Monday, December 26, 2011
Monday, December 19, 2011
Medicaid
Medicaid Alert: All Medicaid Providers - Bevacizumab (Avastin, HCPCS Procedure Code J9035) - Update to Billing Guidelines
This provides new information regarding N.C. Medicaid’s coverage of the drug Avastin for breast carcinoma. The N.C. Medicaid program will discontinue coverage of Avastin for breast carcinoma under the Physician’s Drug Program for recipients who are newly diagnosed and/or beginning treatment for breast carcinoma on and after date of service April 1, 2012, instead of January 1, 2012, as previously communicated in the December 2011 general Medicaid bulletin. Medicaid will also continue to reimburse for Avastin for those recipients who were already receiving Avastin for breast carcinoma prior to date of service April 1, 2012, so their treatment may be completed. Claims paid for Avastin on and after April 1, 2012, for breast carcinoma recipients not already on Avastin treatment prior to April 1, 2012, may be recouped.
Until date of service April 1, 2012, providers may continue to bill for recipients who receive Avastin for breast carcinoma and the other covered diagnoses. Refer to the May 2010 general Medicaid bulletin article for current billing guidelines. Providers should watch for a future bulletin article with detailed billing guidelines regarding billing for breast carcinoma diagnoses on and after April 1, 2012.
HP Enterprise Services, 1-800-688-6696 or 919-851-8888
Kickback and Physician Self-Referral
2011
- 11-29-2011
- After it self-disclosed conduct to the OIG, City Hospital, Inc., The Charles Town General Hospital d/b/a Jefferson Memorial Hospital, and West Virginia University Hospitals-East, Inc. (collectively respondents), West Virginia, agreed to pay $949,595 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that the respondents entered into several arrangements with physicians or physician groups for which the hospitals failed to collect office rental payments. The conduct included: (1) payments of costs and expenses pursuant to recruitment agreements in excess of the actual additional incremental costs; (2) payment of student loans without a written recruitment agreement; and (3) payment of costs and expenses pursuant to unwritten extensions of recruitment agreements.
- 10-04-2011
- After it self-disclosed conduct to the OIG, County of Monterey d/b/a Natividad Medical Center (NMC), California, agreed to pay $174,508.46 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that NMC entered into a professional medical services agreement with a physician group for certain call coverage and clinic services. The compensation terms of the agreement offered incentives for the physician group to refer their private practice and medically indigent adult patients to NMC.
- 10-03-2011
- After it self-disclosed conduct to the OIG, Westfields Hospital, Wisconsin, agreed to pay $204,150 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that Westfields Hospital provided space, services, and supplies to certain physician group practices without entering into a formal written contract and without collecting payment.
- 9-08-2011
- After it self-disclosed conduct to the OIG, Whidbey Island Hospital District (WIHD), Washington, agreed to pay $858,571 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that WIHD had over 100 violations surrounding various physician contracts and arrangements. Some of the violations included: (1) a number of hospitalist contracts had expired and new contracts had not been signed; (2) there were no written agreements in place for a number of medical staff leadership and call coverage arrangements; and (3) a variety of improper lease arrangements, personal service arrangements, malpractice subsidies, and a housing allowance and an equipment loan with one physician.
- 07-13-2011
- After it self-disclosed conduct to the OIG, Good Samaritan Hospital Medical Center (GSHMC), New York, agreed to pay $55,018.50 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that GSHMC entered into an improper financial relationship with a physician professional corporation. The contract did not specify the terms of the intended agreement and the physician profession corporation received accelerated payments from GSHMC that did not comply with contractually agreed to payments. The payments were not consistent with fair market value.
- 07-13-2011
- After it self-disclosed conduct to the OIG, St. Catherine of Siena Medical Center (St. Catherine), New York, agreed to pay $2,596,014 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that St. Catherine contracted with a physician owned professional services company. The company received remuneration that was not consistent with fair market value and received payments for services that were not performed under the contract.
- 05-11-2011
- After it self-disclosed conduct to the OIG, Pacifica Hospital of the Valley (Pacifica), California, agreed to pay $764,250 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that Pacifica paid indirect improper remuneration to a physician in the form of payments to a marketing firm for marketing services that were never rendered under joint marketing agreements. The remuneration created a financial relationship between Pacifica and the physician that caused Pacifica to present claims for health services that resulted from prohibited referrals in violation of the Stark law.
- 03-24-2011
- After it self-disclosed conduct to the OIG, Fairview Northland Regional Health Care (FNRHC), Minnesota, agreed to pay $50,000 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks. The OIG alleged that FNRHC entered into an unwritten lease agreement with a physician practice.
False and Fraudulent Claims
2011
- 11-17-2011
- After it self-disclosed conduct to the OIG, Pitt County Memorial Hospital (PCMH), North Carolina, agreed to pay $68,479.04 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that PCMH employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 11-14-2011
- After it self-disclosed conduct to the OIG, Providence Hospital, Alabama, agreed to pay $5,938.54 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Providence Hospital employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 11-02-2011
- After it self-disclosed conduct to the OIG, Sonoma Healthcare Center (SHC), California, agreed to pay $106,650.11 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that SHC employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 10-26-2011
- After it self-disclosed conduct to the OIG, New York City Health and Hospital Corporation (HHC), New York, agreed to pay $442,909.35 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that HHC employed eight individuals that it knew or should have known were excluded from participation in Federal health care programs.
- 10-26-2011
- After it self-disclosed conduct to the OIG, Conestoga View Nursing, L.P. d/b/a Conestoga View, Pennsylvania, agreed to pay $264,879.84 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Conestoga View employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 10-06-2011
- After it self-disclosed conduct to the OIG, Blue Hill Memorial Hospital (BHMH), Maine, agreed to pay $40,000 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that BHMH employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 09-20-2011
- After it self-disclosed conduct to the OIG, Maine Coast Memorial Hospital (MCMH), Maine, agreed to pay $186,398.71 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that MCMH employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 09-15-2011
- Jenq-Sheng Liu, Jenq-Sheng Liu, M.D., P.S.C. d/b/a Blue Grass Women's Clinic, and Su-Mei Liu, (defendants), Kentucky, agreed to pay $58,952.57 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that the defendants fraudulently billed Medicaid for six different Current Procedural Terminology codes. Su-Mei Liu agreed to a five-year period of exclusion from all Federal health care programs.
- 09-06-2011
- After it self-disclosed conduct to the OIG, Cape Cod Hospital (CCH) a subsidiary of Cape Cod Healthcare, Inc., Massachusetts, agreed to pay $115,605.36 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that CCH employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 09-06-2011
- After it self-disclosed conduct to the OIG, Visiting Nurse Association of Cape Cod (VNA) a subsidiary of Cape Cod Healthcare, Inc., Massachusetts, agreed to pay $278,169.84 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that VNA employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 08-30-2011
- After it self-disclosed conduct to the OIG, St. Joseph Health Services of Rhode Island (St. Joseph), Rhode Island, agreed to pay $123,032 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that St. Joseph employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 08-23-2011
- Savient Pharmaceuticals, Inc. (Savient), New Jersey, agreed to pay $100,000 to resolve Civil Monetary Penalties liability under the Medicaid Drug Rebate Program. Savient failed to submit pricing information and to pay a rebate to state Medicaid programs for covered drugs that the state Medicaid programs reimburse.
- 08-19-2011
- After it self-disclosed conduct to the OIG, Hospice of the Finger Lakes (HFL), New York, agreed to pay $35,831.70 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that HFL employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 08-09-2011
- After it self-disclosed conduct to the OIG, Kmart Corporation (Kmart), Indiana, agreed to pay $945,021.19 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Kmart employed four individuals that it knew or should have known were excluded from participation in Federal health care programs.
- 08-09-2011
- After it self-disclosed conduct to the OIG, North American Partners in Anesthesia (NAPA), New York, agreed to pay $506,231 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that five physicians formerly associated with NAPA had furnished services at a gastroenterologist's office that inaccurately reflected procedures as having been done on two separate days when they were actually done on a single day. The false statements resulted in higher charges and caused NAPA to submit false claims in connection with those services.
- 07-25-2011
- After it self-disclosed conduct to the OIG, Trustees of Indiana University (IU), Indiana, agreed to pay $603,522 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that IU improperly claimed services provided by third and fourth year students in its professional optometry degree program under the physician fee schedule. The services could not be properly claimed under the physician fee schedule because the students were not in a graduate medical education program and the services were not provided in a teaching hospital or teaching setting.
- 07-22-2011
- After it self-disclosed conduct to the OIG, Health Management Services, Inc. (HMS), Louisiana, agreed to pay $6,545.61 for allegedly violating the Civil Monetary Penalties Law. Specifically, HMS disclosed the alteration of continuous positive airway pressure downloads for patients by two individuals at HMS in order to obtain Federal health care program reimbursement.
- 07-22-2011
- After it self-disclosed conduct to the OIG, Margaret R. Pardee Memorial Hospital (Pardee), North Carolina, agreed to pay $94,729 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Pardee employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 07-18-2011
- After it self-disclosed conduct to the OIG, Premier Health Care Services (PHCS), Ohio, agreed to pay $39,039 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that PHCS's wholly owned subsidiary, Lucas County Emergency Physicians (LCEP), submitted false claims to Medicare and Medicaid. Specifically, while employed by LCEP, a physician provided physician services at two hospitals where he improperly billed Medicare and Medicaid under the physician fee schedule for services which were performed by residents only.
- 07-18-2011
- After it self-disclosed conduct to the OIG, Mercy Health Partners (MHP), Ohio, agreed to pay $82,855 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that two of MHP's hospitals, St. Vincent Mercy Medical Center and St. Charles Mercy Hospital, submitted false claims to Medicare and Medicaid. Specifically, a physician improperly billed under the physician fee schedule for physician services which were performed by residents only.
- 06-10-2011
- After it self-disclosed conduct to the OIG, Valley Obstetrics and Gynecology (VOG), Washington, agreed to pay $72,439.62 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that VOG employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 06-22-2011
- After it self-disclosed conduct to the OIG, University of Nevada School of Medicine (UNSOM), Nevada, agreed to pay $138,321.70 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that UNSOM submitted or caused to be submitted claims for physicians' services provided by two physicians to beneficiaries of Federal health care programs using the provider identification numbers of two physicians who did not furnish the services.
- 06-21-2011
- Daniel Herrington, the owner of One Source Medical Services a durable medical equipment (DME) company, Florida, agreed to pay $124,141.50 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Herrington, through the DME company, billed Medicare for custom molded diabetic shoe inserts when in fact only prefabricated inserts were provided to beneficiaries.
- 06-10-2011
- After it self-disclosed conduct to the OIG, WellStar Cobb Hospital (WCH), Georgia, agreed to pay $9,216.73 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that WCH employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 06-06-2011
- After it self-disclosed conduct to the OIG, University of North Texas Health Science Center at Fort Worth (UNTHSC), Texas, agreed to pay $859,500 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that UNTHSC submitted claims for physicians' services provided to beneficiaries of Federal health care programs using the provider identification numbers of 103 physicians who neither furnished the service nor personally supervised the services rendered.
- 05-13-2011
- After it self-disclosed conduct to the OIG, Internal Medicine Associates (IMA), Indiana, agreed to pay $58,573.55 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that IMA employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 05-12-2011
- Beth Israel Deaconess Medical Center in Boston, Massachusetts (BIDMC) agreed to pay $233,932.54 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that BIDMC improperly billed Medicare for Lupron drug injections to male patients under HCPCS Code J1950 when BIDMC should have known that the proper code for these claims was the lower reimbursed HCPC Code J9217.
- 05-12-2011
- Beth Israel Deaconess Hospital in Needham, Massachusetts (BIDH-N) agreed to pay $59,701.60 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that BIDH-N improperly billed Medicare for Lupron drug injections to male patients under HCPCS Code J1950 when BIDH-N should have known that the proper code for these claims was the lower reimbursed HCPCS Code J9217.
- 05-10-2011
- After it self-disclosed conduct to the OIG, Colorado-Fayette Medical Center (CFMC), Texas, agreed to pay $50,000 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that CFMC presented claims for items or services that it knew or should have known were not provided as claimed and were false or fraudulent.
- 04-29-2011
- Fort Smith Regional Healthcare Foundation (Foundation), Arkansas, agreed to pay $233,000 to resolve Sparks Health System's (Sparks) liability for allegedly violating the Civil Monetary Penalties Law. The Foundation was created from the sale of Sparks and bears liability for this settlement. Sparks self-disclosed conduct to the OIG and the OIG alleged that Sparks presented claims for items that it knew or should have know were false or fraudulent.
- 04-06-2011
- After it self-disclosed conduct to the OIG, Calvin Community, Iowa, agreed to pay $56,663 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Calvin Community employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 03-21-2011
- Betty J. Feir, PhD, Texas, agreed to pay $61,270 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Dr. Feir billed Federal health care programs for services provided by auxiliary personnel instead of her and for services performed by the auxiliary personnel while she was not present.
- 03-11-2011
- Deaconess Hospital (Deaconess), Indiana, agreed to pay $76,592.52 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Deaconess employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
- 02-07-2011
- Logan Emergency Ambulance Service Authority (Logan), West Virginia, agreed to pay $79,176 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Logan employed an individual that it knew or should have known was excluded from participation in Federal health care programs.
Criminal and Civil Enforcement
December 2011
- December 14, 2011; U.S. Department of Justice
- Three Patient Recruiters for Miami Home Health Companies Sentenced to Prison in $25 Million Health Care Fraud Scheme
WASHINGTON - Two patient recruiters for a Miami health care agency were sentenced today to 18 and 12 months in prison, respectively, for their participation in a $25 million home health Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services.
- December 14, 2011; U.S. Department of Justice
- Owners of Houston Mental Health Company and Assisted Living Facility Indicted for Alleged Roles in $90 Million Medicare Fraud Scheme
PHILADELPHIA - A 23-count Indictment was returned and four Informations were unsealed today charging a total of eight defendants, including Philadelphia physician Dr. Kermit B. Gosnell and members of his former staff, in a drug conspiracy case. Gosnell is charged with illegally prescribing highly-addictive painkillers and sedatives outside the usual course of professional practice and not for a legitimate medical purpose, along with related charges.
PHOENIX- A federal grand jury in Phoenix returned a 130 count indictment against Angelo Chirban, 62, and Marilyn Chirban, 60, of Queen Creek, Arizona, for Conspiracy to Illegally Distribute Controlled Substances, Illegal Distribution of Controlled Substances, Health Care Fraud Conspiracy, Health Care Fraud, and Transactional Money Laundering.
POCATELLO - The co-owners of Pocatello Physical Therapy, P.A., were sentenced in U.S. District Court today for altering records in a federal health care audit, U.S. Attorney Wendy J. Olson announced. Dan DesFosses, 65, and Colin "Ric" Benedetti, 58, both of Pocatello, appeared before U.S. District Judge Edward J. Lodge at the federal courthouse. DesFosses and Benedetti were each sentenced to three years of probation. DesFosses was fined $1,000 and ordered to pay $9,757.66 in restitution. Benedetti was ordered to pay $2,442 in restitution. Both will be required to do 300 hours of community service.
NEWARK, N.J. - Thirteen New Jersey doctors and a nurse practitioner are charged in a cash-for tests referral scheme for allegedly taking illegal kickback payments to refer patients to an Orange, N.J., medical testing facility, New Jersey U.S. Attorney Paul J. Fishman and U.S. Department of Health and Human Services, Office of Inspector General Special Agent in Charge Tom O'Donnell announced.
Friday, December 9, 2011
Local Coverage Determinations [LCD]
Local Coverage Determination (LCD) formerly known as Local Medical Review Policies (LMRP) is defined as a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary) - Section 522 of the Benefits Improvement and Protection Act (BIPA). Refer: http://www.cms.hhs.gov/mcd/overview.asp for more information.
CMS Local Coverage Determination for all States
http://www.cms.hhs.gov/mcd/search.asp
Similarly Commercial insurances has developed Local Coverage Determinations based on the Medical necessity and are generally known as Medical Coverage Guidelines.
Florida BCBS Medical Coverage Guidelines http://mcgs.bcbsfl.com/
Humana Medical Coverage Guidelines http://apps.humana.com/tad/tad_new/Home.aspx
Wellcare Coverage Guidelines http://www.wellcare.com/Provider/CCGs
Anthem BCBS Medical Coverage Guidelines http://www.anthem.com/wps/portal/ca/popcontent?content_path=provider/f0/s0/t0/pw_a112249.htm&label=Medical%20Policies%20and%20Clinical%20UM%20Guidelines
Anthem BCBS Anesthesia Coding and Billing Guidelines http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a050123.htm
BCBS Illinosis Medical Coverage Guidelines http://medicalpolicy.hcsc.net/medicalpolicy/disclaimer.do?corpEntCd=IL1#hlink
Aetna Medical Coverage Guidelines https://xsearch.aetna.com/searchresults.aspx
UHC Medical Coverage Guidelines https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=cdc94e74bc62c010VgnVCM100000c520720a____
Cigna Medical Coverage Guidelines http://www.cignagovernmentservices.com
Physicians United Plan (PUP) Referral and Authorization Guide http://www.pupcorp.com/PDFDocuments/RAG.pdf
BCBS Texas Reimbursement for Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) and applicable Modifiers
CMS Local Coverage Determination for all States
http://www.cms.hhs.gov/mcd/search.asp
Similarly Commercial insurances has developed Local Coverage Determinations based on the Medical necessity and are generally known as Medical Coverage Guidelines.
Florida BCBS Medical Coverage Guidelines http://mcgs.bcbsfl.com/
Humana Medical Coverage Guidelines http://apps.humana.com/tad/tad_new/Home.aspx
Wellcare Coverage Guidelines http://www.wellcare.com/Provider/CCGs
Anthem BCBS Medical Coverage Guidelines http://www.anthem.com/wps/portal/ca/popcontent?content_path=provider/f0/s0/t0/pw_a112249.htm&label=Medical%20Policies%20and%20Clinical%20UM%20Guidelines
Anthem BCBS Anesthesia Coding and Billing Guidelines http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a050123.htm
BCBS Illinosis Medical Coverage Guidelines http://medicalpolicy.hcsc.net/medicalpolicy/disclaimer.do?corpEntCd=IL1#hlink
Aetna Medical Coverage Guidelines https://xsearch.aetna.com/searchresults.aspx
UHC Medical Coverage Guidelines https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=cdc94e74bc62c010VgnVCM100000c520720a____
Cigna Medical Coverage Guidelines http://www.cignagovernmentservices.com
Physicians United Plan (PUP) Referral and Authorization Guide http://www.pupcorp.com/PDFDocuments/RAG.pdf
BCBS Texas Reimbursement for Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) and applicable Modifiers
Radiology codes additions and Deletions CPT codes 2012
74174 Computed tomographic angiography, abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing
77424 Intraoperative radiation treatment delivery, x-ray, single treatment session
77425 Intraoperative radiation treatment delivery, electrons, single treatment session
77469 Intraoperative radiation treatment management
78226 Hepatobiliary system imaging, including gallbladder when present;
78227 Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed
78579 Pulmonary ventilation imaging (eg, aerosol or gas)
78582 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging
78597 Quantitative differential pulmonary perfusion, including imaging when performed
78598 Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed
Deleted codes
71090 Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation;
73542 Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation;
75722 Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation;
75724 Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation;
75940 Percutaneous placement of IVC filter, radiological supervision and interpretation;
77079 appendicular skeleton (peripheral) (eg, radius, wrist, heel)
77083 Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites;
78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function;
78584 Pulmonary perfusion imaging, particulate, with ventilation; single breath
78585 Pulmonary perfusion imaging, particulate, with ventilation; rebreathing and washout, with or without single breath
78586 Pulmonary ventilation imaging, aerosol; single projection
78587 multiple projections (eg, anterior, posterior, lateral views)
78588 Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections;
78591 Pulmonary ventilation imaging, gaseous, single breath, single projection;
78593 Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection
78594 multiple projections (eg, anterior, posterior, lateral views)
78596 Pulmonary quantitative differential function (ventilation/ perfusion) study;
CPT codes 99221-99233 vs 99241 - 99255
Can we bill CPT 99221 as a replacement code for Hospital Consultations that do not met "a detailed or comprehensive history” and “a detailed or comprehensive examination”?
No you cannot report CPT 99221 since physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.
In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.
Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Please note: Medicare contractors have been advised to expect changes to physician billing practices accordingly. Contractors will not find fault with providers who report subsequent hospital care codes (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected),even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Reference: Medicare Learning Network MM7405
No you cannot report CPT 99221 since physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.
In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.
Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Please note: Medicare contractors have been advised to expect changes to physician billing practices accordingly. Contractors will not find fault with providers who report subsequent hospital care codes (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected),even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Reference: Medicare Learning Network MM7405
CPT code 96110
Effective January 1, 2012 CPT code 96110 (Developmental screening, with interpretation and report, per standardized instrument form) would be deleted from the category of "physical therapy, occupational therapy, and outpatient speech-language pathology services". It has been replaced by HCPCS code G0451.
HCPCS code G0451 Long Description: Development testing, with interpretation and report, per standardized instrument form
HCPCS code G0451 short Description: Devlopment test interpt & rep
HCPCS code G0451 Long Description: Development testing, with interpretation and report, per standardized instrument form
HCPCS code G0451 short Description: Devlopment test interpt & rep
Integumentary System 2012 CPT changes
Integumentary System
For CY 2012, the CPT Editorial Panel deleted 24 skin substitute codes and established a 2-tier structure with 8 new codes (CPT codes 15271 through 15278) to report the application of skin substitute grafts, which are distinguished according to the anatomic location and surface area rather than by product description. Additionally, the CPT Editorial Panel created a new add-on code (CPT code 15777) to report implantation of a biological implant for soft tissue reinforcement. The detail list and of added and deleted CPT codes are as follows.
New CPT codes
15271 Skin sub graft trnk/arm/leg (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area)
15272 Skin sub graft t/a/l add-on (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure))
15273 Skin sub grft t/arm/lg child
15274 Skn sub grft t/a/l child add
15275 Skin sub graft face/nk/hf/g
15276 Skin sub graft f/n/hf/g addl
15277 Skn sub grft f/n/hf/g child
15278 Skn sub grft f/n/hf/g ch add
15777 Acellular derm matrix implt
Deleted CPT codes
15170 Acell graft trunk/arms/legs
15171 Acell graft t/arm/leg add-on
15175 Acellular graft f/n/hf/g
15176 Acell graft f/n/hf/g add-on
15300 Apply skinallogrft t/arm/lg
15301 Apply sknallogrft t/a/l addl
15320 Apply skin allogrft f/n/hf/g
15321 Aply sknallogrft f/n/hfg add
15330 Aply acell alogrft t/arm/leg
15331 Aply acell grft t/a/l add-on
15335 Apply acell graft f/n/hf/g
15336 Aply acell grft f/n/hf/g add
15340 Apply cult skin substitute
15341 Apply cult skin sub add-on
15360 Apply cult derm sub t/a/l
15361 Aply cult derm sub t/a/l add
15365 Apply cult derm sub f/n/hf/g
15366 Apply cult derm f/hf/g add
15400 Apply skin xenograft t/a/l
15401 Apply skn xenogrft t/a/l add
15420 Apply skin xgraft f/n/hf/g
15421 Apply skn xgrft f/n/hf/g add
15430 Apply acellular xenograft
15431 Apply acellular xgraft add
For CY 2012, the CPT Editorial Panel deleted 24 skin substitute codes and established a 2-tier structure with 8 new codes (CPT codes 15271 through 15278) to report the application of skin substitute grafts, which are distinguished according to the anatomic location and surface area rather than by product description. Additionally, the CPT Editorial Panel created a new add-on code (CPT code 15777) to report implantation of a biological implant for soft tissue reinforcement. The detail list and of added and deleted CPT codes are as follows.
New CPT codes
15271 Skin sub graft trnk/arm/leg (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area)
15272 Skin sub graft t/a/l add-on (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure))
15273 Skin sub grft t/arm/lg child
15274 Skn sub grft t/a/l child add
15275 Skin sub graft face/nk/hf/g
15276 Skin sub graft f/n/hf/g addl
15277 Skn sub grft f/n/hf/g child
15278 Skn sub grft f/n/hf/g ch add
15777 Acellular derm matrix implt
Deleted CPT codes
15170 Acell graft trunk/arms/legs
15171 Acell graft t/arm/leg add-on
15175 Acellular graft f/n/hf/g
15176 Acell graft f/n/hf/g add-on
15300 Apply skinallogrft t/arm/lg
15301 Apply sknallogrft t/a/l addl
15320 Apply skin allogrft f/n/hf/g
15321 Aply sknallogrft f/n/hfg add
15330 Aply acell alogrft t/arm/leg
15331 Aply acell grft t/a/l add-on
15335 Apply acell graft f/n/hf/g
15336 Aply acell grft f/n/hf/g add
15340 Apply cult skin substitute
15341 Apply cult skin sub add-on
15360 Apply cult derm sub t/a/l
15361 Aply cult derm sub t/a/l add
15365 Apply cult derm sub f/n/hf/g
15366 Apply cult derm f/hf/g add
15400 Apply skin xenograft t/a/l
15401 Apply skn xenogrft t/a/l add
15420 Apply skin xgraft f/n/hf/g
15421 Apply skn xgrft f/n/hf/g add
15430 Apply acellular xenograft
15431 Apply acellular xgraft add
2012 HCPCS code changes -J codes
New J codes effective for the year 2012
J0131 Acetaminophen injection
J0221 Lumizyme injection
J0257 Glassia injection
J0490 Belimumab injection
J0588 Incobotulinumtoxin
J0712 Ceftaroline fosamil inj
J0840 Crotalidae poly immune fab
J0897 Denosumab injection
J1557 Gammaplex injection
J1725 Hydroxyprogesterone caproate
J2265 Minocycline hydrochloride
J2507 Pegloticase injection
J7131 Hypertonic saline sol
J7180 Factor XIII anti-hem factor
J7183 Wilate injection
J7326 Gel-one
J7665 Mannitol for inhaler
J8561 Oral everolimus
J9043 Cabazitaxel injection
J9179 Eribulin mesylate injection
J9228 Ipilimumab injection
Deleted codes
J7130 Hypertonic saline solution
J7184 Wilate injection
Deleted codes
J7130 Hypertonic saline solution
J7184 Wilate injection
Timely Filing Limit for Cigna Insurance NEW UPDATES!!!!!!!!!
CIGNA will adopt a common time frame for health care professionals to follow for submitting claims to CIGNA. Except where state law requires a longer time frame, the claim filing limit will change from 180 days to 90 days for participating health care professionals. The changes to the claim filing time frame will occur in phases, with the initial phase effective on August 1, 2011.
Providers will be notified in writing of any changes and receive an amendment to their agreement, or they will be contacted by a CIGNA representative. The claim filing time change also applies to health care professionals whose CIGNA contract includes GWH-CIGNA business. Certain states have regulatory requirements that supersede the CIGNA time frames, and health care professionals in these states will have a claim filing limit that meets state requirements.
* When CIGNA is the primary payer, claims must be received by CIGNA within 90 days of the date of service to be considered for payment.
* When CIGNA is the secondary payer, the claim must be submitted within 90 days of the receipt by the health care professional of the Explanation of Payment from the primary payer.
Only participating health care professionals who receive a notification and amendment to their agreement from CIGNA, or who are newly contracted with CIGNA, are affected by this change on August 1 and November 1, 2011. There will be additional phases in 2012, and affected health care professionals will be notified in advance of any changes.
Effective August 1, 2011, the claim filing limit in provider agreements will change from 180 days to 90 days, for participating health care professionals who have received notification and an amendment to the agreement in AK, AR, AZ, CO, CT, DE, IL, IN, KS, LA, ME, MI, MO, NH, NY, OH, OK, RI, SC, TX, UT, VT, WI and WV.
Effective November 1, 2011 for CA, GA, KY, MA, MS, NV, PA, TN and WA.
Providers will be notified in writing of any changes and receive an amendment to their agreement, or they will be contacted by a CIGNA representative. The claim filing time change also applies to health care professionals whose CIGNA contract includes GWH-CIGNA business. Certain states have regulatory requirements that supersede the CIGNA time frames, and health care professionals in these states will have a claim filing limit that meets state requirements.
* When CIGNA is the primary payer, claims must be received by CIGNA within 90 days of the date of service to be considered for payment.
* When CIGNA is the secondary payer, the claim must be submitted within 90 days of the receipt by the health care professional of the Explanation of Payment from the primary payer.
Only participating health care professionals who receive a notification and amendment to their agreement from CIGNA, or who are newly contracted with CIGNA, are affected by this change on August 1 and November 1, 2011. There will be additional phases in 2012, and affected health care professionals will be notified in advance of any changes.
Effective August 1, 2011, the claim filing limit in provider agreements will change from 180 days to 90 days, for participating health care professionals who have received notification and an amendment to the agreement in AK, AR, AZ, CO, CT, DE, IL, IN, KS, LA, ME, MI, MO, NH, NY, OH, OK, RI, SC, TX, UT, VT, WI and WV.
Effective November 1, 2011 for CA, GA, KY, MA, MS, NV, PA, TN and WA.
Colonoscopy Coding and Reimbursement
What is Screening Colonoscopy?Screening Colonoscopy is an investigation or testing the patients with a scope who currently has no symptoms but are at high risk for colon / rectal cancer and / or any other abnormality of the Intestinal tract. A screening colonoscopy is used to identify and remove polyps in its precancerous stage before it develops to a cancer. The high risk persons are those with a family / personal history of colon polyps and patients with Inflammatory Bowel disease.
What is the difference between Colonoscopy and Sigmoidoscopy?
In colonoscopy the physician inserts the colonoscope into the anus and advances the scope through the colon past the splenic flexure. The lumen of the colon and rectum is visualized. In Sigmoidoscopy the physician inserts the sigmoidoscope into the anus and advances the scope into the sigmoid colon. The lumen of the sigmoid colon and rectum alone are visualized.
How to report a partial Colonoscopy procedure?
Using Colonoscopy if the sigmoid colon alone is visualized for a diagnostic purpose then the procedure performed would be reported as Sigmoidoscopy i.e to bill CPT 45330 that descries 'Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)' instead of CPT 45378 - Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure). This does not refer to a reduced procedure or a discontinued procedure.
What are the applicable CPT's and ICD's?
CPT's to report Colonoscopy and SigmoidoscopyG0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
45330-45345 Sigmoidoscopy Services
45378-45392 Colonoscopy Services
ICD-9 Codes that Support Medical Necessity almost for all insurances
V76.41 Screening for malignant neoplasm of the rectum
V76.51 Screening for malignant neoplasm, colon
V67.09 Follow-up examination following other surgery
V10.0 Personal history of malignant neoplasm of unspecified site in gastrointestinal tract
V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
V12.72 Personal history of colonic polyps
V16.0 Family history of malignant neoplasm of gastrointestinal tract
211.3 Benign neoplasm of colon
211.4 Benign neoplasm rectum and anal canal
235.2 Neoplasm of uncertain behavior of stomach, intestines, and rectum
569.0 Anal and Rectal Polyp
Preventive benefits are applied to screening colonoscopies or flexible sigmoidoscopies (G-codes when reported with a screening diagnosis V-code); non-preventive benefits are applied for colonoscopies or flexible sigmoidoscopies reported with diagnosis codes for specific illnesses, signs or symptoms. It is important to assign the correct ICD-9-CM diagnosis to the procedures as per the Local Coverage Determinations applicable in CMS http://www.cms.hhs.gov/mcd/search.asp
How the Colonoscopies are reimbursed?
Each CPT has its Relative Value Units assigned by Centres for Medicare and Medicaid Services (To check the RVU for each CPT please refer http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp). Accurate coding helps the physician to get the appropriate reimbursement. Consider if the physician performs a cold biopsy [CPT 45380] and a snare polypectomy [CPT 45385] for a patient on the same date of service, the reimbursement would not be fully calculated as per the individual RVUs for both the CPT's whereas the base code for colonoscopy procedure CPT 45378 has to be considered in determining the reimbursement for the Colonoscopies performed on the day. CPT 45378 is a component and a column 2 code for both CPT 45385 and CPT 45380 (To check the list of Column 1 and Column 2 status assigned to Colonoscopy procedures please refer http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=ascending&itemID=CMS046401&intNumPerPage=10). The reimbursement ratio is calculated as CPT 45385 + [CPT 45380 - CPT 45378] = Actual reimbursement. This formula applies when multiple endoscopy procedures like Sigmoidoscopy procedures (Base code CPT 45330), Esophagoscopy (Base code CPT 43200) and EGD (Base code CPT 43235) are performed on the same day.
Do Commercial insurance cover Screening Colonoscopy?
Yes, all the commercial carriers would cover routine screening colonoscopy if medically necessary.
Aetna reimbursement for screening colonoscopy: Aetna considers routine screening as medically necessary preventive services for members aged 50 years and older when the tests are recommended by their physician. For more details please refer http://www.aetna.com/cpb/medical/data/500_599/0516.html
Cigna reimbursement for Screening Colonoscopy: http://www.cignagovernmentservices.com/partb/pubs/mb/2001/01_3/forall/b0103b06b.html
Humana reimbursement for Screening Colonoscopy: http://apps.humana.com/tad/tad_new/Search.aspx?criteria=G0121&searchtype=freetext
Tricare Coverage and reimbursement for Colonoscopyhttp://www.tricare.mil/survey/hcsurvey/issue-briefs/issuebriefFY06Q2.pdf
http://www.tricare.mil/contracting/healthcare/t3manuals/change2/tp08/C7S2_2.PDF
http://www.medtronsoftware.com/pdf/091709_Tricare%20_Providers-MC_Part_B_Covered_Preventive_Services.pdf
What is Virtual Colonoscopy?
Virtual colonoscopy is also known as Computed Tomographic Colonography (CTC) is a minimally invasive imaging examination of the colon and rectum. CTC uses CT acquired images and advanced 2-dimensional (2D) and 3-dimensional (3D) image display techniques for interpretation. These images are interpreted by a radiologist to determine the presence of several types of abnormalities of the colon. CMS assigned CPT 0066T to report Computed Tomographic Colonography (virtual colonoscopy) screening (investigational) and CPT 0067T to report Computed Tomographic Colonography (virtual colonoscopy) diagnostic.
Important links
CMS Medicare learning Network: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0746.pdf
American Gastroenterology Association: http://www.gastro.org/user-assets/Documents/03_Practice_Management/Colonoscopy_Bundling_Statement.pdf
Centers for Disease Control and Prevention: http://www.cdc.gov/cancer/colorectal/
What is the difference between Colonoscopy and Sigmoidoscopy?
In colonoscopy the physician inserts the colonoscope into the anus and advances the scope through the colon past the splenic flexure. The lumen of the colon and rectum is visualized. In Sigmoidoscopy the physician inserts the sigmoidoscope into the anus and advances the scope into the sigmoid colon. The lumen of the sigmoid colon and rectum alone are visualized.
How to report a partial Colonoscopy procedure?
Using Colonoscopy if the sigmoid colon alone is visualized for a diagnostic purpose then the procedure performed would be reported as Sigmoidoscopy i.e to bill CPT 45330 that descries 'Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)' instead of CPT 45378 - Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure). This does not refer to a reduced procedure or a discontinued procedure.
What are the applicable CPT's and ICD's?
CPT's to report Colonoscopy and SigmoidoscopyG0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
45330-45345 Sigmoidoscopy Services
45378-45392 Colonoscopy Services
ICD-9 Codes that Support Medical Necessity almost for all insurances
V76.41 Screening for malignant neoplasm of the rectum
V76.51 Screening for malignant neoplasm, colon
V67.09 Follow-up examination following other surgery
V10.0 Personal history of malignant neoplasm of unspecified site in gastrointestinal tract
V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
V12.72 Personal history of colonic polyps
V16.0 Family history of malignant neoplasm of gastrointestinal tract
211.3 Benign neoplasm of colon
211.4 Benign neoplasm rectum and anal canal
235.2 Neoplasm of uncertain behavior of stomach, intestines, and rectum
569.0 Anal and Rectal Polyp
Preventive benefits are applied to screening colonoscopies or flexible sigmoidoscopies (G-codes when reported with a screening diagnosis V-code); non-preventive benefits are applied for colonoscopies or flexible sigmoidoscopies reported with diagnosis codes for specific illnesses, signs or symptoms. It is important to assign the correct ICD-9-CM diagnosis to the procedures as per the Local Coverage Determinations applicable in CMS http://www.cms.hhs.gov/mcd/search.asp
How the Colonoscopies are reimbursed?
Each CPT has its Relative Value Units assigned by Centres for Medicare and Medicaid Services (To check the RVU for each CPT please refer http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp). Accurate coding helps the physician to get the appropriate reimbursement. Consider if the physician performs a cold biopsy [CPT 45380] and a snare polypectomy [CPT 45385] for a patient on the same date of service, the reimbursement would not be fully calculated as per the individual RVUs for both the CPT's whereas the base code for colonoscopy procedure CPT 45378 has to be considered in determining the reimbursement for the Colonoscopies performed on the day. CPT 45378 is a component and a column 2 code for both CPT 45385 and CPT 45380 (To check the list of Column 1 and Column 2 status assigned to Colonoscopy procedures please refer http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=ascending&itemID=CMS046401&intNumPerPage=10). The reimbursement ratio is calculated as CPT 45385 + [CPT 45380 - CPT 45378] = Actual reimbursement. This formula applies when multiple endoscopy procedures like Sigmoidoscopy procedures (Base code CPT 45330), Esophagoscopy (Base code CPT 43200) and EGD (Base code CPT 43235) are performed on the same day.
Do Commercial insurance cover Screening Colonoscopy?
Yes, all the commercial carriers would cover routine screening colonoscopy if medically necessary.
Aetna reimbursement for screening colonoscopy: Aetna considers routine screening as medically necessary preventive services for members aged 50 years and older when the tests are recommended by their physician. For more details please refer http://www.aetna.com/cpb/medical/data/500_599/0516.html
Cigna reimbursement for Screening Colonoscopy: http://www.cignagovernmentservices.com/partb/pubs/mb/2001/01_3/forall/b0103b06b.html
Humana reimbursement for Screening Colonoscopy: http://apps.humana.com/tad/tad_new/Search.aspx?criteria=G0121&searchtype=freetext
Tricare Coverage and reimbursement for Colonoscopyhttp://www.tricare.mil/survey/hcsurvey/issue-briefs/issuebriefFY06Q2.pdf
http://www.tricare.mil/contracting/healthcare/t3manuals/change2/tp08/C7S2_2.PDF
http://www.medtronsoftware.com/pdf/091709_Tricare%20_Providers-MC_Part_B_Covered_Preventive_Services.pdf
What is Virtual Colonoscopy?
Virtual colonoscopy is also known as Computed Tomographic Colonography (CTC) is a minimally invasive imaging examination of the colon and rectum. CTC uses CT acquired images and advanced 2-dimensional (2D) and 3-dimensional (3D) image display techniques for interpretation. These images are interpreted by a radiologist to determine the presence of several types of abnormalities of the colon. CMS assigned CPT 0066T to report Computed Tomographic Colonography (virtual colonoscopy) screening (investigational) and CPT 0067T to report Computed Tomographic Colonography (virtual colonoscopy) diagnostic.
Important links
CMS Medicare learning Network: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0746.pdf
American Gastroenterology Association: http://www.gastro.org/user-assets/Documents/03_Practice_Management/Colonoscopy_Bundling_Statement.pdf
Centers for Disease Control and Prevention: http://www.cdc.gov/cancer/colorectal/
Aetna Reimbursement for Chiropractic Services
Aetna considers chiropractic services medically necessary when all of the following criteria are met:
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is documented within the initial 2 weeks of chiropractic care.
If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.
Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary.
Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.
Chiropractic care in persons, whose condition is neither regressing nor improving, is considered not medically necessary.
Manipulation is considered experimental and investigational when it is rendered for non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder, dysmenorrhea, and epilepsy; not an all inclusive list) because its effectiveness for these indications is unproven.
Manipulation of infants is considered experimental and investigational for non-neuromusculoskeletal indications.
Chiropractic manipulation has no proven value for treatment of idiopathic scoliosis or for treatment of scoliosis beyond early adolescence, unless the member is exhibiting pain or spasm, or some other medically necessary indications for chiropractic manipulation are present.
Reference: http://www.aetna.com/cpb/medical/data/100_199/0107.html
Please note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Also check the list of all CPT / HCPCS codes to report Chiropractic services
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is documented within the initial 2 weeks of chiropractic care.
If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.
Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary.
Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.
Chiropractic care in persons, whose condition is neither regressing nor improving, is considered not medically necessary.
Manipulation is considered experimental and investigational when it is rendered for non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder, dysmenorrhea, and epilepsy; not an all inclusive list) because its effectiveness for these indications is unproven.
Manipulation of infants is considered experimental and investigational for non-neuromusculoskeletal indications.
Chiropractic manipulation has no proven value for treatment of idiopathic scoliosis or for treatment of scoliosis beyond early adolescence, unless the member is exhibiting pain or spasm, or some other medically necessary indications for chiropractic manipulation are present.
Reference: http://www.aetna.com/cpb/medical/data/100_199/0107.html
Please note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Also check the list of all CPT / HCPCS codes to report Chiropractic services
Thursday, December 8, 2011
Medicare Telehealth Services Expanded for 2012
Better bone up on your telehealth services coding. Physicians and their patients are embracing web-based health solutions at a rapid rate, according to CNBC.com. In keeping with the times, Medicare will cover smoking cessation services in 2012, including those furnished remotely.
The Centers for Medicare & Medicaid Services (CMS) is adding four codes for smoking cessation to the list of distant site telehealth services covered under Medicare Part B, effective Jan. 1, 2012, and adding policy instructions to its manuals. The CPT® and HCPCS Level II codes are:
CMS also is allowing initial inpatient telehealth consultation codes G0425-G0427 to be billed when the place of service is in the emergency department. Note the descriptor changes (emphasized):
These codes should be submitted with modifier GQ Via asynchronous telecommunications systems or GT Via interactive audio and video telecommunications systems to identify the telehealth technology used to provide the service.
Source: CMS Transmittal 2354, CR 7504, issued Nov. 18.
The Centers for Medicare & Medicaid Services (CMS) is adding four codes for smoking cessation to the list of distant site telehealth services covered under Medicare Part B, effective Jan. 1, 2012, and adding policy instructions to its manuals. The CPT® and HCPCS Level II codes are:
| 99406 | Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes |
| 99407 | Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes |
| G0436 | Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes |
| G0437 | Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 10 minutes |
| G0425 | Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth |
| G0426 | Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth |
| G0427 | Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth |
Source: CMS Transmittal 2354, CR 7504, issued Nov. 18.
HHS Releases Seed $ for Quality Innovations
The U.S. Department of Health & Human Services (HHS) is awarding up to $1 billion to innovative projects across the country testing creative ways to deliver high quality medical care and save money. The Health Care Innovation Challenge will also give preference to projects that rapidly hire, train, and deploy health care workers.
Funded by the Affordable Care Act, the Health Care Innovation Challenge will award grants in March to applicants who will implement the most compelling new ideas to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (particularly those with the highest health care needs). Projects that can begin within six months and focus on rapid workforce development will be given priority when grants are awarded, HHS says.
Awards will be expected to range from approximately $1 million to $30 million over three years. Applications are open to providers, payers, local government, community-based organizations, and particularly to public-private partnerships and multi-payer approaches. Each grantee project will be evaluated and monitored for measurable improvements in quality of care and savings generated.
For more information, including a fact sheet and the Funding Opportunity Announcement, please see the Health Care Innovation Challenge initiative website.
Funded by the Affordable Care Act, the Health Care Innovation Challenge will award grants in March to applicants who will implement the most compelling new ideas to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (particularly those with the highest health care needs). Projects that can begin within six months and focus on rapid workforce development will be given priority when grants are awarded, HHS says.
Awards will be expected to range from approximately $1 million to $30 million over three years. Applications are open to providers, payers, local government, community-based organizations, and particularly to public-private partnerships and multi-payer approaches. Each grantee project will be evaluated and monitored for measurable improvements in quality of care and savings generated.
For more information, including a fact sheet and the Funding Opportunity Announcement, please see the Health Care Innovation Challenge initiative website.
PECOS
Announcement from CMS:
All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.New Screening Criteria
In the continued effort to reduce fraud, waste, and abuse, CMS implemented new screening criteria to the Medicare provider/supplier enrollment process beginning in March 2011. Newly-enrolling and revalidating providers and suppliers are placed in one of three screening categories limited, moderate, or high each representing the level of risk to the Medicare program for the particular category of provider/supplier, and determining the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application.Notices Will Be Sent to Providers/Suppliers
Between now and March 2013, MACs will be sending notices to individual providers/suppliers; please begin the revalidation process as soon as you hear from your MAC. Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. The easiest and quickest way to revalidate your enrollment information is by using Internet-based PECOS (Provider Enrollment, Chain, and Ownership System), at https://pecos.CMS.hhs.gov.Fees Levied
Section 6401a of the Affordable Care Act requires institutional providers and suppliers to pay an application fee when enrolling or revalidating (institutional provider includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A; CMS-855B, not including physician and non-physician practitioner organizations; CMS-855S; or associated Internet-based PECOS enrollment applications); these fees may be paid via www.Pay.gov.In order to reduce the burden on the provider, CMS is working to develop innovative technologies and streamlined enrollment processes including Internet-based PECOS. Updates will continue to be shared with the provider community as these efforts progress.
For more information about provider revalidation, review the Medicare Learning Networks Special Edition Article #SE1126, titled Further Details on the Revalidation of Provider Enrollment Information.
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