NDC to HCPCS Crosswalk List of codes

June 5, 2016, 2:43 am

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A critical component to filing claims with a NDC Code is to ensure that the appropriate HCPCS/CPT code is billed with the NDC Code. A NDC to HCPCS crosswalk identifies the assigned HCPCS/CPT code(s) for the NDC code associated to the drug service(s) billed based upon the information submitted and reported by the manufacture To ensure accurate appropriate billing of drug services, we use the crosswalk to determine whether the appropriate HCPCS/CPT code is billed for the submitted NDC code. All drug services must bill the assigned HCPCS/CPT code(s) associated to the drug’s NDC that was supplied/ administered based upon the drug form as supplied by the manufacture. In the instance a bulk powder is compounded, the NDC code applicable for the drug that was supplied by the manufacture as a bulk powder must be submitted; therefore, the HCPCS/CPT code billed must be applicable for the bulk powder and not associated to the form the drug was compounded into (i.e. pellet, injectable, tablet, etc.).

Below identifies multiple NDC to HCPCS Crosswalk examples:

HCPCS Drug Code      HCPCS Description    NDC Code    NDC Description(Brand Name)

 J2270     Injection, morphine sulfate, up to 10mg    00548-3391-10     Morphine Sulfate 1MG/ML SOLN

J3490       Unclassified drugs    51927-1000-00     Morphine Sulfate POWD

J3490       Unclassified drugs      54569-3260-00     Marcaine 0.25% SOLN

J1030   Injection, Methylprednisolone Acetate, 40 mg   00009-0280-03  Depo-Medrol 40 MG/ML SUSP

J1040    Injection, Methylprednisolone Acetate, 80 mg  00009-3475-03     Depo-Medrol 80 MG/ML SUSP

J0897   Injection, denosumab, 1 mg      55513-0710-01    Prolia 60 MG/ML SOLN

J0897     Injection, denosumab, 1 mg      55513-0730-01     Xgeva 120 MG/1.7ML SOLN

J2270     Injection, morphine sulfate, up to 10mg       00548-3391-10    Morphine Sulfate 1MG/ML SOLN

J3490       Unclassified drugs       51927-1000-00         Morphine Sulfate POWD

S0020     Injection, Bupivacaine Hydrochloride, 30 mL    54569-3260-00    Marcaine 0.25% SOLN

J3490    Unclassified drugs         54569-3260-00         Marcaine 0.25% SOLN

J1030     Injection, Methylprednisolone Acetate, 40 mg   00009-0280-03     Depo-Medrol 40 MG/ML SUSP

J1040    Injection, Methylprednisolone Acetate, 80 mg     00009-3475-03    Depo-Medrol 80 MG/ML SUSP

J0897     Injection, denosumab, 1 mg           55513-0710-01   Prolia 60 MG/ML SOLN

J0897      Injection, denosumab, 1 mg         55513-0730-01       Xgeva 120 MG/1.7ML SOLN

J7316     Injection, ocriplasmin, 0.125 mg      24856-0001-00        Jetrea 0.5MG/ 0.2ML SOLN

J3590      Unclassified biologics    24856-0001-00         Jetrea 0.5MG/ 0.2ML SOLN

J9999      Not otherwise classified, antineoplastic drugs     00085-1388-01     Sylatron 296 MCG KIT

J3490         Unclassified drugs      37803-0203-05         Baclofen POWD


*NOTE – Submitting a claim with a HCPCS/CPT code that does not align with the billed NDC code may result in a denial of payment.

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Reporting NDC code for Unclassified drugs

June 8, 2016, 2:47 am

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Unclassified Drugs

An unclassified drug is defined as a drug that does not have a specific, designated HCPCS/CPT code. Unclassified HCPCS/CPT codes should only be used when a specific HCPCS/CPT code is not available for the drug being billed. Claims being sumitted with an unspecified HCPCS/CPT code when there is a designated HCPCS/CPT code for that drug will result in a denial of payment.
The following guidelines are for providers who submit unclassifed drug codes on the CMS-1500 claim form or its electronic equivalent:
Apply the appropriate unclassified drug HCPCS/CPT (e.g. J3490, J3590, J9999, etc) that is aligned with the billed NDC Code. The following identifies the list of unclassified drug HCPCS/CPT codes:

• 90399 – Unlisted Immune Globulin

• 90749 – Unlisted Vaccine/Toxoid

• A9699 – Radiopharmaceutical, Therapeutic, Not Otherwise Classified

• D9630 – Other Drugs and/or Medicaments, by report

• J1599 – Injection, Immune Globulin, Intravenous, Nonlyophilized (e.g., liquid), Not Otherwise Specified, 500 mg

• J3490 – Unclassified Drugs

• J3590 – Unclassified Biologics

• J7199 – Hemophilia Clotting Factor, Not Otherwise Classified

• J7599 - Immunosuppressive Drug, Not Otherwise Classified

• J7699 – NOC Drugs, Inhalation Solution Administered Through DME

• J7799 - NOC Drugs, Other Than Inhalation Drugs, Administered Through DME

• J8498 – Antimetic Drug, Rectal/Suppository, Not Otherwise Specified

• J8499 – Prescription Drug, Oral, Nonchemotherapeutic, NOS

• J8597 – Antiemetic Drug, Oral, Not Otherwise Specified

• J8999 – Prescription Drug, Oral, Chemotherapeutic, NOS

• J9999 - Not Otherwise Classified, Antineoplastic Drugs

• Q0181 - Unspecified oral dosage form, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment, not to exceed a 48-hour dosage regimen

• Q2039 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

• Q4082 - Drug or biological, not otherwise classified, Part B drug Competitive Acquisition Program (CAP)

• S5000 – Prescription Drug, Generic

• S5001 – Prescription Drug, Brand

• Q9977- Compounded Drug, Not Otherwise Classsified


The following are examples:

Unclassified Drug HCPCS    Unclassified HCPCS Description    NDC Code      NDC Description


J9999      Not otherwise classified, antineoplastic drugs   00085-1388-01   Sylatron 296MCG KIT

J3490           Unclassified drugs            38779-1756-00     FentaNYL Citrate POWD

J3590            Unclassified biologics       66658-0234-28      Kineret 100MG/0.67ML SOLN

J8499       Prescription drug, oral, non-chemotherapeutic, Not otherwise Specified   51655-0113-25         Benadryl 25MG CAPS

J8999       Prescription drug, oral, chemotherapeutic, Not otherwise Specified         59572-0410-00         Revlimid 10MG Caps

J7599      Immunosuppressive drug, not otherwise classified   00004-0298-09   CellCept Intravenous

J7699       NOC drugs, inhalation solution administered through DME.      00487-9301-33    Sodium Chloride 0.9% NEBU

A9699      Radiopharmaceutical, therapeutic, not otherwise classified       50419-0208-01    Xofigo 27 MCCI/ML SOLN

Drug invoice example and reporting NDC code based on invoice

June 10, 2016, 2:56 am

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Surgical Implanted Pain Medication Pumps (SIPMP) Compound Drug Billing Guidelines

The following billing guidelines must be followed when submitting claims for SIPMP compounded drug(s) refills in order to prevent the services from denying or being underpaid.

 • All services related to the SIPMP refill, programming, drug(s), and compounding must be submitted on the same claim for each date of service in order to be services from being denied or prevent a delay in payment.

 •Each compounded drug(s) used for the SIPMP refill must be submitted on a separate line of the claim with the 11-digit NDC Code assigned to each of the drug(s) used in the SIPMP refill.

• The accurate NDC quantity (with the amount converted based upon the NDC assigned unit of measure) must be submitted in the metric decimal quantity (up to 2 decimal spaces – i.e. 0.01)

• When the NDC quantity is converted and the metric decimal quantity is less than 2 decimal places, the NDC quantity must be rounded up to 0.01. (i.e. 0.007, 0.0012, 0.0004, etc)

• All compounded powder NDC codes are assigned a GR (Gram) unit of measurement, so the NDC quantity submitted must be for quantity amount based upon GR (Gram) unit of measure rounded up to 2 decimal quantities.

• If applicable, Florida Blue will allow a single ‘compounding fee’ up to $70.00 when submitted and billed appropriately. The compounding fee is reimbursing for any fees and/or supplies charges by the compounding pharmacy.

 • In order to be considered for payment of the compounding fee, the following instructions must be used when submitting the claim: • A separate line must be billed using the following data elements:

• HCPCS code = J3490

• NDC code = 00000000070

 • NDC quantity = 1

• HCPCS quantity = 1

The following is an example to provide guidance with submitting an electronic and paper claim:


• The following identifies the information that may be referenced on the invoice received from the compounding pharmacy identifying the drug and amounts used for the patient that came into the office 04/17/2014 to have their SIPMP programmed and refilled:

**Invoice Example #1

EMC loop segment for NDC qualifier, NDC CODE, AND NDC quantity

June 13, 2016, 3:05 am

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Field Name Field Description Loop ID Segment


HCPCS/CPT Procedure Code Enter the appropriate HCPCS/CPT Code aligned with the NDC Code billed, if applicable. 2400 SV101


HCPCS/CPT Units
Enter the applicable units billed based upon the HCPCS/CPT code assigned dosage/quantity. The HCPCS/CPT unit must be submitted with a whole numeric value. (Unlisted Drug HCPCS/CPT codes do not have a specified quantity associated to the Unlisted HCPCS/CPT code. The HCPCS/CPT units billed should equal the number of drug containers (i.e. vial, bottle, tube) used for the services being billed.) **A HCPCS/CPT unit of 1 or greater must be billed on all claims**
2400
SV104

NDC Qualifier
Enter N4 in this field.
2410
L1N02


National Drug Code (NDC)
Enter the 11-digit NDC assigned to the drug administered/supplied (do not include hyphens/spaces). 11-digit NDC Code is required using 5-4-2 format.
2410
L1N03


Monetary Amount
Enter the Total Charge Amount for each line of service
2400
SV102


NDC Quantity
Enter the NDC quantity in decimal format (up to two decimal places) based upon the reported unit of measure assigned to the NDC Code. (NDC units billed must be converted based upon unit of measure assigned to NDC Code)


**NOTE – NDC Quantity should never be billed with a MG (ME) - milligram dosage being reported within the NDC quantity • MG is not a valid unit of measure for any NDC codes. • Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.
2410
CTP04
54

Unit of Measurement (UoM)
Enter the NDC unit of measurement associated to the billed NDC Code (UN, ML, or GR) • The NDC Quantity 4 units of measurement (UoM) reported for all drugs: UN, ML, GR, or F2. • There are no products currently reported with the unit of measure of F2 (international unit) • Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.
2410
CTP05

Inpatient Rehabilitation Facility Billing Requirements

June 15, 2016, 3:08 am

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• Indicate “11X” or “12X” type of bill

• First digit – type of facility ( 1-Hospital)

• Second digit – bill classification (1-Inpatient Hospital, including Medicare Part A or 2-Inpatient Hospital for Medicare Part B)

• Third digit – frequency (e.g., admit through discharge claim)

• Refer to contractual reimbursement terms to determine if billing is based on rehabilitation room and board revenue codes or HIPPS Case Mix Group codes. Typically only Medicare Advantage contracts are negotiated based on the inpatient prospective payment system. (Note: HIPPS Case Mix Group code must be billed with revenue code 024).

• Room and board revenue code should be one of the following: 118, 128, 138, 148 or 158

• Submit actual number of days the member was in the facility. Day of discharge or death is not considered a covered day, unless admitted and discharged/deceased on the same day.

• Individual therapist providing occupational, physical and/or speech therapy may not bill separately for services provided in the facility.
Note: All charges for physician services should be billed separately on the CMS-1500 claim form.

To be eligible for admission to a Medicare-certified rehabilitation hospital or unit, members must require intensive rehabilitation services. The general threshold for establishing the need for inpatient hospital rehabilitation services is that the member must require and receive at least 3 hours of occupational and/or physical therapy per day. The therapy must be provided as treatment for one or more of the following conditions: amputation, brain injury, burns, congenital deformity, joint replacement, neurological disorders (including multiple sclerosis, motor neuron diseases, muscular dystrophy, polyneuropathy and Parkinson's disease),  steoarthritis/hip, Polyarthritis (including rheumatoid arthritis), spinal cord injury, stroke, systemic vasculitis, and trauma (major or multiple).



Rehabilitation Facilities

Rehabilitation facilities are contracted to provide occupational, physical, and speech therapy.

• OT – Occupational therapists evaluate and treat problems interfering with functional performance. Targeted areas may include motor control/coordination, sensory motor skills, cognition, and visual perceptual skills.

• PT – Physical therapists evaluate and treat components of movement, which include range of motion, muscle strength, muscle tone, endurance, posture, balance and coordination, and mobility.

• RT – Respiratory therapists assess, evaluate, treat, manage and care for patients with respiratory problems (e.g., asthma or emphysema). Clinical tasks are diagnostic and therapeutic to include administration of medical gases (i.e., oxygen, helium, and carbon dioxide), aerosol and humidity therapy, intermittent positive-pressure breathing therapy, incentive spirometry, artificial mechanical ventilation, arterial blood gas analysis, and pulmonary function testing. Respiratory therapists work under the supervision of physicians to administer prescribed respiratory therapy to patients with chronic illnesses. Outpatient services are only covered when provided in the comprehensive outpatient rehabilitation facility.

• ST – Speech-language pathologists evaluate and treat conditions relating to speech including: motor speech and voice disorders; expressive and receptive language disorders; articulation fluency; attention, memory, problem solving, and other cognitive deficits.

Note: Inpatient Rehabilitation Facilities are also contracted to provide medical and nursing services.

Outpatient Rehabilitation Facilities Billing Requirements

June 18, 2016, 3:22 am

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• Multiple dates of service should not be grouped on one line.

• Indicate “74X” or “75X”’ type of bill, which is field 4 on paper claims

o First digit – Type of facility (7)

o Second digit – bill classification (4 for outpatient rehabilitation facility or 5 for comprehensive outpatient rehabilitation facility)

o Third digit – frequency (e.g., admit thru discharge claim)

• The individual therapist providing occupational, physical, and/or speech therapy may not bill separately for services provided in the facility. The facility should bill these services using the appropriate CPT codes.


PSA Facility Transfer

The Psychiatric and Substance Abuse PSA facility must agree to transfer a member requiring acute care medical or surgical services, in a non-emergency situation, to the nearest participating provider that can furnish covered services.

• Do not bill the member for services that are deemed by Florida Blue as not medically necessary. The facility may bill the member for non-covered services per the member benefits.

• When two or more diagnoses are made for the same case, the primary diagnosis for billing purposes will be the diagnosis that precipitated the admission. The facility must bill the primary diagnosis as substance abuse unless a psychiatric condition is clearly the reason for admission, and can be substantiated by treatment plans, medical records, and psychological evaluations. Bill 23-hour observations as an inpatient service with a “111” type of bill, as well as separate admits and discharge dates.

CPT CODE G0839 and who is covered benefit

June 22, 2016, 2:50 am

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Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)


HCPCS/CPT Codes
G0389 – Ultrasound exam for AAA screening


ICD-10-CM Codes
See https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual Change Requests (CRs) and coding translations for ICD-10


Who Is Covered

Medicare beneficiaries:
• With certain risk factors for AAA; and
• Who receive a referral from their physician, physician assistant, nurse
practitioner, or clinical nurse specialist


Frequency
Once in a lifetime


Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

What is Modifiers - For Beginners

June 25, 2016, 12:30 am

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Modifiers

A modifier provides a physician with the means to indicate that a service/procedure is altered by some specific circumstance, but not changed in its definition or code. By modifying the meaning of a service, modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions can be found in the most current CPT and HCPCS coding books.

When multiple modifiers are necessary for a single claim line, modifiers should be submitted in the order that they affect payment.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation.

Modifiers may be used to indicate that:

• A service or procedure has both a professional and technical component

• A service or procedure was performed by more than one physician and/or in more than one location

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual events occurred


Procedure Modifier and Diagnosis Codes

A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. Inclusion of a complete and accurate list of diagnosis codes associated with the patient at the time of the encounter, including chronic conditions not necessarily treated at the time of the encounter, is part of correctly coding an encounter. It ensures that we can best match patients with appropriate care and disease management programs and members are properly classified by risk programs. We encourage you to purchase current copies of CPT, HCPCS, and ICD 10 CM code books.

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Documentation is required when billing modifier 24

June 28, 2016, 7:30 am

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Based on widespread probes of office evaluation and management (E/M) services, First Coast has discovered that the 24 modifier for E/M services, when billing within a global surgery period, has been billed incorrectly at least 60 percent of the time. Clinical review of documentation demonstrates that modifier 24 was either not supported for the encounter, or was improperly applied (i.e., a different modifier should have been submitted).

To address this widespread improper billing, First Coast implemented a pre-payment edit on April 16, 2012, applicable to office visit E/M claims (codes 99201-99205 and 99212-99215) billed with the 24 modifier.

Claims
For claims containing modifier 24 received on or after April 16, 2012, began developing to the provider to provide supporting documentation that justifies the use of the 24 modifier. Providers must respond within the specified timeframe included in the development letter. Failure to submit the documentation timely may result in a claim denial.

Reopenings
Also effective April 16, 2012, no longer accepts:
• Telephone requests via the interactive voice response or a customer service representative to add or change the 24 modifier on a previously denied claim.
• Written or fax requests (processed on or after April 16) to add or change the 24 modifier without supporting documentation. The provider will be sent a written notification that their request could not be completed.

Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “-24,” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.

How to use modifiers to indicate the status of an ABN
If a provider or supplier expects that the service or item furnished to the beneficiary may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the beneficiary of his or her financial liability, appeal rights, and protections under the fee-for-service (FFS) Medicare program.

Providers and suppliers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the beneficiary.

Modifier criteria:

• Modifier GZ -- must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed by the beneficiary.

Note: Effective July 1, 2011, all claims line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.

• Modifier GA -- must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file.

Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifier GA or modifier GZ.

E/M Service: Global Surgery Denials

June 29, 2016, 10:54 pm

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Denial Reason, Reason/Remark Code(s)
•CO-97 - Global Surgery Denials: Services submitted for the same patient by the same doctor on the same day as or within the post-op period of a major/minor procedure are bundled into the global surgery package and are not paid separately

Resources 
•Before you submit a claim for post-surgical E/M services, verify the post-operative period by checking the surgery date and number of follow-up days associated with the surgical procedure
•Refer to CPT modifiers 24 and 25
•Access complete instructions for documenting and submitting CPT modifier 24 and 25 on the Palmetto GBA Modifier Lookup Web page, which you can find in the Self Service Tools of our home page

Additional Modifiers May Apply

When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.
To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB). Access the database directly from the CMS website.

•CPT modifier 24:
oThis modifier may be used to indicate that an evaluation and management (E/M) service or eye exam, which falls within the global period of a major or minor surgery and which is performed by the surgeon, is unrelated to the surgery
oThis modifier may only be submitted with E/M and eye exam codes
oDiagnosis is clearly unrelated to the surgery; supporting documentation is not required with the claim
oDiagnosis may be related to the surgery or it is unclear whether the diagnosis is unrelated to the surgery: supporting documentation must be submitted with the claim. For electronic claims, submit supporting documentation in the documentation field. The documentation must substantiate that the service is unrelated to the surgery and may include the primary ICD-9 code that reflects the reason for the E/M service.
oSpecial note for ophthalmologists: If the exam and prior surgery were performed on different eyes, indicate this information clearly in the electronic documentation field. HCPCS modifiers RT and LT may not be submitted with eye exam codes.
•CPT modifier 25:
oThis modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery. Documentation in the patient's medical record must support the use of this modifier.
oThis modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 through 99285, 99321 through 99323, and 99341 through 99345
oNo supporting documentation is required with the claim when this modifier is submitted
oThis modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under Correct Coding Initiative (CCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.
oBefore submitting this modifier, verify whether the services are bundled through CCI. CCI edits may be updated as often as quarterly. Access the CMS website for the National Correct Coding Initiative.
oCode pairs identified with indicator '0' in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator '0' codes.
oCode pairs identified with indicator '1' may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 25 is submitted.
oCode pairs identified with indicator '9' are not subject to CCI edits. No modifier is required in these situations.

Was the E/M service performed by the same physician within the global period of a surgery? 
•Is the E/M service unrelated to the surgery? If yes, see CPT modifier 24.
•Is the E/M service related to the surgery? If the E/M service is related to the surgery and is performed within the global period, the E/M service is not separately payable.

Was the E/M service performed by the same physician on the same day as a minor surgical procedure? 
See CPT modifier 25 if the E/M service is significant and separately identifiable from the surgery (above and beyond the other service provided, or beyond the usual pre/post op care for the other procedure). If the E/M service is not over and above the usual preoperative and postoperative care associated with the surgery, the E/M service is not separately payable.

Did the E/M service result in a decision to perform major surgery (surgery with 90 follow-up days) that same day or the next day? 
•If yes, submit CPT modifier 57 with the E/M service

•If no, the E/M service may not be submitted separately

CPT CODE A9270 , REVENUE CODE 0637 - self administered drug codes

July 1, 2016, 11:06 pm

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How to bill non-covered self-administered drugs

The Centers for Medicare & Medicaid Services (CMS) provides instructions to contractors regarding Medicare payment for drugs and biologicals incident-to a physician’s service. The instructions also provide the contractor with a process for understanding if an injectable drug is “usually” self-administered (to mean a drug you would normally take on your own) and therefore not covered by Medicare.

• The term “usually” means that the drug is self-administered more than 50 percent of the time for all Medicare beneficiaries who use the drug, and are considered excluded from coverage.

Providers are not required to bill non-covered self-administered drugs, unless requested by the beneficiary or secondary insurance. If a line item denial is required that holds the beneficiary liable for the non-covered self-administered pharmacy services, the outpatient claim should be submitted as follows:

• Revenue code 0637
• HCPCS code that describes the services rendered; or,
• Use A9270 ( non-covered item or service) when there is no other appropriate code
• Modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit)

• Reason code 31324 will append to the line item when the GY modifier is present, and holds the beneficiary liable
• Reason code 31947 will apply to the line item when the GY modifier is not present, and holds the provider liable
• Advanced beneficiary notice (ABN) is not required
• Charges non-covered
• Do not submit the charges as covered


The outpatient code editor (OCE) status indicator is ‘E’ (non-covered) when revenue code 0637 is submitted without a HCPCS. In order to bypass the return to provider (RTP) reason code W7050 (non-covered based on statutory exclusion), the charges must be submitted as non-covered or as outlined above.

• Reason code 31947 will apply to the line item when the charges are submitted as non-covered without a HCPCS, and holds the provider liable

CPT code 43235, 43236, 43237, 43238, 43239 and covered DX

July 6, 2016, 7:36 am

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LCD for Diagnostic and Therapeutic Esophagogastroduodenoscopy (L29167)

Coding Information for CPT/HCPCS Codes



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.


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.

99999 Not Applicable

43235
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF
SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

43236
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY
SUBSTANCE

43237
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED
TO THE ESOPHAGUS

43238
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED
INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S),
ESOPHAGUS (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION
LIMITED TO THE ESOPHAGUS)

43239
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH BIOPSY, SINGLE OR MULTIPLE

43241
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR
CATHETER PLACEMENT


43243
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL AND/OR
GASTRIC VARICES

43244
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH BAND LIGATION OF ESOPHAGEAL AND/OR GASTRIC
VARICES


43245 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH DILATION OF GASTRIC OUTLET FOR OBSTRUCTION
(EG, BALLOON, GUIDE WIRE, BOUGIE)

43246
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH DIRECTED PLACEMENT OF PERCUTANEOUS
GASTROSTOMY TUBE

43247
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH REMOVAL OF FOREIGN BODY

43248
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILATION
OF ESOPHAGUS OVER GUIDE WIRE

43249
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH BALLOON DILATION OF ESOPHAGUS (LESS THAN 30
MM DIAMETER)

43250
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER
LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY

43251
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER
LESION(S) BY SNARE TECHNIQUE

43255
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD

43258
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,
STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS
APPROPRIATE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER
LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS,
BIPOLAR CAUTERY OR SNARE TECHNIQUE

ICD-9 Codes that Support Medical Necessity

040.2 WHIPPLE'S DISEASE
112.84 CANDIDAL ESOPHAGITIS
150.0 -
152.9 opens in
new window
MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS -
MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED
SITE
155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY
156.0 -
156.9 opens in
new window
MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT
NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE
157.0 -
157.9 opens in new window
MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT
NEOPLASM OF PANCREAS PART UNSPECIFIED
159.8 MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE
SYSTEM AND INTRA-ABDOMINAL ORGANS
176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES
197.4 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE
INCLUDING DUODENUM
197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM
AND PERITONEUM

198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED
SITES
202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
211.0 -
211.9 opens in
new window
BENIGN NEOPLASM OF ESOPHAGUS - BENIGN NEOPLASM OF
OTHER AND UNSPECIFIED SITE IN THE DIGESTIVE SYSTEM
214.3 LIPOMA OF INTRA-ABDOMINAL ORGANS
214.9 LIPOMA UNSPECIFIED SITE
215.9 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT
TISSUE SITE UNSPECIFIED
228.04 HEMANGIOMA OF INTRA-ABDOMINAL STRUCTURES
230.1 -
230.8 opens in
new window
CARCINOMA IN SITU OF ESOPHAGUS - CARCINOMA IN SITU OF
LIVER AND BILIARY SYSTEM
235.2 -
235.4 opens in
new window
NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH
INTESTINES AND RECTUM - NEOPLASM OF UNCERTAIN
BEHAVIOR OF RETROPERITONEUM AND PERITONEUM
239.0 NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM
251.5 ABNORMALITY OF SECRETION OF GASTRIN
261 NUTRITIONAL MARASMUS
263.0 -
263.9 opens in
new window
MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED
PROTEIN-CALORIE MALNUTRITION
280.0 -
280.9 opens in
new window
IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS
(CHRONIC) - IRON DEFICIENCY ANEMIA UNSPECIFIED
285.1 ACUTE POSTHEMORRHAGIC ANEMIA
300.11 CONVERSION DISORDER
306.4 GASTROINTESTINAL MALFUNCTION ARISING FROM MENTAL
FACTORS
307.1 ANOREXIA NERVOSA
307.50 EATING DISORDER UNSPECIFIED
307.51 BULIMIA NERVOSA
307.52 PICA
307.53 RUMINATION DISORDER
307.54 PSYCHOGENIC VOMITING
438.82 DYSPHAGIA CEREBROVASCULAR DISEASE
447.2 RUPTURE OF ARTERY
448.0 HEREDITARY HEMORRHAGIC TELANGIECTASIA
456.0 ESOPHAGEAL VARICES WITH BLEEDING
456.1 ESOPHAGEAL VARICES WITHOUT BLEEDING
456.20 -
456.21 opens in
new window
ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE
WITH BLEEDING - ESOPHAGEAL VARICES IN DISEASES
CLASSIFIED ELSEWHERE WITHOUT BLEEDING
507.0 PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS
530.0 -
530.89 opens in
new window
ACHALASIA AND CARDIOSPASM - OTHER DISEASES OF
ESOPHAGUS
531.00 -
531.91 opens in
new window
ACUTE GASTRIC ULCER WITH HEMORRHAGE WITHOUT
OBSTRUCTION - GASTRIC ULCER UNSPECIFIED AS ACUTE OR
CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH
OBSTRUCTION
532.00 -
532.91 opens in
new window
ACUTE DUODENAL ULCER WITH HEMORRHAGE WITHOUT
OBSTRUCTION - DUODENAL ULCER UNSPECIFIED AS ACUTE OR
CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH
OBSTRUCTION
533.00 -
533.91 opens in
new window
ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH
HEMORRHAGE WITHOUT OBSTRUCTION - PEPTIC ULCER OF
UNSPECIFIED SITE UNSPECIFIED AS ACUTE OR CHRONIC
WITHOUT HEMORRHAGE OR PERFORATION WITH
OBSTRUCTION
534.00 -
534.91 opens in
new window
ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE WITHOUT
OBSTRUCTION - GASTROJEJUNAL ULCER UNSPECIFIED AS
ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR
PERFORATION WITH OBSTRUCTION
535.00 -
535.71 opens in
new window
ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - EOSINOPHILIC
GASTRITIS, WITH HEMORRHAGE
536.1 ACUTE DILATATION OF STOMACH
536.2 PERSISTENT VOMITING
536.3 GASTROPARESIS
536.40 -
536.49 opens in
new window
GASTROSTOMY COMPLICATION UNSPECIFIED - OTHER
GASTROSTOMY COMPLICATIONS
536.8 DYSPEPSIA AND OTHER SPECIFIED DISORDERS OF FUNCTION
OF STOMACH
537.0 -
537.89 opens in
new window
ACQUIRED HYPERTROPHIC PYLORIC STENOSIS - OTHER
SPECIFIED DISORDERS OF STOMACH AND DUODENUM
538 GASTROINTESTINAL MUCOSITIS (ULCERATIVE)
551.3 DIAPHRAGMATIC HERNIA WITH GANGRENE
552.3 -
552.8 opens in
new window
DIAPHRAGMATIC HERNIA WITH OBSTRUCTION - HERNIA OF
OTHER SPECIFIED SITES WITH OBSTRUCTION
553.3 DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR
GANGRENE
555.0 -
555.9 opens in
new window
REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL
ENTERITIS OF UNSPECIFIED SITE
560.9 UNSPECIFIED INTESTINAL OBSTRUCTION
562.01 DIVERTICULITIS OF SMALL INTESTINE (WITHOUT
HEMORRHAGE)
562.02 DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE
562.03 DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE
569.62 MECHANICAL COMPLICATION OF COLOSTOMY AND
ENTEROSTOMY
569.71 -
569.79 opens in
new window
POUCHITIS - OTHER COMPLICATIONS OF INTESTINAL POUCH
569.82 ULCERATION OF INTESTINE
569.87 VOMITING OF FECAL MATTER
571.1 ACUTE ALCOHOLIC HEPATITIS
571.2 ALCOHOLIC CIRRHOSIS OF LIVER
571.3 ALCOHOLIC LIVER DAMAGE UNSPECIFIED
571.40 CHRONIC HEPATITIS UNSPECIFIED
571.41 CHRONIC PERSISTENT HEPATITIS
571.42 AUTOIMMUNE HEPATITIS
571.49 OTHER CHRONIC HEPATITIS
571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL
571.6 BILIARY CIRRHOSIS
572.3 PORTAL HYPERTENSION
574.00 -
574.01 opens in
new window
CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS
WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER WITH
ACUTE CHOLECYSTITIS WITH OBSTRUCTION
574.10 -
574.11 opens in
new window
CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS
WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER WITH
OTHER CHOLECYSTITIS WITH OBSTRUCTION
574.20 -
574.21 opens in
new window
CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS
WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER
WITHOUT CHOLECYSTITIS WITH OBSTRUCTION
574.30 -
574.31 opens in
new window
CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS
WITHOUT OBSTRUCTION - CALCULUS OF BILE DUCT WITH
ACUTE CHOLECYSTITIS WITH OBSTRUCTION
574.40 -
574.41 opens in
new window
CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS
WITHOUT OBSTRUCTION - CALCULUS OF BILE DUCT WITH
OTHER CHOLECYSTITIS WITH OBSTRUCTION
575.0 ACUTE CHOLECYSTITIS
575.5 FISTULA OF GALLBLADDER
576.0 POSTCHOLECYSTECTOMY SYNDROME
576.4 FISTULA OF BILE DUCT
577.0 ACUTE PANCREATITIS
577.1 CHRONIC PANCREATITIS
577.2 CYST AND PSEUDOCYST OF PANCREAS
578.0 -
578.9 opens in
new window
HEMATEMESIS - HEMORRHAGE OF GASTROINTESTINAL TRACT
UNSPECIFIED
579.0 -
579.9 opens in
new window
CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION
694.0 DERMATITIS HERPETIFORMIS
710.1 SYSTEMIC SCLEROSIS
747.61 GASTROINTESTINAL VESSEL ANOMALY
750.3 CONGENITAL TRACHEOESOPHAGEAL FISTULA ESOPHAGEAL
ATRESIA AND STENOSIS
750.4 OTHER SPECIFIED CONGENITAL ANOMALIES OF ESOPHAGUS
750.5 CONGENITAL HYPERTROPHIC PYLORIC STENOSIS
750.6 CONGENITAL HIATUS HERNIA
750.7 OTHER SPECIFIED CONGENITAL ANOMALIES OF STOMACH
783.0 ANOREXIA
783.21 -
783.3 opens in
new window
LOSS OF WEIGHT - FEEDING DIFFICULTIES AND
MISMANAGEMENT
784.42 DYSPHONIA
784.43 HYPERNASALITY
784.44 HYPONASALITY
784.49 OTHER VOICE AND RESONANCE DISORDERS
784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
784.91 -
784.99 opens in
new window
POSTNASAL DRIP - OTHER SYMPTOMS INVOLVING HEAD AND
NECK
786.2 COUGH
786.50 -
786.59 opens in
new window
UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN
786.6 SWELLING MASS OR LUMP IN CHEST
787.01 -
787.91 opens in
new window
NAUSEA WITH VOMITING - DIARRHEA
789.00 -
789.09 opens in
new window
ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER
SPECIFIED SITE
789.30 -
789.39 opens in
new window
ABDOMINAL OR PELVIC SWELLING MASS OR LUMP
UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS
OR LUMP OTHER SPECIFIED SITE
789.51 -
789.59 opens in
new window
MALIGNANT ASCITES - OTHER ASCITES
789.60 -
789.69 opens in
new window
ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL
TENDERNESS OTHER SPECIFIED SITE
790.5 OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS
790.99 OTHER ABNORMAL FINDINGS ON EXAMINATION OF BLOOD
792.1 NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS
793.4 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND
OTHER EXAMINATION OF GASTROINTESTINAL TRACT
793.6
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND
OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING
RETROPERITONEUM
799.4 CACHEXIA
862.22 INJURY TO ESOPHAGUS WITHOUT OPEN WOUND INTO CAVITY
874.4 -
874.5 opens in
new window
OPEN WOUND OF PHARYNX WITHOUT COMPLICATION - OPEN
WOUND OF PHARYNX COMPLICATED
935.1 -
935.2 opens in
new window
FOREIGN BODY IN ESOPHAGUS - FOREIGN BODY IN STOMACH
936 FOREIGN BODY IN INTESTINE AND COLON
938 FOREIGN BODY IN DIGESTIVE SYSTEM UNSPECIFIED
947.0 BURN OF MOUTH AND PHARYNX
947.2 -
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
* According to the ICD-9-CM book, diagnosis codes E864.1, E864.2, E864.3, E864.4 and E961 are secondary diagnosis codes and should not be billed as the primary diagnosis.
947.3 opens in
new window BURN OF ESOPHAGUS - BURN OF GASTROINTESTINAL TRACT
959.01 -
959.09 opens in
new window
OTHER AND UNSPECIFIED INJURY TO HEAD - OTHER AND
UNSPECIFIED INJURY TO FACE AND NECK
983.2 -
983.9 opens in
new window
TOXIC EFFECT OF CAUSTIC ALKALIS - TOXIC EFFECT OF
CAUSTIC UNSPECIFIED
990 EFFECTS OF RADIATION UNSPECIFIED
996.82 COMPLICATIONS OF TRANSPLANTED LIVER
997.4 DIGESTIVE SYSTEM COMPLICATIONS NOT ELSEWHERE
CLASSIFIED
E864.1* ACCIDENTAL POISONING BY ACIDS NOT ELSEWHERE
CLASSIFIED
E864.2* ACCIDENTAL POISONING BY CAUSTIC ALKALIS NOT
ELSEWHERE CLASSIFIED
E864.3* ACCIDENTAL POISONING BY OTHER SPECIFIED CORROSIVES
AND CAUSTICS NOT ELSEWHERE CLASSIFIED
E864.4* ACCIDENTAL POISONING BY UNSPECIFIED CORROSIVES AND
CAUSTICS NOT ELSEWHERE CLASSIFIED
E961* ASSAULT BY CORROSIVE OR CAUSTIC SUBSTANCE EXCEPT
POISONING
V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF
UNSPECIFIED SITE IN GASTROINTESTINAL TRACT
V10.03 -
V10.04 opens in
new window
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF
ESOPHAGUS - PERSONAL HISTORY OF MALIGNANT NEOPLASM
OF STOMACH
V10.09 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER
SITES IN GASTROINTESTINAL TRACT
V12.71 PERSONAL HISTORY OF PEPTIC ULCER DISEASE
V12.72 PERSONAL HISTORY OF COLONIC POLYPS
V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM
DISEASES
V18.51 -
V18.59 opens in
new window
FAMILY HISTORY, COLONIC POLYPS - FAMILY HISTORY, OTHER
DIGESTIVE DISORDERS
V55.1 ATTENTION TO GASTROSTOMY
V58.61 LONG-TERM (CURRENT) USE OF ANTICOAGULANTS
V58.64 LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTIINFLAMMATORIES
V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V69.1 INAPPROPRIATE DIET AND EATING HABITS
N/A
XX000 Not Applicable

Diagnoses that DO NOT Support Medical Necessity
N/A
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CRNA services modifiers

July 6, 2016, 10:58 pm

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CRNA Services


AA
Anesthesia services personally performed by an anesthesiologist. The -AA modifier is used for all basic procedures.

P1
Normal healthy patient.

P2
Patient with mild systemic disease.

P3
Patient with severe systemic disease.

P4
Patient with severe systemic disease that is a constant threat to life.

P5
Moribund patient who is not expected to survive without the operation.

QS
Monitored anesthesia care service (can be billed by CRNA or a physician). This modifier for monitored anesthesia care (QS) is for informational purposes. Please report actual monitoring time on the claim form. This modifier must be billed with another modifier to show that the service was personally performed or medically directed.

QX
CRNA service; with medical direction by a physician.

QZ
CRNA service; without medical direction by a physician.

Where to use Modifier 77

July 9, 2016, 7:32 am

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Modifier 77

Key Points/Instruction/What you need to know

Modifier 77 is used to report a repeat procedure by another physician and is appended to the repeat procedure to:
•Report the same service provided by another physician.
•Indicate that a basic procedure or service had to be repeated.
Appropriate Uses:
•Adding modifier 77 to the professional component of an X-Ray or Electrocardiogram (EKG) procedure when the patient has two or more tests and more than one physician provides the interpretation and report.
oCMS  will reimburse a second interpretation of the same EKG or X-ray only under unusual circumstances, such as:
•A questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed, or
•A change in diagnosis resulting from a second interpretation
Note: Absent these circumstances, Novitas Solutions may reimburse only the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.
Inappropriate Uses:
•Billing for multiple services which are considered bundled.
•Appending Modifier 77 to an Evaluation and Management Code.

Claim Submission Instructions

Report each procedure on separate lines.
List the procedure code once by itself and then again with modifier 77.
Do not use the units' field to indicate the procedure was performed more than once on the same day.
Add modifier 77 when billing for multiple services on a single day and the service cannot be quantity billed.

Modifier and corrrect coding initative applied hospital and facility

July 12, 2016, 11:36 pm

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Coding a Facility Claim Procedure, Modifier and Diagnosis Codes   -    A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. We have applied procedure code edits to outpatient claims for our Medicare Advantage members since 2008. Effective September 15, 2012, wewill apply these edits to our Commercial outpatient claims.

Complete and accurate procedure code, modifier and diagnosis code usage at the time of billing ensures accurate processing of correct coding initiative edits. Wecan only use the primary modifier submitted with the alternate procedure code for outpatient billing. We encourage you to purchase current copies of CPT, HCPCS and ICD code books.


The correct coding initiative edits and medically unlikely edits will apply to outpatient claims from the following hospitals and facilities:

• Acute care hospitals

• Long term acute care hospitals

• Ambulatory surgical centers

• Psychiatric facilities

• Substance abuse facilities

• Inpatient rehabilitation facilities

• Skilled nursing facilities


Note: Ambulatory surgical centers will follow institutional correct coding initiative edits forour commercial business, while our Medicare Advantage business will process against the professional edits.



Modifiers

A modifier allows a provider to indicate that a service or procedure is altered by some specific circumstance, but the definition or code is not changed. Modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions are found in the most current CPT and HCPCS coding books.

Weprocess claims using only the first modifier for outpatient institutional claims. While up to three modifiers are accepted, claims are processed using only the first modifier. Therefore, submit the most important modifier affecting reimbursement in the first position on paper and electronic claims.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit an appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation. 4


Modifiers may be used to indicate that:

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual Events Occurred

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Modifier KX for use with Therapy Services

July 15, 2016, 7:33 am

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Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed.

By adding modifier KX to a claim, you are stating that your claim has met specific documentation requirements in the policy, and would be available upon request from the Medicare Administrative Contractor (MAC).

Add this modifier to each procedure code once the specific therapy cap has been met.

Modifier KX should follow the appropriate therapy modifiers.

Documentation must support and justify that the beneficiary qualifies for the therapy cap exception and that services are reasonable and necessary and require the skills of a therapist
The KX may be submitted on physical therapy, occupational therapy or speech language pathology claims.
Appropriate Use:
When additional documentation supports the medical requirements of the service under a valid medical policy.
Inappropriate Use:
When the claim provides all information on the service billed and medical documentation does not provide further explanation.
Claim does not meet policy guidelines/ Indications and Limitations of Coverage and/or Medical Necessity.
The most frequent use of the KX modifier is in relation to therapy services.
Physical/Speech/Occupational Therapy
When the service qualifies for an automatic claims processing exception * based on the published list of excepted conditions and complexities, submit the service with Healthcare Common Procedure Coding System (HCPCS) modifier KX.
The KX must be added to each claim line identified as a therapy service when therapy cap exceptions meet all guidelines for an automatic exception and must follow the required therapy HCPCS modifiers GN (speech-language pathology), GO (occupational therapy) and GP (physical therapy). This allows payment for the approved therapy services, even though they are above the therapy cap financial limits.
The presence of the KX modifier demonstrates that services billed:
Qualify for the therapy cap exception
Are reasonable and necessary services that require the skills of a therapist,
Are justified by appropriate documentation in the medical record
Therapy services submitted without the KX modifier, for claims above the therapy threshold, will deny.
Exceptions to therapy caps based on the medical necessity of the service are in effect only when included in Congressional legislation.

Payment Guide for Modifier 20, 52 and 22

July 18, 2016, 11:52 pm

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Allowable Adjustments


Effective January 1, 2000, the replacement code (CPT 69990) for modifier -20 - microsurgical techniques requiring the use of operating microscopes may be paid separately only when submitted with CPT codes:


61304 through 61546

61550 through 61711

62010 through 62100

63081 through 63308

63704 through 63710

64831

64834 through 64836

64840 through 64858

64861 through 64871

64885 through 64891

64905 through 64907.


Payment Due to Unusual Circumstances (Modifiers “-22” and “-52”)


The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.

Procedures Billed With Two or More Surgical Modifiers

July 21, 2016, 11:35 pm

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Carriers may receive claims for surgical procedures with more than one surgical modifier. For example, since the global fee concept applies to all major surgeries, carriers may receive a claim for surgical care only (modifier “-54”) for a bilateral surgery (modifier “-50”). They may also receive a claim for multiple surgeries requiring the use of an assistant surgeon.

Following is a list of possible combinations of surgical modifiers.

(NOTE: Carriers must price all claims for surgical teams “by report.”)

• Bilateral surgery (“-50”) and multiple surgery (“-51”).

• Bilateral surgery (“-50”) and surgical care only (“-54”).

• Bilateral surgery (“-50”) and postoperative care only ("55”).

• Bilateral surgery (“-50”) and two surgeons (“-62”).

• Bilateral surgery (“-50”) and assistant surgeon (“-80”).

• Bilateral surgery (“-50”), two surgeons (“-62”), and surgical care only (“-54”).

• Bilateral surgery (“-50”), team surgery (“-66”), and surgical care only (“-54”).

• Multiple surgery (“-51”) and surgical care only (“-54”).

• Multiple surgery (“-51”) and postoperative care only ("55”).

• Multiple surgery (“-51”) and two surgeons (“-62”).

• Multiple surgery (“-51”) and surgical team (“-66”).

• Multiple surgery (“-51”) and assistant surgeon (“-80”).

• Multiple surgery (“-51”), two surgeons (“-62”), and surgical care only (“-54”).

• Multiple surgery (“-51”), team surgery (“-66”), and surgical care only (“-54”).

• Two surgeons (“-62”) and surgical care only (“-54”).

• Two surgeons (“-62”) and postoperative care only (“55”).

• Surgical team (“-66”) and surgical care only (“-54”).

• Surgical team (“-66”) and postoperative care only (“55”).


Payment is not generally allowed for an assistant surgeon when payment for either two surgeons (modifier “-62”) or team surgeons (modifier “-66”) is appropriate. If carriers receive a bill for an assistant surgeon following payment for co-surgeons or team surgeons, they pay for the assistant only if a review of the claim verifies medical necessity.

Medicare part B modifiers full list

July 22, 2016, 5:03 am

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Modifiers to be used for Part B

Program	Category	Modifier Code	Description
PART - B	Physician Quality Reporting	1P	Physician Quality Reporting System – Performance measure exclusion modifier due to medical reasons.
PART - B	Surgical	22	Unusual procedural services.
PART - B	E/M	24	Evaluation and Management (E/M) – Unrelated E/M service by the same physician during a postoperative period.
PART - B	E/M	25	Significant, separately identifiable Evaluation and Management (E/M) service by the same physician on the same day of the procedure or other service.
PART - B	Radiology/Pathology	26	Professional component.
PART - B	Physician Quality Reporting	2P	Physician Quality Reporting System  – Performance measure exclusion modifier due to patient reasons.
PART - B	Physician Quality Reporting	3P	Physician Quality Reporting System  – Performance measure exclusion modifier due to system reasons.
PART - B	Coding	50	Bilateral procedure.
PART - B	Surgical	51	Multiple procedures.
PART - B	Coding	52	Reduced services.
PART - B	Coding	53	Discontinued procedure.
PART - B	Surgical	54	Surgical care only.
PART - B	Surgical	55	Postoperative management only.
PART - B	Surgical	56	Preoperative management only.
PART - B	E/M	57	Evaluation and Management (E/M) – Decision for surgery.
PART - B	Surgical	58	Staged or related procedure or service by the same physician during the postoperative period.
PART - B	Coding	59	National Correct Coding Initiative (NCCI) – Distinct procedural service.
PART - B	Surgical	62	Two surgeons.
PART - B	Surgical	66	Surgical team.
PART - B	ASC	73	Ambulatory Surgical Center (ASC) – Discontinued procedure prior to administration of anesthesia.
PART - B	ASC	74	Ambulatory Surgical Center (ASC) – Discontinued procedure after administration of anesthesia.
PART - B	Coding	76	Repeat procedure by same physician.
PART - B	Coding	77	Repeat procedure by another physician.
PART - B	Surgical	78	Return to the operative room for a related procedure during the postoperative period.
PART - B	Surgical	79	Unrelated procedure or service by the same physician during the postoperative period.
PART - B	Surgical	80	Assistant surgeon.
PART - B	Surgical	81	Minimum assistant surgeon.
PART - B	Surgical	82	Assistant surgeon (when qualified resident surgeon not available).
PART - B	Physician Quality Reporting	8P	Physician Quality Reporting System– Performance measure reporting modifier – action not performed, reason not otherwise specified.
PART - B	Laboratory	90	Referenced (outside) laboratory.
PART - B	Laboratory	91	Repeat clinical diagnostic laboratory test.
PART - B	Coding	99	Multiple modifiers.
PART - B	Anesthesia	AA	Services performed personally by an anesthesiologist.
PART - B	Anesthesia	AD	Medical supervision by a physician, more than four concurrent procedures.
PART - B	Psychiatric	AH	Clinical psychologist.
PART - B	E/M	AI	Principal physician of record.
PART - B	Psychiatric	AJ	Clinical social worker.
PART - B	HPSA/PSA	AQ	Physician providing a service in a Health Professional Shortage Area (HPSA).
PART - B	HPSA/PSA	AR	Physician provided service in a Physician Scarcity Area (PSA).
PART - B	Surgical	AS	Physician Assistant (PA), Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP) services for assistant-at-surgery.
PART - B	Chiropractic	AT	Acute treatment.
PART - B	Outpatient Hospital	AY	Item or service furnished to an ESRD patient that is not for the treatment of ESRD.
PART - B	Health Professional Shortage Area (HPSA)	AZ	Physician providing a service in a dental health professional shortage area for the purpose of an Electronic Health Record (EHR) incentive payment.
PART - B	ESRD	CB	Service ordered by a RDF physician as part End Stage Renal Disease (ESRD) beneficiary’s dialysis benefit.
PART - B	Coding	CC	Procedure code change.
PART - B	Catastrophe/Disaster	CR	Catastrophe/Disaster-related claims.
PART - B	Disaster-related claims	CS	Gulf oil spill 2010 related.
PART - B	Anatomical	E1	Upper left eyelid.
PART - B	Anatomical	E2	Lower left eyelid.
PART - B	Anatomical	E3	Upper right eyelid.
PART - B	Anatomical	E4	Lower right eyelid.
PART - B	Drugs	EA	Erythropoiesis Stimulating Agent (ESA) – Anemia, chemo-induced.
PART - B	Drugs	EB	Erythropoiesis Stimulating Agent (ESA) – Anemia, radio-induced.
PART - B	Drugs	EC	Erythropoiesis Stimulating Agent (ESA) – Anemia, non-chemo/radio.
PART - B	Anatomical	F1	Left hand, second digit.
PART - B	Anatomical	F2	Left hand, third digit.
PART - B	Anatomical	F3	Left hand, fourth digit.
PART - B	Anatomical	F4	Left hand, fifth digit.
PART - B	Anatomical	F5	Right hand, thumb.
PART - B	Anatomical	F6	Right hand, second digit.
PART - B	Anatomical	F7	Right hand, third digit.
PART - B	Anatomical	F8	Right hand, fourth digit.
PART - B	Anatomical	F9	Right hand, fifth digit.
PART - B	Anatomical	FA	Left hand, thumb.
PART - B	ASC	FB	Ambulatory Surgical Center (ASC) – Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device.
PART - B	ASC	FC	Ambulatory Surgical Center (ASC) – Partial credit received for replaced device.
PART - B	Anesthesia	G8	Monitored Anesthesia Care (MAC) for deep complex, complicated or markedly invasive surgical procedure.
PART - B	Anesthesia	G9	Monitored Anesthesia Care (MAC) for patient who has history of severe cardiopulmonary condition.
PART - B	ABN	GA	Waiver of liability statement issued, as required by payer policy.
PART - B	Resident	GC	Service performed in part by a resident under the direction of a teaching physician.
PART - B	Resident	GE	Service performed by a resident without the presence of a teaching physician under the primary care exception.
PART - B	Radiology	GG	Performance and payment of a screening mammography and diagnostic mammography on the same patient, same day.
PART - B	Opt-Out	GJ	“Opt-Out” physician or practitioner service provided in an emergency or urgent service.
PART - B	Ambulance	GM	Multiple patients on one ambulance trip.
PART - B	PT/OT	GN	Physical/Occupational Therapy (PT/OT) – Services delivered under an outpatient speech language pathology plan of care.
PART - B	PT/OT	GO	Physical/Occupational Therapy (PT/OT) – Services delivered under an outpatient occupational therapy plan of care.
PART - B	PT/OT	GP	Physical/Occupational Therapy (PT/OT) – Services delivered under an outpatient physical therapy plan of care.
PART - B	Telehealth	GT	Via interactive audio and video telecommunications system.
PART - B	Hospice	GV	Attending physician not employed or paid under arrangement by the patient’s hospice provider.
PART - B	Hospice	GW	Service not related to the hospice patient’s terminal condition.
PART - B	Excluded	GY	Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
PART - B	ABN	GZ	Advance Beneficiary Notice (ABN) was not signed by the beneficiary.
PART - B	CAP	J1	“No pay” Competitive Acquisition Program (CAP)modifier for drug line.
PART - B	CAP	J2	Competitive Acquisition Program (CAP) emergency re-supply.
PART - B	CAP	J3	Competitive Acquisition Program (CAP) “Furnish as Written.”
PART - B	Drugs	JW	Drug amount discarded/not administered to any patient.
PART - B	Drugs	KD	Drug or biological infused through Durable Medical Equipment (DME).
PART - B	Medical Policy	KX	Requirements specified in the medical policy have been met.
PART - B	Anatomical	LC	Left circumflex coronary artery.
PART - B	Anatomical	LD	Left anterior descending coronary artery.
PART - B	Laboratory	LR	Laboratory round trip.
PART - B	Eye	LS	FDA-monitored Intraocular Lens (IOL) implant.
PART - B	Anatomical	LT	Left side.
PART - B	CAP	MS	Competitive Acquisition Program (CAP) Medicare secondary payer.
PART - B	Anesthesia	P1	Physical Status – A normal healthy patient.
PART - B	Anesthesia	P2	Physical Status – A patient with mild systemic disease.
PART - B	Anesthesia	P3	Physical Status – A patient with severe systemic disease.
PART - B	Anesthesia	P4	Physical Status – A patient with severe systemic disease that is a constant threat to life.
PART - B	Anesthesia	P5	Physical Status – A moribund patient who is not expected to survive without the operation.
PART - B	Anesthesia	P6	Physical Status – A declared brain-dead patient whose organs are being removed for donor purposes.
PART - B	Wrong Procedure	PA	Surgery wrong body part. Wrong surgical or other invasive procedures performed on a patient.
PART - B	Wrong Procedure	PB	Surgery wrong patient. Wrong surgical or other invasive procedures performed on a patient
PART - B	Wrong Procedure	PC	Wrong surgery on patient. Wrong surgical or other invasive procedures performed on a patient.
PART - B	Radiology	PI	Positron Emission Tomography (PET) or PET/Computed Tomography (CT).
PART - B	Radiology	PS	Positron Emission Tomography (PET) or PET/Computed Tomography (CT).
PART - B	Surgical	PT	Colorectal cancer screening test; converted to diagnostic test or other procedure.
PART - B	Clinical Research Studies	Q0	Investigational clinical service provided in a clinical research study that is in an approved clinical research study.
PART - B	Clinical Research Studies	Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study.
PART - B	Kidney	Q3	Live kidney donor surgery and related services.
PART - B	Physician	Q5	Service furnished by a substitute physician under a reciprocal billing arrangement.
PART - B	Physician	Q6	Services furnished by a locum tenens physician.
PART - B	Footcare	Q7	One class A finding.
PART - B	Footcare	Q8	Two class B findings.
PART - B	Footcare	Q9	One class B and two class C findings.
PART - B	Prison/Custody	QJ	Services/items provided to a prisoner or patient in state or local custody; however, the state or local government, as applicable, meets the requirements in 42 CFR 411.4(b).        For outpatient claims, providers should append modifier QJ on all lines with a line item date of service during the incarceration period. All associated charges should be billed as non-covered.
PART - B	Anesthesia	QK	Medical direction of two, three or four concurrent procedures.
PART - B	Ambulance	QL	Patient pronounced dead after ambulance called (do not use origin and destination modifiers, only QL).
PART - B	Anesthesia	QS	Monitored Anesthesia Care (MAC) services.
PART - B	Laboratory	QW	Clinical Laboratory Improvement Amendments (CLIA) waived test.
PART - B	Anesthesia	QX	Certified Registered Nurse Anesthetist (CRNA) service with medical direction by a physician.
PART - B	Anesthesia	QY	Medical direction of one Certified Registered Nurse Anesthetist (CRNA) by an anesthesiologist.
PART - B	Anesthesia	QZ	Certified Registered Nurse Anesthetist (CRNA) service without medical direction by a physician.
PART - B	DME	RA	Replacement of a Durable Medical Equipment (DME), orthotic or prosthetic item.
PART - B	Anatomical	RC	Right coronary artery.
PART - B	Anatomical	RT	Right side.
PART - B	ASC	SG	Ambulatory Surgical Center (ASC) – Facility service.
PART - B	Anatomical	T1	Left foot, second digit.
PART - B	Anatomical	T2	Left foot, third digit.
PART - B	Anatomical	T3	Left foot, fourth digit.
PART - B	Anatomical	T4	Left foot, fifth digit.
PART - B	Anatomical	T5	Right foot, great toe.
PART - B	Anatomical	T6	Right foot, second digit.
PART - B	Anatomical	T7	Right foot, third digit.
PART - B	Anatomical	T8	Right foot, fourth digit.
PART - B	Anatomical	T9	Right foot, fifth digit.
PART - B	Anatomical	TA	Left foot, great toe.
PART - B	Radiology/Pathology	TC	Technical component.
PART - B	Radiology	UN	Portable X-Ray Supplier – Two patients served.
PART - B	Radiology	UP	Portable X-Ray Supplier – Three patients served.
PART - B	Radiology	UQ	Portable X-Ray Supplier – Four patients served.
PART - B	Radiology	UR	Portable X-Ray Supplier – Five patients served.
PART - B	Radiology	US	Portable X-Ray Supplier – Six patients served.

Difference between modifiers 52, 53

July 22, 2016, 5:03 am

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Documentation Requirements for Modifier 52 & 53

Modifier 52 – Reduced Services

*  Surgical Procedures: An operative report and a concise statement on how the service performed differs from the usual.

*  Non-Surgical Procedures: Provide a concise statement on how the service performed differs from the usual in the comment field of the electronic claim; a separate attachment is not required.
Note: If a statement explaining the reduction of the service or procedure is not submitted with the surgical or non-surgical procedure, the code billed with the 52 modifier will be denied, even if we receive an operative report.

Modifier 53 – Discontinued Procedure

*  Surgical Procedures: An operative report is required.
* Non-Surgical Procedures: Provide a concise statement on how the service performed differs from the usual in the comment field of the electronic claim or Item 19 of the paper form.