Duplex Scan Of Lower Extremity Arteries - 93925, 93926 - Coverage info

Procedure code and Description

Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral.

93925 A complete duplex scan of the lower extremity arteries includes examination of the full length of the common femoral, superficial femoral and popliteal arteries. The iliac, deep femoral, and tibioperoneal arteries may also be examined. Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited  study

93926  The limited study is reported when only one extremity is examined or when less than a full examination is performed (e.g., only one or two vessels or follow-up) Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral

Duplex Scan Of Lower Extremity Arteries

Coverage Indications, Limitations, and/or Medical Necessity
Noninvasive peripheral arterial studies include two types of testing, noninvasive physiologic studies and duplex scans. Noninvasive physiologic studies are functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements or plethysmography. A complete extremity physiologic study includes pressure measurements and an additional physiologic technique, e.g., Doppler ultrasound study or plethysmography.

Plethysmography implies volume measurement procedures including air impedance or strain gauge methods. Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part.

Noninvasive physiologic studies are performed using equipment separate and distinct from the duplex scanner. Duplex scanning combines the information provided by two-dimensional imaging with pulsed-wave doppler techniques which allows analysis of the blood flow velocity.

Vascular studies include patient care required to perform the studies, supervision of the studies and interpretation of study results with copies for patient records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided. The display may be a two-dimensional image with spectral analysis and color flow or a plethysmographic recording that allows for quantitative analysis.]

Indications

In general, noninvasive arterial studies are indicated when endovascular or other invasive correction is contemplated, but not to follow noninvasive medical treatment regimens or to monitor unchanged symptomatology. The latter may be followed with physical findings, including Ankle/Brachial Indices (ABIs), and/or progression or relief of signs and/or symptoms.

Duplex scanning of the lower extremity arteries performed to establish the level and/or degree of arterial occlusive disease, will be considered medically necessary if a) significant signs and/or symptoms indicate a high likelihood of limb ischemia, and b) the patient is a candidate for invasive therapeutic procedures under any of the following circumstances:

• The patient has symptoms of peripheral vascular ischemia and is found on physical examination to have absence or marked diminution of pulses (suspected to be secondary to obstruction of lower extremity arteries) of one or both lower extremities.

• The patient has developed sudden pallor, numbness, and coolness of an extremity and vascular obstruction (embolism or thrombosis) is suspected.
• Claudication of less than one block or of such severity that it interferes significantly with the patient's occupation or lifestyle.
• The patient has an aneurysm or arteriovenous malformation of a lower extremity artery.
• The patient has sustained lower extremity trauma with possible vascular injury or the patient has sustained iatrogenic vascular injury.
• Rest pain of ischemic origin (typically including the forefoot), associated with absent pulses, which becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent position.
• Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of the extremity occurring in the absence of pulses.

Follow-up studies post-operative conditions:
In the immediate post-operative period if re-established pulses are lost, become equivocal, or if the patient develops related signs and/or symptoms of ischemia with impending repeat intervention.
Following bypass surgery or post-angioplasty with or without stent placement at three months, six months and one year when clinically indicated.

Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease evidenced by signs (i.e. decreased ABI from previous exam) or symptoms (i.e., recurrence of claudication symptoms that interfere significantly with the patient’s occupation or lifestyle). For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not considered necessary to do both.

Limitations


A routine history and physical examination, which includes Ankle/Brachial Indices (ABIs), can readily document the presence or absence of ischemic disease in a majority of cases. It is not medically necessary to proceed beyond the physical examination for minor signs and symptoms such as hair loss, absence of a single pulse, relative coolness of a foot, shiny thin skin, or lack of toe nail growth unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.

An ABI is not a separately reimbursable procedure when performed by itself and would be considered part of the physical examination. When the ABI is abnormal (i.e., <0 .9="" accompanied="" ankle="" another="" appropriate="" at="" be="" before="" blood="" by="" complete="" elevated="" except="" in="" indication="" it="" more="" must="" or="" p="" patients="" pressure.="" proceeding="" rest="" severely="" sophisticated="" studies="" to="" with="">
Examples of additional signs and symptoms that do not indicate medical necessity include:

• Continuous burning of the feet is considered to be a neurologic symptom.
• "Leg pain, nonspecific" or "Pain in limb" as single diagnoses are too general to warrant further investigation unless they can be related to other signs and symptoms.
• Edema rarely occurs with arterial occlusive disease unless it is in the immediate postoperative period, in association with another inflammatory process or in association with rest pain.
• Absence of relatively minor pulses (eg, dorsalis pedis or posterior tibial) in the absence of ischemic symptoms. The absence of pulses is not an indication to proceed beyond the physical examination unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.
• Screening of an asymptomatic patient is not covered.

In general, non-invasive studies of the arterial system are to be utilized when invasive correction is contemplated, but not to follow non-invasive medical treatment regimens (e.g., to evaluate pharmacologic intervention) or to monitor unchanged symptomatology. The latter may be followed with physical findings including ABIs and/or progression or relief of signs and/or symptoms.

Noninvasive vascular testing studies are medically necessary only if the outcome will potentially impact the clinical management of the patient. For example, if a patient is (or is not) proceeding on to other diagnostic and/or therapeutic procedures regardless of the outcome of non-invasive studies, and non-invasive vascular procedures will not provide any unique diagnostic information that would impact patient management, then the non-invasive procedures are not medically necessary. If it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then non-invasive vascular studies are not medically necessary. It is also expected that the studies are not redundant of other diagnostic procedures that must be performed.

When an uninterpretable study (i.e., poor quality or not in accordance with regulatory standards) results in performing another type of study, only the successful study should be billed. For example, when an uninterpretable non-invasive physiologic study (CPT code 93922, 93923 or 93924) is performed which results in performing a duplex scan (CPT codes 93925 or 93926), only the duplex scan should be billed.

Noninvasive vascular procedures will not be covered when performed based on internal protocols of the testing facility; a referral for one noninvasive study is not a blanket referral for all studies. Each procedure must be specifically ordered by the physician/nonphysician practitioner treating the patient and the medical necessity criteria specified in this LCD must be met.

Typically, it is appropriate for follow-up studies post-angioplasty, with or without stent placement to be performed at three months, six months and one year. Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease evidenced by signs (i.e. decreased ABI from previous exam) or symptoms (i.e. recurrence of claudication). For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not considered necessary to do both.

Performance of both a physiological test (93922, 93923, 93924) and duplex scanning (93925, 93926) of extremity arteries during the same encounter would not generally be expected. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available upon request. Note: Reimbursement of physiologic testing will not be allowed after a duplex scan has been performed.

Since the signs and symptoms of arterial occlusive disease and venous disease are so divergent, the performance of simultaneous arterial and venous studies during the same encounter should be rare. Consequently, documentation must clearly support the medical necessity of both procedures if performed during the same encounter.

Performance of both non-invasive extracranial arterial studies (CPT code 93880 or 93882) and non-invasive evaluation of extremity arteries (CPT code 93925 or 93926) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available upon request.

The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported (CPT 2005, page 370 and CPT 2006, page 388). The appropriate assignment of a specific ultrasound CPT code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. If an examination is performed with hand-carried equipment, the quality of the exam, printout, and report must be in keeping with accepted national standards.

Revenue Codes

Code Description
0920 Other Diagnostic Services - General Classification
0921 Other Diagnostic Services - Peripheral Vascular Lab
0929 Other Diagnostic Services - Other Diagnostic Service


CPT/HCPCS Codes

Group 1 Codes
93925 Lower extremity study
93926 Lower extremity study

CPT CODE -37421, 76942, ICD code for Varicose veins treatment, Revenue code

ICD 10 code for varicose veins

I83001 Varicose veins of unsp lower extremity with ulcer of thigh
I83002 Varicose veins of unsp lower extremity with ulcer of calf
I83003 Varicose veins of unsp lower extremity with ulcer of ankle
I83004 Varicos vn unsp lower extremity w ulcer of heel and midfoot
I83005 Varicos vn unsp lower extremity w ulcer oth part of foot
I83008 Varicos vn unsp low extrm w ulcer oth part of lower leg
I83009 Varicose veins of unsp lower extremity w ulcer of unsp site
I83011 Varicose veins of right lower extremity with ulcer of thigh
I83012 Varicose veins of right lower extremity with ulcer of calf
I83013 Varicose veins of right lower extremity with ulcer of ankle
I83014 Varicose veins of r low extrem w ulcer of heel and midfoot
I83015 Varicose veins of r low extrem w ulcer oth part of foot
I83018 Varicose veins of r low extrem w ulcer oth part of lower leg
I83019 Varicose veins of right lower extremity w ulcer of unsp site
I83021 Varicose veins of left lower extremity with ulcer of thigh
I83022 Varicose veins of left lower extremity with ulcer of calf
I83023 Varicose veins of left lower extremity with ulcer of ankle
I83024 Varicose veins of l low extrem w ulcer of heel and midfoot
I83025 Varicose veins of l low extrem w ulcer oth part of foot
I83028 Varicose veins of l low extrem w ulcer oth part of lower leg
I83029 Varicose veins of left lower extremity w ulcer of unsp site
I8310 Varicose veins of unsp lower extremity with inflammation
I8311 Varicose veins of right lower extremity with inflammation
I8312 Varicose veins of left lower extremity with inflammation
I83201 Varicos vn unsp low extrm w ulc of thigh and inflammation
I83202 Varicos vn unsp low extrm w ulc of calf and inflammation
I83203 Varicos vn unsp low extrm w ulc of ankle and inflammation
I83204 Varicos vn unsp low extrm w ulc of heel and midft and inflam
I83205 Varicos vn unsp low extrm w ulc oth part of foot and inflam
I83208 Varicos vn unsp low extrm w ulc oth prt low extrm and inflam
I83209 Varicos vn unsp low extrm w ulc of unsp site and inflam
I83211 Varicos vn of r low extrem w ulc of thigh and inflammation
I83212 Varicos vn of r low extrem w ulc of calf and inflammation
I83213 Varicos vn of r low extrem w ulc of ankle and inflammation
I83214 Varicos vn of r low extrem w ulc of heel & midft and inflam
I83215 Varicos vn of r low extrem w ulc oth part of foot and inflam
I83218 Varicos vn of r low extrem w ulc oth prt low extrm & inflam
I83219 Varicos vn of r low extrem w ulc of unsp site and inflam
I83221 Varicos vn of l low extrem w ulc of thigh and inflammation
I83222 Varicos vn of l low extrem w ulc of calf and inflammation
I83223 Varicos vn of l low extrem w ulc of ankle and inflammation
I83224 Varicos vn of l low extrem w ulc of heel & midft and inflam
I83225 Varicos vn of l low extrem w ulc oth part of foot and inflam
I83228 Varicos vn of l low extrem w ulc oth prt low extrm & inflam
I83229 Varicos vn of l low extrem w ulc of unsp site and inflam
I83811 Varicose veins of right lower extremities with pain
I83812 Varicose veins of left lower extremities with pain
I83813 Varicose veins of bilateral lower extremities with pain
I83819 Varicose veins of unspecified lower extremities with pain
I83891 Varicose veins of right low extrm w oth complications
I83892 Varicose veins of left lower extremities w oth complications
I83893 Varicose veins of bi low extrem w oth complications
I83899 Varicose veins of unsp lower extremities w oth complications
I8390 Asymptomatic varicose veins of unspecified lower extremity
I8391 Asymptomatic varicose veins of right lower extremity
I8392 Asymptomatic varicose veins of left lower extremity
I8393 Asymptomatic varicose veins of bilateral lower extremities
I863 Vulval varices
I868 Varicose veins of other specified sites

Indications of Coverage and/or Medical Necessity

Varicose veins are a manifestation of chronic venous disease (CVD) caused by ambulatory venous hypertension. Varicose veins are superficially located, dilated, tortuous, veins of the lower extremities. They are usually caused by insufficiency, or valvular reflux, of the valvular apparatus (primary disease), or as a result of previous thrombosis or trauma (secondary disease). These dilated superficial veins of the lower limbs are considered pathologic when they are 5 mm or greater in diameter or sometimes 3 mm or greater in diameter (depending on the indication as outlined further in the LCD) when measured in the upright position and have greater than 500 milliseconds of reflux by duplex scan. CVD can cause clinically significant pain and result in a decrease in quality of life and even disability which may necessitate treatment which would be considered reasonable and necessary. CVD is progressive, and over time may progress to secondary skin changes (edema, lipodermatosclerosis, and ulceration), which is referred to as chronic venous insufficiency (CVI). CVD and CVI can be further complicated by superficial thrombophlebitis and variceal hemorrhage.

The superficial venous system has one-way valves that prevent backflow of blood (reflux) when normal and allow movement of blood toward the heart. The axial superficial veins communicate with the deep venous system at different locations. The point where the great saphenous vein (GSV) joins the common femoral vein, saphenofemoral junction (SFJ), is located proximally at the groin. The point where the small saphenous vein (SSV) joins the popliteal vein, saphenopopliteal junction (SPJ), is typically located behind the knee. Reflux involves the main axial superficial veins: GSV and SSV saphenous veins and their tributaries. Clinically significant reflux can also be found in accessory great saphenous veins (i.e., anterior or posterior) which parallel the GSV in the saphenous compartment, the SSV, circumflex veins which course oblique to the GSV, or perforating veins (veins that connect the superficial to the deep veins). There are numerous perforator veins found throughout the leg from the thigh to the ankle that traverse the muscular fascia of the lower extremity and, under normal circumstances, drain from the superficial veins toward the deep (intramuscular) veins. Variations in the anatomy of the deep and superficial venous systems are common.

The evaluation of a patient with lower extremity venous incompetence and its advanced consequences—edema and skin changes—should include the assessment of history and physical examination including the CEAP classification and revised Venous Clinical Severity Score (VCSS). A duplex ultrasound scan of the deep and superficial venous systems must support the examination findings.

The treatment of C1 disease (spider telangiectasia and their feeding reticular veins) is considered cosmetic, and therefore, not reasonable and necessary for the purposes of Medicare coverage.

For patients with C2 disease and VCSS score < 6, the plan of care must include at least a 90 day course of compression therapy further defined below. (C2 patients with VCSS < 6, who failed at least a 90 day course of compression therapy, would start a new 90 day episode of care, and proposed interventions should be addressed in the plan of care.)

For patients with C2 disease and VCSS score > 6, or patients with C3-C6 disease, proposed interventions for a 90 day episode of care should be addressed in the treatment plan.


Limitations of Coverage and/or Medical Necessity

CPT code 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)] is not applicable (incorrect coding) for saphenous ablation and is not covered.

CPT code 76942 has limited coverage by qualified physicians for image-guided foam sclerotherapy, as outlined in this policy.

Thermal ablation includes the necessary ultrasound imaging for any additional procedures done with the thermal ablation.

CPT add-on code 76937 (ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting) is not a covered service for outpatient varicose vein procedures.

Local anesthesia and minimal to no sedation is the standard of care. Monitored Anesthesia Care (MAC) or moderate (conscious) sedation needs clear support in the medical record based on patient clinical presentation/characteristics and may be subject to prepayment review.

Photothermal sclerosis (also referred to as an intense pulsed light source, e.g., the PhotoDerm VascuLight, VeinLase), transdermal laser treatment, and mechanicochemical ablation (MOCA) (Clarivein) do not meet the Medicare reasonable and necessary threshold for coverage. Providers are required to code to specificity. If no such procedure of service exists, then report the service using the appropriate unlisted procedure code. Unlisted procedure, vascular surgery code 37799 should be reported until the specific CPT codes are established. Claims billed for these procedures will be denied.

If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a non-covered (cosmetic) procedure. Isolated injections for the treatment of telangiectasias and reticular veins less than 3mm in diameter are considered cosmetic and do not meet the Medicare reasonable and necessary threshold for coverage. Claims billed for these procedures will be denied.

Device/sclerosant combination procedures without a unique CPT code are described by CPT code 37799. The sclerosant is included in the procedure. Coverage is limited to the ‘sclerotherapy’ indications.


Revenue Codes

Code Description
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
0362 Operating Room Services - Organ Transplant - Other than Kidney
0367 Operating Room Services - Kidney Transplant
0369 Operating Room Services - Other OR Services
0490 Ambulatory Surgical Care - General Classification
0499 Ambulatory Surgical Care - Other Ambulatory Surgical Care
0510 Clinic - General Classification
0511 Clinic - Chronic Pain Center
0512 Clinic - Dental Clinic
0513 Clinic - Psychiatric Clinic
0514 Clinic - OB-GYN Clinic
0515 Clinic - Pediatric Clinic
0516 Clinic - Urgent Care Clinic
0517 Clinic - Family Practice Clinic
0519 Clinic - Other Clinic
0761 Specialty Services - Treatment Room
0920 Other Diagnostic Services - General Classification
0921 Other Diagnostic Services - Peripheral Vascular Lab
0929 Other Diagnostic Services - Other Diagnostic Service


ICD-10 Codes that Support Medical Necessity

I80.11 Phlebitis and thrombophlebitis of right femoral vein
I80.12 Phlebitis and thrombophlebitis of left femoral vein
I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.221 Phlebitis and thrombophlebitis of right popliteal vein
I80.222 Phlebitis and thrombophlebitis of left popliteal vein
I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.231 Phlebitis and thrombophlebitis of right tibial vein
I80.232 Phlebitis and thrombophlebitis of left tibial vein
I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity
I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity
I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral
I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified
I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh
I83.002 Varicose veins of unspecified lower extremity with ulcer of calf
I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle
I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot
I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot
I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg
I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.019 Varicose veins of right lower extremity with ulcer of unspecified site
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.029 Varicose veins of left lower extremity with ulcer of unspecified site
I83.10 Varicose veins of unspecified lower extremity with inflammation
I83.11 Varicose veins of right lower extremity with inflammation
I83.12 Varicose veins of left lower extremity with inflammation
I83.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation
I83.202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation
I83.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation
I83.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation
I83.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation
I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation
I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation
I83.811 Varicose veins of right lower extremities with pain
I83.812 Varicose veins of left lower extremities with pain
I83.813 Varicose veins of bilateral lower extremities with pain
I83.891 Varicose veins of right lower extremities with other complications
I83.892 Varicose veins of left lower extremities with other complications
I83.893 Varicose veins of bilateral lower extremities with other complications
I87.2 Venous insufficiency (chronic) (peripheral)
R60.0 Localized edema
ICD-10 Codes that DO NOT Support Medical Necessity
I78.0 Hereditary hemorrhagic telangiectasia
I78.1 Nevus, non-neoplastic
I78.8 Other diseases of capillaries
I78.9 Disease of capillaries, unspecified
I80.11 Phlebitis and thrombophlebitis of right femoral vein
I80.12 Phlebitis and thrombophlebitis of left femoral vein
I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.221 Phlebitis and thrombophlebitis of right popliteal vein
I80.222 Phlebitis and thrombophlebitis of left popliteal vein
I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.231 Phlebitis and thrombophlebitis of right tibial vein
I80.232 Phlebitis and thrombophlebitis of left tibial vein
I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity
I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity
I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral
I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation
I83.811 Varicose veins of right lower extremities with pain
I83.812 Varicose veins of left lower extremities with pain
I83.813 Varicose veins of bilateral lower extremities with pain
I83.891 Varicose veins of right lower extremities with other complications
I83.892 Varicose veins of left lower extremities with other complications
I83.893 Varicose veins of bilateral lower extremities with other complications
I87.091 Postthrombotic syndrome with other complications of right lower extremity
I87.092 Postthrombotic syndrome with other complications of left lower extremity
I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity
I87.099 Postthrombotic syndrome with other complications of unspecified lower extremity
I87.2 Venous insufficiency (chronic) (peripheral)
R60.0 Localized edema

CPT code G0402, G0403, G0404, G0405 and coverage frequency

Preventive Physical Examination (IPPE)

Also known as the “Welcome to Medicare Preventive Visit” HCPCS/CPT Codes

G0402 – IPPE
G0403 – EKG for IPPE
G0404 – EKG tracing for IPPE
G0405 – EKG interpret & report for IPPE

ICD-10-CM Codes

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


Who Is Covered

All new Medicare beneficiaries who are within the first 12 months of their first Medicare Part B coverage period

Frequency

Once in a lifetime

Must furnish no later than 12 months after the effective date of the first Medicare Part B coverage period


Beneficiary Pays

G0402:
• Copayment/coinsurance waived
• Deductible waived
G0403, G0404, and G0405:
• Copayment/coinsurance applies
• Deductible applies

CPT code 76977, 77078, 77080, 77081 and G0130 - covred ICD 10 and benefit period

Bone Mass Measurements

HCPCS/CPT Codes

76977 – Ultrasound bone density measurement and interpretation, peripheral site(s), any method

77078 – Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

77080 – Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

77081 – DXA, bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)

G0130 – Single energy X-ray absorptiometry (SEXA) bone density study, 1 or more sites, appendicular skeleton (peripheral) (eg, radius, wrist, heel)


ICD-10-CM Codes

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

Who Is Covered

Certain Medicare beneficiaries who fall into at least one of the following categories:

• Women determined by their physician or qualified non-physician practitioner (NPP) to be estrogen deficient and at clinical risk for osteoporosis;

• Individuals with vertebral abnormalities;

• Individuals getting (or expecting to get) glucocorticoid therapy for more than 3 months;

• Individuals with primary hyperparathyroidism; or

• Individuals being monitored to assess response to U.S. Food and Drug Administration (FDA)-approved osteoporosis drug therapy

Frequency

• Every 2 years; or

• More frequently if medically necessary Beneficiary Pays

• Copayment/coinsurance waived

• Deductible waived

Bone Density Scan CPT COde

Bone density scan is performed to check the density of bones. We use to   do do bone density scan to check oosteopenia  or osteoporosis present in bone. We  used CPT 77080 and 77081 in the year of 2014. CPT 77080 is  used to code for bone density scan of axial  bone   like hip, pelvis and  spine while 77081 was used to code axial bone like wrist, radius, heel etc.

Do and Don't for Bone density CPT code

Do not report 77080 in conjuction with 77085, 77086
Do not report 77085 cpt code  in conjunction with 77080, 77086
Do not report 77086 cpt code   in conjunction with 77080, 77085
While coding 77085 and 77081  together do remember to use modifier  XU with cpt code 77081. 
While coding 77081 and 77080 are bill together use modifier XU with CPT code 77080.


Insurance Carriers

Medicare covers bone mass measurements every 2years for "qualified" individuals considered to be at risk for osteoporssiis. Medicare beneficiary who meets the medical  indications for  one of the following categories:

1. an estrogen-defiicient, postmenopausal woman
2. an individual with verteebraal  abnormalities
3. an individual  with know primary hyperparathyrodism
4. some individuals reveiving steroid therapy
5. individuals receiving FDA-approved osteoporosis drug therapy    

Medicare's Coverage of Chiropractic Services

Chiropractic services are becoming more popular as a way to correct spinal problems.

Chiropractic services must be provided by doctors of chiropractic, also known as 'chiropractors' and 'chiropractic physicians'. These doctors perform 'spinal manipulation' or 'chiropractic adjustments.' Chiropractors must be licensed or legally authorized to perform chiropractic services in your state.

Medicare covers ‘manual manipulation’ of the spine to correct an acute ‘subluxation.’ ‘Subluxation’ means a partial dislocation of one or more bones in your spine. Your treatments must be addressing acute symptoms and not chronic illnesses.

When we say ‘manual manipulation,’ we mean the chiropractor is using his or her hands to perform the therapy. Medicare does allow a chiropractor to use a hand-held device, but it must be one they control by hand. Medicare can’t pay the doctor for having the device, and it won’t pay extra if the doctor chooses to use the device instead of using his or her hands.

All spinal dislocations have to be proven through an X-ray or a specific physical exam. No other testing or therapy is covered, and Medicare must be able to verify that the services are medically necessary and will give you a reasonable expectation of recovery or improvement.

If your chiropractor takes an X-ray or performs another kind of test to assess your condition, Medicare will not pay for the X-ray or any other diagnostic services. Instead, your doctor will use the results of these tests to determine a treatment plan.

If your doctor performs a physical exam, he or she will look for pain or tenderness, observable misalignments, your range of motion, and changes in the tissues around your spine.

Your doctor will ask you about your symptoms, family history, your past medical history, the severity of your symptoms, when the symptoms came on, for how long, and their intensity. Your doctor will ask you about factors that aggravate your condition and any treatments or medications you may have used to treat your pain.

Medicare may only pay for your doctor to treat acute problems and new injuries. He or she must develop a treatment plan that has specific goals that are expected to be achieved and objective measures that will be used to evaluate how effective the treatment is.

If your treatment changes from addressing an injury to maintaining or preventing future deterioration of your spine, then Medicare can no longer pay for these chiropractic services. Continued treatments that don’t have achievable, clearly defined goals would be considered ‘maintenance therapy.’
This means, there is no expectation of improvement but the doctor plans to continue treatments that keep you at the same level of health. Medicare does not cover maintenance therapy.

Medically necessary chiropractic services are covered by Medicare – you will only need to pay 20 percent of the Medicare-approved amount, and your Part B deductible will apply. You will be charged for any other services or tests (such as the X-rays and the physical exam used to evaluate your condition. Medicare also will not pay for massage therapy).

Billing and coverage for drug wastage

Can I bill for drug wastage from a multi-dose/multiuse vial or package of drug or biological?

Answer:

Providers may not bill for drug wastage for multi-does/multiuse vials or packages from which an amount is administered to one patient

Even if a provider is unable to store unused doses for later use because the pharmacy incorrectly reconstituted the drug using sterile water instead of bacteriostatic water, a provider may not bill for drug wastage in a multi-dose/multiuse vial or package

Tips for Submitting Accurate Claims:

Each HCPCS code is associated with a specific number of units and type of units may be described by various units of measure

Verify the number and type of units associated with the HCPCS code before calculating the quantity on your claim

Verify calculations with the physician if needed

Submit the number of units (based on the HCPCS code) for the amount actually administered and not the number of units in the entire multi dose/multiuse vial or package

First Coast Service Options Inc. (First Coast) will consider payment for the unused and discarded portion of a single-use drug/biological product after administration of the appropriate (reasonable and necessary) dosage for the patient’s condition. This applies to drugs priced through the Average Sales Price (ASP) drug/biological program. The Centers for Medicare & Medicaid Services (CMS) encourages physicians, hospitals, and other providers to provide injectable drug therapy incident to a physician’s services in a fashion that maximizes efficiency of therapy in a clinically appropriate manner. If a physician, hospital, or other provider must discard the unused portion of a single-use vial or other single-use package after administering a dose/quantity appropriate to the clinical context for a Medicare beneficiary, the program provides payment for the entire portion of drug or biological indicated on the vial or package label.

If less than a complete vial is administered at the time of service, and the unused portion is discarded, drug wastage must be documented in the patient’s medical record with the date, time, and quantity wasted. Upon review, any discrepancy between amount administered to the patient and the billed amount will be denied, unless wastage is clearly documented. The amount billed as “wastage” must not be administered to another patient or billed again to Medicare. All procedures for drug storage, reconstitution and administration should conform to applicable Federal Drug Administration (FDA) guidelines and provider scope of practice.

Note: For billing purposes, First Coast does not require the use of modifier JW. Drug wastage is billed by combining on a single line the wastage and administered dosage amount.

Skilled Nursing Facility Coverage Requirements and Benefit Period

To qualify for Medicare Part A coverage of SNF services, the following conditions must be met:
◘ The beneficiary was an inpatient of a hospital for a medically necessary stay of at least 3 consecutive days;
◘ The beneficiary transferred to a participating SNF within 30 days after discharge from the hospital (unless the beneficiary’s condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after discharge and it is medically predictable at the time of the hospital discharge the beneficiary will require covered care within a predictable time period);
◘ The beneficiary requires skilled nursing services or skilled rehabilitation services on a daily basis. Skilled services must be:
■ Performed by or under the supervision of professional or technical personnel;
■ Ordered by a physician; and
■ Rendered for an ongoing condition for which the beneficiary had also received inpatient hospital services or for a new condition that arose during the SNF care for that ongoing condition;
◘ As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF; and
◘ The services delivered are reasonable and necessary for the treatment of the beneficiary’s inpatient illness or injury and are reasonable in terms of duration and quantity.

Benefit Period
Coverage for care in SNFs is measured in “benefit periods” (sometimes called a “spell of illness”). In each benefit period, Medicare Part A covers up to 20 days in full. After that, Medicare Part A covers an additional 80 days with the beneficiary paying coinsurance for
each day. After 100 days, the SNF coverage available during that benefit period is “exhausted,” and the beneficiary pays for all care, except for certain Medicare Part B services.
A benefit period begins the day the Medicare beneficiary is admitted to a hospital or SNF as an inpatient and ends after the beneficiary has not been in a hospital (or received skilled care in a SNF) for 60 consecutive days. Once the benefit period ends, a new benefit period
begins when the beneficiary has an inpatient admission to a hospital or SNF. New benefit periods do not begin due to a change in diagnosis, condition, or calendar year. Understanding the benefit period is important because SNFs must sometimes submit claims for which they do not expect to receive payment to ensure the benefit period is properly tracked in the Common Working File (CWF).

Medicare Part A Payment
The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services. Part A payment is primarily based on the Resource Utilization Group (RUG) assigned to the beneficiary following required Minimum Data Set (MDS) 3.0 assessments. As a part of the
Resident Assessment Instrument (RAI), the MDS 3.0 is a data collection tool that classifies beneficiaries into groups based on the average resources needed to care for someone with similar needs. The MDS 3.0 provides a core set of screening, clinical, and functional status
elements, including common definitions and coding categories. It standardizes communication about resident problems and conditions.
General Payment Tips
• Medicare will not pay under the SNF PPS unless you bill a covered day.
• Ancillary charges are only allowed for covered days and are included in the PPS rate.

Medicare Part B Payment
Medicare Part B may pay for:
◘ Some services provided to beneficiaries residing in a SNF whose benefit period exhausted or who are not otherwise entitled to payment under Part A;
◘ Outpatient services rendered to beneficiaries who are not inpatients of a SNF; and
◘ Services excluded from SNF PPS and SNF consolidated billing.

Consolidated Billing Under the consolidated billing provision, SNF Part A inpatient services include all Medicare Part A services considered within the scope or capability of SNFs. In
some cases, the SNF must obtain some services it does not provide directly. For these services, the SNF must make arrangements to pay for the services and must not bill Medicare separately for those services.

Skilled Services

Skilled Nursing and skilled rehabilitation services are those services furnished pursuant to physician orders that:
•    Require the skills of qualified technical or professional health personnel, such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and
•    Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the beneficiary and to achieve the medically desire result.

Medicare non covered items and services - part 3

MEDICARE PROGRAM NON COVERED SERVICES

3)Services and Supplies That Have Been Denied as Bundled or Included in the Basic Allowance of Another Service
The following services and supplies that have been denied as bundled or included in the basic allowance of another service will not be paid:
• Fragmented services included in the basic allowance of the initial service;
• Prolonged care (indirect);
• Physician standby services;
• Case management services (for example, telephone calls to and from the beneficiary); and
• Supplies included in the basic allowance of a procedure.

4) Items and Services Reimbursable by Other Organizations or Furnished Without Charge

A) Services Reimbursable Under Automobile, No-Fault, or Liability Insurance or Workers’Compensation (the Medicare Secondary Payer Program)
Payment will not be made for items and services when payment has been made or can reasonably
be expected to be paid promptly under:
• Automobile insurance;
• No-fault insurance;
• Liability insurance; or
• Workers’ Compensation (WC) law or Plan of the U.S. or a State.

Exceptions
Medicare may make payment if the primary payer denies the claim and documentation is provided
indicating that the claim has been denied in the following situations:
• The Group Health Plan denies payment for services because:
◦ The beneficiary is not covered by the health plan;
◦ Benefits under the plan are exhausted for particular services;
◦ The services are not covered under the plan;
◦ A deductible applies; or
◦ The beneficiary is not entitled to benefits;
• The no-fault or liability insurer denies payment or does not pay the bill because benefits have been exhausted;
• The WC Plan denies payment (for example, when it is not required to pay for certain medical conditions); or
• The Federal Black Lung Program does not pay the bill.
In liability, no-fault, or WC situations, a conditional payment for covered services may be made to prevent beneficiary financial hardship when:
• The claim is not expected to be paid promptly;
• A properly submitted claim was denied in whole or in part; or
• A proper claim has not been filed with the primary insurer due to the beneficiary’s physical or mental incapacity. A conditional payment is made on the condition that the insurer and/or the beneficiary will reimburse Medicare to the extent that payment is subsequently made by the insurer.

B) Items and Services Authorized or Paid by a Government Entity
In general, payment will not be made for the following items and services authorized or paid by a
government entity:
• Those that are furnished by a government or nongovernment provider or other individual at
public expense pursuant to an authorization issued by a Federal agency (for example, Veterans Administration authorized services);
• Those that are furnished by a Federal provider or agency that generally provides services to the public as a community institution or agency (hospitals, SNFs, Home Health Agencies, and comprehensive Outpatient Rehabilitation Facilities are not included in this category). Federal hospitals, like other nonparticipating hospitals, may be paid for emergency inpatient and outpatient hospital services;
• Those that a Federal, State, or local government entity directly or indirectly pays for or furnishes without expectation of payment from any source and without regard to the individual’s ability to pay; and
• Those that a nongovernment provider or supplier furnishes and the charges are paid by a government program other than Medicare or where the provider or supplier intends to look to another government program for payment (unless the payment by the other program is limited to Medicare deductible and coinsurance amounts).

C) Items and Services for Which the Beneficiary, Another Individual, or an Organization Has No Legal Obligation to Pay For or Furnish
Payment will not be made when the beneficiary, another individual, or an organization has no legal
obligation to pay for or furnish the items or services.
Some examples include:
•X-rays or immunizations that are gratuitously furnished to the beneficiary without regard to his or her ability to pay and without
expectation of payment from any source; and
• An ambulance transport provided by a volunteer ambulance company. If the ambulance company asks but does not require a donation from the beneficiary to help offset the cost of the service, there is no enforceable legal obligation for the beneficiary or any other individual to pay for the service.
When items or services are furnished without charge to indigent Medicare patients and non-Medicare indigent patients because of their inability to pay, both groups must be consistently billed.

D) Defective Equipment or Medical Devices Covered Under Warranty
No payment will be made under cost reimbursement for defective medical equipment or medical devices under warranty if they are replaced free of charge by the warrantor or if an acceptable replacement could have been obtained free of charge under the warranty, but it was purchased instead.

Exceptions
When defective equipment or medical devices are replaced under warranty, hospital or other provider services that are furnished by parties other than the warrantor are covered despite the warrantor’s liability.

Payment may be made for defective equipment or medical devices as follows:
• When a replacement from another manufacturer is substituted because the replacement offered under the warranty is not acceptable to the beneficiary or to the beneficiary’s physician;
• Partial payment, if defective equipment or medical devices are supplied by the warrantor and a charge or a pro rata payment is imposed; and
• Payment is limited to the amount that would have been paid under the warranty if an acceptable replacement could have been purchased at a reduced price under a warranty, but the full price was paid to the original manufacturer or a new replacement was purchased from a different manufacturer or other source.

Railroad Medicare Coverage of Supplies if You Have Diabetes

Railroad Medicare covers certain supplies if you have Medicare Part B and have diabetes. These supplies include:

•    Blood glucose self-testing equipment and supplies
•    Therapeutic shoes and inserts
•    Insulin pumps and the insulin used in the pumps

Blood Glucose Self-testing Equipment and Supplies
Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:
•    Blood glucose monitors
•    Blood glucose test strips
•    Lancet devices and lancets
•    Glucose control solutions for checking the accuracy of testing equipment and test strips

Railroad Medicare covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.
If you:

1.    Use insulin, you may be able to get up to 100 test strips and lancets every month, and 1 lancet device every 6 months
2.    Do not use insulin, you may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months
If your doctor documents why it is medically necessary, Railroad Medicare will cover additional test strips and lancets for you.
Medicare and Railroad Medicare will only cover blood glucose self-testing equipment and supplies if you get a prescription from your doctor which includes:
•    That you have diabetes
•    What kind of blood glucose monitor you need and why
•    Whether or not you use insulin
•    How often you need to test your blood glucose

Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.

All Medicare-enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. You cannot submit a claim for blood glucose monitor test strips yourself. You should make sure that the pharmacy or supplier accepts assignment for Medicare-covered supplies. If the pharmacy or supplier accepts assignment, Medicare will pay the pharmacy or supplier directly. You should only pay your coinsurance amount when you get your supply from your pharmacy or supplier for assigned claims. If your pharmacy or supplier does not accept assignment, charges may be higher, and you may pay more. You may also have to pay the entire charge at the time of service and wait for Medicare to send you its share of the cost.

Before you get a supply, be sure to ask the supplier or pharmacy the following questions:
•    Are you enrolled in Medicare?
•    Do you accept assignment?
If the answer to either of these two questions is 'no,' you may wish to consider calling another supplier or pharmacy in your area that answers 'yes' to be sure your purchase is covered by Medicare.

Therapeutic Shoes and Inserts
If you have Medicare Part B, have diabetes, and meet certain conditions (see below), Railroad Medicare will cover therapeutic shoes if you need them. The types of shoes that are covered each year include one of the following:
•    One pair of depth-inlay shoes and three pairs of inserts or
•    One pair of custom-molded shoes (including inserts) if you cannot wear depth-inlay shoes because of a foot deformity and two additional pairs of inserts

Note: In certain cases, Medicare may also cover shoe modifications instead of inserts.
In order for Medicare to pay for your therapeutic shoes, the doctor treating your diabetes must certify that you meet all of the following three conditions:

•    You have diabetes
•    You have at least 1 of the following conditions in one or both feet
o    Partial or complete foot amputation
o    Past foot ulcers
o    Calluses that could lead to foot ulcers
o    Nerve damage because of diabetes with signs of problems with calluses
o    Poor circulation, or
o    Deformed foot
•    You are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes

Medicare also requires the following:

•    A podiatrist or other qualified doctor must prescribe the shoes, and
•    A doctor or other qualified individual like a pedorthist, orthotist, or prosthetist must fit and provide the shoes to you

Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year, and the fitting of the shoes or inserts is covered in the Medicare payment for the shoes.

Insulin Pumps and the Insulin Used in the Pumps
Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Railroad Medicare coverage who have diabetes and who meet certain conditions. If you need to use an insulin pump, your doctor will need to prescribe it.

Railroad Medicare covers the cost of insulin pumps and the insulin used in the pumps. However, if you inject your insulin with a needle (syringe), Medicare Part B does not cover the cost of the insulin, but your Medicare prescription drug benefit (Part D) covers the insulin and the supplies necessary to inject it. This includes syringes, needles, alcohol swabs and gauze. Your Medicare Part D plan will cover the insulin and any other medications to treat diabetes at home as long as you are on the Medicare Part D plan’s formulary.

Coverage for diabetes-related durable medical equipment (DME) is provided as a Medicare Part B benefit. The Medicare Part B deductible and coinsurance or copayment applies after the yearly Medicare part B deductible has been met.

Medicare non covered items and services - part 2

NOT COVERED ITEMS AND SERVICE UNDER THE MEDICARE PROGRAM AND APPLICABLE EXCEPTIONS

 (2) Non-Covered Items and Services
A) Custodial Care
Custodial care furnished in the beneficiary’s home or an institution is not covered. Custodial care is
personal care that does not require the continuing attention of trained medical or paramedical
personnel and serves to assist an individual in the activities of daily living. The following activities are
considered custodial care:
• Walking;
• Getting in and out of bed;
• Bathing;
• Dressing;
• Feeding;
• Using the toilet;
• Preparing a special diet; and
• Supervising the administration of medication that can usually be self-administered.
Exceptions
Individual reasonable and necessary services may be covered under Part B even though Part A denies coverage of a beneficiary’s overall hospital or SNF stay because it is determined to be
custodial.Care furnished to a beneficiary who has elected the hospice care option is considered custodial only if it is not reasonable and necessary for the palliation or management of the terminal illness and related conditions.

B) Cosmetic Surgery
Cosmetic surgery and expenses incurred in connection with cosmetic surgery are not covered.
Cosmetic surgery includes any surgical procedure directed at improving the beneficiary’s appearance.

Exceptions
The prompt (as soon as medically feasible) repair of an accidental injury or the improvement of the
functioning of a malformed body member are covered. Some examples include:
• Surgery performed in connection with the treatment of severe burns;
• Surgery to repair the face following a serious automobile accident; and
• Surgery for therapeutic purposes that may coincidentally also serve some cosmetic purpose.

C) Items and Services Furnished by the Beneficiary’s Immediate Relatives and Members
of the Beneficiary’ s Household
Payment for items and services furnished by the beneficiary’s immediate relatives and members of
the beneficiary’s household will not be made since these items and services are ordinarily furnished
gratuitously because of the relationship between the beneficiary and the provider or supplier.
The following items and services will also not be paid:
• Charges for services furnished by a related physician or supplier that are submitted by an unrelated individual, partnership, or professional corporation; and
• Those services furnished incident to a physician’s professional service when the ordering or supervising physician has a prohibited relationship to the beneficiary.

A professional corporation is:
• Completely owned by one or more physicians or is owned by other health care professionals as authorized by State law; and
• Operated for the purpose of conducting the practice of medicine, osteopathy, dentistry,
podiatry, optometry, or chiropractic.

Any physician or group of physicians that is incorporated constitutes a professional corporation. Items and services furnished by non-physician suppliers that have a prohibited relationship with the beneficiary and are not incorporated will not be paid, regardless of whether the supplier is owned by a sole proprietor who is related to the beneficiary or owned by a partnership in which one of the partners is related to the beneficiary. This payment restriction applies only to professional corporations, regardless of the beneficiary’s relationship to any of the stockholders, officers, or directors of the corporation or to the individual who furnished the service.
A beneficiary’s immediate relatives include the following degrees of relationship:
• Husband and wife;
• Natural or adoptive parent, child, and sibling;
• Stepparent, stepchild, stepbrother, and stepsister;
• Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
• Grandparent and grandchild; and
• Spouse of grandparent or grandchild.
If the marriage upon which a step- or in-law relationship is based becomes terminated through
divorce or death, the prohibited relationship will continue to exist.
Members of the beneficiary’s household include the following who share a common abode with him
or her as part of a single family unit:
• Individuals who are related by blood, marriage, or adoption;
• Domestic employees; and
• Other individuals who live together as part of a single family unit (does not include roomers or boarders).

D) Dental Services
Items and services that are furnished in connection with the care, treatment, filling,removal, or replacement of teeth or the structures directly supporting the teeth are not covered. The structures that directly support the teeth are the periodontium, which includes:
• The gingivae;
• The dentogingival junction;
• The periodontal membrane;
• The cementum; and
• The alveolar process.
Whether or not the beneficiary is hospitalized has no direct bearing on if payment will be made for a
given dental procedure.

Exceptions
Some dental services may be covered depending upon whether the primary procedure that the
dentist performs is covered. For example, the following services are covered:
• An x-ray that is taken in connection with the reduction of a fracture of the jaw or facial bone; and
• A tooth extraction that is performed to prepare the jaw for radiation treatments of neoplastic disease.

I)Non-Physician Services Furnished to Hospital and Skilled Nursing Facility Inpatients That Are Not Provided Directly or Under Arrangement
In general, non-physician services furnished to Part A and Part B hospital inpatients and Part A
SNF inpatients that are not provided directly or under arrangement are not covered.
Exceptions
The following are covered:
• Physician services furnished to hospital and SNF inpatients (with the exception of therapy,
which must be provided by the SNF);
• Physician assistant services;
• Nurse practitioner services;
• Clinical nurse specialist services;
• Certified nurse-midwife services;
• Qualified clinical psychologist services; and
• Certified registered nurse anesthetist services.
The following Part A SNF inpatient services may be covered if they are not provided directly or under arrangement and are furnished by an authorized provider or supplier:
• Home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies (including related necessary ambulance services);
• Epoetin Alfa (EPO);
• Hospice care related to a beneficiary’s terminal condition;
• Radioisotope services;
• Some customized prosthetic devices;
• Some chemotherapy and chemotherapy administration services; and
• The following services that are considered beyond the scope of a SNF when furnished in a participating hospital or Critical Access Hospital, including ambulance services related to such services (does not apply to services furnished in an Ambulatory Surgical Center):
◦ Cardiac catheterization;
◦ Computerized axial tomography scans;
◦ Magnetic resonance imaging;
◦ Ambulatory surgery that involves the use of an operating room;
◦ Radiation therapy; and
◦ Emergency services.

E) Certain Foot Care Services and Supportive Devices for the Feet
The following foot care services and devices are generally not covered, except as described below
under Exceptions:
• Treatment of flat foot;
• Routine foot care, which includes:
◦ The cutting or removal of corns and calluses;
◦ The trimming, cutting, clipping, or debriding of nails;
◦ Other hygienic and preventive maintenance care (for example, cleaning and soaking the feet, use of skin creams to maintain skin tone of either ambulatory or bedridden patients, and any other
service performed in the absence of localized illness, injury, or symptoms involving the foot); and
◦ Orthopedic shoes and other supportive devices for the feet.
Exceptions
The following devices and services are covered:
• Orthopedic shoes that are an integral part of a leg brace;
• Therapeutic shoes furnished to diabetics;
• Services that are a necessary and integral part of an otherwise covered service (for example, the diagnosis and treatment of ulcers, wounds, or infections);
• Treatment of warts on the foot (including plantar warts);
• Treatment of mycotic nails as follows:
◦ For an ambulatory beneficiary, the physician attending the mycotic condition must document that:
▪ There is clinical evidence of mycosis of the toenail; and
▪ The beneficiary has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
◦ For a non-ambulatory beneficiary, the physician attending the beneficiary’s mycotic condition must document that:
▪ There is clinical evidence of mycosis of the toenail; and
▪ The beneficiary suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
• Presence of a systemic condition such as one of the following metabolic, neurologic, and peripheral vascular diseases (this is not an all-inclusive list):
◦ Diabetes mellitus;*
◦ Arteriosclerosis obliterans;
◦ Buerger’s disease;
◦ Chronic thrombophlebitis;* and
◦ Peripheral neuropathies that involve the feet:
▪ Associated with malnutrition and vitamin deficiency:*
▫ Malnutrition (general, pellagra);
▫ Alcoholism;
▫ Malabsorption (celiac disease, tropical sprue); and
▫ Pernicious anemia;
▪ Associated with carcinoma;*
▪ Associated with diabetes mellitus;*
▪ Associated with drugs and toxins;*
▪ Associated with multiple sclerosis;*
▪ Associated with uremia (chronic renal disease);*
▪ Associated with traumatic injury;
▪ Associated with leprosy or neurosyphilis; and
▪ Associated with hereditary disorders:
▫ Hereditary sensory radicular neuropathy;
▫ Angiokeratoma corporis diffusum (Fabry’s); and
▫ Amyloid neuropathy.
*For Medicare to cover routine procedures for this condition, the beneficiary must be under the active care of a MD or a DO who has documented the condition.

F) Investigational Devices
Category A devices, as categorized by the U.S. Food and Drug Administration, are considered
not medically reasonable and necessary and are therefore not covered.

Category B devices may be covered if they are considered medically reasonable and necessary
and all other applicable Medicare coverage requirements are met.

G) Services Related to and Required as a Result of Services That Are Not Covered
Medical and hospital services that are related to and required as a result of services that are not covered will not be paid. Some examples of these services are:
• Cosmetic surgery;
• Non-covered organ transplants; and
• Services related to follow-up care or complications that require treatment during a hospital stay in which a non-covered service is performed.

Exceptions
When a beneficiary is hospitalized for a non-covered service and requires services that are not related to the non-covered service, the unrelated services are covered. For example, if a beneficiary breaks a leg while he or she is in the hospital for a non-covered service, the services to treat the broken leg are covered since they are not related to the non-covered service.

When a beneficiary is discharged from a hospital stay in which he or she receives non-covered
services and subsequently requires services to treat a condition or complication that arose as a
result of the non-covered services, reasonable and necessary medical or hospital services may be
covered. Some examples include:
• Repair of complications after transsexual or cosmetic surgery; and
• Treatment of an infection at the surgical site of a non-covered service.
Any subsequent services that could be incorporated into a global fee are considered paid in the global fee and will not be paid again.

When Medicare Pays First, Second or Even Third

When Medicare began in the 1960s, it was the primary payer for all services except those covered by workers compensation. Then in 1980, Congress enacted provisions to shift costs from the Medicare program to private insurers, when possible. This legislation stopped Medicare from making payment if the payment has already been made, or would be expected to be made, by Group Health Plans (GHP) and Workers Compensation (WC) Plans.

Medicare Pays First When:
• You have retiree insurance (from either you or your spouse’s former employment)
• You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has less than 20 employees
• You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has less than 100 employees
• You’re also receiving Medicaid benefits
Note: If you have group health care plan coverage that is primary to Medicare (pays first), it will continue to do so until it pays up to the limits of its coverage. Then Medicare becomes primary.

Medicare Pays Second When:
• You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has 20 or more employees
• You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has 100 or more employees
• You have End-Stage Renal Disease (ESRD) and you are in the first 30 months your Medicare eligibility. Then Medicare pays first after that.
• You’re covered by no-fault or liability insurance for an services related to an accident


Insurance that pays after Medicare is referred to as supplemental insurance. Your retiree coverage may act as supplemental insurance or you may purchase a Medigap policy from a private insurance company.
Medicare works supplemental insurance companies through a process called ‘crossover.’ Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

If your supplemental insurance does not participate in crossover with Medicare, you will be responsible for ensuring your insurance receives information about claims Medicare has processed. Many providers will file claims to your supplemental insurance after Medicare has processed your claim. If you provider will not file to your supplemental insurance, contact the plan to verify what information they will need to process a claim. Many supplemental insurance plans will ask you to send a copy of your Medicare Summary Notice (MSN). If you need an MSN, you may request one from our Customer Service unit.

Medicare non covered items and services - part 1

THE FOUR CATEGORIES OF ITEMS AND SERVICES THAT ARE NOT COVERED UNDER THE MEDICARE PROGRAM AND APPLICABLE EXCEPTIONS

The following four categories of items and services that are not covered under the Medicare Program are discussed in this publication:
1)Services and supplies that are not medically reasonable and necessary;
2)Non-covered items and services;
3)Services and supplies that have been denied as bundled or included in the basic allowance of
another service; and
4) Items and services reimbursable by other organizations or furnished without charge.
Where applicable, exceptions (items and services that may be covered) are also included in this discussion.

1)    Services and Supplies That Are Not MedicallyReasonable and Necessary

Services and supplies that are not medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary’s condition will not be covered. Some examples include:
• Services furnished in a hospital that, based on the beneficiary’s condition, could have been
furnished in a lower-cost setting (for example, the beneficiary’s home or a nursing home);
• Hospital services that exceed Medicare length of stay limitations;

• Evaluation and management services that exceed those considered medically reasonable and
necessary;
• Therapy or diagnostic procedures that exceed Medicare usage limits;
• Screening tests, examinations, and therapies for which the beneficiary has no symptoms or documented conditions,with the exception of certain screening tests, examinations, and therapies as described under Exceptions;
• Services not warranted based on the diagnosis of the beneficiary (for example, acupuncture and
transcendental meditation); and
• Items and services administered to a beneficiary for the purpose of causing or assisting in causing death (assisted suicide).
In general, Medicare-covered services are those services considered medically reasonable and necessary to the overall diagnosis or treatment of the beneficiary’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:
• Proper and needed for the diagnosis or treatment of the beneficiary’s medical condition;
• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition; and
• Not mainly for the convenience of the beneficiary, provider, or supplier.

Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For every service billed, you must indicate the specific sign, symptom, or beneficiary complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment
for services without beneficiary symptoms or complaints or specific documentation.

Exceptions
• Annual Wellness Visit;
• Initial Preventive Physical Examination (also known as the “Welcome to Medicare Preventive
Visit”);
• Colorectal cancer screening;
• Screening mammography;
• Clinical breast examinations;
• Screening Pap tests;
• Screening pelvic examinations;
• Prostate cancer screening;
• Cardiovascular disease screenings;
• Diabetes screening tests;
• Glaucoma screening;
• Human Immunodeficiency Virus (HIV) screening;
• Bone mass measurements;
• Medical nutrition therapy (for certain beneficiaries diagnosed with diabetes, renal disease, or who
have received a kidney transplant within the last 3 years);
• Diabetes Self-Management Training (for beneficiaries diagnosed with diabetes);
• Vaccines;
• Ultrasound screening for abdominal aortic aneurysm;
• Intensive behavioral therapy for cardiovascular disease;
• Intensive behavioral therapy for obesity;
• Counseling to prevent tobacco use for asymptomatic beneficiaries;
• Screening for depression;
• Screening and behavioral counseling interventions in primary care to reduce alcohol misuse; and
• Screening for sexually transmitted infections (STI) and high intensity behavioral counseling
to prevent STIs. Items and services  administered for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, may be covered provided they are not furnished for the specific purpose of causing death.