cms claims processing manual chapter 13

Medicare covers 18 F FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, or following an inconclusive SPECT. Limitations: In the event a patient receives a SPECT test with inconclusive results, a PET scan may be covered. However, if a patient receives a 18 F FDG PET study with inconclusive results, a follow up SPECT test is not covered.NOTE: If modifier KX is present on the professional component service, Contractors shall process the service as 18 F NaF PET rather than 18 F FDG PET. Contractors shall also return as unprocessable 18 F NaF PET oncologic professional component claims (e.g., claims billed with modifiers 26 and KX).Neurology: For the identification of regions of abnormal glucose metabolism associated with foci of epileptic seizures. IMPORTANT SAFETY INFORMATION Radiation Risks: Radiation-emitting products, including fludeoxyglucose F 18 injection, may increase the risk for cancer, especially in pediatric patients. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker. Blood Glucose Abnormalities: In the oncology and neurology setting, suboptimal imaging may occur in patients with inadequately regulated blood glucose levels. In these patients, consider medical therapy and laboratory testing to assure at least two days of normoglycemia prior to fludeoxyglucose F18 injection administration. Adverse Reactions: Hypersensitivity reactions with pruritus, edema and rash have been reported; have emergency resuscitation equipment and personnel immediately available. Siemens' PETNET Solutions is a manufacturer of Fludeoxyglucose F18 Injection ( 18 F FDG). Indication and important safety information as approved by the US Food and Drug Administration can be found at the links below for 18 F FDG, adult dose 5-10 mCi, administered by intravenous injection.

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Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for Breast cancer are nationally covered. Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are nationally covered. Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for initial antitumor treatment strategy for melanoma are nationally covered. References: Final Decision Memorandum on Positron Emission Tomography (PET) for Solid Tumors (CAG-00191R4) Short descriptor: PET tumor init tx strat The transmittals can be found on the following Internet pages: References: Transmittal 120. Medicare Claims Processing Manual revised July 2007, Chapter 13, Section 60.16 Billing and Coding for PET Scans Effective for Services on or After April 3, 2009. (Rev. 1888, Issued: 01-06-10, Effective: 11-10-09, Implementation: 01-04-10) The Centers for Medicare and Medicaid Services (CMS) nationally covers three 18 F FDG PET scans when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-tumor therapy. Short descriptor: PS - PET tumor subsq tx strategy The transmittals can be found on the following Internet pages: References: Transmittal 120. Medicare Claims Processing Manual revised July 2007, Chapter 13, Section 60.16 Billing and Coding for PET Scans Effective for Services on or After April 3, 2009. (Rev. 1888, Issued: 01-06-10, Effective: 11-10-09, Implementation: 01-04-10) Diagnostic tests such as 18 F FDG PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in order to affect management decisions in patients with ischemic cardiomyopathy and left ventricular dysfunction.

Generally, MACs must pay for only one interpretation of an EKG or X-ray procedure furnished to an emergency room patient. Payment for a second interpretation, which may be identified through the use of CPT modifier 77, may be made only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed, or a changed diagnosis resulting from a second interpretation of the results of the procedure. Absent these circumstances, reimbursement can only be made for the interpretation and report that directly contributed to the diagnosis and treatment of the patient. CPT modifier 77 should not be used solely because two interpretations were performed. When only one claim for an interpretation is received, it must be presumed that the one service submitted was a service to the individual beneficiary rather than a quality control measure. The claim may be paid if it otherwise meets any applicable reasonable and necessary test. Payment must be made for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. As a rule: This interpretation may be an oral report to the treating physician that will be written at a later time. When MACs receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, pay that claim. In such cases, MACs must determine that the radiologist's claim was actually quality control and institute payment recovery action. Documentation may be submitted with the initial claim, or if a denial is received, the documentation should be submitted with the request for redetermination.

Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker. Adverse Reactions: No adverse reactions have been reported for Ammonia N 13 Injection based on a review of the published literature, publicly available reference sources and adverse drug reaction reporting systems. However, the completeness of these sources is not known. Siemens' PETNET Solutions is a manufacturer of Ammonia N 13 Injection. Indication and important safety information as approved by the US Food and Drug Administration can be found at the links below for 13 N Ammonia, adult dose 8-12 mCi, administered by intravenous injection. Emergency resuscitation equipment and personnel should be immediately available. Cancer Risk: Sodium fluoride F18 injection may increase the risk of cancer. Adverse Reactions: No adverse reactions have been reported for Sodium Fluoride F 18 based on a review of the published literature, publicly available reference sources, and adverse drug reaction reporting systems. Siemens' PETNET Solutions is a manufacturer of Sodium Fluoride F 18 Injection ( 18 F NaF). Indication and important safety information as approved by the US Food and Drug Administration can be found at the links below for sodium fluoride 18 F NaF, adult dose 8-12 mCi, administered by intravenous injection. Full Prescribing Information Sodium Fluoride F 18 Injection (8-12 mCi) as an intravenous injection in adults 0.1 MB. You may also be using compatibility mode. Our site was not designed to run in IE 7 or below but you can still continue to use it. To disable compatibility mode - View our Instructions. Please select a specific contract in the 'Search Within' box for Medicare related information. Professional component billing based on a review of the findings of these procedures without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service.

Palmetto GBA will deny a claim subsequently received from a radiologist for the same interpretation as a quality control service to the hospital rather than a service to the individual beneficiary. Example 4 Same as Example 3 except that the claim from the radiologist uses CPT modifier 77 and indicates that, while the ER physician’s finding that the patient did not have pneumonia was correct; there was also a suspicious area of the lung suggesting a tumor that required further testing. In situations such as this, both claims can be paid. Claim Submission Instructions For claims submitted electronically, the unusual circumstances must be submitted in the appropriate documentation record or may be submitted via fax. Failure to use CPT modifier 77 and submit the necessary documentation will result in denial of the service. Limitations of liability and refund requirements apply. Should you receive a denial of service that you do not agree with, you may request a redetermination of the claim. Regardless of physician type or specialty, when requesting redetermination documentation must be submitted. These guidelines are available on the CMS website, Publication 100-04 (PDF, 482 KB), Medicare Claims Processing Manual, Chapter 13, Section 100.1. Please let us know if this article was helpful. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic. For procedures furnished in settings in which TC payments are made, carriers must pay separately for the expendable source associated with these procedures under CPT code Q3001 except in the case of remote after-loading high intensity brachytherapy procedures (CPT codes 77781-77784). In the four codes cited, the expendable source is included in the RVUs for the TC of the procedures.

The documentation submitted must support that the interpretation results were provided in time to contribute to the diagnosis and treatment of the patient. This documentation may be submitted with the initial claim or if requesting an appeal, must be submitted with the appeal request. Including the time of the report submission to the treating physician might be one method to demonstrate that the report was sufficiently timely to be used in diagnosis or treatment. Interpretations provided days or hours after the care of the patient, would not meet policy requirements. Doing so can reduce or eliminate the need to submit additional documentation and reduce or eliminate the need to submit appeals. If documentation was submitted with either the first or second claim, it will be reviewed for payment determination. If the documentation supports that the radiologist’s interpretation was provided in time to contribute to the diagnosis and treatment of the patient, that claim is paid, and the claim from the other physician would be denied as not reasonable and necessary, or if previously paid, overpayment collection action would be initiated. If the documentation submitted does not show that the interpretation was provided in time to contribute to the diagnosis and treatment of the patient, or if no documentation was submitted the claim will be denied as a duplicate. Example 2 A physician sees a beneficiary in the ER on January 1 and orders a single view chest X-ray. The physician reviews the X-ray, treats, and discharges the beneficiary. Example 3 A physician sees a beneficiary in the ER on January 1 and orders a single view chest X-ray. If the first claim is from the treating physician in the ER, and there is no indication the claim should not be paid (e.g., no reason to think that a complete, written interpretation has not been performed) payment of the claim is appropriate.

The HDR code (7778x) is employed for each HDR application (or fraction of treatment, whether multiple fractions daily, weekly or monthly). The remote afterloading CPT codes are used each time a treatment is given (i.e. each time the equipment is used to load radioactive material into the patient and provide a therapeutic dose of radiation).20. Brachytherapy is routinely designated complex (CPT code 77263) because it requires complex treatment volume design, dose levels near normal tissue tolerance, analysis of special tests, complex fractionation, or delivery concurrent with other therapeutic modalities or treatment of previously irradiated tissues. A separate treatment planning charge is not generated when external beam radiation therapy and brachytherapy are performed by physicians using the same provider numbers. However, if the two separate services are provided by physicians with different provider numbers, then each may charge 77263.21. Brachytherapy simulation CPT code 77290 is the complex process of obtaining images of the implanted region for purposes of making position adjustments and for performing dose calculations. Subsequent “check” verification simulations during the course of temporary implants to confirm or correct applicator position are reported as simple CPT code 77280.22. Computer-generated, three-dimensional reconstruction may be used for brachytherapy. Documentation is required with three-dimensional reconstruction and distribution. The scan images used for computer data entry should be based on three-dimensional depictions of the implanted site. The source positions may be digitized directly from these images or the three- dimensional reconstruction and the tumor volume and normal tissue image may be merged electronically. Simple three-dimensional representations by treatment planning computer programs derived from planar radiographic images are not sufficient justification for the use of this code.

Code 77295 precludes the use of codes 77326-77328 Brachytherapy Isodose for the same treatment volume.23. Services 77750-77799 include admission to the hospital and daily visits.Coding guidance in relation to where the service is rendered.GlobalGlobal brachytherapy procedures can be reimbursed by Medicare Part B only in the office or free-standing facility setting (11) or independent clinic (49).TechnicalTechnical component or technical only codes can be reimbursed by Medicare Part B only in the officeor free-standing facility setting (11) or independent clinic (49). In the ASC (24), the ASC usually billsthe technical component of the surgical code to the carrier.ProfessionalProfessional component or professional only codes may be reimbursed by Part B in an inpatienthospital (21), outpatient hospital setting (22) as well as an office or free-standing radiology facility(11), independent clinic (49) or an ASC (24).Prostate Brachytherapy Performed in an Ambulatory Surgical Center (ASC)Please refer to CMS payment rules for ASCs which can be found at: performed for the treatment of prostate cancer includes low dose rate (permanent seed)and high dose rate (HDR) brachytherapy. Other ASC approved codes are 19296, 19297 and19298 for breast, 57155 and 58346 for gynecological, 31643 pulmonary, and 43241 for esophagealapplicator insertions. The date of service for the radioelement claim must match the date of service for theprocedure performed.1. The expendable source Q3001 is only reimbursed when billed in an office or free-standing radiological facility (11), independent clinic (49). For electronic billing in item 19 narrative, list iodine (I-125); palladium (Pd-103); and cesium (Cs-131), the number of seeds ordered, invoice price and the number of seeds used in the procedure. It is recognized that a small number of additional seeds is ordered and billed to cover plan changes or intra-operative loss. 2.

There are specific C codes for certain radioelements payable under OPPS. These C codes are not payable by the Carrier. 70.5 - Radiation Physics Services (CPT Codes 77300 - 77399) (Rev. 1, 10-01-03) Carriers pay for the PC and TC of CPT codes 77300-77334 and 77399 on the same basis as they pay for radiologic services generally. All ICD-9-CM diagnosis codes must be coded to the highest level of specificity2. An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Services not meeting medical necessity guidelines should be billed with modifier -GA or - GZ. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Fiscal Intermediary, occurrence code 32 and the date of the ABN is required. Admission, subsequent hospital care and discharge day summary is included in the global fee for brachytherapy procedure.2. Special treatment procedure (77470) (eg., total body irradiation, hemibody irradiation, per oral irradiation, endocavitary or intraoperative cone irradiation, brachytherapy). The delivery of brachytherapy often requires special arrangements with the operating room and radiation safe ward, coordination of the applicator insertion process with other specialists, preparation and provision of the applicators and related equipment, scheduling and integration of required physics support, and acquisition and preparation of the radiation sources. Brachytherapy is often delivered in conjunction with external radiation, chemotherapy, or surgery. Non-radioactive “dummy” sources are used to geographically define the “eventual position” of the radioactive sources in temporary implant devices, whereas permanently implanted sources are imaged directly. Contrast may be utilized to delineate adjacent normal tissues and organs.

Subsequent “check” verification simulations during the course of temporary implants to confirm or correct applicator position are reported as simple CPT code 772805. The pulmonologist should not report their services with the brachytherapy codes.8. The radiation oncologist should bill for the treatment plan with CPT procedure codes 77261- 77263. Only one treatment planning code is allowed per course of treatment. When brachytherapy is used as an adjunct to external beam radiation therapy (EBRT), a single complex plan (77263) is reported to indicate that both modalities were utilized. If there is concurrent EBRT with brachytherapy refer to policy RAD014 for further information.9. CPT code 77790 (Supervision, handling, loading of radioelement) is designated for manual- loading LDR brachytherapy only.10. Dosimetry calculation during brachytherapy (the determination of dwell times, other than those times estimated in the isodose plan) should be reported with CPT procedure code 77300.11. Isodose plans are reported using CPT procedure codes 77326-77328. Unlike external beam radiation, this fractionation may be weekly or daily. Since each fraction may be fundamentally different within each course of therapy, a separate charge (77336) may be required if the HDR fraction falls mid-week during a course of external beam treatment, since the prescription and review are fundamentally different for the two courses of therapy.) 16. Special medical radiation physics (CPT code 77370) is used for brachytherapy when requested by the physician for a consultation on an individual patient. It requires a written report for the patient’s chart that must be analyzed by the physician to design or modify a brachytherapy treatment plan. This code may be reported once per course of treatment.17. Do not report radiographs used in brachytherapy simulation with CPT procedure code 77417.18.

In the OPPS setting use the source specific C code that best describes the radioelement should be used and it is priced off the OPPS fee schedule. Payment for Brachytherapy Sources in an ASC. The Medicare Improvement for Patients and Providers Act of 2008 requires CMS to pay for brachytherapy sources for the period of July 1, 2008 through December 31, 2009, at hospitals’ charges adjusted to costs. As a result of the legislative amendment, there is no prospective rate under the OPPS for that period. CR-6205 Note that when billing for stranded sources, providers should bill the number of units of the appropriate source HCPCS C-code according to the number of brachytherapy sources in the strand, and should not bill as one unit per strand. It is recognized that a small number of additional seeds is ordered and billed to cover plan changes or intra-operative loss. Until standard pricing can be established, the contractor will request by mail additional documentation (operative note and seed invoice) to confirm billed amount and number of seeds used.For claims submitted to the fiscal intermediary:Hospital Inpatient Claims: 1. The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. 2. The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67. 3. For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.) Hospital Outpatient Claims: 1.

The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82). 2. The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.Radioelements inserted in the in-patient or outpatient setting should not be billed to Medicare Part Bbut to Part A under OPPS or Inpatient billing rules.In the hospital setting (21 or 22) the radioelement is covered by source specific C-codes. A thorough assessment of your community's needs is the crucial first step. PMG calls allow peer-to-peer education focused on preparing rural hospitals for new payment and care delivery models. RHCs have been eligible for participation in the Medicare program since March l, 1978. Services rendered by approved RHCs to Medicare beneficiaries are covered under Medicare effective with the date of the clinic’s approval for participation. More covered services are described in the Medicare Benefit Policy Manual, chapter 13. The purpose of this event is to provide DRCHSD participating hospitals and clinics with a collaborative learning environment to make connections, share best practices, and gather lessons learned to empower and support participating organizations. Through presentations and interactive discussions, participants will be able to improve and strengthen their organizations. We look forward to your participation at this educational and informative virtual event. Sessions are free of charge, but registration is required.

Topics for discussion are determined based on MBQIP Data Reports, technical assistance trends and requests. In the case ofDSH). 120.3.3 - Model Letter to Nonparticipating Hospital That Requests to Bill. Payment. 70.1 - Determining Start Date of Timely Filing Period--Date of ServiceSubstandard Quality of Care and Extended and Partial Extended. problem inFDA- approved and. Devices cleared by the FDA through the 510(k) process;.Radiology,. and with special capabilities for performing angiographicAs such, patients eat relatively normal-sized meals and do not need to restrict.Information, Eligibility, and Entitlement Manual. Chapter 3,. The midnight-to-midnight method is to be used in. AOA). 2037A - Request from a Medicare Participating Hospital to Add Swing-. Bed. made by RO Financial Management Personnel and the Intermediary..Manual. This instruction has been revised as of July 1, 2003, based on a. Payment is the lower of the charge or the Medicare physician fee schedule amount. Deductible and coinsurance apply, and coinsurance is based on the allowed amount. Charges must be reported by HCPCS code. Payment for physicians’ radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service. AB MACs (A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment system (PPS) payment to hospitals. Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. CWF performs reject edits to incoming claims from suppliers of radiology services.

Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on a line item TC of a radiology service billed by a supplier. The CWF will generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim. For CAHs, payment to the CAH for inpatients is made at 101 percent of reasonable cost. Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A). The SNF must bill radiology services furnished its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS). Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier. If billed by the SNF, Medicare pays according to the Medicare Physician Fee Schedule. Examples of tests covered under this rule include, but are not limited to: x-rays, EKGs, EEGs, cardiac monitoring, and ultrasound services furnished on or after January 1, 1994. (Note that screening mammography services are covered under another provision of the Act and are not subject to the anti-markup payment limitation.) The anti-markup payment limitation applies to the technical component or “TC” of certain diagnostic tests that are payable on the Medicare Physician Fee Schedule (MPFS). Effective January 1, 2009, the anti-markup payment limitation also applies to the professional component or (“PC”) of diagnostic tests (other than clinical diagnostic tests).

The supervision requirement for physician billing is not met when the test is administered by supplier personnel regardless of whether the test is performed at the physician's office or at another location. A physician who accepts assignment is permitted to bill and collect from the beneficiary only the applicable deductible and coinsurance for the acquired test. A physician who does not accept assignment is permitted to bill and collect from the beneficiary only the fee schedule amount (as defined above) for the acquired test. The limiting charge provision is not applicable. If the physician does not identify who performed the test and provide the other required information, no payment is allowed. An example is when the attending physician orders radiology tests from a radiologist and the radiologist purchases the tests from an imaging center with whom the radiologist does not meet the criteria for “sharing a practice.” Under the anti-markup payment limitation, the billing physician or other supplier may not mark up the charge for a test from the acquisition price and must accept as full payment for the test (even if assignment is not accepted) the lowest of: the fee schedule amount as if the performing physician or other supplier had billed directly, the billing entity’s actual charge, or the performing physician or other supplier’s net charge to the billing entity. The billing physician or other supplier must be financially related to the physician or group that ordered the tests through common ownership or control. If the performing physician or other supplier meets the criteria for “sharing a practice” with the billing physician or other supplier, then the anti-markup payment limitation will not apply and the lower of the physician fee schedule amount or the billed amount will be paid. The physician or other supplier that performed the component that is subject to the antimarkup rule must be enrolled in the Medicare program.