rendered. This decision will be binding unless the provider files a second-level appeal within 60 days of notification of such decision.


Second Level: Forward a written request for the second-level appeal to BCBSKS customer service within 60 days following the first-level appeal denial notification. The second and final appeal determination shall be made by a physician or clinical peer. The contracting provider agrees to abide by the second-level appeal determination.


All appeal decisions under this agreement must be provided within 60 days of receipt of the provider's request. Any appeals decision not provided within the aforementioned time frames shall be considered as decisions made in favor of the provider and claim payments will be adjusted accordingly.


A contracting provider agrees to accept the determination made at each level or to appeal the determination at the next step of the appeals process. If throughout the appeals process the decision on the claim changes in the provider's favor, an additional payment will be made. However, a refund will be requested if the decision reverses a previous determination (either partially or totally).

The result of the appeals process shall be binding on the provider and BCBSKS subject only to the provision for binding arbitration previously stated herein.

The contracting provider agreement requires providers to cooperate in utilization review and medical necessity determinations. Utilization review is the process of determining the appropriateness of services rendered to and payments made on behalf of members. Appropriateness of service and payment determinations consist of the following activities:


A. MEDICAL NEED FOR SERVICES RENDERED

Medical necessity policy applies to all services rendered to BCBSKS members and includes any services or supplies used to diagnose and/or treat illness or injury. The service should be widely accepted by a peer group of practicing providers, based on scientific criteria and determined to be reasonably safe. Health care professionals should discuss all appropriate treatment alternatives available to patients regardless of benefit coverage limitations. To be determined medically necessary, the service must be consistent with the diagnosis and treatment of the condition; be in accordance with standards of good health care practice; and not be for the convenience of the patient or provider. The following procedures/equipment would be subject to medical necessity and utilization review:

1. Established procedures/equipment of questionable current usefulness in the treatment of a specific condition(s).

2. Procedures/equipment which tend to be redundant when performed/supplied in combination with other procedures/equipment; or procedures/equipment which are unlikely to provide additional medical benefits, or are contradicting to one another.

3. Specific procedures/equipment or patterns of care which vary significantly from a peer group.


B. PRE-ADMISSION CERTIFICATION & CONCURRENT REVIEW

Before admitting a member to a hospital for elective (non-obstetrical, non-life threatening) inpatient care, medical information will need to be supplied to BCBSKS in order to certify medical necessity. A length of stay will be assigned at the time of pre-certification and will be subject to concurrent review. Concurrent review is the process of obtaining current medical information to review for the medical necessity of a requested extension to the length of stay or course of treatment. For the most accurate and complete information, all pre-admission certification should be validated through the BCBSKS provider portal (Availity®).


BCBSKS pre-admission certification and concurrent review activity are conducted in compliance with URAC guidelines. This includes the availability of either the expedited or standard appeal to services denied for medical necessity during the pre-admission certification and concurrent review processes. To initiate an appeal (phone or fax), you must have complete information since the time frame begins with the appeal request. These appeal options are only available prior to claim submission and are subject to time frames as established by BCBSKS, Department of Labor, and URAC. All pre-admission certification appeals for professional and hospital services will be reviewed concomitantly.


C. OUTPATIENT PRE-CERTIFICATION/PRIOR AUTHORIZATION

Under certain circumstances, pre-certification/prior authorization may be required for outpatient services/procedures. BCBSKS will notify contracting providers at least 30 days in advance of such requirement.


Pre-certification/prior authorization may also be required for other outpatient services such as home medical equipment and case management, including those services specified by employers, and outpatient procedures which necessitate a greater level of facility care than is usually needed.

Following provider notification, continued failure to complete pre-certification/prior authorization activities will result in a 50 percent Maximum Allowable Payment (MAP) reduction up to $200 with the member held harmless. Compliance audits will take place on a post-payment basis, which may result in refunds.


D. CASE MANAGEMENT

Case management is a process that identifies and coordinates alternative treatment plans to enhance care through effective administration of available health care resources in the most cost-efficient manner. The process is accomplished through the development of a treatment plan by the patient or legal representative, the physician, other health care providers, and the BCBSKS case manager.


E. PREPAYMENT AND DATA ANALYSIS

BCBSKS will identify any trends or patterns of patient care, i.e., through data analysis, which appear inconsistent with overall patterns or trends. Prepayment review will be implemented if attempts to work with the provider have failed to resolve the issue. Specific utilization guidelines may be applied to individual prepay members. Prepayment review means all claims will be reviewed before payment and records will be required.


F. APPROPRIATE PLACE OF SERVICE

The provider agrees to use (to the extent possible) those inpatient, extended care, ancillary services and other health facilities and health professionals which have contracted with BCBSKS. Providers agree to render services to members in the most appropriate and economical setting consistent with the member’s diagnosis, treatment needs, and medical condition.

Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally requesting contract cancellation. In the event members request referrals to non-contracting providers, providers should have patients sign a statement acknowledging full understanding of the non-contracting referral and the patient’s financial responsibilities. The statement should be filed in the patient’s chart.


G. RESOLUTION OF PROBLEMS

Providers agree to work with BCBSKS and other providers of care in the resolution of any utilization or medical review problems that may be identified. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally contract cancellation.


H. MEDICAL NECESSITY/UTILIZATION REVIEW DENIALS

Occasionally BCBSKS does not consider an item or service to be medically necessary. In such situations the item or service becomes a provider write-off. In the few situations where services are known to be denied as not medically necessary (including deluxe items) and the patient insists on the services, the provider must obtain a patient waiver in advance of the services being rendered. (See Section X. WAIVER FORM)
Failure to discuss the above with the patient in advance, document this in the medical record, and obtain the waiver will result in a provider write-off.

NOTE: BCBSKS members are not to be billed for services determined to be unnecessary through the medical and utilization review process, per the Contracting Provider Agreements.

Content of service refers to specific services and/or procedures that are considered to be an integral part of previous or concomitant services or procedures to the extent that separate reimbursement is not recognized. Not all content of service issues are identified in the policies and procedures. BCBSKS staff may identify and classify specific coding and nomenclature issues as they arise. Examples of services that can be considered content of service are:

• Examination of the patient.

• History of illness and/or review of patient records.

• Evaluation of tests or studies (i.e., radiology or pathology).

• Any entries into the patient's records.

• Evaluation of reports of tests or studies earlier referred to another physician for an opinion and subsequently returned for use in the office visit being conducted.

• Advice or information provided during or in association with the visit.

• Case management.

• The prescription of any medicinals, home supplies or equipment during or as a result of the visit.

• The application or the re-application of any standard dressing during a visit.

• Therapeutic, prophylactic, or diagnostic injection administration provided on the same day as an office visit, home visit, or nursing home visit.

• Additional charges beyond the regular charge for services requested after office hours, holidays or in an emergency situation.

• Items of office overhead such as malpractice insurance, telephones, personnel, supplies, cleaning, disinfectants, photographs, equipment sterilization, etc.

• Telephone calls and web-based correspondence are content of service when billed with another service on the same day. Such services are not covered if billed separately and the only service rendered on that day.

• Anesthesia provided in an office setting is considered content of service and not reimbursed separately. The provider cannot require the patient to sign a waiver or bill the patient for this service.

Some content of service issues related to specific services and/or procedures are identified throughout the policy and procedure documents.

NOTE: All-inclusive procedure codes must be used when available.

Locating PLBs

• Provider-level adjustments can increase or decrease the transaction payment amount.

• Adjustment codes are located in PLB03-1, PLB05-1, PLB07-1, PLB09-1, PLB11-1 and PLB13-1.

• The PLB is not always associated with a specific claim in the 835, but must be used to balance the transaction.

• Use the Reference ID to identify the claim. Exceptions are the FB, IR, J1, L6 and CS adjustment codes (when used for provider write-off only).



The most commonly used 835 adjustment codes

The following pages explain the most commonly used PLB codes (FB, WO, 72, IR, J1, L6 and CS) and provide details of the data found in corresponding Reference ID fields.


Forward Balance (FB) 

Overpayment recovery (WO) 

Authorized Return (72) 

Internal Revenue Service 

Withholding 

Non-Reimbursable (J1) 

Interest Owed (L6) 

Adjustment (CS) 

Note:

UnitedHealthcare has two claims processing systems that will be referenced throughout this document:

1. Our Commercial claim platform is used for the majority of our business, including most commercial products and select Medica claims.

2. Our Medicare Solutions claim platform is used for Medicare Advantage products (formerly called SecureHorizons and MedicareComplete from SecureHorizons) and Evercare. Additionally, select OptumHealth Behavioral Solutions (“Optum”) and select Medica claims are processed on this platform.



Adjustment Code Reference ID

Forward Balance (FB)

• Used to reflect a balance being moved forward to a future remit or a balance that is brought forward from a prior remit.

• When a balance is moving forward to a future remit, the PLB FB contains the TRN02 (check or Electronic Funds Transfer [EFT] trace number) from the current 835 transaction.

• When a balance has been brought forward from a prior remit, the PLB FB contains the TRN02 (check or EFT trace number) that was the Reference ID in the prior remit.

Commercial and Medicare Solutions platform information and posting tips

Medicare Solutions platform note: Forward Balance is only used for select government business (SecureHorizons®, MedicareComplete® from SecureHorizons, or Evercare® by UnitedHealthcare Medicare and Retirement).

• Use the dollar amount in the PLB to balance the 835 transaction.

• A negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice.

• The PLB FB is used to move a negative balance from a current 835 transaction into a future 835 transaction. Typically, this happens when we report an overpayment and there aren’t sufficient funds to recoup the entire overpayment amount.

• Forward Balance is tracked at the transaction level and is not claim-specific.




Adjustment Code Reference ID

Overpayment Recovery (WO)

• Used when a previous overpayment is recouped from the provider of service.

• Used when a reversal and corrected claim are not reported in the same transaction. WO prevents the prior claim payment from being deducted from the transaction.

• Used to offset the PLB 72.

• Used when a reversal and corrected claim are reported and the overpayment is not immediately recouped. WO prevents the prior claim payment from being deducted from the transaction.

• The Reference ID for the PLB WO contains the beginning date of service from the claim and the patient account number.

• When reporting a voided check, the Reference ID in the PLB WO is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund. We report a reversal to the original claim and a corrected claim in the 835. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the amount as a negative value in the PLB WO.

• If the reversal and corrected claim are not reported in the same 835 transaction, the 835 transaction that contains the reversal claim reports a negative value in the PLB WO. The 835 transaction that contains the corrected claim reports a positive value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• If a refund is not received within the timeframe requested in the letter, UnitedHealthcare recoups the money and reports this using the WO adjustment code. The 835 transaction that contains the overpayment recovery reduction will report a positive value in the PLB WO.



Underpayments

• Used to balance the 835 transaction when the reversal and corrected claims are not reported in the same 835 transaction and prior payment is not being recouped. The 835 transaction that contains the reversal claim will report a negative value in the PLB WO. The 835 transaction that contains the corrected claim will report a positive value in the PLB WO.

• When the reversal and corrected claim are reported in the same 835 transaction, no PLB is reported.
Provider refund check reporting

• When a refund check is received, the amount of the refund is reported as a positive value in the PLB WO and a negative value in the PLB 72.



Voided checks

When a check is voided, the amount of the voided check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

Provider refund check reporting

• When a provider’s refund check is received, the amount of the check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Voided checks

• When our check is voided, the amount of the check is reported as a positive value in the PLB WO and a negative value in the  PLB 72. The Reference ID in the PLB WO will contain the voided check number.

Overpayment Reduction (Non-Medicare Advantage products)

When we identify a claim overpayment, we report a reversal to the original claim and a corrected claim if there are sufficient funds from other claim payments to recover the amount of the overpayment. If sufficient funds are not available, we handle the overpayment with a manual recovery process after a certain amount of time.

Overpayment Reduction (specific to Medicare Advantage products and plans carrying the Medicare Solutions or Evercare®name)

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund and report a reversal to the original claim and a corrected claim. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the
overpayment amount as a negative value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• UnitedHealthcare sends a letter requesting a refund. If the refund is not received within the requested timeframe,

UnitedHealthcare recoups the money. The overpayment reduction is reported as a positive value in the PLB WO.





Adjustment Code Reference ID

Authorized Return (72)

• Used to report the dollar amount returned by the provider of service for a previous overpayment.

• Used to report a voided check.

The Reference ID in the PLB 72 contains the beginning date of service from the claim and the patient account number (Commercial and Medicare Solutions platforms).

When reporting a voided check, the Reference ID in the PLB 72 is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

For Solicited Refunds:

• The reversal and corrected claim were reported in a prior 835 and included a PLB WO so that overpayment funds weren’t recouped.

• Once the refund is received by UnitedHealthcare, the refund amount is noted as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• A PLB WO with the amount of the refund is then created to offset the PLB 72 and balance the 835 transaction. The PLB WO will contain a positive value.

For Unsolicited Refunds:

• When we post a refund, we usually enter both a reversal of payment and a corrected claim so that the reversal and PLB 72 will be in the same 835 file.

• If the refund does not cover the entire overpayment amount, the 835 will also contain a PLB WO for the amount remaining to be refunded. The PLB WO will contain a negative value.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• When we receive a refund, we note the refund amount as a negative value in the PLB segment with the 72 Adjustment
Reason Code.

• When a physician returns a UnitedHealthcare check, the voided check amount is noted as a negative value in the PLB 72.

The Reference ID in the PLB 72 will contain the voided check number.

• A PLB WO with the amount of the refund or voided check is reported as a positive value to offset the PLB 72 and balances the 835 transaction. We do not report a reversal and corrected claim in the 835 transaction.



Adjustment Code Reference ID

Internal Revenue Service Withholding (IR)

• Used for IRS tax withholding.

• The Reference ID in the PLB IR contains the beginning date of service from the applicable claim and the patient account number (Commercial platform).

• The Reference ID in the PLB IR contains the comment ‘IRS Withhold for TIN XXXXXXXXX’ (Medicare Solutions platform).

Commercial and Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• The payment amount sent to the IRS is reported in the PLB segment with an IR Adjustment Reason Code and a positive dollar amount.

• The claim will be in the same 835 as the PLB. Post the claim payment amount(s) to your patient accounts, but note that you will not physically receive funds for the payment amounts.




Adjustment Code Reference ID

Non-Reimbursable (J1)

• Used when the service provider is also the employer group and they request that monies be applied towards the Group
Medical Plan coverage premium instead of the claim.

The Reference ID in the PLB J1 contains the comment “Suppressed Payment Arrangement.”

Commercial platform information and posting tips (does not apply to Medicare Solutions platform) Use the dollar amount in the PLB to balance the 835 transaction.

• J1 will be in the same 835 as the claim.

• Post amounts to your patient accounts, but note that you will not physically receive funds for the claim payments.

• The dollar amount of the suppressed payment for the PLB J1 will be a positive value.




Adjustment Code Reference ID

Interest Owed (L6)

• Used to report interest paid on claims.

No Reference ID is included with the PLB L6. The amount reported is a sum of the AMT*I segments.

Commercial and Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• The amount of interest paid is reported in the PLB L6 as a negative amount and adds to the check total. The claim is in the same 835 transaction.

• To associate interest amounts with corresponding claims, use the AMT*1 segments at the claim level.

• The claim will contain an AMT segment in loop 2100 with an “I” (Interest) Amount Qualifier Code in the AMT01 and the interest amount in the AMT02.




Adjustment Code Reference ID

Adjustment (CS)

• Used to report the reissued payment amount for a lost check; or to

• Reduce a PLB FB balance if we write off an amount a provider owes; or to

• Reduce a PLB FB balance when the overpayment amount has been reduced.

• When reporting repayment for a lost check, the Reference ID contains the check number of the lost check (Medicare Solutions platform only).

• When reducing a prior PLB FB balance, the Reference ID is “Payer Write-Off” (Commercial platform).

• When a PLB FB balance is reduced due to claims reprocessing, the Reference ID will contain the beginning date of service and Patient Account Number of the associated claim (Commercial platform).

Commercial platform information and posting tips

Use the amount in the PLB to balance the transaction.

• A PLB FB balance was created on a prior 835 transaction. This was likely due to a recovery (PLB WO) being reported when there weren’t sufficient funds to recoup the entire overpayment amount. (See PLB FB Adjustment Code for additional information.)

• When a PLB FB remains uncollected and we decide not to recoup all or part of the remaining amount due, the amount written off will be reported in the 835 with a PLB CS.

• The 835 transaction will include the PLB FB and the balance amount from the prior 835 and a PLB CS for the amount of payer write-off. The PLB FB will report a positive amount (indicating an amount is brought forward from a prior 835) and the PLB CS will report a negative amount.

Medicare Solutions platform information and posting tips

Use the amount in the PLB to balance the transaction.

• The amount of the lost check is reported in the PLB CS as a negative value.

• The claim associated with the lost check will not be reported in an 835 transaction again. Only the payment will be reissued.

Procedure Codes and Description

81240F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT

81241F5 (COAGULATION FACTOR V) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, LEIDEN VARIANT

81291MTHFR (5,10-METHYLENETETRAHYDROFOLATE REDUCTASE) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, COMMON VARIANTS (EG, 677T, 1298C)

Coverage Indications, Limitations, and/or Medical Necessity

Indications

This is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients.

Testing for FVL and F2 G20210A mutations is indicated for pregnant patients who have a history of personal VTE associated with a non-recurrent (transient) risk factor who are not otherwise receiving anticoagulant prophylaxis. The results of genetic testing can inform risk stratification for venous thromboembolism (VTE) recurrence and subsequent need for antenatal prophylaxis. However, Medicare will not add coverage of thrombophilia testing for pregnant women because they likely represent a very small group of potential Medicare (disabled) patients. Claims submitted on this limited Medicare population will deny per the policy, but should be appealed for coverage with submission of medical records supporting the necessity for testing, and specify how testing changed anticoagulant prophylaxis management for the patient.

Background

Thrombophilia (or hypercoagulability) is the propensity to develop thrombosis due to either an acquired or inherited defect in the coagulation system. The major clinical manifestation of thrombophilia is VTE. Acquired thrombophilia risk factors include but are not limited to advancing age (> 50), trauma, malignancy, chemotherapy, major surgery, immobilization, pregnancy, estrogen, inflammation, antiphospholipid antibody syndrome, myeloproliferative disorders, heparin-induced thrombocytopenia, liver disease, nephrotic and prolonged air travel. Inherited thrombophilia risk factors include deficiencies in antithrombin, Protein C, Protein S, mutations in FVL and F2, and dysfibrinogenemias. Mixed or unknown risk factors include hyperhomocysteinemia, elevated levels of Factor VIII, acquired Protein C resistance in the absence of Factor V Leiden, and elevated levels of Factors IX and XI.

Testing for thrombophilia may consist of functional testing, antigenic testing, and genetic testing. Functional testing for thrombophilia may include tests such as:
Anti-phospholipid antibody (lupus anticoagulant);

Protein C;

Protein S;

Activated Protein C resistance (a surrogate for Factor V Leiden mutation);

Factor VIII

Fibrinogen

C-reactive protein

Homocysteine levels

Antigenic testing may be performed to identify specific glycoprotein antibodies associated with abnormal functional anti-phospholipid antibody studies, or to subtype deficiencies detected by decreased Protein S, Protein C and Antithrombin functional activity.

VTE is characteristically seen in deficiencies in Protein C, Protein S and antithrombin, as well as with FVL and F2 mutations. This is unlike the combination of arterial and venous thrombosis associated with hyperhomocysteinemia and lupus anticoagulant.

Genetic Testing for Thrombophilia

Genetic testing is available for a number of types of inherited thrombophilia, including mutations in the FVL, F2 and MTHFR genes. However, the clinical utility of testing is uncertain. The clinical utility of genetic testing depends on the ability of testing results to change management that results in improved clinical outcomes. The clinical utility of genetic testing for thrombophilia is based on the overall risk of thromboembolism and the risk/benefit ratio of treatment, primarily with anticoagulants.

During the previous 5 years, a number of guidelines and/or position statements on testing for thrombophilia have been published. In 2011, The Evaluation of Genomic Applications in Practice and Prevention Working Groups (EGAPP) addressed genetic testing for FVL and F2 mutations. The expert consensus recommended:
There is no evidence that knowledge of FVL/F2 mutation status in patients with VTE affects anticoagulation treatment to avoid recurrence;

There is convincing evidence that anticoagulation beyond three months reduces recurrence of VTE, regardless of mutation status;

There is no evidence that knowledge of FVL/F2 mutation status among symptomatic family members of patients with VTE leads to anticoagulation aimed at avoiding initial episodes of VTE (See note).

Note: The Medicare benefit applies only to individuals with signs and symptoms of disease. There is no Medicare benefit for assessment of thrombosis risk in asymptomatic patients (aka screening for inherited thrombophilia) or in asymptomatic individuals whose relatives have documented inherited thrombophilia.

In 2008, the American College of Chest Physician’s (ACCP) published guidelines for the treatment of thromboembolic disease stated the following concerning genetic testing for thrombophilia:
The presence of hereditary thrombophilia has not been used as a major factor to guide duration of anticoagulation for VTE in these guidelines because evidence from prospective studies suggests that these factors are not major determinates of the risk of recurrence.

In the 2012 ACCP Clinical Practice Guidelines, Guyatt et al (2012) and Bates et al (2012) make the following recommendations for treatment and management of VTE:
In persons with asymptomatic thrombophilia (i.e., without a previous history of VTE), we recommend against the long ­term daily use of mechanical or pharmacologic thromboprophylaxis to prevent VTE;

For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic­ or intermediate ­dose low­ molecular­weight heparin (LMWH) and postpartum prophylaxis for 6 weeks with prophylactic­ or intermediate­ dose LMWH or vitamin K antagonists (VKAs) targeted at INR 2.0 to 3.0 rather than no prophylaxis;

For all pregnant women with prior VTE, we suggest postpartum prophylaxis for 6 weeks with prophylactic­ or intermediate­ dose LMWH or VKAs targeted at INR 2.0 to 3.0 rather than no prophylaxis;

For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis;

For pregnant women at moderate to high risk of recurrent VTE (single unprovoked VTE, pregnancy­ or estrogen ­related VTE, or multiple prior unprovoked VTE not receiving long­ term anticoagulation), we suggest antepartum prophylaxis with
prophylactic­ or intermediate­ dose LMWH rather than clinical vigilance or routine care.

In the 2013 American Congress of Obstetricians and Gynecologists (ACOG) clinical management guidelines for inherited thrombophilia in pregnancy, ACOG experts note that the following guidelines are based on limited or inconsistent scientific evidence:
“Screening for thrombophilia is controversial. It is useful only when results will affect management decisions, and it is not useful in situations where treatment is indicated for other risk factors.

Screening may be considered in the following clinical settings:

A personal history of VTE that was associated with a non-recurrent risk factor (e.g., fractures, surgery, and prolonged immobilizations).

A first-degree relative (e.g., parent or sibling) with a history of high-risk thrombophilia.” (See note below)

ACOG also stated that testing for inherited thrombophilia in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. They indicate that there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin (LMWH) prevents recurrence in these patients, and note insufficient evidence to either screen for or treat women with inherited thrombophilia including complications such as fetal growth restriction or preeclampsia.

On behalf of the American College of Medical Genetics (ACMG) (reaffirmed in 2006), Grody, et al (2001) recommended testing for FVL for the following indications:
Age under 50, any venous thrombosis;

Venous thrombosis in unusual sites (such as hepatic, mesenteric, and cerebral veins;

Recurrent venous thrombosis;

Venous thrombosis and a strong family history of thrombotic disease;

Venous thrombosis in pregnant women or women taking oral contraceptives;

Relatives of individuals with venous thrombosis under age 50;

Myocardial infarction in female smokers under age 50.

ACMG suggested that FVL testing may also be considered in the following situations:
Venous thrombosis, age over 50, except when active malignancy is present;

Relatives of individuals known to have FVL. Knowledge that they have the FVL mutation may influence management of pregnancy and may be a factor in decision ­making regarding oral contraceptive use;

Women with recurrent pregnancy loss or unexplained severe preeclampsia, placental abruption, intrauterine fetal growth retardation, or stillbirth. Knowledge of FVL carrier status may influence management of future pregnancies.

FVL testing is not recommended for the following:
A general population screen;

A routine initial test during pregnancy or prior to the use of oral contraceptives, hormone replacement therapy (HRT) or selective estrogen receptor modulators (SERMs);

A prenatal or newborn test, or as a routine test in asymptomatic children;

A routine initial test in individuals with arterial thrombosis (testing may be considered, however, in selected young individuals [under age 50] with unexplained arterial thrombosis in the absence of other risk factors for atherosclerotic vascular disease).

In 2013, (ACMG) published a practice guideline on the lack of evidence for MTHFR polymorphism testing. Among a number of recommendations, ACMG experts concluded:
MTHFR polymorphism genotyping should not be ordered as part of the clinical evaluation for thrombophilia or recurrent pregnancy loss;

MTHFR polymorphism genotyping should not be ordered for at-risk family members.

Non-coverage Summary

Genetic testing for inherited thrombophilias is controversial. While the association between FVL and F2 mutations and increased risk for VTE is apparent, the actual impact of this increased risk on clinical management is less certain. Older professional society guidelines recommend genetic testing for thrombophilia for a wide range of indications, while more recent consensus statements and recommendations suggest much more limited clinical utility of testing.

The population for which genetic testing results have direct implications for treatment is pregnant women with a previous history of VTE associated with a transient risk factor (e.g., surgery, trauma). These women would typically not be treated with antepartum anticoagulant prophylaxis unless they were found to have a genotype associated with a high risk of VTE recurrence (FVL homozygosity, F2 G20210A homozygosity, or compound heterozygosity for FVL and F2 G20210A). Genetic testing for these patients is indicated.

There may also be benefit to screening pregnant women with a family history of known thrombophilia, as those women found to have a high risk genotype would be offered antenatal prophylactic anticoagulant therapy even in the absence of a personal history of VTE. However, the Medicare benefit applies only to patients with signs and symptoms of disease and does not include screening in asymptomatic patients.

Finally, despite many earlier publications suggesting a link between MTHFR polymorphisms and a risk for a wide spectrum of obstetric and cardiovascular complications, it is now accepted that MTHFR genotype alone is not associated with VTE. There is no clinical indication for MTHFR genotyping in any population.

There is insufficient evidence in the published peer-reviewed scientific literature to support coverage for genetic testing for inherited thrombophilias outside the pregnant women as described above. Genetic testing for FVL and F2 G20210A is considered investigational for all other indications. However, Medicare may consider coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will change clinical management of the patient. Denied claims can be appealed with supporting evidence of specific medical necessity. Only providers with evidence of formal training with board eligibility or certification in hematology/oncology, hematopathology or coagulation disorders at an accredited program satisfy reasonable and necessary criteria for these tests . There is broad consensus in the medical literature that MTHFR genotyping has no clinical utility in any clinical scenario. This testing is considered investigational and is NOT a Medicare benefit.


Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
0xTBD

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

Procedure Codes and Description

Group 1 Codes:

81206BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MAJOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE

81207BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MINOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE

81208BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; OTHER BREAKPOINT, QUALITATIVE OR QUANTITATIVE

81219CALR (CALRETICULIN) (EG, MYELOPROLIFERATIVE DISORDERS), GENE ANALYSIS, COMMON VARIANTS IN EXON 9

81270JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) GENE ANALYSIS, P.VAL617PHE (V617F) VARIANT

81402MOLECULAR PATHOLOGY PROCEDURE, LEVEL 3 (EG, >10 SNPS, 2-10 METHYLATED VARIANTS, OR 2-10 SOMATIC VARIANTS [TYPICALLY USING NON-SEQUENCING TARGET VARIANT ANALYSIS], IMMUNOGLOBULIN AND T-CELL RECEPTOR GENE REARRANGMENTS, DUPLICATION/DELETION VARIANTS OF 1 EXON, LOSS OF HETEROZYGOSITY [LOH], UNIPARENTAL DISOMY [UPD])

81403MOLECULAR PATHOLOGY PROCEDURE, LEVEL 4 (EG, ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, ANALYSIS OF >10 AMPLICONS USING MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 2-5 EXONS)

81445TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50 GENES (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED

81450TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, HEMATOLYMPHOID NEOPLASM OR DISORDER, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50 GENES (EG, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), INTERROGATION FOR SEQUENCE VARIANTS, AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED

81455TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN OR HEMATOLYMPHOID NEOPLASM, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 51 OR GREATER GENES (EG, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED

81479UNLISTED MOLECULAR PATHOLOGY PROCEDURE

Coverage Indications, Limitations, and/or Medical Necessity


Indications and Limitations of Coverage

This policy provides coverage for multi-gene non-NGS panel testing and NGS testing for the diagnostic workup for myeloproliferative disease (MPD), and limited coverage for single-gene testing of patients with BCR-ABL negative MPD. MPD includes polycythemia vera (PV), essential thrombocytopenia (ET), and primary myelofibrosis (PMF).

For laboratories performing single gene technologies, a sequential genetic testing approach is expected. Once a positive result is obtained and the appropriate diagnosis is established, further testing should stop. Reflex testing to the next gene will be considered reasonable and necessary if the following sequence of genetic tests produce a negative result:

BCR-ABL negative test results, progress to #2

JAK 2, cv negative test results, progress to #3 or #4

JAK, exon 12 (JAK2 exon 12 is only done when PV is suspected)

CALR/MPD (CALR/MPD is only done when either ET or PMF is suspected; testing for CALR/MPD does NOT require a negative JAK2 exon 12, just a negative JAK2 V617F result)


Genetic testing of the JAK2 V617F mutation (81270) is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

Patient would meet World Health Organization’s diagnostic criteria for myeloproliferative disease (i.e. polycythemia vera, essential thrombocytopenia, primary myelofibrosis) if JAK2 V617F were identified.


Genetic testing of JAK2 exon 12 (81403), performed to identify PV, is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

Patient would meet World Health Organization’s diagnostic criteria for PV, if JAK2 exon 12 testing were positive; and

JAK2 V617F mutation analysis was previously completed and was negative.


Genetic testing of the CALR gene (81479) (only found in ET and PMF) is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

JAK2 V617F mutation analysis was previously completed and negative; and

Patient would meet World Health Organization’s diagnostic criteria for MPD (i.e. ET, PMF) if a clonal marker were identified.


Genetic testing of the MPD gene (81402) is medically necessary when the following criteria are met:
Genetic testing impacts medical management; and

JAK2 V617F mutation analysis was previously completed and negative; and

Patient would meet World Health Organization’s diagnostic criteria for MPD (i.e. ET, MPF) if a clonal marker were identified.


Note: In a single-gene sequential approach (not mandated by this policy), CALR would be a higher priority single gene test than MPD because:
CALR mutations is more prevalent than MPD mutations in ET/PMF patients; and

CALF mutations are reported to predict a more indolent disease course than patients with JAK2 mutations.


For laboratories performing next generation sequencing (NGS or “hotspot”) testing platforms: Molecular testing for BCR-ABL, JAK 2, JAK, exon 12, and CALR/MPD genes by NGS is covered as medically necessary for the identification of myeloproliferative disorders.

Background

Myeloproliferative Disorders

Myeloproliferative disorders are a group of conditions that cause abnormal growth of blood cells in the bone marrow. They include polycythemia vera (PV), essential thrombocytosis (ET), primary myelofibrosis (PMF), and chronic myelogenous leukemia (CML). The World Health Organization (WHO) further classifies PV, ET, and PMF as Philadelphia chromosome negative myeloproliferative neoplasms (MPNs). The diagnosis of an MPN is suspected based upon clinical, laboratory, and pathological findings (i.e. bone marrow morphology). MPNs are related, but distinct from, myelodysplastic syndromes (MDS). In general, MDS are characterized by ineffective or dysfunctional blood cells, while MPN are characterized by an increase in the number of blood cells.

Polycythemia Vera

Polycythemia vera is a chronic myeloproliferative disease characterized by increased hemoglobin, hematocrit, and red blood cell mass. There is an associated increased risk for thrombosis and transformation to acute myelogenous leukemia or primary myelofibrosis; however, patients are often asymptomatic. Criteria for a diagnosis of PV are based upon CBC and clinical features. The JAK2 V617F mutation is present in the vast majority of PV, accounting for approximately 90% of cases. Functionally similar mutations in JAK2 exon 12 account for most remaining cases of JAK2 V617F mutation-negative PV. Together, they are identified in 98% of PV cases and lead to high diagnostic certainty.

Among the proposed revised World Health Organization (WHO) criteria for diagnosis is presence of the somatic JAK2 V617F mutation or functionally similar exon 12 mutation. Absence of a JAK2 mutation, combined with normal or increased serum erythropoietin level, greatly decreases the likelihood of a PV diagnosis. WHO proposed revision criteria for PV do not address additional molecular markers, including CALR mutation status.

Essential Thrombocythemia

Essential thrombocythemia is a disorder of sustained increased platelet count. The majority of ET patients (60%) carry a somatic JAK2 V617F mutation, while a smaller percentage (5-10%) have activating MPD mutations. Revision to the WHO criteria for diagnosis of ET has been proposed and includes exclusion of PV, PMF, CML, myelodysplastic syndrome, or other myeloid neoplasm. Also included in the proposed major criteria for diagnosis is demonstration of somatic JAK2 V617F mutation or MPD exon 10 mutation 12. Proposed criteria additionally state that 70% of patients without a JAK2 or MPD mutation carry a somatic mutation of the calreticulin (CALR) gene. Among confirmed ET cases, mutations in CALR are more common than MPD. Positive CALR mutation status is suggested as indicating a more indolent course 5.

Primary Myelofibrosis

Primary myelofibrosis (PMF) is a rare disorder in which the bone marrow is replaced with fibrous tissue, leading to bone marrow failure. Clinical features are similar to ET. The approximate incidence is 1 in 100,000 individuals. Persons can be asymptomatic in the early stages of the disease. For such patients, treatment may not initially be necessary. Progression of the disease can include transformation to acute myeloid leukemia. Treatment is generally symptomatic and aimed at preventing complications.

Demonstration of a clonal marker is important for diagnosis. Somatic molecular markers in PMF patients are similar to those in patients with ET, and include JAK2 V617F, MPD, and CALR. Somatic mutations in JAK2 are identified in 50-60% of PMF cases, and MPD mutations in 10%. Mutations in CALR are less common than JAK2, but more common than MPD.

Molecular Genetic Testing 

One JAK2 gene mutation, V617K, is most commonly reported, occurring in over 90% of all polycythemia vera (PV) cases and about 50% of ET cases. Testing for JAK2 V617K gene mutations can be useful in diagnosis and is incorporated into the WHO’s diagnostic criteria for these conditions.

The thrombopoietin receptor MPD is one of several JAK2 cognate receptors and is considered essential for myelopoiesis. The mutation frequency of MPD mutations associated with myeloproliferative disorders is substantially less (<10 2008="" 3.="" a="" acquired="" an="" be="" british="" clonal="" committee="" criteria="" diagnostic="" disease="" e.g.="" et="" for="" gene="" genes="" group="" guideline="" health="" hematology="" identified.="" if="" in="" include="" indicated="" individuals="" jak2="" marker="" may="" meet="" modification="" mpd="" mutation="" mutations.="" myeloproliferative="" of="" or="" organization="" p="" pathogenetic="" presence="" recommended="" s="" standards="" testing="" than="" the="" therefore="" to="" were="" who="" world="" would="">
Calreticulin (CALR) mutations have been identified in patients with myeloproliferative neoplasms and recent studies have investigated the utility of CALR mutation testing for the diagnosis and classification of myeloproliferative neoplasms. The mutations themselves are variable; however, generally focused in the exon 9 region.

Studies have shown that a significant proportion of patients with myeloproliferative neoplasms and normal JAK2 617F mutation testing have a CALR gene mutation. CALR mutations account for a large proportion of JAK2/MPD-negative ET and PMF cases. Approximately 60% of JAK2/MPD-negative ET patients are CALR-positive and 30% of JAK2/MPD-negative PMF patients are CALR-positive. Overall, CALR mutations are identified in approximately 21% of ET cases and 16% of PMF cases. CALR mutations have not been reported in PV case series 2.

For this reason, CALR gene testing may be indicated for individuals who would meet World Health Organization’s diagnostic criteria for myeloproliferative disease if a clonal marker were identified. Proponents have argued for revised WHO criteria that includes CALR mutation status in the classification system for ET and PMF 12. Current NCCN guidelines do not make recommendations for CALR genetic testing; however, these guidelines are specific to MDS and do not broadly address myeloproliferative neoplasms, such as ET or PMF. Somatic mutations in non-MDS genes, such as CALR, are listed as being associated with conditions that can mimic other myelodysplastic syndromes.

Aside from diagnostic utility, some research suggests distinct clinical outcomes associated with CALR mutation status; however, the findings have not been confirmed in other studies. It is suggested that ET patients with CALR mutations have lower polycythemic transformation rates, but not lower myelofibrotic transformation rate, compared with ET patients harboring a JAK2 mutation. Others reported a higher platelet count, younger age of diagnosis, lower leukocyte count, and decreased risk for thrombosis, compared with a JAK2 positive ET population 1. CALR-mutated ET has also been associated with better thrombosis-free survival and lower leukocyte counts; overall survival has been reported as not different among CALR mutated and non-mutated ET 2,15.

Although they are useful for establishing a diagnosis, the presence of specific clonal markers does not dictate treatment. Controversy exists generally regarding the treatment of asymptomatic individuals with ET. Some argue against treatment if there are no associated complications. In general, the main goal of treatment with PV and ET is to identify persons at high risk for thrombosis and prevent complications. Persons with PV and ET are determined to be at high-risk due to age >60 years and past history of thrombotic event(s). CALR mutational status is not currently used for risk stratification 11.

In summary, multiple studies have demonstrated the diagnostic value of CALR mutation status in a population of JAK2 and MPD negative patients with suspected ET and PMF. The presence of a somatic CALR mutation can prove useful in obtaining an accurate diagnosis. Emerging evidence suggests possible differences in clinical phenotype among the associated clonal markers, including CALR-positive ET cases. However, CALR mutation status is currently not incorporated into clinical risk stratification and more research is needed in this area.


Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
0xTBD

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A







ICD-10 Codes that Support Medical Necessity

ICD-10 CODEDESCRIPTION

C88.8Other malignant immunoproliferative diseases
C92.10Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.20Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission
C92.21Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission
C92.22Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse
C93.10Chronic myelomonocytic leukemia not having achieved remission
C94.40Acute panmyelosis with myelofibrosis not having achieved remission
C94.41Acute panmyelosis with myelofibrosis, in remission
C94.42Acute panmyelosis with myelofibrosis, in relapse
C94.6Myelodysplastic disease, not classified
D45Polycythemia vera
D46.0Refractory anemia without ring sideroblasts, so stated
D46.1Refractory anemia with ring sideroblasts
D46.20Refractory anemia with excess of blasts, unspecified
D46.21Refractory anemia with excess of blasts 1
D46.22Refractory anemia with excess of blasts 2
D46.ARefractory cytopenia with multilineage dysplasia
D46.BRefractory cytopenia with multilineage dysplasia and ring sideroblasts
D46.CMyelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.4Refractory anemia, unspecified
D46.ZOther myelodysplastic syndromes
D46.9Myelodysplastic syndrome, unspecified
D47.1Chronic myeloproliferative disease
D47.3Essential (hemorrhagic) thrombocythemia
D47.4Osteomyelofibrosis
D47.Z9Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D47.9Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified
D72.821Monocytosis (symptomatic)
D72.829Elevated white blood cell count, unspecified
D75.1Secondary polycythemia
D75.81Myelofibrosis
D75.89Other specified diseases of blood and blood-forming organs
D75.9Disease of blood and blood-forming organs, unspecified

10>

Having problems locating a claim you submitted to First Coast Service Options (First Coast)?

Claim not on file inquiry

There are steps you can take to make sure your claim was received by First Coast.

1. Before contacting customer service, check claim status.

• Reminder: The interactive voice response system (IVR) and customer service access the same claims system database. If the IVR has no record of a claim, customer service will also have no record.


2. Electronic claims

If you have not received an acknowledgement, you may have received a reject notification. If you have received a reject notification, the batch of claims you submitted contains an error that must be corrected.

3. Paper claims

If you are submitting the claims through the paper process, please allow sufficient time for us to receive, scan, and enter claims into the system. This process could take up to seven business days.

4. If the claim is not on file and still within the timely filing limits, resubmit the claim.


Enrollee not eligible on DOS Claim will deny if the client is not eligible during dates of service billed.

Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.


Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.

*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected

HCPCS CODES:


Group 1 Codes:

A4640REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD OWNED BY PATIENT

A9270NON-COVERED ITEM OR SERVICE

E0181POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY

E0182PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY

E0184DRY PRESSURE MATTRESS

E0185GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0186AIR PRESSURE MATTRESS

E0187WATER PRESSURE MATTRESS

E0188SYNTHETIC SHEEPSKIN PAD

E0189LAMBSWOOL SHEEPSKIN PAD, ANY SIZE

E0196GEL PRESSURE MATTRESS

E0197AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0198WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0199DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E1399DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS


Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

While this Standard Documentation language makes reference to “Affordable Care Act Section 6407 (ACA 6407) requirements”, technically these requirements are found in the Social Security Act Section 1843(a)(11)(B) and its implementing regulation at 42 CFR 410.38. The CMS regulation contains the details for the face-to-face examination, written order prior to delivery and the list of items subject to these requirements.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

For some items in this policy to be covered by Medicare, a written order is required to be in the supplier’s file prior to delivery of the specified item(s). There are two differing order requirements that may apply depending upon the specific item prescribed:
The Affordable Care Act Section 6407 (ACA 6407) specifies the five elements that must be contained in this written order. For purposes of this policy, this order is termed the 5-element order (5EO).

A written order prior to delivery (WOPD) that meets all of the requirements of a standard detailed written order (DWO).


If the supplier delivers an item addressed in this policy without first receiving the completed order, the item will be denied. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and/or to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about these prescription requirements and the type of denial that will result from non-compliance.

A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:
The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or

The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or

The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

Impaired nutritional status

Fecal or urinary incontinence

Altered sensory perception

Compromised circulatory status
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.

The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out". Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the beneficiary's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the beneficiary in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Policy Article will be denied as not reasonable and necessary.

Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GA – Waiver of liability statement issued as required by payer policy, individual case

GZ – Item or service expected to be denied as not reasonable and necessary

KX - Requirements specified in the medical policy have been met




Coverage Indications, Limitations, and/or Medical Necessity - Group 2

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (described by the diagnosis codes listed in the table below) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
Use of an appropriate group 1 support surface, and
Regular assessment by a nurse, physician, or other licensed healthcare practitioner, and
Appropriate turning and positioning, and
Appropriate wound care, and
Appropriate management of moisture/incontinence, and
Nutritional assessment and intervention consistent with the overall plan of care

The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (described by the diagnosis codes listed in the table below),

The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (described by the diagnosis codes listed in the table below), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days
If the beneficiary is on a group 2 surface, there should be a care plan established by the physician or home care nurse which includes the above elements. The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out" (see Appendices section).

When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.

When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces – Group 2 Policy Article will be denied as not reasonable and necessary. (See Coding Guidelines and Documentation sections concerning billing of E1399.)

Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management.

Appropriate use of the KX modifier (see Documentation section) is the responsibility of the supplier. The supplier should maintain adequate communication on an ongoing basis with the clinician providing the wound care in order to accurately determine that use of the KX modifier still reflects the clinical conditions which meet the criteria for coverage of a group 2 support surface, and that adequate documentation exists in the medical record reflecting these conditions. Such documentation should not be submitted with a claim but should be available upon request.



HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service
GA – Waiver of liability statement issued, as required by payer policy, individual case
GZ – Item or service expected to be denied as not reasonable and necessary
KX - Requirements specified in the medical policy have been met

HCPCS CODES:


Group 1 Codes:
E0193POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)
E0277POWERED PRESSURE-REDUCING AIR MATTRESS
E0371NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0372POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0373NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS
E1399DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS



ICD-10 Codes that Support Medical Necessity


ICD-10 CODEDESCRIPTION

L89.100Pressure ulcer of unspecified part of back, unstageable

L89.102Pressure ulcer of unspecified part of back, stage 2

L89.103Pressure ulcer of unspecified part of back, stage 3

L89.104Pressure ulcer of unspecified part of back, stage 4

L89.110Pressure ulcer of right upper back, unstageable

L89.112Pressure ulcer of right upper back, stage 2

L89.113Pressure ulcer of right upper back, stage 3

L89.114Pressure ulcer of right upper back, stage 4

L89.120Pressure ulcer of left upper back, unstageable

L89.122Pressure ulcer of left upper back, stage 2

L89.123Pressure ulcer of left upper back, stage 3

L89.124Pressure ulcer of left upper back, stage 4

L89.130Pressure ulcer of right lower back, unstageable

L89.132Pressure ulcer of right lower back, stage 2

L89.133Pressure ulcer of right lower back, stage 3

L89.134Pressure ulcer of right lower back, stage 4

L89.140Pressure ulcer of left lower back, unstageable

L89.142Pressure ulcer of left lower back, stage 2

L89.143Pressure ulcer of left lower back, stage 3

L89.144Pressure ulcer of left lower back, stage 4

L89.150Pressure ulcer of sacral region, unstageable

L89.152Pressure ulcer of sacral region, stage 2

L89.153Pressure ulcer of sacral region, stage 3

L89.154Pressure ulcer of sacral region, stage 4

L89.200Pressure ulcer of unspecified hip, unstageable

L89.202Pressure ulcer of unspecified hip, stage 2

L89.203Pressure ulcer of unspecified hip, stage 3

L89.204Pressure ulcer of unspecified hip, stage 4

L89.210Pressure ulcer of right hip, unstageable

L89.212Pressure ulcer of right hip, stage 2

L89.213Pressure ulcer of right hip, stage 3

L89.214Pressure ulcer of right hip, stage 4

L89.220Pressure ulcer of left hip, unstageable

L89.222Pressure ulcer of left hip, stage 2

L89.223Pressure ulcer of left hip, stage 3

L89.224Pressure ulcer of left hip, stage 4


L89.300Pressure ulcer of unspecified buttock, unstageable

L89.302Pressure ulcer of unspecified buttock, stage 2

L89.303Pressure ulcer of unspecified buttock, stage 3

L89.304Pressure ulcer of unspecified buttock, stage 4

L89.310Pressure ulcer of right buttock, unstageable


L89.312Pressure ulcer of right buttock, stage 2

L89.313Pressure ulcer of right buttock, stage 3

L89.314Pressure ulcer of right buttock, stage 4

L89.320Pressure ulcer of left buttock, unstageable


L89.322Pressure ulcer of left buttock, stage 2
L89.323Pressure ulcer of left buttock, stage 3

L89.324Pressure ulcer of left buttock, stage 4

L89.42Pressure ulcer of contiguous site of back, buttock and hip, stage 2

L89.43Pressure ulcer of contiguous site of back, buttock and hip, stage 3

L89.44Pressure ulcer of contiguous site of back, buttock and hip, stage 4

L89.45Pressure ulcer of contiguous site of back, buttock and hip, unstageable
N/A

HCPCS CODES:

FRAMES: 


Group 1 Codes:

V2020FRAMES, PURCHASES
V2025DELUXE FRAME

Group 2 Paragraph: EYEGLASS LENSES

Group 2 Codes:

V2100SPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00, PER LENS

V2101SPHERE, SINGLE VISION, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENS

V2102SPHERE, SINGLE VISION, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENS

V2103SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS

V2104SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS

V2105SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2106SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER, PER LENS

V2107SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00 SPHERE, .12 TO 2.00D CYLINDER, PER LENS

V2108SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS

V2109SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2110SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO 7.00D SPHERE, OVER 6.00D CYLINDER, PER LENS

V2111SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D CYLINDER, PER LENS

V2112SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25D TO 4.00D CYLINDER, PER LENS

V2113SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2114SPHEROCYLINDER, SINGLE VISION, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS

V2115LENTICULAR, (MYODISC), PER LENS, SINGLE VISION

V2118ANISEIKONIC LENS, SINGLE VISION

V2121LENTICULAR LENS, PER LENS, SINGLE

V2199NOT OTHERWISE CLASSIFIED, SINGLE VISION LENS

V2200SPHERE, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D, PER LENS

V2201SPHERE, BIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENS

V2202SPHERE, BIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENS

V2203SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS

V2204SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS

V2205SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2206SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER, PER LENS

V2207SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,.12 TO 2.00D CYLINDER, PER LENS

V2208SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS

V2209SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2210SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, OVER 6.00D CYLINDER, PER LENS
V2211SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D CYLINDER, PER LENS

V2212SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25 TO 4.00D CYLINDER, PER LENS

V2213SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2214SPHEROCYLINDER, BIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS

V2215LENTICULAR (MYODISC), PER LENS, BIFOCAL

V2218ANISEIKONIC, PER LENS, BIFOCAL

V2219BIFOCAL SEG WIDTH OVER 28 MM

V2220BIFOCAL ADD OVER 3.25D

V2221LENTICULAR LENS, PER LENS, BIFOCAL

V2299SPECIALTY BIFOCAL (BY REPORT)

V2300SPHERE, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D, PER LENS

V2301SPHERE, TRIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENS

V2302SPHERE, TRIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00, PER LENS

V2303SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00D CYLINDER, PER LENS

V2304SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.25-4.00D CYLINDER, PER LENS

V2305SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00 CYLINDER, PER LENS

V2306SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER, PER LENS

V2307SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS

V2308SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS

V2309SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2310SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, OVER 6.00D CYLINDER, PER LENS

V2311SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D CYLINDER, PER LENS

V2312SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25 TO 4.00D CYLINDER, PER LENS

V2313SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS

V2314SPHEROCYLINDER, TRIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS

V2315LENTICULAR, (MYODISC), PER LENS, TRIFOCAL

V2318ANISEIKONIC LENS, TRIFOCAL

V2319TRIFOCAL SEG WIDTH OVER 28 MM

V2320TRIFOCAL ADD OVER 3.25D
V2321LENTICULAR LENS, PER LENS, TRIFOCAL

V2399SPECIALTY TRIFOCAL (BY REPORT)

V2410VARIABLE ASPHERICITY LENS, SINGLE VISION, FULL FIELD, GLASS OR PLASTIC, PER LENS

V2430VARIABLE ASPHERICITY LENS, BIFOCAL, FULL FIELD, GLASS OR PLASTIC, PER LENS

V2499VARIABLE SPHERICITY LENS, OTHER TYPE



Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations,and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

Statutory coverage criteria for refractive lenses are specified in the related Policy Article.

For beneficiaries who are aphakic (i.e., who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens), the following lenses or combinations of lenses are covered when determined to be medically necessary:
Bifocal lenses in frames; or
Lenses in frames for far vision and lenses in frames for near vision; or
When a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), payment will be made for the contact lens(es), and lens(es) in frames for near vision to be worn at the same time as the contact lens(es) and lenses in frames to be worn when the contacts have been removed.
For beneficiaries who are pseudophakic (i.e., those who have an IOL), refer to the Policy Article for information about coverage of the initial pair of lenses.

For aphakic beneficiaries (i.e., those who do not have an IOL), replacement lenses are covered when they are medically necessary. Refer to the Policy Article for information about noncoverage of replacement lenses for pseudophakic beneficiaries.

Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating physician. When these features are provided as a beneficiary preference item and are billed with an EY modifier (see Documentation section), they will be denied as not reasonable and necessary.

UV protection is considered reasonable and necessary following cataract extraction; therefore, additional medical necessity justification by the treating physician beyond inclusion on the order is not necessary.

The addition of UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary. Additional information regarding the coding and billing of UV coating (V2755) on lenses with UV protective properties inherent in the material may be found in the Policy Article.

Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to an aphakic beneficiary, will be denied as not reasonable and necessary.

Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional vision in only one eye. In this situation, an impact-resistant material is covered for both lenses, if eyeglasses are covered. Claims for code V2784 that do not meet this coverage criterion will be denied as not reasonable and necessary.

Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GA – Waiver of liability statement issued as required by payer policy, individual case

GY - Item or service statutorily excluded or doesn’t meet the definition of any Medicare benefit category

GZ – Item or service expected to be denied as not reasonable and necessary

KX – Requirements specified in the medical policy have been met

LT - Left side

RT - Right side

HCPCS CODES:


Group 1 Codes:

A4450TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES

A4452TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4461SURGICAL DRESSING HOLDER, NON-REUSABLE, EACH

A4463SURGICAL DRESSING HOLDER, REUSABLE, EACH

A4465NON-ELASTIC BINDER FOR EXTREMITY

A4490SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH

A4495SURGICAL STOCKINGS THIGH LENGTH, EACH

A4500SURGICAL STOCKINGS BELOW KNEE LENGTH, EACH

A4510SURGICAL STOCKINGS FULL LENGTH, EACH

A4649SURGICAL SUPPLY; MISCELLANEOUS

A6010COLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGEN

A6011COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF COLLAGEN

A6021COLLAGEN DRESSING, STERILE, SIZE 16 SQ. IN. OR LESS, EACH

A6022COLLAGEN DRESSING, STERILE, SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH

A6023COLLAGEN DRESSING, STERILE, SIZE MORE THAN 48 SQ. IN., EACH

A6024COLLAGEN DRESSING WOUND FILLER, STERILE, PER 6 INCHES

A6025GEL SHEET FOR DERMAL OR EPIDERMAL APPLICATION, (E.G., SILICONE, HYDROGEL, OTHER), EACH

A6154WOUND POUCH, EACH

A6196ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING

A6197ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

A6198ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING

A6199ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND FILLER, STERILE, PER 6 INCHES

A6203COMPOSITE DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6204COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6205COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6206CONTACT LAYER, STERILE, 16 SQ. IN. OR LESS, EACH DRESSING

A6207CONTACT LAYER, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

A6208CONTACT LAYER, STERILE, MORE THAN 48 SQ. IN., EACH DRESSING

A6209FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6210FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING

A6211FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6212FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6213FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY
SIZE ADHESIVE BORDER, EACH DRESSING

A6214FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6215FOAM DRESSING, WOUND FILLER, STERILE, PER GRAM

A6216GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6217GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING

A6218GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6219GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6220GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE
ADHESIVE BORDER, EACH DRESSING

A6221GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6222GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT
ADHESIVE BORDER, EACH DRESSING

A6223GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE MORE THAN 16 SQ. IN., BUT
LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6224GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING

A6228GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH
DRESSING

Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

If the coverage criteria described below are not met, the claim will be denied as not reasonable and necessary.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the completed order, the item will be denied as not reasonable and necessary.

Surgical dressings are covered for as long as they are medically necessary. Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals. (Refer to Coding Guidelines in the associated Policy Article)

Surgical dressings used in conjunction with investigational wound healing therapy (e.g., platelet derived wound healing formula) may be covered if all applicable coverage criteria are met based on the number and type of surgical dressings that are appropriate to treat the wound if the investigational therapy were not being used.

When a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required. Reasons for use of additional tape must be well documented. An adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes.

Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary and the reasons must be well documented. An exception is an alginate or other fiber gelling dressing wound cover or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover.

It may not be appropriate to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e.g., hydrogel and alginate).

Because composite dressings, foam and hydrocolloid wound covers, and transparent film, when used as secondary dressings, are meant to be changed at frequencies less than daily, appropriate clinical judgment should be used to avoid their use with primary dressings which require more frequent dressing changes. When claims are submitted for these dressings for changes greater than once every other day, the quantity in excess of that amount will be denied as not reasonable and necessary. While a highly exudative wound might require such a combination initially, with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow. An example of an inappropriate combination is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.

Dressing size must be based on and appropriate to the size of the wound. For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. For example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size.

The quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings.

Dressing needs may change frequently (e.g., weekly) in the early phases of wound treatment and/or with heavily draining wounds. Suppliers are also expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly. No more than a one month's supply of dressings may be provided at one time, unless there is documentation to support the necessity of greater quantities in the home setting in an individual case. An even smaller quantity may be appropriate in the situations described above.

Surgical dressings must be tailored to the specific needs of an individual patient. When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing, that are ordered by the physician, and that are medically necessary are covered.

The following are some specific coverage guidelines for individual products when the products themselves are necessary in the individual patient. The medical necessity for more frequent change of dressings must be documented in the patient's medical record and submitted with the claim (see Documentation section).

ALGINATE OR OTHER FIBER GELLING DRESSING (A6196-A6199):

Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers); and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). They are not medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. One wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change. It is usually inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels.

COMPOSITE DRESSING (A6203-A6205):

Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.

CONTACT LAYER (A6206-A6208):

Contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change. Usual dressing change is up to once per week.

FOAM DRESSING (A6209-A6215):

Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate. Usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week. When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to 3 times per week. Usual dressing change for foam wound fillers is up to once per day.

GAUZE, NON-IMPREGNATED (A6216-A6221, A6402-A6404, A6407):

Usual non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per day for a dressing with a border. It is usually not necessary to stack more than 2 gauze pads on top of each other in any one area.

GAUZE, IMPREGNATED, WITH OTHER THAN WATER, NORMAL SALINE, HYDROGEL, OR ZINC PASTE (A6222-A6224, A6266):

Usual dressing change for gauze dressings impregnated with other than water, normal saline, hydrogel or zinc paste is up to once per day.

GAUZE, IMPREGNATED, WATER OR NORMAL SALINE (A6228-A6230):

There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline or sterile water. When these dressings are billed, they will be denied as not reasonable and necessary.

HYDROCOLLOID DRESSING (A6234-A6241):

Hydrocolloid dressings are covered for use on wounds with light to moderate exudate. Usual dressing change for hydrocolloid wound covers or hydrocolloid wound fillers is up to 3 times per week.

HYDROGEL DRESSING (A6231-A6233, A6242-A6248):

Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers). Hydrogel dressings are not usually medically necessary for stage II ulcers. Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacro-coccygeal area). Usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. Usual dressing change for hydrogel wound covers with adhesive border is up to 3 times per week.

The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not medically necessary. Documentation must substantiate the medical necessity for code A6248 billed in excess of 3 units (fluid ounces) per wound in 30 days.

Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not medically necessary.

SPECIALTY ABSORPTIVE DRESSING (A6251-A6256):

Specialty absorptive dressings are covered when used for moderately or highly exudative wounds (e.g., stage III or IV ulcers). Usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.

TRANSPARENT FILM (A6257-A6259):

Transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds. Usual dressing change is up to 3 times per week.

WOUND FILLER, NOT ELSEWHERE CLASSIFIED (A6261-A6262):

Usual dressing change is up to once per day.

WOUND POUCH (A6154):

Usual dressing change is up to 3 times per week.

TAPE (A4450, A4452):

Tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze. Additional tape is usually not required when a wound cover with an adhesive border is used. The medical necessity for tape in these situations must be documented. Tape change is determined by the frequency of change of the wound cover. Quantities of tape submitted must reasonably reflect the size of the wound cover being secured. Usual use for wound covers measuring 16 square inches or less is up to 2 units per dressing change; for wound covers measuring 16 to 48 square inches, up to 3 units per dressing change; for wound covers measuring greater than 48 square inches, up to 4 units per dressing change.

LIGHT COMPRESSION BANDAGE (A6448-A6450), MODERATE/HIGH COMPRESSION BANDAGE (A6451, A6452),SELF-ADHERENT BANDAGE (A6453-A6455), CONFORMING BANDAGE (A6442-A6447), PADDING BANDAGE (A6441):

Most compression bandages are reusable. Usual frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.

Conforming bandage dressing change is determined by the frequency of change of the selected underlying dressing.

GRADIENT COMPRESSION WRAP (A6545):

Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not reasonable and necessary. Refer to Policy Article for statement concerning noncoverage if the ulcer has healed.

Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

A1 – Dressing for one wound

A2 – Dressing for two wounds

A3 – Dressing for three wounds

A4 – Dressing for four wounds

A5 – Dressing for five wounds

A6 – Dressing for six wounds

A7 – Dressing for seven wounds

A8 – Dressing for eight wounds

A9 – Dressing for nine wounds

AW – Item furnished in conjunction with a surgical dressing

EY – No physician or other licensed health care provider order for this item or service

GY - Item or service statutorily noncovered or does not meet the definition of any Medicare benefit

LT - Left side

RT - Right side

0318 Enrollee not eligible on DOS

Claim will deny if the client is not eligible during dates of service billed. Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.



0313 Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.
*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected



0039 Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.


0983 Enrollee Not on File 

Verify the enrollee’s Medicaid ID number.



0456  Enrollee Not Covered for this Service

Verify the enrollee is covered for the service you are billing.


0004 Enrollee ID Missing or Not in Valid Format

Verify the enrollee number for eligibility. The twelve digit enrollee number should appear as it is on the Medicaid Card.

0364 Primary carrier payment equals or exceeds DMAS’ allowed amount

The claim was submitted with COB code indicating there was a primary carrier which paid on this claim and that the primary carrier’s payment to you equaled or exceeded Medicaid’s allowed amount. DMAS will not reimburse you if the primary carrier payment exceeds the Medicaid allowed amount.

0017 Missing Former Reference Number

The original Internal Control Number (ICN) for claims that are being submitted to adjust or void the original PAID claim must be provided.


0077  Adjustment Denied - Original Payment Request Already  Adjusted/Voided

An adjustment or void request cannot be submitted for a payment that has been previously adjusted or voided.

CERT Signature Denials


Denial Reason, Reason/Remark Code(s)

CO-226: Information from the billing/rendering provider was not provided or was insufficient/incomplete

MA81: Missing/incomplete/invalid provider/supplier signature

Resolution/Resources:

The CERT review contractor assesses errors when signatures in practitioners’ medical records, including X-ray reports and orders, do not meet Medicare requirements. As a result, Palmetto GBA must initiate claim adjustments and recoup any related overpayments from providers.

If you received Medicare Remittance Advice notification of these errors and disagree with the denials, send a written request for a redetermination (appeal) to Palmetto GBA. A redetermination is the first level of appeal and must be requested within 120 days of the date shown on the remittance advice notice of the denied services.  

Do not refile the claim. The decision for the denial was based upon CERT’s review of medical records; therefore, it can only be resolved by filing an appeal with Palmetto GBA.

Please clearly indicate 'CERT' when completing the redetermination form


Absence of Valid Orders/Requisitions/Documentation of ‘Intent’

CO-226: Information from the Billing/Rendering Provider was not provided or was insufficient/incomplete

N455: Missing physician order

Incomplete/Invalid Orders/Requisitions/Documentation of ‘Intent’

CO-226: Information from the Billing/Rendering Provider was not provided or was insufficient/incomplete

N456: Incomplete/invalid physician order

Resolution/Resources

The CERT Review Contractor assesses errors when there is no evidence of 'intent' or documentation of the request, in accordance with Medicare requirements. As a result, Palmetto GBA must initiate claim adjustments and recoup any related overpayments from providers. For denial purposes, these messages will be applied in situations involving ordering-treating physicians or qualified non-physician practitioners.

If you received Medicare Remittance Advice notification of these errors and disagree with the denials, send a written request for a redetermination (appeal) to Palmetto GBA. A redetermination is the first level of appeal and must be requested within
120 days of the date shown on the remittance advice notice of the denied services.

Do not refile the claim. The decision for the denial was based upon CERT’s review of medical records; therefore, it can only be resolved by filing an appeal.

Please clearly indicate 'CERT' when completing the redetermination form

Measure Name:Annual Monitoring of Anticonvulsant, Carbamazepine

Rule Description:

1) The percentage of patients 18 years and older who received at least 180 days of carbamazepine therapy and had at least one therapeutic monitoring event during the measurement year.

2) The percentage of patients 18 years and older who received at least 180 days of phenobarbital therapy and had at least one therapeutic monitoring event during the measurement year.

3) The percentage of patients 18 years and older who received at least 180 days of phenytoin therapy and had at least one therapeutic monitoring event during the measurement year.

4) The percentage of patients 18 years and older who received at least 180 days of valproic acid therapy and had at least one therapeutic monitoring event during the measurement year.

General Criteria Summary

1.Continuous enrollment: 1year
2.Anchor date: 31st  December of the measurement year
3.Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment
4.Medical coverage: Yes
5.Drug coverage: Yes
6.Attribution time frame: 1 year
7.Exclusions apply: Yes
8.Age range: 18 years and older



Note: Four separate denominator measures are being created because each subset used in a measure has to reference a specific rule.  It would be confusing to customers if we had measures that referred to rules that seemed unrelated. Therefore, there are separate subset and measure specifications for each Annual Monitoring denominator, even though the calculation of each denominator is exactly the same.

Denominator Description: All patients aged 18 years and older who received at least 180 treatment days of ambulatory anticonvulsant medication therapy during the measurement year

Inclusion Criteria: Patients aged 18 years and older as of the end of the measurement year who received at least 180 treatment days of ambulatory anticonvulsant medication therapy during the measurement year.  The four types of anticonvulsants checked are carbamazepine, phenobarbital, phenytoin, and valproic acid.



CPT Description: Drug serum concentration for carbamazepine

80156Carbamazepine; total
80157Carbamazepine; free

LOINC
Description: Drug serum concentration for carbamazepine
3432-2Drug serum concentration for carbamazepine
3433-0Drug serum concentration for carbamazepine
9415-1Drug serum concentration for carbamazepine
14056-6Drug serum concentration for carbamazepine
14639-9Drug serum concentration for carbamazepine
18270-9Drug serum concentration for carbamazepine
29147-6Drug serum concentration for carbamazepine
29148-4Drug serum concentration for carbamazepine
32058-0Drug serum concentration for carbamazepine
32852-6Drug serum concentration for carbamazepine
47097-1Drug serum concentration for carbamazepine

CPTDescription: Drug serum concentration for phenobarbital
80184Phenobarbital

LOINCDescription: Drug serum concentration for phenobarbital
3948-7Drug serum concentration for phenobarbital
3951-1Drug serum concentration for phenobarbital
10547-8Drug serum concentration for phenobarbital
14874-2Drug serum concentration for phenobarbital
34365-7Drug serum concentration for phenobarbital

CPTDescription: Drug serum concentration for phenytoin
80185Phenytoin; total
80186Phenytoin; free

LOINCDescription: Drug serum concentration for phenytoin
3968-5Drug serum concentration for phenytoin
3969-3Drug serum concentration for phenytoin
14877-5Drug serum concentration for phenytoin
32109-1Drug serum concentration for phenytoin

40460-8Drug serum concentration for phenytoin

CPTDescription: Drug serum concentration for valproic acid
80164Dipropylacetic acid (valproic acid)


LOINCDescription: Drug serum concentration for valproic acid
4086-5Drug serum concentration for valproic acid
4087-3Drug serum concentration for valproic acid
4088-1Drug serum concentration for valproic acid
14946-8Drug serum concentration for valproic acid
18489-5Drug serum concentration for valproic acid
21590-5Drug serum concentration for valproic acid
32119-0Drug serum concentration for valproic acid
32283-4Drug serum concentration for valproic acid

Description Common Resolutions 

0453 Enrolled in HMO or an Encounter Claim for F. F. S. Verify the enrollee eligibility and bill the claim to the appropriate
carrier.

0302 Duplicate of History File Record, Same Provider, Same Dates of Service Provider has already received payment for this date of service. Review your prior remittance to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline *Note- make sure the prior remittance’s provider number matches the number of the remit with the denied claim


0301 Duplicate Payment Request-Same Provider, Same Dates of Service Provider has already received payment for this date of service. Review your prior remittances to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline *Note- make sure the prior remittance’s provider number matches the number of the remittance with the denied claim

0318 Enrollee not eligible on DOS Claim will deny if the client is not eligible during dates of service billed. Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.

1393 No Srvc Taxonomy Code on the Claim Verify that the servicing provider taxonomy code was on the claim.

0309 Services Not Covered Verify the client’s eligibility on our Medicall system. If the client is eligible, contact the Provider Helpline to verify that the client is enrolled in the program for which services were billed.

0313 Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.

*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected

0732 Servicing Provider Invalid Verify the 10 digit number entered for the servicing provider.

0155 Procedure Requires Authorization The procedure/revenue code billed requires a preauthorization and there is no PA number on the claim. You must get preauthorization from the appropriate area depending on the service being provided. The preauthorization number received is required on the claim.

0039 Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.

0983 Enrollee Not on File Verify the enrollee’s Medicaid ID number.

0456 Enrollee Not Covered for this ServiceVerify the enrollee is covered for the service you are billing.

0485 Authorization by Medallion PCP Not Indicated The members primary care provider must authorize services

0308 Your payment request was filedpast the filing time limit without acceptable documentation

Virginia Medicaid is mandated by federal regulations to require the initial submission of all claims (including accident cases) within 12 months from the date of service. Medicaid is not authorized to make payment on claims submitted after the 12 month timely filing limit, except under the conditions listed in the Providers Manual Chapter V pgs 2-3. For additional details regarding the timely filing regulations, please reference the appropriate Provider Manual, Chapter 5 0022 Servicing Provider is Not Eligible to Bill this Payment Request Type

The servicing provider billed on the claim is not eligible to bill this claim.

1357 NPI Servicing Provider Not on File

Verify the 10 digit NPI entered for the servicing provider.

0385 Re-bill on Title XVIII Invoice If the claim is being submitted to Medicaid for deductible and coinsurance secondary to Medicare’s payment, and the claim to Medicare was submitted in a CMS-1500 format, then the claim to Medicaid must be submitted on a Title XVIII claim format.

0028 Admit Date Missing or Invalid UB 04–. The admit date must be numeric without any dashes or slashes.

0367 This enrollee is covered by Medicare part B, Rebill on Title 18 Medicaid requires claims be submitted on a Title 18 for Medicare Part B deductible and coinsurance. See Medicaid Memo dated 3/18/04.

0161 Authorization Not Valid for Dates of Service

The payment request's from and thru dates of service must fall within the PA's begin and end dates. CMS – 1500 and UB-04: Please verify the correct PA number was entered.

0731 Servicing Provider Not Eligible on DOS

The servicing provider was not eligible on the date of service. Contact Provider Enrollment Unit.

0370 Wrong Procedure Code Billed Check your claim to verify that the correct/valid procedure code was billed, if you feel the code is correct call the Provider Helpline to verify the code billed

0757 Servicing Provider Can Not be a Group Provider

The servicing provider number used on your claim can’t be a group NPI number.

0756 Billing Provider is not a Group Provider

The billing provider must be enrolled as a group provider. Contact Provider Enrollment

0730 Servicing Provider Not a Member of the Group

The servicing provider is not a member of the group provider, Contact Provider Enrollment

0480 Not CLIA Certified to perform procedure

Check that the CLIA number used on the claim is certified to perform the procedure.

0129 Revenue Code Not Covered UB 04 – Verify that the revenue code being billed is valid for the provider type and service

0026 Covered Days Missing or Invalid

UB 04 – Value code 80, enter the number of covered days for inpatient hospitalization or the number of days for re-occurring out-patient claims. The format for value code is digit: do not format the number of covered or non-covered days as dollar and cents.

0004 Enrollee ID Missing or Not in Valid Format

Verify the enrollee number for eligibility. The twelve digit enrollee number should appear as it is on the Medicaid Card.
0734 Covered Days Entered is greater than the Statement Period The covered days entered cannot exceed the difference between the from and thru dates.

1370 Invalid Present on Admission Flag

This requirement only applies to inpatient facility claims. The locator for the POA is right after the diagnosis code. A POA indicator is required for the primary, secondary and the external reason code. Review all diagnosis codes on the claim to assure the POA indicator was used. For more detail, please refer to the Hospital Manual, Chapter 5


0157 Approved Authorization Not on File The procedure billed requires authorization and the authorization is not on file. Verify that the authorization number on the claim is the correct authorization for the service billed.

0162 Number of procedures exceeds number authorized The number of units or visits billed is greater than the number of units or visits authorized on the PA

0191 Provider Referral Required The procedure code entered on the CMS-1500 or the revenue code on the UB-04 requires a referral, Verify the correct provider number is entered correctly on the claim.

0178 Invalid Diagnosis Code The primary diagnosis is not valid. Please verify that the diagnosis code is valid and is in the correct format.

0179 Invalid Discharge Status for Type Bill UB-04 –Enter the code indicating the disposition or discharge status of
the patient at the end service for the period covered on this bill (If the third position of type of bill is 2 or 3 the discharge status should be 30. If the third position of type of bill is 1 or 4 the discharge status should not be 30.

0014 Billed Amount Missing or Invalid CMS-1500 – Billed charges should be on each line. Do not use a decimal point.

UB-04 – The billed charges must be numeric without spaces.

0017 Missing Former Reference Number The original Internal Control Number (ICN) for claims that are being submitted to adjust or void the original PAID claim must be provided.

0055 The Type of Bill Missing or Invalid UB 04 –Type of Bill - Enter the code as appropriate

0077 Adjustment Denied - Original Payment Request Already Adjusted/Voided

An adjustment or void request cannot be submitted for a payment that has been previously adjusted or voided.

0110 Diagnosis Code Does Not Agree with Age The diagnosis given is not compatible with the enrollee's age.

0119 Service Period Not Equal Accommodation Days UB 04 - If a revenue code(s) is billed for accommodation or room and
board, the service units billed for the revenue code(s) must be equal to the number of days covered by the from-thru dates of service for the payment request.

0158 Enrollee Disagrees with Authorization

The authorization number used on the claim is not for the same enrollee as billed.

0160 Procedure Disagrees with Authorization The procedure billed on the claim is not the same procedure that has been authorized.

0352 Only Paid Payment Requests Can be Adjusted/Voided Only paid payment requests can be adjusted or voided. If the claim
previously denied, you must submit the claim as a new c laim.

0364 Primary carrier payment equals or exceeds DMAS’ allowed amount The claim was submitted with COB code indicating there was a primary carrier which paid on this claim and that the primary carrier’s payment to you equaled or exceeded Medicaid’s allowed amount. DMAS will not reimburse you if the primary carrier payment exceeds the Medicaid allowed amount.

0035 Missing/Invalid Type of Accommodation Code UB 92 –,Enter the total number of covered accommodation days or
ancillary units of service where appropriate. Th s number is equal to the number of covered days.

0352 Only Paid Payment Requests Can be Adjusted/Voided Only paid payment requests can be adjusted or voided. If the claim previously denied, you must submit the claim as a new claim.

0015 Primary Carrier Pay Missing or Invalid

CMS-1500 – our records show there is a primary carrier and no TPLinformation is on the claim.

UB-04: if claim was submitted with a COB code of ‘83’ (primary carrier billed and paid) under ‘code’, the payment made by the primary carrier must be under ‘amount.”