CPT code 12001,12018 - Laceration repair

CPT Codes for Laceration Repair 

Laceration 

Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities : 2.5 cm or less - cpt 12001



Simple Repairs

CPT Codes 12001 – 12018

** Usually included in all minor and major Usually included in all minor and major surgical procedures

** Cannot be reported separately when performed in conjunction with minor/major procedure

** However, can be reported if that is the only service provided e.g. simple closure of laceration


Intermediate Repairs (12001 – 12057)

Use for repair of wounds or defects which:



**  Require layered closure, one/more deeper layers SC tissue & superficial (nonmuscle) fascia

**  Need prolonged support y g (sum of lengths)

Need obliteration of “dead” space

Need prolonged support



Guidelines:

**  Code by site and length

**  Report in addition to excision code

Note: Not appropriate to be

**  used with excision of benign to control tension

**  used with excision of benign lesions 0.5 cm or less (11400, 11420, 11440) for Medicare & Aetna




Surgical Team

Under some circumstances highly complex procedures are carried out under the “surgical team” concept. Each participating physician would report the basic procedure with the addition of modifier -66.

Starred Surgical (*) Procedures

Certain services listed in the schedule are marked with a star (*) after the CPT® code.

These are relatively small surgical procedures for which the usual global package does not apply. Payment for the starred (*) service includes anesthesia for infiltration, digital block, or topical application.

When the starred (*) service is performed at the time of the initial visit, and theservice is the major service rendered during the visit, an office visit will be paid when billed with CPT® code 99025. Example: procedure code 12001 (repair of laceration) and procedure code 99025 (initial new patient exam) would both be paid.

When the starred (*) service is performed at the time of an initial or other visit involving significant identifiable service(s), the appropriate E/M service is listed in addition to the starred (*) service. Example: when an initial consult is performed and a joint injection is also performed, it is appropriate to bill and be paid for both the consult and the injection.

When a starred (*) service is performed at the time of a follow-up visit and the surgical procedure constitutes the major service, the evaluation and management service is not paid in addition to the surgical procedure. When the starred (*) service requires hospitalization, an appropriate hospital visit is listed, in addition to the starred (*) surgical procedure and its follow-up care.

Note: When follow-up days are listed as "0" the follow-up services shall be billed as independent procedures.

Note: When billing starred (*) surgical procedures for injection codes into bursa, joints, etc., the Injectable medications may be billed separately using 99070 or the appropriate J code listed in Medicare’s Level II codes. The drug shall be reimbursed at AWP.



HELPFUL CODING HINTS

As part of Oxford’s ongoing effort to provide the best service possible to all providers, Oxford periodically reviews claims data to identify issues that can delay processing. This article is the second in a series of updates that will be featured in this publication on a regular basis. One of the areas frequently noted to cause difficulty is the inappropriate use of repair CPT codes in the ranges of 12001 through 13160 (Repair; simple, intermediate, complex). These codes cannot be billed for more than a quantity of one per each group of anatomic site and classification, and are frequently billed incorrectly with multiple quantities (e.g., 12001 quantity 2.) To ensure timely and correct reimbursement, physicians, when repairing multiple wounds, should total the sums of the lengths of the repairs performed in each anatomic site and bill with the appropriate corresponding repair code.

According to the AMA CPT 2001 description, “when multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor.” The following example illustrates this rule: The physician performs a simple repair 1 cm in length on the trunk and a simple repair 1.5 cm in length on the arm. The provider should bill CPT code 12001 with a quantity of one, since the total length of the repairs is equal to 2.5 cm. The AMA CPT 2001 description for code 12001 is “simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less.”

Providers should not add lengths of repairs from different groupings of anatomic sites (e.g., ears and legs) and should not add together lengths of different classifications (e.g., simple and complex repairs). Please remember to add the total lengths of repairs for each group of anatomic sites. The codes within the same classification and anatomic site cannot be billed in multiple quantities.




HCPC Code 12001


To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the data provided by CMS:


Step 1. Access the Medicare Physician Fee Schedule Look-up on the CMS website at www.cms.hhs.gov.

Step 2. To find the RVU for the procedure: Provide your search criteria selecting the year, “Single HCPCS Code” and “Relative

Value Units.” To find the GPCI: Provide your search criteria selecting the year, “Single HCPCS Code” and “Geographic Practice Cost Index (GPCI).”

Step 3. To find the RVU for the procedure: On the next page, select “Default Fields.” To find the GPCI: On the next page, select “Specific Locality” and “Default Fields.”

Step 4.

To find the RVU for the procedure:

Continue the process by providing the HCPCS (for this example we are using 12001  Repair superficial wounds in a non-facility setting), and select the appropriate modifier if applicable.

To find the GPCIs for the procedure: Continue the process by selecting the “Carrier Locality” (for this example we are selecting “Rest of Texas”).

Step 5.

To find the RVU for the procedure: Submit your search criteria to find the RVUs for the procedure.

To find the GPCIs for the procedure: Submit your search criteria to find the GPCIs for the locality.

 Step 6. Proceed with the calculations. [(Work RVU x Work GPCI)

+ (PE RVU x PE GPCI)
+ (MP RVU x MP GPCI)]
x Division Conversion Factor
= Division MAR


The MAR for CPT code 12001 (Repair superficial wounds) in a non-facility setting provided for the “Rest of Texas” in 2009 is $184.66.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a facility setting, follow the steps above using the Facility RVUs in place of the Non-facility RVUs.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the Trailblazer website:

Step 1. Go to the TrailBlazer Health Enterprises, LLC website at www.TrailBlazerhealth.com.

Step 2. If you have already registered on this site, sign in. If you have not, you must register to use the site. There is no cost to use this website.

Step 3. Use the Search function on the Homepage to search for ‘Fee Schedules’ and locate the Medicare Fee Schedule.

Step 4. Select the year of the fee schedule you want (2009), your state (Texas), and yourlocality (Rest of Texas) in the appropriate windows.

Step 5. Enter the procedure code (CPT) (and modifier if applicable) about which you seek information.

Step 6. Find the Medicare CF and divide it into the Division CF (2009 CF – $53.68) to derive the Division multiplier.

Step 7. Find the non-facility Participating Amount and multiply the amount by the Division ratio.

CPT U0001,U0002, 87635 - Coronavirus - ICD J12.89, A41.89, B34.2

CPT code and Description

U0001 - 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when specimens are sent to the CDC and CDC-approved local/state health department laboratories.

U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health department laboratories.

87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.  Use of code 87635 will help the labs to efficiently report and track testing services related to SARS-CoV-2 and will streamline the reporting and reimbursement for this test in the US.

There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) can be used by laboratories and healthcare facilities to bill Medicare as well as by other health insurers that choose to adopt this new code for such tests. HCPCS code (U0002) generally describes 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets). The Medicare claims processing system will be able to accept these codes on April 1, 2020 for dates of service on or after February 4, 2020.


CPT code and reimbursement rate


U0001 - $35.92

U0002 - $51.33

Modifiers:

The appropriate modifier should be assigned based on the below information,

GT - Via Interactive Audio and Video Telecommunications systems
GQ - Via Asynchronous Telecommunications systems.
95 - Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system (reported only with codes from Appendix P)
G0 -Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

POS:
​​Telemedicine service can be billed under POS 02.

Diagnosis:
The codes for classifying coronavirus (not associated with SARS) include,
Pneumonia due to coronavirus:  J12.89 (Other viral pneumonia) and B97.29 (Other coronavirus as the cause of diseases classified elsewhere)
Sepsis due to coronavirus:  A41.89 (Other specified sepsis) and B97.29
Other infection caused by coronavirus:  B34.2 (Coronavirus infection, unspecified)
If the provider documents “suspected”, “possible” or “probable” COVID-19, do not assign code B97.29. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828).


Medicaid will start to cover these services effective from March 16th, 2020 and the date of service would be February 4th, 2020.


FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19)

Q1. Do the Essential Health Benefits (EHB) currently include coverage for the diagnosis and treatment of COVID-19?

A1. Yes. EHB generally includes coverage for the diagnosis and treatment of COVID-19.
However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered. Nongrandfathered health insurance plans purchased by individuals and small employers, including qualified health plans purchased on the Exchanges, must provide coverage for ten categories of EHB.1 These ten categories of benefits include, among other things, hospitalization and laboratory services. Under current regulation, each state and the District of Columbia generally determines the specific benefits that plans in that state must cover within the ten EHB categories.

This standard set of benefits determined by the state is called the EHB-benchmark plan. All 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of COVID19.2 Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and will be waiving any cost-sharing that would otherwise apply to the test. Furthermore, many states are encouraging their issuers to cover a variety of COVID-19 related services, including testing and treatment, without cost-sharing, while several states have announced that health plans in the state must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing.

Q2. Is isolation and quarantine for the diagnosis of COVID-19 covered as EHB?

A2. All EHB-benchmark plans cover medically necessary hospitalizations. Medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission are generally covered as EHB. The cost-sharing and specific coverage limitations associated with these services may vary by plan. For example, some plans may require prior authorization before these services are covered or may apply other limitations. Quarantine outside of a hospital setting, such as a home, is not a medical benefit, nor is it required as EHB. However, other medical benefits that occur in the home that are required by and under the supervision of a medical provider, such as home health care or telemedicine, may be covered as EHB, but may require prior authorization or be subject to cost-sharing or other limitations.

Q3. When a COVID-19 vaccine is available, will it be covered as EHB, and will issuers be permitted to require cost-sharing?

A3. A COVID-19 vaccine does not currently exist. However, current law and regulations require specific vaccines to be covered as EHB without cost-sharing, and before meeting any applicable deductible, when the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, if ACIP recommends a new vaccine, plans are not required to cover the vaccine until the beginning of the plan year that is 12 months after ACIP issues the recommendation. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost-sharing, prior to that date.

In addition, as part of a plan’s responsibility to cover prescription drugs as EHB, as described above to cover ACIP-recommended vaccines, if a plan does not provide coverage of a vaccine (or other prescription drugs) on the plan’s formulary enrollees may use the plan’s drug exceptions process to request that the vaccine be covered under their plan, pursuant to 45 CFR 156.122(c)

Does Aetna cover the cost of COVID-19 testing for members?

CVS Health recently announced Aetna will waive co-pays and apply no cost-sharing for all diagnostic testing related to COVID-19 and there will be no member out of pocket cost. This policy will cover the cost of physician-ordered testing for patients who meet CDC guidelines, which can be done in any approved laboratory location. Aetna will waive the member costs associated with diagnostic testing at any authorized location for all Commercial, Medicare and Medicaid lines of business. Self-insured plan sponsors will be able to opt-out of this program at their discretion.

How will doctors and hospitals have access to COVID-19 lab testing?
 
Patients who have concerns that they may have been exposed to COVID-19 or may have symptoms of COVID-19 should contact their physician or local/state Department of Health for testing. The test specimens will be obtained and then sent to a laboratory. We are not currently able to do specimen collection or testing at MinuteClinic or CVS Retail pharmacies. The CDC states that coronavirus testing may be performed on patients with a doctor’s approval.

CPT Category III Codes, definition, guidelines and examples

CPT Category III Codes

The following CPT codes are an excerpt of the CPT Category III code set, a temporary set of codes for emerging technologies, services, procedures, and service paradigms. For more information on the criteria for CPT Category I, II and III codes, see Applying for Codes.

To assist users in reporting the most recently approved Category III codes in a given CPT cycle, the AMA’s CPT website publishes updates of the CPT Editorial Panel (Panel) actions of the Category III codes in July and January according to the Category III Code Semi-Annual Early Release Schedule. This was approved by the CPT Editorial Panel as part of the 1998- 2000 CPT-5 projects. Although publication of Category III codes through early release to the CPT website allows for expedient
dispersal of the code and descriptor, early availability does not imply that these codes are immediately reportable before the indicated implementation date.

Publication of the Category III codes to this website takes place on a semiannual basis when the codes have been approved by the CPT Editorial Panel. The complete set of Category III codes for emerging technologies, services, procedures, and service paradigms are published annually in the code set for each CPT publication cycle.


As with CPT Category I codes, inclusion of a descriptor and its associated code number does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy



1. What is a Category III CPT code?

Category III CPT Codes are temporary codes for emerging technology, services and procedures that allow for specific data collection associated with those services and procedures. There are no assigned RVU’s or established payment for the Category II CPT codes. When these procedures become more commonly adopted and established, the societies will work with the American Medical Association (AMA) to move these codes from Category III to Category I CPT status.

Physicians will report the WATCHMAN LAA Closure procedure with Category III CPT Code: 0281T. The code descriptor for 0281T is:

Percutaneous transcatheter closure of the left atrial appendage with implant. Includes fluoroscopy, transseptal puncture, catheter placements, left atrial angiography, left atrial appendage angiography, radiologic supervision and interpretation.


2. How do Category III CPT Codes differ from Category I CPT Codes?

Category I codes have assigned relative value units (RVUs) or work values and have an associated payment amount. A Category III CPT code does not have assigned RVUs and therefore, there is no payment rate established and reimbursement is at the payer’s discretion. In addition, a Category III code does not require FDA approval whereas; procedures described by a Category I CPT code must have FDA approval.

3. In the interim, how do physicians work with payers in establishing an appropriate payment rate for the WATCHMAN LAA Closure procedure when they are reported with Category III CPT Codes? For physician services reported with a Category III CPT Code, providers will reference or crosswalk a procedure code with similar or equivalent resources (i.e., RVUs) as the WATCHMAN LAA Closure implant (i.e., suggested CPT codes include but are not limited to: 93580: transcatheter closure of atrial septal defect with implant or 93581: transcatheter closure of ventricular septal defect with implant). It will be important for the provider to document the services provided in regards to resources and time for appropriate consideration of the payment for the professional component of the procedure.

Recommended items to support your claims submissions include the following:

* Copy of operative report
* Letter of medical necessity
* Copy of the FDA approval letter (Boston Scientific can supply electronic copy)

Copy of relevant published clinical literature supporting the use of the WATCHMAN LAA Closure System If physicians are employed by the hospital and their compensation is based on productivity from an RVU tracking methodology, it is important to work closely with the hospital administrators in benchmarking WATCHMAN LAA closure procedures to a procedure with established RVU’s utilizing similar resources, time, competency and risk. These discussions should happen in advance of a WATCHMAN implant being performed.




Guidelines for using Category III Codes
Unless an NCD, LCD or coverage article is published to address coverage for a specific Category III CPT code, UnitedHealthcare considers all services and procedures listed in the current and future Category III CPT code list as not proven effective and will deny submitted claims as not medically necessary. Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meeting all technical requirements for coverage, but are determined to be any of the following:


** Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used
** Not proven to be safe and effective based on peer review or scientific literature
** Experimental
** Not medically necessary in the particular case
** Furnished at a level, duration or frequency that is not medically appropriate
** Not furnished in accordance with accepted standards of medical practice, or
** Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition.
** Items and services must be established as safe and effective to be considered medically necessary. That is, the items and services must be:
** Consistent with the symptoms or diagnosis of the illness or injury under treatment;
** Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental or investigational);
** Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier;
** Furnished at the most appropriate level that can be provided safely and effectively to the patient.




Example Category III Codes

CPT Code Description Noncovered

0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)

0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for
primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)

0058T Cryopreservation; reproductive tissue, ovarian

0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue

0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume greater or equal to 200 cc of tissue

0085T Breath test for heart transplant rejection (Not Covered by Medicare) [See the Medicare Advantage Policy Guideline titled Heartsbreath Test for Heart Transplant
Rejection (NCD 260.10)]

0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy [See the Medicare Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]

0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle [See the Medicare
Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]

0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation

0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation

0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia

0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia

0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation

0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes

CPT Category II codes, why and what is the purpose,description, example

What is the purpose of CPT II codes?

CPT II codes help define nationally established performance measures by facilitating data collection regarding the quality of care rendered.


CPT II codes describe:

• Clinical components, such as those typically included in evaluation, management, or other clinical services;
• Results from clinical laboratory or radiology tests and other procedures;
• Identified processes intended to address patient safety practices; or
• Services reflecting compliance with state or federal law.


Why use CPT Category II codes?

CPT Category II codes can relay important information related to health outcome measures such as

** BMI
** CVD cholesterol management
** Controlling blood pressure
** Comprehensive diabetes care
** Tobacco cessation

What do we hope to achieve?

Amerigroup Kansas strives to ensure that we promote the most efficient processes for our providers while continuously improving the quality of care and services that our members receive. By increasing the use of CPT Level II codes, we hope to:

** Improve the health status of our members
** Monitor and ensure our members receive seamless, continuous and appropriate care throughout the continuum of care
** Improve the provider experience



How do I identify a CPT II code?

CPT II codes contain five characters – the first four numerical characters are followed by an alphabetical fifth character, the letter ‘F’.

The current set of CPT II codes contains the following sub-categories:

• Composite Measures 0001F – 0015F
• Patient Management 0500F – 0575F
• Patient History 1000F – 1220F
• Physical Examination 2000F – 2050F
• Diagnostic/Screening Processes or Results 3006F – 3573F
• Therapeutic, Preventive, or Other Interventions 4000F – 4306F
• Follow-Up or Other Outcomes 5005F – 5100F
• Patient Safety 6005F – 6045F
• Structural 7010F – 7025F


Why should my organization use CPT II Codes?


Not only can using CPT II codes ease the administrative burden of chart review for many HEDIS™ performance measures, use of these codes enables organizations to monitor internal performance for key measures throughout the year, rather than once per year as measured by health plans and Pay for Performance. By identifying opportunities for improvement, interventions can be implemented to improve performance during the service year.

How should my organization bill CPT II Codes?

CPT II codes are billed in the procedure code field; just as CPT Category I codes are billed. CPT II codes describe clinical components usually included in evaluation and management or clinical services and are not associated with any relative value. Therefore, CPT II codes are billed with a $0.00 billable charge amount.


NOTE: Once the lab results are received, please submit the appropriate Category II Code to PSHP.


Where can I find a list of CPT II Codes?

CPT II codes are released annually as part of the full CPT code set and are updated semi-annually in January and July by the AMA. The current listing of CPT II codes can be found on the AMA Web site at:

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billinginsurance/cpt/about-cpt/category-ii-codes.page.



Category II Modifiers
 Four Category II modifiers (1P, 2P, 3P, and 8P) are used to report services that were considered but not provided because of medical reason(s), patient choice, or system reasons. Modifier 1P (performance measure exclusion modifier due to medical reasons) is used to report that one of the performance measures was not performed, because it was not indicated (eg, already performed) or was contraindicated (eg, because of a patient's allergy).


Modifier 2P (performance measure exclusion modifier due to patient choice) is used to report that the performance measure was not performed because of a patient's religious, social, or economic reasons; the patient declined (ie, noncompliance with treatment); or other specific reasons.

Modifier 3P (performance measure exclusion modifier due to system reasons) is used to report that the performance measure was not performed because the payer does not cover the service, the resources to perform the service are not available, or other reasons attributable to the health care delivery system. These modifiers are only used with Category II codes and only when allowed based on the specific reporting instructions for each performance measure.


Modifier 8P (performance measure reporting modifier—action not performed, not otherwise specified) is used as a reporting modifier to allow the reporting of circumstances when an action described in a measure’s numerator is not performed and the reason is not otherwise specified


CPT Category II code short list HEDIS/Other measure Indicator description CPT Category ll codes*

Adult BMI BMI assessed/documented 3008F

CVD cholesterol management LDL test & level 3048F, 3049F, 3050F


Controlling blood pressure Blood pressure readings 3074F, 3075F, 3077F, 3078F, 3079F, 3080F


Comprehensive diabetes care  A1c test & A1c level 3044F, 3045F, 3046F

Eye Exam 2022F, 2024F, 2026F
LDL test & level 3048F, 3049F, 3050F
Nephropathy screening 3060F, 3061F, 3062F, 4009F, 3066F
Blood pressure readings 3074F, 3075F, 3077F, 3078F, 3079F 3080F
Tobacco cessation Screening, counseling, intervention 1031F, 1032F, 1033F, 1034F, 1035F, 1036F, 4001F, 4004F
Fall risk assessment Assessment, plan of care 0518F, 1100F, 1101F



F code Code descriptor(s) From AMA

4010F Angiotensin converting enzyme (ACE) inhibitor or Angiotensin receptor blocker (ARB) therapy prescribed or currently being taken
3080F Most recent diastolic blood pressure 90 mm Hg
3079F Most recent diastolic blood pressure 80 – 89 mm Hg
3078F Most recent diastolic blood pressure < 80 mm Hg
3077F Most recent systolic blood pressure 140 mm Hg
3075F Most recent systolic blood pressure 130 to 139 mm Hg
3074F Most recent systolic blood pressure < 130 mm Hg
3072F Low risk for retinopathy (no evidence of retinopathy in the prior year)
3066F Documentation of treatment for nephropathy (e.g. patient receiving dialysis, patient being treated for ESRD, CRF, ARF or renal insufficiency, any visit to a nephrologist)
3062F Positive macroalbuminuria test result documented and reviewed
3061F Negative microalbuminuria test result documented and reviewed
3060F Positive microalbuminuria test result documented and reviewed
3050F Most recent LDL -C 130 mg/dL
3049F Most recent LDL -C 100-129 mg/dL
3048F Most recent LDL -C < 100 mg/dL
3046F Most recent hemoglobin A1c (HbA1c) level > 9.0%
3045F Most recent hemoglobin A1c (HbA1c) level 7.0% to 9.0%
3044F Most recent hemoglobin A1c (HbA1c) level < 7.0%
2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed
2024F Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed
2022F Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed
1170F Functional status assessed
1160F Review of all medications by a prescribing practitioner or clinical pharmacist (such as, prescriptions, OTCs, herbal therapies and supplements) documented in the medical
1159F Medication list documented in medical record
1158F Advance care planning discussion documented in the medical record
1157F Advance care plan or similar legal document present in the medical record
1126F Pain severity quantified; no pain present
1125F Pain severity quantified; pain present
1111F Discharge medications reconciled with the current medication list in outpatient medical record
0503F Postpartum care visit

Category I CPT Codes, requirements and basics and comparison vs Category III Codes

Category I CPT Codes

Category I CPT codes describe a procedure or service identified with a five-digit CPT code and descriptor nomenclature. The inclusion of a descriptor and its associated specific five-digit identifying code number in this category of CPT codes is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.

In developing new and revised regular CPT codes the Advisory Committees and the Editorial Panel require:

•    that the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
•    that the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States;
•    that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature;
•    that the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and
•    that the suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.”




Requirement for Category I CPT Codes

All Category I codes have been reviewed by the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel and have met the following criteria:

• the service/procedure necessary for the procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;

• the suggested procedure/service is a distinct service performed by many physicians or other qualified health professionals across the United States;

• the suggested service/procedure and clinical efficacy of the service/procedure is well established and documented in peer review literature that meets the requirements set in the code change proposal form;

• the suggested service/procedure is performed with the frequency consistent with the intended clinical use;

• the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and

• the procedure or service is consistent with current medical practice.

Therefore, when a physician provides such a service or procedure and has documented his or her work properly and according to payer guidelines, the payer should not deny reimbursement for that service or procedure by claiming it is experimental or investigational.

Basic Code Sets
99201-99499 Evaluation and Management
00100-01999 Anesthesia
10021-69990 Surgery
70010-79999 Radiology
80047-89356 Pathology and Laboratory
90281-99607 Medicine


Modifiers usage on Category I CPT Codes


• Modifiers are used to “modify” the code that is chosen for a given procedure.

• These are listed in the front cover of the CPT book with a description

Example:
51 Multiple Procedure
52 Reduced Service


“Who maintains CPT?

The CPT Editorial Panel is responsible for maintaining the CPT code set. This panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is comprised of 17 members. Of these, 11 are physicians nominated by the National Medical Specialty Societies and approved by the AMA Board of Trustees. One of the 11 is reserved for expertise in performance measurement.   One physician is nominated from each of the following: the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for two members of the CPT Health Care Professionals Advisory Committee (one co-chair "full seat" and one "rotating seat" member at-large).”


Comparison: Category I Versus Category III Codes

Category III CPT codes are a set of temporary codes for emerging technology, services, and procedures. These codes are intended to be used to track the usage of these services, and the data collected may be used to substantiate widespread usage in the Food and Drug Administration (FDA) approval process. However, Category III codes are not given an automatic designation for services or procedures, as the CPT Editorial Panel determined that they did not meet the requirements for a Category I code.
Category I CPT codes are restricted to clinically recognized and generally accepted services, and not emerging technologies, services, and procedures. Category III CPT codes are not required to conform to the CPT Category I code requirements but instead are for reporting services or procedures that must have a relevance for research, either ongoing or planned, or the need to be tracked to evaluate the frequency of use.

Another important consideration in the development of Category III codes was the elimination of local codes under the Health Information Portability and Accountability Act (HIPAA). The local codes were temporary codes used by third-party payers as a mechanism to identify services and supplies such as services and procedures that had not yet been substantiated through research. Thus, Category III codes have, in part, taken the place of these local codes. As with Category I CPT codes, inclusion of a descriptor and its associated code number in CPT nomenclature does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Additionally, inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy.

To expedite the availability of CPT Category III codes and to reflect the need to more quickly establish tracking mechanisms, the new CPT Category III codes are released semiannually via electronic distribution on the AMA CPT Web site (www.ama-assn.org/go/cpt ). The codes are effective six months after they are first posted. (Category III codes that are posted in July become effective the following January 1, and Category III codes that are posted in January become effective the following July 1.) The full set of Category III codes is then included in the next published edition of the CPT codebook for that CPT cycle. Such an early release is possible for Category III codes because the codes are not reviewed by the Relative Value Update Committee (RUC) for valuation by the Centers for Medicare and Medicaid Services (CMS). The AMA’s CPT Web site features updates of the CPT Editorial Panel actions and early release of the Category III codes on July 1 and January 1 in each CPT cycle

W series CPT code list

W series CPT codes Introduction


Current Procedural Terminology (CPT) codes are used for reporting medical services and procedures performed by physicians.  Their purpose is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services, thereby providing an effective means for reliable nationwide communication among physicians, patients, and third parties.  This system of terminology is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs.

CPT V. 6.0 provides the software to update the CPT files.  The software includes all CPT codes to code outpatient services for reimbursement and workload purposes (as determined by the American Medical Association) and the Common Procedure Coding System from the Health Care Financing Administration (HCPCS).  These codes may also be utilized to report inpatient services in certain instances.

In addition to the National CPT and HCPCS codes, the VA also uses the following VA specific HCPCS format codes.  These codes are not included in the HCPCS or CPT manuals.

W-CODES (VA NATIONAL CODES)



CPT Code Service Description Billing Unit Rate as of July 1, 2016 Max Daily Unit/ Service Limit Place of ServiceW5014 Art Therapy Individual - certified 45-50 min $63.43 1 11,99
W5026 Art Therapy Individual - certified 75-80 min $82.47 1 11,99
W5027 Art Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5028 Art Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5015 Art Therapy Group - certified 45-60 min $24.64 1 11,99
W5029 Art Therapy Group - certified 75-80 min $32.04 1 11,99
W5030 Art Therapy Group - licensed 45-60 min $27.74 1 11,99
W5031 Art Therapy Group - licensed 75-80 min $36.07 1 11,99
W5012 Dance Therapy Individual - certified 45-50 min $63.43 1 11,99
W5032 Dance Therapy Individual - certified 75-80 min $82.47 1 11,99
W5033 Dance Therapy Individual - licensed 45-60 min $69.78 1 11,99
W5034 Dance Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5013 Dance Therapy Group - certified 45-60 min $24.64 1 11,99
W5035 Dance Therapy Group - certified 75-80 min $32.04 1 11,99
W5036 Dance Therapy Group - licensed 45-60 min $27.74 1 11,99
W5037 Dance Therapy Group - licensed 75-80 min $36.07 1 11,99
W5010 Equine Assisted Therapy Individual -certified 45-50 min $63.43 1 99
W5044 Equine Assisted Therapy Individual -certified 75-80 min $82.47 1 99
W5045 Equine Assisted Therapy Individual - licensed 45-50 min $69.78 1 99
W5046 Equine Assisted Therapy Individual - licensed 75-80 min $91.41 1 99
W5011 Equine Assisted Therapy Group - certified 45-60 min $24.64 1 99
W5047 Equine Assisted Therapy Group - certified 75-80 min $32.04 1 99
W5048 Equine Assisted Therapy Group - licensed 45-60 min $27.74 1 99
W5049 Equine Assisted Therapy Group - licensed 75-80 min $36.07 1 99
W5020 Horticultural Therapy Individual - certified 45-50 min $63.43 1 99
W5050 Horticultural Therapy Individual - certified 75-80 min $82.47 1 99
W5051 Horticultural Therapy Individual - licensed 45-50 min $69.78 1 99
W5052 Horticultural Therapy Individual - licensed 75-80 min $91.41 1 99
W5021 Horticultural Therapy Group - certified 45-60 min $24.64 1 99
W5053 Horticultural Therapy Group - certified 75-80 min $32.04 1 99
W5054 Horticultural Therapy Group - licensed 45-60 min $27.74 1 99
W5055 Horticultural Therapy Group - licensed 75-80 min $36.07 1 99
W5022 Face to face caregiver peer to peer support 15 min $16.29 8/11 hrs per month 11,12,99
W5023 Collateral (telephonic) caregiver peer to
peer support
15 min $8.14 8/16 hrs per month 11,12,99
W5024 Mobile Crisis and Stabilization 15 min $26.13 12 hrs 12,99
W5025 Crisis Assessment 1 $313.54 1 12,99
W5016 Music Therapy Individual - certified 45-50 min $63.43 1 11,99
W5038 Music Therapy Individual - certified 75-80 min $82.47 1 11,99
W5039 Music Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5040 Music Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5017 Music Therapy Group - certified 45-60 min $24.64 1 11,99
W5041 Music Therapy Group - certified 75-80 min $32.04 1 11,99
W5042 Music Therapy Group - licensed 45-60 min $27.74 1 11,99
W5043 Music Therapy Group - licensed 75-80 min $36.07 1 11,99
W5018 Drama Therapy Individual - certified 45-50 min $63.43 1 11,99
W5056 Drama Therapy Individual - certified 75-80 min $82.47 1 11,99
W5057 Drama Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5058 Drama Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5019 Drama Therapy Group - certified 45-60 min $24.64 1 11,99
W5059 Drama Therapy Group - certified 75-80 min $32.04 1 11,99
W5060 Drama Therapy Group - licensed 45-60 min $27.74 1 11,99
W5061 Drama Therapy Group - licensed 75-80 min $36.07 1 11,99
W5000 Respite Care In Home/Commuinty Based 1 Hour $25.66 6/6 hrs per day 12,99
W5001 Respite Care Residential/Out of Home 1 overnight stayminimum of 12 hours $203.43 1/24 units per waiver year 12,99
W5062 Intensive In Home Services (EBP) Weekly $253.88 1 12
W5063 Intensive In Home Services weekly $201.42 1 12
W5066 Customized Goods and Services Billed Charges $2000.00 max 99

CPT CODE    DESCRIPTION

W0100    GENERAL MEDICAL EXAM, VA FACILITY
W0105    PSYCHIATRY EXAM, PER HOUR, VA FACILITY
W0110    NEUROLOGICAL EXAM, VA FACILITY
W0115    ENT EXAM, VA FACILITY
W0120    OPTHOMOLOGY EXAM, VA FACILITY
W0125    AUDIOLOGY EXAM, VA FACILITY
W0130    ORTHOPEDIC EXAM, VA FACILITY
W0135    CARDIOLOGY EXAM, VA FACILITY
W0140    DERMATOLOGY EXAM, VA FACILITY
W0145    NEUROSURGICAL EXAM, VA FACILITY
W0150    GU EXAM, VA FACILITY
W0155    GI EXAM, VA FACILITY
W0160    PULMONARY EXAM, VA FACILITY
W0200    POW EXAM, VA FACILITY, PER HOUR
W0210    AGENT ORANGE EXAM, VA FACILITY
W0220    SOCIAL/INDUSTRIAL SURVEY, PER HOUR
W0230    PTSD EXAM, VA FACILITY, PER HOUR
W5000    GENERAL MEDICAL EXAM, NON-VA FACILITY
W5010    PSYCHIATRIC EXAM, NON-VA FACILITY
W5015    NEUROLOGICAL EXAM, NON-VA FACILITY
W5020    ENT EXAM, NON-VA FACILITY
W5025    OPTHOMOLOGY EXAM, NON-VA FACILITY
W5030    AUDIOLOGY EXAM, NON-VA FACILITY
W5035    ORTHOPEDIC EXAM, NON-VA FACILITY
W5040    CARDIOLOGY EXAM, NON-VA FACILITY
W5045    DERMATOLOGY EXAM, NON-VA FACILITY
W5050    NEUROSURGICAL EXAM, NON-VA FACILITY
W5055    GU EXAM, NON-VA FACILITY
W5060    GI EXAM, NON-VA FACILITY
W5065    PULMONARY EXAM, NON-VA FACILITY
W5220    SOCIAL/INDUSTRIAL SURVEY, PER HOUR, NON-VA FACILITY
W5230    PTSD EXAM, NON-VA FACILITY

CPT 21010, 21050, 21116, 21240, 29800, 70330 -70355 - Temporomandibular Joint Disorder

Coding Code Description CPT

20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
21010 Arthrotomy, temporomandibular joint
21050 Condylectomy, temporomandibular joint
21060 Menisectomy, partial/complete, temporomandibular joint (separate procedure)
21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
21085 Impression and custom preparation; oral surgical splint
21089 Unlisted maxillofacial prosthetic procedure
21116 Injection procedure for temporomandibular joint arthrography
21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement
21480 Closed treatment of temporomandibular dislocation; initial or subsequent
21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent
21490 Open treatment of temporomandibular dislocation
29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
29804 Arthroscopy, temporomandibular joint, surgical
70328 Radiologic exam, temporomandibular joint, open and closed mouth; unilateral
70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral
70332 Temporomandibular joint arthrography, radiological supervision and interpretation
70350 Cephalogram, orthodontic
70355 Orthopantogram (eg, panoramic x-ray)

HCPCS

J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose
J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose
S3900 Surface electromyography (EMG) CDT
D7880 Occlusal orthotic device
D7881 Occlusal orthotic device adjustment
D7899 Unspecified TMD therapy, by report
D7999 Unspecified oral surgery procedure
D9940 Occlusal guard

Introduction

The temporomandibular joint (TMJ) is the joint where the jawbone connects to the skull. There is one joint on each side of the jaw. The areas of the bones forming the joint are covered with cartilage and separated by a small disk. This disk helps keep joint movement smooth. Sometimes the disc erodes or moves out of its proper position. Arthritis may develop in the joint and damage the cartilage, or an injury can damage the joint. Regardless of the cause, TMJ disorders (TMJD) can result in pain and affect the function of the joint and the muscles that control jaw movement. TMJDs may go away without treatment, or pain relievers can be used to alleviate symptoms. This policy describes the services that the health plan covers (considers medically necessary) to diagnose and treat TMJ symptoms and disorders. On some plans, services to treat TMJ problems are limited to a specific benefit which may have a dollar limit.



Policy Coverage Criteria

Treatment Medical Necessity

Diagnostic procedures The following diagnostic procedures may be considered medically necessary in the diagnosis of temporomandibular joint (TMJ) disorder:

* Diagnostic x-ray, tomograms, and arthrograms
* Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for presurgical evaluations)
* Cephalograms (x-rays of jaws and skull)
* Pantograms (x-rays of maxilla and mandible)

Note: Cephalograms and pantograms should be reviewed on an individual basis.

Surgical treatments The following surgical treatments may be considered medically necessary in the treatment of TMJ disorder:

* Arthrocentesis
* Manipulation for reduction of fracture or dislocation of the TMJ
* Arthroscopic surgery in patients with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment
* Open surgical procedures (when TMJ disorder results from congenital anomalies, trauma, or disease in patients who have failed conservative treatment) including, but not limited to:
o Arthroplasties
o Condylectomies
o Meniscus or disc plication
o Disc removal

Nonsurgical treatments The following nonsurgical treatments may be considered medically necessary in the treatment of TMJ disorder:

* Intraoral removable prosthetic devices/appliances (encompassing fabrication, insertion, adjustment)
* Pharmacologic treatment (eg, anti-inflammatory, muscle relaxing, analgesic medications)


Diagnostic procedures The following diagnostic procedures are considered investigational in the diagnosis of TMJ disorder:

* Arthroscopy of the TMJ for purely diagnostic purposes
* Computerized mandibular scan (this measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to TMJD)

* Electromyography (EMG), including surface EMG
* Joint vibration analysis
* Kinesiography
* Muscle testing
* Neuromuscular junction testing
* Range-of-motion measurements
* Somatosensory testing
* Standard dental radiographic procedures
* Thermography
* Transcranial or lateral skull x-rays; intraoral tracing or gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJD)
* Ultrasound imaging/sonogram

Nonsurgical treatments The following nonsurgical treatments are considered investigational in the treatment of TMJ disorder:
* Biofeedback
* Botulinum toxin
* Dental restorations/prostheses
* Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function
* Electrogalvanic stimulation
* Hyaluronic acid
* Iontophoresis
* Orthodontic services
* Percutaneous electrical nerve stimulation (PENS)
* Transcutaneous electrical nerve stimulation (TENS)
* Ultrasound
.



Description
Temporomandibular joint disorder (TMJD) refers to a group of disorders characterized by pain in the temporomandibular joint and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of nonsurgical and surgical treatment possibilities for patients whose symptoms persist.

Background

Temporomandibular joint disorder (TMJD; also known as temporomandibular joint syndrome) refers to a cluster of problems associated with the temporomandibular joint (TMJ) and musculoskeletal structures. The etiology of TMJD remains unclear and is believed to be multifactorial. TMJD are often divided into two main categories: articular disorders (eg, ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis, joint dislocation) and masticatory muscle disorders (eg, myofascial pain, myofibrotic contracture, myospasm, neoplasia). Diagnosis

In the clinical setting, TMJD is often a diagnosis of exclusion and involves physical examination, patient interview, and review of dental records. Diagnostic testing and radiologic imaging is generally only recommended for patients with severe and chronic symptoms. Diagnostic criteria for TMJD have been developed and validated for use in both clinical and research settings.1-3 Symptoms attributed to TMJD are varied and include, but are not limited to, clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).

Treatment

For many patients, symptoms of TMJD are short-term and self-limiting. Conservative treatments, such as eating soft foods, rest, heat, ice, and avoiding extreme jaw movements, and antiinflammatory medication, are recommended before consideration of more invasive and/or permanent therapies, such as surgery.


The most recent literature review was through December 20, 2016. Recent literature searches have concentrated on identifying systematic reviews and meta-analyses. For treatment of temporomandibular joint disorders (TMJD), the focus has been on studies that compared novel treatments with conservative interventions and/or placebo controls (rather than no-treatment control groups) and that reported pain reduction and/or functional outcomes (eg, jaw movement).

Botulinum Toxin A 2015 systematic review by Chen et al evaluated the literature on botulinum toxin (Botox) for treatment of temporomandibular joint disorders.36 Eligibility included RCTs comparing any dose or type of botulinum toxin with any alternative intervention or placebo. Five RCTs met the inclusion criteria; three were parallel group studies, and two were crossover studies. Study sizes tended to be small; all but 1 study included 30 or less participants. Three of the 5 studies were judged to be at high risk of bias. All studies administered a single injection of botulinum toxin and followed patients up at least 1 month later. Four studies used a placebo (normal saline) control group and the fifth used botulinum toxin to fascial manipulation.

The primary outcome was a validated pain scale. Data were not pooled due to heterogeneity among trials. In a qualitative review of the studies, only 2 of the 5 trials found a significant short-term (1-to-2 months) benefit of botulinum toxin compared with control on pain reduction. Summary of Evidence

For individuals who have suspected temporomandibular joint disorder (TMJD) who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. Relevant outcomes are test accuracy, test validity, and other performance measures. None of the systematic reviews found that these diagnostic techniques accurately identify patients with TMJD and many of the included studies had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have a confirmed diagnosis of TMJD who receive intraoral devices or appliances or pharmacologic treatment, the evidence includes randomized controlled trials (RCTs) and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of intraoral appliances (44 studies) and meta-analyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Other systematic reviews found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [vs placebo]). The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have a confirmed diagnosis of TMJD who receive acupuncture, biofeedback, transcutaneous electrical nerve stimulation, orthodontic services, or hyaluronic acid, the evidence includes RCTs, systematic reviews of these RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic reviews did not find that these technologies reduced pain or improved functional outcomes significantly more than control treatments. Moreover, many individual studies were small and/or had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have a confirmed diagnosis of TMJD, who receive arthrocentesis or arthroscopy, the evidence includes RCTs and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Only 1 review, which included 3 RCTs, compared arthrocentesis or arthroscopy with nonsurgical interventions for TMJD. Pooled analyses of the RCTs found that arthrocentesis and arthroscopy resulted in superior pain reduction than control interventions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. A systematic review of RCTs found insufficient evidence that botulinum toxin improves the net health outcome in patients with temporomandibular joint disorders. Studies tended to be small, have a high risk of bias, and only 2 of 5 RCTs found that botulinum toxin reduced pain more than a comparator.

FQHC cpt g0466, g0467, g0468, g0469, g0470

Specific Payment Codes for the Federally Qualified Health Center

In accordance with Section 1834(o)(1)(A) and 1834(o)(2)(C) of the Social Security Act, we established specific payment codes that FQHCs must use when submitting a claim for FQHC services for payment under the FQHC PPS. Detailed Healthcare Common Procedure Coding System (HCPCS) coding with the associated line item charges listing the visit that qualifies the service for an encounter-based payment and all other FQHC services furnished during the encounter are also required.

FQHC Visits

A FQHC visit is a medically-necessary medical or mental health visit, or a qualified preventive health visit. The visit must be a face-to-face (one-on-one) encounter between a FQHC patient and a FQHC practitioner during which time one or more FQHC services are furnished. A FQHC practitioner is a physician, nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), or a certified diabetes self-management training/medical nutrition therapy (DSMT/MNT) provider.

A FQHC visit can also be a visit between a home-bound patient and a RN or LPN under certain conditions. Outpatient DSMT/MNT, and transitional care management (TCM) services also may qualify as a FQHC visit when furnished by qualified practitioners and the FQHC meets the relevant program requirements for provision of these services. If these services are furnished on the same day as an otherwise billable visit, only one visit is payable.

The PPS is designed to reflect the cost for all the services associated with a comprehensive primary care visit, even if not all the services occur on the same day. Stand-alone billable visits are typically evaluation and management (E/M) type of services or screenings for certain preventive services. The professional component of a procedure is usually a covered service, but is not a stand-alone billable visit, even when furnished by a FQHC practitioner.

To qualify for Medicare payment, all the coverage requirements for a FQHC visit must be met. A FQHC visit must be furnished in accordance with the applicable regulations at 42 CFR Part 405 Subpart X, including 42 CFR 405.2463 that describes what constitutes a visit. For additional information on FQHC policies and requirements, see CMS Pub 100-02, Chapter 13,
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf.

Effective January 1, 2016 CPT code 99490 (chronic care management) is paid based on the PFS national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a FQHC claim. When reporting this service as a stand-alone billable visit a FQHC payment code is not required.


Specific Payment Codes

Following are the specific payment codes and the appropriate descriptions of services that correspond to these payment codes. FQHCs must use these codes when submitting claims to Medicare under the FQHC PPS:

G0466 – FQHC visit, new patient

A medically-necessary, face-to-face (one-on-one) encounter between a new patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving medical services. A new patient is one who has not received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within the past three years prior to the date of service.

To qualify as a FQHC visit, the encounter must include one of the services listed under “Qualifying Visits.”

If a new patient is also receiving a mental health visit on the same day, the patient is considered “new” for only one of these visits, and FQHCs should use G0466 to bill for the medical visit and G0470 to bill for the mental health visit.

Additional information on new patient determinations is available on the CMS FQHC PPS website (http://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHCCenter.

htm) under “Frequently Asked Questions” (http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-FAQs.pdf).


G0467 – FQHC visit, established patient 

A medically-necessary, face-to-face (one-on-one) encounter between an established patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving medical services. An established patient is one who has received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within three years prior to the date of service.

To qualify as a FQHC visit, the encounter must include one of the services listed under “Qualifying Visits.”

If an established patient is also receiving a mental health visit on the same day, the FQHC can bill for 2 visits and should use G0467 to bill for the medical visit and G0470 to bill for the mental health visit.


G0468 – FQHC visit, IPPE or AWV

A FQHC visit that includes an Initial Preventive Physical Exam (IPPE) or Annual Wellness Visit (AWV) and includes the typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving an IPPE or AWV, including all services that would otherwise be billed as a FQHC visit under G0466 or G0467.


G0469 – FQHC visit, mental health, new patient

A medically-necessary, face-to-face (one-on-one) mental health encounter between a new patientand a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving a mental health visit.

A new patient is one who has not received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within the past three years prior to the date of service.

To qualify as a FQHC mental health visit, the encounter must include a qualified mental health service, such as a psychiatric diagnostic evaluation or psychotherapy. If a new patient is receiving both a medical and mental health visit on the same day, the patient is considered “new” for only one of these visits, and FQHCs should not use G0469 to bill for the mental health visit; instead, FQHCs should use G0466 to bill for the medical visit and G0470 to bill for the mental health visit.

G0470 – FQHC visit, mental health, established patient

A medically-necessary, face-to-face (one-on-one) mental health encounter between an established patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving a mental health visit. An established patient is one who has received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within three years prior to the date of service.

If an established patient is receiving both a medical and mental health visit on the same day, the FQHC can bill for 2 visits and should use G0467 to bill for the medical visit and G0470 to bill for the mental health visit.

To qualify as a FQHC mental health visit, the encounter must include a qualified mental health service, such as a psychiatric diagnostic evaluation or psychotherapy.

Adjustments Applicable to Specific Payment Codes1 

New Patient Adjustment: The PPS payment rate will be adjusted by a factor of 1.3416 when a FQHC furnishes care to a patient who is new to the FQHC. For medical visits, use G0466 only if the beneficiary is new to the FQHC or any of its sites for any professional services. For mental health visits, use G0469 only if the beneficiary is new to the FQHC or any of its sites for any professional services.

IPPE and AWV Adjustment: The PPS payment rate will be adjusted by a factor of 1.3416 when a FQHC furnishes an IPPE or an Annual Wellness Visit (AWV) to a Medicare beneficiary. A FQHC that furnishes an IPPE or AWV would include all medical services in G0468. FQHCs would not bill G0466 or G0467 on the same day, unless there was a subsequent illness or injury that would qualify for additional payment, which the FQHC would attest to by submitting the claim with modifier 59.


Qualifying Visits

The qualifying visits that correspond to the specific payment codes are as follows:



G0466 - FQHC visit, new patient

HCPCS Qualifying Visits for G0466 Effective Date

92002 Eye exam new patient

92004 Eye exam new patient

97802 Medical nutrition indiv in

99201 Office/outpatient visit new

99202 Office/outpatient visit new

99203 Office/outpatient visit new

99204 Office/outpatient visit new

99205 Office/outpatient visit new

99304 Nursing facility care init October 1, 2016

99305 Nursing facility care init October 1, 2016

99306 Nursing facility care init October 1, 2016

99324 Domicil/r-home visit new pat

99325 Domicil/r-home visit new pat

99326 Domicil/r-home visit new pat

99327 Domicil/r-home visit new pat

99328 Domicil/r-home visit new pat

99341 Home visit new patient

99342 Home visit new patient

99343 Home visit new patient

99344 Home visit new patient

99345 Home visit new patient

994062 Behav chng smoking 3-10 min October 1, 2016

994072 Behav chng smoking > 10 min October 1, 2016

99497 Advncd care plan 30 min

G0101 Ca screen; pelvic/breast exam

G0102 Prostate ca screening; dre

G0108 Diab manage trn per indiv

G0117 Glaucoma scrn hgh risk direc

G0118 Glaucoma scrn hgh risk direc

G0296 Visit to determ LDCT elig

G0442 Annual alcohol screen 15 min

G0443 Brief alcohol misuse counsel

G0444 Depression screen annual


HCPCS Qualifying Visits for G0466 Effective Date

G0445 High inten beh couns std 30 min

G0446 Intens behave ther cardio dx

G0447 Behavior counsel obesity 15 min

G0490 Home visit RN, LPN by RHC/FQ October 1, 2016

Q0091 Obtaining screen pap smear



G0467 – FQHC visit, established patient:

HCPCS Qualifying Visits for G0467

92012 Eye exam establish patient

92014 Eye exam & tx estab pt 1/>vst

97802 Medical nutrition indiv in

97803 Med nutrition indiv subseq

99212 Office/outpatient visit est

99213 Office/outpatient visit est

99214 Office/outpatient visit est

99215 Office/outpatient visit est

99304 Nursing facility care init

99305 Nursing facility care init

99306 Nursing facility care init

99307 Nursing fac care subseq

99308 Nursing fac care subseq

99309 Nursing fac care subseq

99310 Nursing fac care subseq

99315 Nursing fac discharge day

99316 Nursing fac discharge day

99318 Annual nursing fac assessmnt

99334 Domicil/r-home visit est pat

99335 Domicil/r-home visit est pat

99336 Domicil/r-home visit est pat

99337 Domicil/r-home visit est pat

99347 Home visit est patient

99348 Home visit est patient

99349 Home visit est patient

99350 Home visit est patient

994062 Behav chng smoking 3-10 min October 1, 2016

994072 Behav chng smoking > 10 min October 1, 2016

99496 Trans care mgmt 7 day disch

99497 Advncd care plan 30 min

G0101 Ca screen; pelvic/breast exam

G0102 Prostate ca screening; dre

G0108 Diab manage trn per indiv

G0117 Glaucoma scrn hgh risk direc

G0118 Glaucoma scrn hgh risk direc

HCPCS Qualifying Visits for G0467

G0270 Mnt subs tx for change dx

G0296 Visit to determ LDCT elig

G0442 Annual alcohol screen 15 min

G0443 Brief alcohol misuse counsel

G0444 Depression screen annual

G0445 High inten beh couns std 30 min

G0446 Intens behave ther cardio dx

G0447 Behavior counsel obesity 15 min

G0490 Home visit RN, LPN by RHC/FQ October 1, 2016

Q0091 Obtaining screen pap smear



G0468 – FQHC visit, IPPE or AWV:

HCPCS Qualifying Visits for G0468

G0402 Initial preventive exam

G0438 Ppps, initial visit

G0439 Ppps, subseq visit



G0469 – FQHC visit, mental health, new patient:

HCPCS Qualifying Visits for G0469

90791 Psych diagnostic evaluation

90792 Psych diag eval w/med srvcs

90832 Psytx pt &/family 30 minutes

90834 Psytx pt &/family 45 minutes

90837 Psytx pt &/family 60 minutes

90839 Psytx crisis initial 60 min

90845 Psychoanalysis



G0470 – FQHC visit, mental health, established patient:

HCPCS Qualifying Visits for G0470

90791 Psych diagnostic evaluation

90792 Psych diag eval w/med srvcs

90832 Psytx pt &/family 30 minutes

90834 Psytx pt &/family 45 minutes

90837 Psytx pt &/family 60 minutes

90839 Psytx crisis initial 60 min

90845 Psychoanalysis

CPT code 92133, 92134, 92132 - SCODI

Procedure code and Description

Group 1 Paragraph: N/A

Group 1 Codes:

92132 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL

92133 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE


92134 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Medicare will consider scanning computerized ophthalmic diagnostic imaging (SCODI) medically reasonable and necessary in evaluating retinal disorders, glaucoma and anterior segment disorders as documented in this local coverage determination (LCD).

SCODI includes the following tests:

Confocal Laser Scanning Ophthalmoscopy (topography) uses stereoscopic videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina.

Scanning Laser Polarimetry (nerve fiber analyzer) measures change in the linear polarization of light (retardation). It uses both a polarimeter (an optical device to measure linear polarization change) and a scanning laser ophthalmoscope, to measure the thickness of the nerve fiber layer of the retina.

Optical Coherence Tomography (OCT) a non-invasive, non-contact imaging technique.

OCT, especially SCODI, produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of the optic nerve head, nerve fiber layer, and retina.

Scanning computerized ophthalmic diagnostic imaging allows earlier detection of glaucoma and more sophisticated analysis for ongoing management. These tests also provide more precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of time than visual fields and/or disc photos. This allows earlier and more efficient efforts of treatment toward the disease process.

Indications

Glaucoma

Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Glaucoma also is diagnostically challenging. Almost 50% of glaucoma cases remain undetected. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 30% of those suffering from the disease have pressures in the normal range. 

Glaucoma commonly causes a spectrum of related eye and vision changes, including erosion of the optic nerve and the associated retinal nerve fibers, and also loss of peripheral vision. A diagnosis of glaucoma seldom is made on the basis of a single clinical observation, but instead relies upon analysis of an assemblage of clinical data, including: optic nerve, retinal nerve fiber, and anterior chamber structures, as well as looking for hemorrhages of the optic nerve, pigment in the anterior chamber, and, especially visual field loss. Each of these methods has its own strengths and limitations, thus the dependence upon multiple observations. Careful reliance upon all available clinical data can allow early treatment and can prevent unnecessary end-stage therapies.

Scanning Computer Ophthalmic Diagnostic Imaging (SCODI) allows earlier detection of those patients with normal tension glaucoma and more sophisticated analysis for ongoing management. Because SCODI detects glaucomatous damage to the nerve fiber layer or optic nerve of the eye, it can distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure (IOP). It may separate patients with elevated IOP and early glaucoma damage from those without glaucoma.

Technological improvements have rendered SCODI as a valuable diagnostic tool in the diagnosis and treatment of glaucoma. These improvements enable discernment of changes of the optic nerve and nerve fiber layer, even in advanced cases of glaucoma. 

It is expected that only two (SCODI) exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma. 

Retinal Disorders

Retinal disorders are the most common causes of severe and permanent vision loss. Scanning computerized ophthalmic diagnostic imaging (SCODI) is a valuable tool for the evaluation and treatment of patients with retinal disease, especially macular abnormalities. SCODI is able to detail the microscopic anatomy of the retina and the vitreo-retinal interface. SCODI is useful to measure the effectiveness of therapy, and in determining the need for ongoing therapy, or the safety of cessation of that therapy.

Retinal thickness analysis is a non-invasive and non-contact imaging technique that takes direct cross-sectional images of the retina. These high resolution images capture ocular structures and provide data to create thickness maps of the retina. Retinal thickness is directly correlated to ocular disease, including retinal disorders and glaucoma. In contrast, Scanning Laser Polarimetry is not an appropriate diagnostic technique for the management of retinal disorders.

Long Term Use of Chlorquine (CQ) and or Hydroxychloroquine (HCQ)

Clinical evidence has shown that long-term use of chloroquine (CQ) and/or hydroxychloroquine (HCQ) can lead to irreversible retinal toxicity. Therefore, these two medications are deemed high risk, and scanning optical coherence tomography may be indicated to provide a baseline prior to starting the medication and as an annual follow-up. Clinical evidence shows that the resolution of time domain OCT instruments is not sufficient to detect early toxic retinal changes. Because of that, spectral domain-optical coherence tomography (SD-OCT) is expected to be used to detect retinal changes that are due to the use of CQ or HCQ. 

Anterior Segment Disorders

SCODI may be used to examine the structures in the anterior segment structures of the eye. However, it is still seen as experimental/investigational except in the following:

Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma

Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction

Iris tumor

Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber

Calculation of lens power for cataract patients who have undergone prior refractive surgery. Payment will only be made for the cataract codes as long as additional documentation is available in the patient record of their prior refractive procedure. Payment will not be made in addition to A-scan or IOL master.

Limitations

The following codes/ procedures would generally not be necessary with SCODI. When medically needed the same day, documentation must justify the procedures.

92250 - Fundus photography with interpretation and report

92225 - Opthalmoscopy extended with retinal drawing (e.g. For retinal detachment, melanoma) with interpretation and report initial

92226 - Subsequent ophthalmoscopy

76512 - B-scan (with or without superimposed non-quantitative A-scan)

Coverage Topic

Diagnostic Tests, and X-Rays Coding Information

1. Use CPT code(s) 92133 or 92134 to report OCT, include any necessary modifiers (e.g. 26, TC).

1. CPT codes 92133 and 92134 are classified as unilateral or bilateral procedures.

2. Bill the test on a single line, place 00010 in Item 24G on the CMS 1500 claim form or its equivalent.

3. Per CPT guidelines, do not report 92133 and 92134 at the same patient encounter.

4. List the ICD-9 code that best support the medical necessity for the OTC and describes the patient's condition. ICD-9 code(s) must be present on all Physicians’ Service claims and must be coded to the highest level of accuracy and digit level completeness.

5. *When billing for Spectral Domain-Optical Coherence Tomography (SD-OCT) chloroquine (CQ) and/or hydroxychloroquine (HCQ) for retinal toxicity monitoring, place “SD-OCT) in box #19 to reflect that this form of Optical Coherence Tomography was use. 

6. When billing for services, requested by the beneficiary for denial that are Medicare exclusions (i.e. screening) report a screening ICD-9 (V80.2) code and the GY modifier - item or service statutorily excluded or does not meet the definition of any Medicare benefit. A Notice of Exclusion from Medicare Benefits (NEMB) may be used with services excluded from Medicare benefits. See http://www.cms..gov/BNI/01_overview.asp#TopOfPage

7. When billing services, requested by the beneficiary for denial, that would be considered not reasonable and necessary report an ICD-9 code that best described the patients condition and the GA modifier if an ABN signed by the beneficiary is on file or the GZ modifier - item or service expected to be denied as not medically necessary when a signed ABN for this service is not on file.

Denial Summary

The following situations will result in the denial of the initial diagnostic services or in some cases as a result of a postpayment review

Title XVIII of the Social Security Act section 1862(a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.

1. Services submitted without an ICD-9 code to support medical necessity will be denied as not medical necessity

2. Services billed at excessive frequency will be denied as not medically necessity.

3. Optic disc studies are not to be used as a screening tool for all patients. There must be documented indications from the patient’s exam to justify the medical necessity for testing. Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical checkups and eye examinations and services

4. This service performed for screening purposes or in the absence of associated signs, symptoms, illness or injury will be denied as non-covered.

Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

5. Physicians’ services submitted without an ICD-9 code or not coded to the highest level of accuracy and digit level completeness will be denied as unprocessable. 

92134 retina

As you can see, code 92134 in the CPT book is indented under 92133 and simply states “retina,” but it is read as follows: Scanning computer diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina.

Notes:

• If a code contains the wording “unilateral or bilateral,” then the provider will be paid the same amount whether one or both sides are tested. If there is no “unilateral or bilateral” designation, then Medicare reverts to the bilateral surgery indicator found in the MPFSDB for determination of payment.

• CPT code 92134 indicates “unilateral or bilateral,” meaning that the provider is paid the same amount whether one or both eyes are tested.

• By contrast, CPT code 76512 reads: Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed nonquantitative A-scan). This code does not specify “unilateral or bilateral,” and it is paid according to the indicator in the MPFSDB. The indicator is 3, signifying that each side will be paid 100% of the Medicare fee schedule allowed amount for that code.

OCT  92134

The CPT description for OCT (92134) for the retina was given above in the discussion of “unilateral or bilateral.” It does contain the phrase “unilateral or bilateral,” with a bilateral surgery indicator of 2, and it is therefore billed only once regardless of whether one or both sides are tested. Do not use modifier 52 when only one side is tested. Caution is also warranted when billing fundus photography in lieu of OCT because age-related macular degeneration treatment is based on the results of OCT; thus, it is OCT, not fundus photography, for which there is medical necessity

92134-Scanning Computerized Ophthalmic Dagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

* Retinal disorders are most common causes of severe and permanent vision loss. These technologies are valuable tools for evaluation and treatment of patients with retinal disease, especially macular abnormalities.

* These imaging techniques are useful tools to measure effectiveness of therapy, and in determining need for ongoing therapy, or safety of cessation of therapy.

92134-Scanning Computerize Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

* Only one exam/eye/2 months is allowed for the patient whose primary ophthalmological diagnosis is related to a retinal disease

* One exam/eye/month is allowed for the patient who is undergoing active treatment for macular degeneration or diabetic retinopathy

Ganglion Cell Analysis-92134 Isolates Ganglion Cell Layer

• Measures thickness for sum of  GCL and IPL layers using data from Macular cube scans.

• RNFL distribution in the macula depends on individual anatomy, while the GCL+IPL appears regular and elliptical for most normal individuals

Propriety algorithms are adapted for specific anatomy, use GCL and IPL thickness

Fundus Photography & SCODI

* There has been no specific document defining when you can use 92133 and 92134 with 92250

* This means there is no official CMS guidance on using “mutually exclusive” codes on the same date of service.

National Correct Coding Initiative (NCCI) • Developed with RBRVS- 2003

• Insures proper Medicare payments (Resource Based Relative Value System)

• Identify pairs of services not billed together (same physician for same patient on same day)

• Component element edits

o 92012 and 92014

• Medically Unlikely Edits  (MUE) policy manual

o 92133 or 92134 and 92250 but MAY use -59 modifier

o 92133 and 92134 may NOT be used together even with -59 modifier

NCCI Edits Relevant to Optometry

* Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (e.g., CPT codes 92132, 92133, 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to CPT code 92250. (CPT code 92135 was deleted January 1, 2011.)

*CPT code 92071 (fitting of contact lens for treatment of ocular surface disease) should not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a procedure on the cornea.

ICD-10 Codes that Support Medical Necessity 

ICD-10 CODE DESCRIPTION

C69.01 Malignant neoplasm of right conjunctiva

C69.02 Malignant neoplasm of left conjunctiva

C69.11 Malignant neoplasm of right cornea

C69.12 Malignant neoplasm of left cornea

C69.21 Malignant neoplasm of right retina

C69.22 Malignant neoplasm of left retina

C69.31 Malignant neoplasm of right choroid

C69.32 Malignant neoplasm of left choroid

C69.41 Malignant neoplasm of right ciliary body

C69.42 Malignant neoplasm of left ciliary body

C69.51 Malignant neoplasm of right lacrimal gland and duct

C69.52 Malignant neoplasm of left lacrimal gland and duct

C69.61 Malignant neoplasm of right orbit

C69.62 Malignant neoplasm of left orbit

C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa

C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa

D31.01 Benign neoplasm of right conjunctiva

D31.02 Benign neoplasm of left conjunctiva

D31.11 Benign neoplasm of right cornea

D31.12 Benign neoplasm of left cornea

D31.21 Benign neoplasm of right retina

D31.22 Benign neoplasm of left retina

D31.31 Benign neoplasm of right choroid

D31.32 Benign neoplasm of left choroid

D31.41 Benign neoplasm of right ciliary body

D31.42 Benign neoplasm of left ciliary body

D31.51 Benign neoplasm of right lacrimal gland and duct

D31.52 Benign neoplasm of left lacrimal gland and duct

D31.61 Benign neoplasm of unspecified site of right orbit

D31.62 Benign neoplasm of unspecified site of left orbit

D31.91 Benign neoplasm of unspecified part of right eye

D31.92 Benign neoplasm of unspecified part of left eye

H16.001 Unspecified corneal ulcer, right eye

H16.002 Unspecified corneal ulcer, left eye

H16.003 Unspecified corneal ulcer, bilateral

H16.011 Central corneal ulcer, right eye

H16.012 Central corneal ulcer, left eye

H16.013 Central corneal ulcer, bilateral

H16.021 Ring corneal ulcer, right eye

H16.022 Ring corneal ulcer, left eye

H16.023 Ring corneal ulcer, bilateral

H16.031 Corneal ulcer with hypopyon, right eye

H16.032 Corneal ulcer with hypopyon, left eye

H16.033 Corneal ulcer with hypopyon, bilateral

H16.041 Marginal corneal ulcer, right eye

H16.042 Marginal corneal ulcer, left eye

H16.043 Marginal corneal ulcer, bilateral

H16.051 Mooren's corneal ulcer, right eye

H16.052 Mooren's corneal ulcer, left eye

H16.053 Mooren's corneal ulcer, bilateral

H16.061 Mycotic corneal ulcer, right eye

H16.062 Mycotic corneal ulcer, left eye

H16.063 Mycotic corneal ulcer, bilateral

H16.071 Perforated corneal ulcer, right eye

H16.072 Perforated corneal ulcer, left eye

H16.073 Perforated corneal ulcer, bilateral

H18.11 Bullous keratopathy, right eye

H18.12 Bullous keratopathy, left eye

H18.13 Bullous keratopathy, bilateral

H18.20 Unspecified corneal edema

H18.211 Corneal edema secondary to contact lens, right eye

H18.212 Corneal edema secondary to contact lens, left eye

H18.213 Corneal edema secondary to contact lens, bilateral

H18.221 Idiopathic corneal edema, right eye

H18.222 Idiopathic corneal edema, left eye

H18.223 Idiopathic corneal edema, bilateral

H18.231 Secondary corneal edema, right eye

H18.232 Secondary corneal edema, left eye

H18.233 Secondary corneal edema, bilateral

H18.50 Unspecified hereditary corneal dystrophies

H18.51 Endothelial corneal dystrophy

H18.711 Corneal ectasia, right eye

H18.712 Corneal ectasia, left eye

H18.713 Corneal ectasia, bilateral

H18.721 Corneal staphyloma, right eye

H18.722 Corneal staphyloma, left eye

H18.723 Corneal staphyloma, bilateral

H18.731 Descemetocele, right eye

H18.732 Descemetocele, left eye

H18.733 Descemetocele, bilateral

H40.021 Open angle with borderline findings, high risk, right eye

H40.022 Open angle with borderline findings, high risk, left eye

H40.023 Open angle with borderline findings, high risk, bilateral

H40.031 Anatomical narrow angle, right eye

H40.032 Anatomical narrow angle, left eye

H40.033 Anatomical narrow angle, bilateral

H40.061 Primary angle closure without glaucoma damage, right eye

H40.062 Primary angle closure without glaucoma damage, left eye

H40.063 Primary angle closure without glaucoma damage, bilateral

H40.1110 Primary open-angle glaucoma, right eye, stage unspecified

H40.1111 Primary open-angle glaucoma, right eye, mild stage

H40.1112 Primary open-angle glaucoma, right eye, moderate stage

H40.1113 Primary open-angle glaucoma, right eye, severe stage

H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage

H40.1120 Primary open-angle glaucoma, left eye, stage unspecified

H40.1121 Primary open-angle glaucoma, left eye, mild stage

H40.1122 Primary open-angle glaucoma, left eye, moderate stage

H40.1123 Primary open-angle glaucoma, left eye, severe stage

H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage

H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified