Friday, March 17, 2017

CPT 64566 - PTNS for uninary control

CPT/HCPCS Codes

Group 1 Codes:

64566 Neuroeltrd stim post tibial

Coverage Indications, Limitations, and/or Medical Necessity

Background

Posterior Tibial Nerve Stimulation (PTNS), a minimally invasive procedure, consists of insertion of an acupuncture needle above the medial malleolus into a superficial branch of the posterior tibial nerve. An adjustable low voltage electrical impulse (10mA, 1-10 Hz frequency) travels via the posterior tibial nerve to the sacral nerve plexus to alter pelvic floor function by neuromodulation.

Indications

Studies demonstrate that PTNS is safe with statistically significant improvements in the clinical assessment of overactive bladder (OAB) (urge incontinence) and may be considered a clinically significant alternative to failed pharmacotherapy. Treatment regimens consist of 30-minute weekly sessions for 12 weeks.

Limitations

Patients must report an improvement in urge incontinence within 6 weeks (i.e., 6 sessions) of initiation of PTNS for continued coverage.

Treatment beyond the initial 12 sessions will be allowed at a frequency of 1 every 1 to 2 months for the remainder of one year. Subsequent treatment will not be covered.

Stress and neurogenic incontinence would not be expected to improve with PTNS.

There is currently no data that shows sustained improved urge incontinence after one year.


Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable


ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

N39.41 Urge incontinence
N39.46 Mixed incontinence
R32 Unspecified urinary incontinence


CODES NUMBER DESCRIPTION

CPT codes for percutaneous implantation of neurostimulator electrodes (i.e., 64553, 64555,

64561, 64565, 64590) are not appropriate since PTNS uses percutaneously temporarily inserted needles and wires rather than percutaneously implanted electrodes that are left in place.

CPT 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming

64999 Unlisted procedure, nervous system HCPCS L8679 Implantable neurostimulator, pulse generator, any type L8680 Implantable neurostimulator electrode, each

Thursday, March 9, 2017

cpt 64635, 64636 - Lumbar facet blockade

CPT/HCPCS Codes


Group 1 Codes:
64493 Inj paravert f jnt l/s 1 lev
64494 Inj paravert f jnt l/s 2 lev
64495 Inj paravert f jnt l/s 3 lev
64635 Destroy lumb/sac facet jnt
64636 Destroy l/s facet jnt addl

Group 2 Paragraph: The CPT codes listed below will be denied as investigational.


Group 2 Codes:
0216T Njx paravert w/us lumb/sac
0217T Njx paravert w/us lumb/sac
0218T Njx paravert w/us lumb/sac


Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

Background

For the purposes of this LCD, a zygapophyseal (ZP) joint ‘level’ refers to the intra-articular joint or the two medial branch nerves that innervate that ZP joint. 

Additionally, cervical and thoracic facet blockade are not addressed in this LCD, however, are covered when reasonable and necessary.

The spinal facet joints are probable causes of somatic low back pain. The facet, or ZP, joint is a paired diarthrodial articulation at the junction of the superior and inferior articular processes of adjacent vertebrae. Facet joints are innervated by the medial branches of the dorsal rami of the segmental nerves. The medial branch nerves from two adjacent dorsal rami innervate each joint.

Lumbar facet blockade techniques are used in the diagnosis and/or treatment of chronic low back pain (LBP) and may alleviate LBP associated with:
Hypertrophic arthropathy of the facet joints;
Post-traumatic injury states; and/or
Suspected motion segment instability/hypermobility or 
pseudoarthrosis following fusion.
History and physical exam cannot discriminate facet pain from other sources of pain. There are no imaging modalities (e.g. MRI, SPECT, CT, plain radiographs) or physiological tests (e.g. ROM testing) that have adequate diagnostic power to confidently incriminate the facet joint as the pain generator.

Historically, both intra-articular blocks (IA) and medial branch blocks (MBB) have been used for diagnosis and treatment of LBP due to facet arthropathy. An optimal diagnosis of facet mediated pain requires dual medial branch blocks (DMBB). 

The efficacy of IA in the treatment of LBP has not been established in the literature; therefore, this LCD does not allow coverage of therapeutic IA. 

This LCD allows coverage of diagnostic IA and diagnostic DMBB. 

Indications

Diagnostic IA or DMBB
Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain when all of the following criteria are met:

Patients suffering with somatic or non-radicular low back and lower extremity pain, with duration of pain of at least 3 months with no definitive radiological cause.

Average pain levels are of greater than 6 on a scale of 0 to 10.

Pain is at least intermittent or continuous causing functional disability. The functional disability must be documented in the medical record.

Condition has failed to respond to more conservative management, including physical therapy modalities, chiropractic management and medication management. This criterion may be waived if documentation supports inability to undergo the above outlined conservative management.

A positive diagnostic response is based on the following evidence:

Patient has met the above indications.
Patient responds positively to controlled local anesthetic blocks either with placebo control or comparative local anesthetic blocks with appropriate response to each local anesthetic of < 1 mL for each nerve or joint.
Almost complete relief of pain, as indicated by a post procedure pain score of 3 or less on a scale of 0 to 10, and the ability to perform previously painful movement.

Therapeutic DMBB

A DMBB therapeutic injection may be indicated when there has been:

A positive diagnostic response, or

A previous positive therapeutic response.

A positive therapeutic response is described as:

Persistent pain relief for a minimum of six (6) weeks of = (greater than or equal to) 50% with the continued ability to perform previously painful maneuvers.

Facet Destruction by Neurolytic Agent

If adequate but short term relief occurs from prior therapeutic DMBB, then facet destruction by neurolytic agent may be a reasonable treatment option in those with a secure diagnosis of facet pain. 

The effects of appropriately performed facet destruction should last at least six (6) months or more and, in some cases, are permanent. Repeat facet destruction procedures of the same level can be considered reasonable and necessary with appropriate documentation in the medical record of return of pain and loss of function.
Limitations

Care of the patient with chronic LBP requires a multidisciplinary (e.g., physical therapy, chiropractic treatment, home exercise program, etc.) treatment program. 

Lumbar facet blockade for the treatment of acute back pain (less than 3 months’ duration) is considered not reasonable and necessary. 

An injection session is defined as all facet injections administered during a 24 hour period for a specific date of service in the lumbar region. Therefore, 

In the first year, up to six (6) facet injection sessions may be performed in the lumbar region: up to two (2) diagnostic and up to four (4) therapeutic.

In the following years, up to four (4) therapeutic facet injection sessions may be performed in the lumbar region.

A maximum of two (2) facet destruction sessions per nerve level per year may be performed in the lumbar region. The rationale for more frequent facet destruction must be documented in the medical record.

Performance of more than one type of injection for pain treatment, such as epidural, sacroiliac joint injections or lumbar sympathetic injections, on the same day as diagnostic lumbar facet blockade is not considered reasonable and necessary.

IA, DMBB (diagnostic and/or therapeutic) or neurolysis must be performed under fluoroscopic or computed tomographic (CT) guidance; ultrasonic guidance (CPT 0216T, 0217T, 0218T) will be denied as investigational.

Injections into the paravertebral musculature must not be billed as IA or DMBB.

Clinicians performing these services must have appropriate training in interventional pain management and radiographic guidance. Documentation of this training must be maintained at the site of practice.

The following are not covered:

Pulsed radiofrequency lesioning.
Intra-articular or extra-articular facet joint prolotherapy.



Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable




Wednesday, March 8, 2017

CPT 81225, 81226, 81227, 81355


Coverage Indications, Limitations, and/or Medical Necessity

This policy limits CYP2C19 (CPT 81225) and CYP2D6 (CPT 81226) genetic testing to defined indications. All other testing for CYP2C19 and CYP2D6 is non-covered until definitive clinical utility is established to justify coverage.

This policy non-covers CYP2C9 (CPT 81227) and VKORC1 (CPT 81355) genetic testing medications to defined indications. All other testing for CYP2C9 and VKORC1 is non-covered until definitive clinical utility is established to justify coverage.

CYP2C19 Genotyping

Background on CYP2C19 Testing

The CYP450 gene superfamily is composed of many isoenzymes that are involved in the metabolism of about 75% of commonly prescribed drugs. CYP2C19 metabolizes 15% of all currently used drugs, whereas CYP2D6 enzymes metabolize approximately 20-25%, and CYP2C9 metabolizes approximately 10%.

Genetic alterations or “polymorphisms” are common in these isoenzymes, with more than 30 polymorphisms identified in CYP2C19. These polymorphisms can lead to differences in individual drug response secondary to variation in metabolism.

CYP2C19 phenotypes include poor, intermediate, extensive and ultra-rapid metabolizers. The frequency of the various metabolizers phenotypes has been estimated as follows:

2-15% - poor metabolizers

18-45% - intermediate metabolizers

35-50% - extensive metabolizers

5-30% - ultra-rapid metabolizers


The genotypic rates vary by ethnicity. Approximately 2% of whites, 4% of blacks and 14% of Chinese are poor CYP2C19 metabolizers.

Pharmacogenetic testing has been proposed to predict individual response to a variety of CYP2C19-metabolized drugs including clopidogrel, proton pump inhibitors, and tricyclic antidepressants, among others. In certain scenarios, an individual patient may benefit from genetic testing in determining dosage and likely response to specific medications.

Clopidogrel bisulfate (Plavix) is a widely prescribed medication to/for:

Prevent blood clots in patients with acute coronary syndrome (ACS),

Other cardiovascular (CV) disease-related events,

Undergoing percutaneous coronary intervention


Clopidogrel response varies significantly due to genetic and acquired factors including obesity, smoking and non-compliance. Patients with poor response to clopidogrel may experience recurrent CV event or thrombotic events while taking clopidogrel. They are at greater risk for major adverse CV events such as heart attack, stroke and death. These individuals are typically poor to intermediate metabolizers of clopidogrel due to the presence of the associated CYP2C19 polymorphisms. These individuals should be given an alternate treatment strategy (Plavix PI). As such, the clinical utility of CYP2C19 genotyping has been supported with net benefits on improving health outcomes for individuals with ACS who are undergoing percutaneous coronary interventions (PCI). There is insufficient evidence of clinical utility of CYP2C19 genotyping for individuals considering clopidogrel therapy for other indications, such as medical management of ACS without PCI, stroke, or peripheral artery disease.

With regards to CYP2C19 testing for antidepressant treatment, recent evidence has suggested genetic testing prior to initiating certain tricyclic antidepressants, namely amitriptyline, due to the effects of the genotype on drug efficacy and safety. Use of this information to determine dosing has been proposed to improve clinical outcomes and reduce the failure rate of initial treatment. However, even with genotype information, a suggestion is given to start patients on low dose, gradually increasing to avoid adverse side effects. Consequently, genotyping is not needed with this approach.

Proton pump inhibitors are used to treat several gastric acid-related conditions including duodenal ulcer, gastric ulcer and gastroesophageal reflux disease. Proton pump inhibitors can also be used to treat Helicobactor pylori. Several proton pump inhibitors are metabolized by CYP2C19. However, there is insufficient data to warrant CYP2C19 genotyping to determine health outcomes or adverse drug reactions in treatment with proton pump inhibitors.

With regards to Serotonin reuptake inhibitors, there is insufficient evidence to support CYP2C19 genotyping to determine medical management for the treatment of obsessive compulsive disorder at this time.

Covered Indications

In summary, genetic testing of the CYP2C19 gene is considered medically necessary for patients with ACS undergoing PCI who are initiating or reinitiating Clopidogrel (Plavix) therapy.

Non-covered Indications

There is insufficient evidence to demonstrate that genetic testing for the CYP2C19 gene improves clinical outcomes. Consequently, genetic testing for the CYP2C19 gene outside of the specified covered indications is considered investigational.

CYP2D6 Genotyping

Background on CYP2D6 Testing

Genetic alterations or “polymorphisms” are common in these isoenzymes, with more than 100 polymorphisms identified in CYP2D6. These polymorphisms can lead to differences in individual drug response secondary to variation in metabolism.

CYP2D6 phenotypes include poor, intermediate, extensive and ultra-rapid metabolizers. The frequency of the poor metabolizer phenotype varies by ethnicity with 7-10% in Caucasians, 1.9-7.3% in African- Americans, and = 1% in most Asian populations studied. The extensive metabolizer phenotype, observed in 50% of Caucasians, is the most common in this population. Genetic variation, as well as drug-drug interactions, can influence the classification of CYP2D6 metabolism into one of the above phenotypes. In addition, chronic dosing of a CYP2D6 drug can inhibit its own metabolism over time as the concentration of the drug approaches a steady state.

Pharmacogenetic testing has been proposed to predict individual response to a variety of CYP2D6-metabolized drugs including tamoxifen, antidepressants, opioid analgesics, and tetrabenzine for chorea, among others. In certain scenarios, an individual patient may benefit from this genetic testing in determining dosage and likely response to specific medications.

Tamoxifen

Available evidence fails to support direct evidence of clinical utility for testing of CYP2D6 in treatment with tamoxifen. Tamoxifen metabolism and the causes for resistance are complex rather than the result of a single polymorphism.

Antidepressants

In regards to CYP2D6 testing for antidepressant treatment, there was insufficient evidence in the past to support testing to determine treatment. More recently, evidence has supported the use of genetic testing prior to initiating certain tricyclic antidepressants due to the effects of genotype on drug efficacy and safety. Use of this information to determine dosing can improve clinical outcomes and reduce the failure rate of initial treatment. However, there is insufficient evidence for CYP2D6 genotyping for individuals considering antipsychotic medications or other antidepressants with CYP2D6 as a metabolizing enzyme.

Codeine

In addition, the role of CYP2D6 genotyping has been evaluated for use in opioid analgesic drug therapy, specifically codeine analgesia. The efficacy and toxicity, including severe or life- threatening toxicity after normal doses of codeine has been linked to an individual’s CYP2D6 genotype. However, genotyping would indicate avoidance of codeine due to risk of adverse events in only 1-2% of the populations, and there is considerable variation in the degree of severity of adverse events, with most not classified as serious. Furthermore, codeine is widely used without genotyping. At this time, there is insufficient evidence to support clinical utility of genotyping for management of codeine therapy.

Tetrabenazine

The dosing of tetrabenazine is based, in part, on CYP2D6 genotyping. However, a recent study suggests that the necessity to genotype may need to be reconsidered. The Xenazine® manufacturer package insert indicates that poor metabolizers of CYP2D6 should not exceed a maximum does of 50 mg/day.

Drugs for Alzheimer’s Disease

Galantamine is an antidementia drug used in the treatment of Alzheimer’s disease. Studies have been performed that reveal the CYP2D6 genotype significantly influences galantamine concentrations in blood. Still other studies have revealed that urinary assays for CYP2D6 phenotype are technically feasible. At this time, the association between phenotype and drug responsiveness remains unknown. Conformational studies in larger populations are necessary to establish evidence regarding individuals most likely to benefit from galatamine, including information on treatment efficacy and tolerability.

Donepezil (Aricept) is a drugs used to treat an Alzheimer’s disease. Some studies have reported an influence of the CYP2D6 on the response to treatment with this drug. Other studies suggest that therapy based on CYP2D6 genotype is unlikely to be beneficial for treating Alzheimer’s disease patients in routine clinical practice. Additional studies are needed to determine the efficacy and utility of CYP2D6 genotyping in those patients who are treated with donepezil.

Covered Indications

In summary, genetic testing of the CYP2D6 gene is considered medically necessary to guide medical treatment and/or dosing for individuals for whom initial therapy is planned with:

Amitriptyline or nortriptyline for treatment of depressive disorders

Tetrabenazine doses greater than 50 mg/day, or re-initiation of therapy with doses greater than 50 mg/day



Non-covered Indications

There is insufficient evidence to demonstrate that genetic testing for the CYP2D6 gene improves clinical outcomes. Consequently, genetic testing for the CYP2D6 gene outside of the specified covered indications is considered investigational.

CYP2C9 Genotyping

Background on CYP2C9 Testing

CYP2C9 metabolizes approximately 10-15% of all currently used drugs. Genetic alternations or “polymorphisms” are common in these isoenzymes, with 57 polymorphisms identified in CYP2C9, which can lead to differences in individual drug response secondary to variation in metabolism.

Pharmacogenetic testing has been proposed to predict individual response to a variety of CYP2C9-metabolized drugs including celecoxib, fluorbipofen, fluvoxamine and warfarin, among others. In certain scenarios, an individual patient may benefit from this genetic testing in determining dosage and likely response to specific medications. However, there is insufficient evidence to support CYP2C9 genotyping to determine medical management and alter outcomes at this time.

Individuals with low enzyme activity for CYP2C9 substrates are at risk of adverse drug reactions. However, pharmacogenetic testing for individuals being treated with drugs, such as warfarin, may experience little or no benefit from testing. This is, in part, because the CYP2C9 genotype accounts for only part of the variability in drug sensitivity.

Warfarin

While there is extensive literature regarding warfarin and the CYP2C9 genotype, the clinical utility of such testing remains unproven at this time. In fact, pharmacogenetic testing for warfarin treatment has been recommended against by the American College of Medical Genetics and the American College of Chest Physicians. These guidelines suggest that genetic testing for warfarin metabolism is not medically necessary, and evidence of clinical utility remains to be proven. Obstacles for determining clinical utility have been reviewed with suggestions for researchers in this area.

Celecoxib

In addition, limited information is available regarding celecoxib metabolism in individuals with CYP2C9 polymorphisms. More trials are needed to determine clinical utility and appropriateness of pharmacogenetic testing in this population.

Covered Indications

Effective August 3, 2009, the Centers for Medicare & Medicaid Services (CMS) believes that the available evidence supports that coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act (the Act) is appropriate for pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness by any method, and is therefore covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin who:

Have not been previously tested for CYP2C9 or VKORC1 alleles; and

Have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and

Are enrolled in a prospective, randomized, controlled clinical study when that study meets the following standards.


Non-covered Indications

All other coverage for genetic testing for the CYP2C9 gene is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to:

Celecoxib

Fluorbiprofen

Flovoxamine



VKORC1 Genotyping

Background on VKORC1 Testing

The vitamin K epoxide reductase complex subunit 1, encoded by the gene VKORC1, is critical in the vitamin K pathway for coagulation. Warfarin therapy targets VKORC1 to reduce clotting risk.

Variation in response to warfarin therapy has been linked to genetic variations. Retrospective study of European-American patients undergoing long term warfarin therapy identified 5 major haplotypes that were most predictive of approximately 25% of variance in warfarin dose. These are classified into A: low dose haplotype and B: high dose haplotype. This was validated in two European-American populations. Average maintenance dose for A/A haplotypes was approximately 2.7 mg per day; 4.9 mg per day for A/B, and 6.2 mg per day for B/B (p<0.001).

Review by the American College of Medical Genetics (2008) confirmed the analytic validity of testing VKORC1 and confirmed that there is sufficient evidence to support association with final therapeutic dose of warfarin. However, safe warfarin dosing requires careful monitoring and there is insufficient evidence is available to support routine VKORC1 genotyping for determination of final dosing. Further study in prospective clinical trials are needed to determine clinical utility.

Clinical Pharmacogenetics Implementation Consortium guidelines recommend that pharmacogenetic algorithms be used to determine ideal dosing, and recommend including VKORC1 genotyping when available. However the evidence from randomized prospective trials is limited, and impact on clinical outcomes is not yet known, limiting the ability to recommend that genotyping be performed for initial warfarin prescribing.

Meta-analysis of CYP2C9 and VKORC1 genotypes influence the risk of hemorrhagic complications in warfarin treated patients and increase the risk for over-coagulation and hemorrhagic complications with CYP2C9*3 carriers. No significant association was noted between VKORC1 genotypes and hemorrhagic complications in randomized controlled study testing.

Covered Indications

Effective August 3, 2009, the Centers for Medicare & Medicaid Services (CMS) believes that the available evidence supports that coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act (the Act) is appropriate for pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness by any method, and is therefore covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin who:

Have not been previously tested for CYP2C9 or VKORC1 alleles; and

Have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and

Are enrolled in a prospective, randomized, controlled clinical study when that study meets the following standards.


Non-covered Indications

There is insufficient evidence to demonstrate that genetic testing for the VKORC1 gene improves clinical outcomes. Consequently, genetic testing for the VKORC1 gene outside of the specified covered indications is considered investigational.


CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17)

Group 2 Paragraph: N/A

Group 2 Codes:
81226 CYP2D6 (CYTOCHROME P450, FAMILY 2, SUBFAMILY D, POLYPEPTIDE 6) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)

Group 3 Paragraph: N/A

Group 3 Codes:
81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6)
81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG, WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, -1639G>A, C.173+1000C>T)




ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

I20.0 Unstable angina
I20.1 Angina pectoris with documented spasm
I20.8 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I24.0 Acute coronary thrombosis not resulting in myocardial infarction
I24.1 Dressler's syndrome
I24.8 Other forms of acute ischemic heart disease
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 - I25.721 - Opens in a new window Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris - Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.728 - I25.731 - Opens in a new window Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris - Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.758 - I25.761 - Opens in a new window Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris - Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
L24.9 Irritant contact dermatitis, unspecified cause

Tuesday, February 28, 2017

CPT 86152 and 86153 - CTC ASSAYS


Coverage Indications, Limitations, and/or Medical Necessity

Indications

This LCD addresses limited coverage for the CellSearch ® Circulating Tumor Cell (CTC) (Veridex, LLC) assay. All other methods for CTC detection, including PCR (RTPCR) assays, are non-covered.

CTCs represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and proliferate in a distant site. Detection of elevated CTCs during therapy is an accurate indication of subsequent rapid disease progression and mortality in breast, colorectal and prostate cancer.

The assay is reported as a numerical result where five or more cells per 7.5 ml of whole blood predicts worse prognosis in patients with known recurrent breast and prostate cancer, and three or more cells are predictive of shorter Progression Free Survival (PFS) and Overall Survival (OS) in metastatic colorectal cancer.

CTC is indicated for an established diagnosis of:
Breast cancer;
Colorectal cancer;
Prostate cancer.

Limitations

All methods for CTC enrichment/detection other than the CellSearch ® CTC assay, including PCR (RT-PCR) assays, are non-covered as they are considered investigational.

CTC testing will be limited to metastatic breast, colorectal and prostate cancer. CTC testing for all other malignant diagnoses will be denied as not reasonable and necessary.

All assays for CTC are non-covered for routine screening or prognosis.

No further CTC testing would be expected after the transition to palliative/hospice care.

Frequency
Baseline – limited to once prior to initiation of tumor-type specific chemotherapy.
During chemotherapy treatment – may be performed once during chemotherapy.
Following chemotherapy treatment – may be repeated at end of chemotherapy.
Surveillance with no chemotherapy treatments - may be repeated each year.


Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
86152 Cell enumeration & id
86153 Cell enumeration phys interp



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

C18.0 - C21.8 - Opens in a new window Malignant neoplasm of cecum - Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C50.011 - C50.929 - Opens in a new window Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast
C61 Malignant neoplasm of prostate
Showing 1 to 3 of 3 entries in Group 1
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Tuesday, January 31, 2017

CPT 0191T, 0295T, 0394T, 0075T - catagory III codes

CPT/HCPCS Codes

Group 1 Paragraph: The following lists Category III services determined by WPS Medicare to be reasonable and medically necessary. Coverage will only be allowed when the service is delivered in clinical situations meeting medical necessity. For services addressed in a separate LCD all criteria addressed in that LCD must be met

Group 1 Codes:

0075T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL

0076T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

0184T EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)

0191T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE TRABECULAR MESHWORK; INITIAL INSERTION

0249T LIGATION, HEMORRHOIDAL VASCULAR BUNDLE(S), INCLUDING ULTRASOUND GUIDANCE

0295T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; INCLUDES RECORDING, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION

0296T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION AND INITIAL RECORDING)

0297T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; SCANNING ANALYSIS WITH REPORT

0298T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; REVIEW AND INTERPRETATION

0308T INSERTION OF OCULAR TELESCOPE PROSTHESIS INCLUDING REMOVAL OF CRYSTALLINE LENS OR INTRAOCULAR LENS PROSTHESIS

0376T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE TRABECULAR MESHWORK; EACH ADDITIONAL DEVICE INSERTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

0394T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, SKIN SURFACE APPLICATION, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED

0395T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, INTERSTITIAL OR INTRACAVITARY TREATMENT, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED


Group 2 Paragraph: Coverage for this device will be allowed for FDA approved indications.
Payment for 0171T and 0172T will be an inclusive payment. No additional code for approach or hardware placement should be billed or paid.


Group 2 Codes:

0171T INSERTION OF POSTERIOR SPINOUS PROCESS DISTRACTION DEVICE (INCLUDING NECESSARY REMOVAL OF BONE OR LIGAMENT FOR INSERTION AND IMAGING GUIDANCE), LUMBAR; SINGLE LEVEL

0172T INSERTION OF POSTERIOR SPINOUS PROCESS DISTRACTION DEVICE (INCLUDING NECESSARY REMOVAL OF BONE OR LIGAMENT FOR
INSERTION AND IMAGING GUIDANCE), LUMBAR; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Group 3 Paragraph: For claims with dates of service on or after January 9, 2014, PILD, procedure code 0275T, is a covered service only when billed as part of a clinical trial approved by CMS per NCD-150.13. All Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (PILD for LSS) claims:
12/31/2014 and earlier should be processed with code 0275T.
01/01/2015 and after use 2 different codes:
- G0276 for clinical trial with Identifier NCT02079038. Is a blinded randomized controlled clinical trial which includes a CMS-approved placebo procedure arm (See CR 8954);
- 0275T for all other clinical trials (See CR 8757).


Group 3 Codes:

0275T PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), WITH OR WITHOUT THE USE OF AN ENDOSCOPE, SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR

Group 4 Paragraph: The Centers for Medicare & Medicaid Services (CMS) published a final decision memorandum for left atrial appendage closure (LAAC) on February 8, 2016, covering percutaneous LAAC for non-valvular atrial fibrillation through Coverage with Evidence Development under 1862(a)(1)(E) of the Social Security Act per CAG-00445N and NCD 20.34 LAAC.

Group 4 Codes:

0281T PERCUTANEOUS TRANSCATHETER CLOSURE OF THE LEFT ATRIAL APPENDAGE WITH IMPLANT, INCLUDING FLUOROSCOPY, TRANSSEPTAL PUNCTURE, CATHETER PLACEMENT(S), LEFT ATRIAL ANGIOGRAPHY, LEFT ATRIAL APPENDAGE ANGIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION


Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The American Medical Association (AMA) develops temporary Current Procedural Terminology (CPT) Category III codes to track the utilization of emerging technologies, services, and procedures. The CATEGORY III CPT Code description does not establish a service or procedure as safe, effective or applicable to the clinical practice of medicine.

The creation of a CPT Category III code by the AMA "neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice."

Acceptance by individual health care providers, or even a limited group of health care providers, does not indicate general acceptance by the medical community. Testimonials indicating such limited acceptance, and limited case studies distributed by sponsors with financial interest in the outcome, are not sufficient evidence of general acceptance by the medical community. The available published evidence must be considered and its quality shall be evaluated before a conclusion is reached.

Indications and Limitations:

Section 1862(a)(1)(A) of the Social Security Act (SSA) is the statutory basis for denying payment for types of care, items, services, and procedures, not excluded by any other statutory clause while meeting all technical requirements for coverage, that are determined to be any of the following:
Not generally accepted by the medical community as safe and effective in the setting and for the condition for which it is used;

Not proven safe and effective based on peer review or scientific literature;

Experimental;

Not medically necessary for a particular patient;

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 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 of diagnosis of the illness or injury under treatment; and

Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental) and;

Not furnished primarily for the convenience of the patient, the provider or supplier; and

Furnished at the most appropriate level of care that can be provided safely and effectively to the patient.

Medical devices that are not approved for marketing by the Food and Drug Administration (FDA) are considered investigational and are not considered reasonable and necessary under SSA 1862(a)(1)(A). Medicare payment, therefore, may not be made for procedures performed using devices that have not been approved for marketing by the FDA unless performed within the context of a clinical trial qualifying under the National Coverage Determination (NCD) for Routine Costs in Clinical Trials (310.1) or in approved FDA Investigational Device Exemption (IDE) trial.

FDA designation/ determination of a device as 510(k) mean(s) that the device has been approved for marketing by the FDA because it is similar to something already on the market that was "grandfathered in" by the FDA and therefore these devices are eligible for coverage. 

In addition, items, services, or devices may also be not covered under SSA 1862 (a) (1) (D) (E) or (O).

If a provider believes that any Category III code not included in this LCD qualifies for coverage (is proven to be safe and effective as well as reasonable and necessary), that provider may request inclusion of the Category III code in this LCD through the LCD Reconsideration Process. Peer reviewed scientific evidence is required for consideration. 


Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: The following ICD-10 Codes apply to CPT code 0191T and 0376T to support medical necessity.


ICD-10 CODE DESCRIPTION

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

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

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

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

H40.1131 Primary open-angle glaucoma, bilateral, mild stage

H40.1132 Primary open-angle glaucoma, bilateral, moderate stage

H40.1211 Low-tension glaucoma, right eye, mild stage

H40.1212 Low-tension glaucoma, right eye, moderate stage

H40.1221 Low-tension glaucoma, left eye, mild stage

H40.1222 Low-tension glaucoma, left eye, moderate stage

H40.1231 Low-tension glaucoma, bilateral, mild stage

H40.1232 Low-tension glaucoma, bilateral, moderate stage

H40.1311 Pigmentary glaucoma, right eye, mild stage

H40.1312 Pigmentary glaucoma, right eye, moderate stage

H40.1321 Pigmentary glaucoma, left eye, mild stage

H40.1322 Pigmentary glaucoma, left eye, moderate stage

H40.1331 Pigmentary glaucoma, bilateral, mild stage

H40.1332 Pigmentary glaucoma, bilateral, moderate stage

H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage

H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage

H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage

H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage

H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage

H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage


ICD-10 CODE DESCRIPTION

M48.05 Spinal stenosis, thoracolumbar region

M48.06 Spinal stenosis, lumbar region

M48.07 Spinal stenosis, lumbosacral region

Z00.6 Encounter for examination for normal comparison and control in clinical research program

Friday, January 27, 2017

cpt code j3489, j1436 - Bisphosphonate Drug Therapy

CPT/HCPCS Codes

Group 1 Codes:

J1436 INJECTION, ETIDRONATE DISODIUM, PER 300 MG

J1740 INJECTION, IBANDRONATE SODIUM, 1 MG

J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG

J3489 INJECTION, ZOLEDRONIC ACID, 1 MG

Coverage Indications, Limitations, and/or Medical Necessity

Bisphosphonate drugs act to inhibit normal and abnormal bone reabsorption. This action is helpful in reducing pain, reversing hypercalcemia, preventing and reducing fractures in a range of diseases that directly or indirectly impact bone modeling and remodeling.

Bisphosphonates are available in both oral and parenteral forms. Coverage is limited to those drugs administered parenterally (IV). Bisphosphonates are indicated parenterally when the patient has failed a trial of the oral drug or has insurmountable issues related to absorption, compliance or dosing posture.

Etidronate disodium IV, Pamidronate disodium IV, and Zoledronic acid IV, are covered for the following indications:
Hypercalcemia associated with malignancy
Osteoclastic hyperactivity resulting in excessive bone resorption is the underlying complication with metastatic bone disease and hypercalcemia associated with malignancy. Most cases of hypercalcemia, associated with malignancy, occurs in patients who have breast cancer, squamous-cell tumors of the lung or head and neck, renal-cell carcinoma, and certain hematologic malignancies (multiple myeloma and some types of lymphomas). Bisphosphonates, in conjunction with hydration, are indicated for moderate or severe hypercalcemia associated with malignancy with or without bone metastases.

Cancer Treatment-Induced Bone Loss (CTIBL) in Breast and Prostate Cancer

Breast Cancer

Cytotoxic chemotherapy: There are 2 mechanisms of cytotoxic chemotherapy inducing bone loss. First, there is a direct negative effect of the cytotoxic therapy on bone cells, predominantly osteoblasts and, second, many women who are premenopausal have cytotoxic therapy effects on ovarian function, which results in gonadal loss. In addition, in premenopausal women, surgery (oophorectomy) or radiation therapy to the ovary results in bone loss. Hormone therapy, tamoxifen in premenopausal women, and the aromatase inhibitors result in bone loss, as well as gonadotropin-releasing hormone (GnRH) antagonists/agonists, which shut off ovarian function. All of these result in estrogen depletion.

Prostate Cancer

In prostate cancer, cytotoxic therapy again has a negative effect not only on testicular function but also on bone. Surgical therapy, hormone therapy, including antiandrogens and GnRH agonists/antagonists, results in androgen depletion. The final common pathway, estrogen and androgen depletion, results in a decrease in bone mineral density.

Bone metastases secondary to solid tumors, breast cancer, and prostate cancer

Multiple Myeloma

Osteolytic lesions due to metastases

Paget’s Disease of bone (osteitis deformans)

Intravenous bisphosphonates are indicated for moderate to severe Paget’s disease of bone.

Prophylaxis and treatment of heterotopic ossification associated with spinal cord injury, traumatic brain injury, hip replacement, and burns
It is indicated parenterally when the patient has failed a trial of the oral drug or has insurmountable issues related to absorption, compliance or dosing posture.

Besides the indication listed above, Pamidronate Sodium is covered for the following indications:
Osteogenesis Imperfecta

Fibrous dysplasia of bone (McCune-Albright syndrome)

Ibandronate sodium, Pamidronate or Zoledronic acid are covered for the following additional indication:
Treatment of osteoporosis when there is no drug classification contraindications. There also needs to exist either one or more of the following:
Demonstrated intolerance or contraindication for FDA approved oral bisphosphonates dosing regimens, or insurmountable issues related to absorption, compliance or dosing posture.

When adequate trials of FDA-approved oral bisphosphonates result in fallen Bone Mass Density and/or failure to suppress bone turnover (e.g. persisting high bone -turnover marker measurements).

Evidence in the medical record should clearly support the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis.

Ibandronate sodium is covered for:
Hypercalcemia associated with malignancy

Bone metastases secondary to solid tumors, breast cancer, prostate cancer

Zoledronic acid - Injection is covered for the treatment of:
Paget's disease of bone in men and women.

Treatment is indicated in patients with Paget’s disease of bone with elevations in serum alkaline phosphatase of two times or higher than the upper limit of the age-specific normal reference range, or those who are symptomatic, or those at risk for complications from their disease, to induce remission (normalization of serum alkaline phosphatase).

This contractor will cover zoledronic acid at most once per year because after a single treatment with zoledronic acid in Paget’s disease, an extended remission period is observed. Re-treatment with zoledronic acid may be considered, after one year in patients who have relapsed, based on increases in serum alkaline phosphatase, or in those patients who failed to achieve normalization of their serum alkaline phosphatase, or in those patients with symptoms, as dictated by medical practice.


Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A


ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: Note: Diagnosis codes must be coded to the highest level of specificity.

J1436 Etidronate disodium



Group 1 Codes:

ICD-10 CODE DESCRIPTION

C79.51* Secondary malignant neoplasm of bone

C79.52* Secondary malignant neoplasm of bone marrow

C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission

C90.02 Multiple myeloma in relapse

E83.52 Hypercalcemia

M61.011 Myositis ossificans traumatica, right shoulder

M61.012 Myositis ossificans traumatica, left shoulder

M61.021 Myositis ossificans traumatica, right upper arm

M61.022 Myositis ossificans traumatica, left upper arm

M61.031 Myositis ossificans traumatica, right forearm

M61.032 Myositis ossificans traumatica, left forearm

M61.041 Myositis ossificans traumatica, right hand

M61.042 Myositis ossificans traumatica, left hand

M61.051 Myositis ossificans traumatica, right thigh

M61.052 Myositis ossificans traumatica, left thigh

M61.061 Myositis ossificans traumatica, right lower leg

M61.062 Myositis ossificans traumatica, left lower leg

M61.071 Myositis ossificans traumatica, right ankle and foot

M61.072 Myositis ossificans traumatica, left ankle and foot

M61.08 Myositis ossificans traumatica, other site

M61.09 Myositis ossificans traumatica, multiple sites

M61.111 Myositis ossificans progressiva, right shoulder

M61.112 Myositis ossificans progressiva, left shoulder

M61.121 Myositis ossificans progressiva, right upper arm

M61.122 Myositis ossificans progressiva, left upper arm

M61.131 Myositis ossificans progressiva, right forearm
M61.132 Myositis ossificans progressiva, left forearm

M61.141 Myositis ossificans progressiva, right hand

M61.142 Myositis ossificans progressiva, left hand

M61.144 Myositis ossificans progressiva, right finger(s)

M61.145 Myositis ossificans progressiva, left finger(s)

M61.151 Myositis ossificans progressiva, right thigh

M61.152 Myositis ossificans progressiva, left thigh

M61.161 Myositis ossificans progressiva, right lower leg

M61.162 Myositis ossificans progressiva, left lower leg

M61.171 Myositis ossificans progressiva, right ankle

M61.172 Myositis ossificans progressiva, left ankle

M61.174 Myositis ossificans progressiva, right foot

M61.175 Myositis ossificans progressiva, left foot

M61.177 Myositis ossificans progressiva, right toe(s)

M61.178 Myositis ossificans progressiva, left toe(s)

M61.18 Myositis ossificans progressiva, other site

M61.19 Myositis ossificans progressiva, multiple sites

M61.211 Paralytic calcification and ossification of muscle, right shoulder

M61.212 Paralytic calcification and ossification of muscle, left shoulder

M61.221 Paralytic calcification and ossification of muscle, right upper arm

M61.222 Paralytic calcification and ossification of muscle, left upper arm

M61.231 Paralytic calcification and ossification of muscle, right forearm

M61.232 Paralytic calcification and ossification of muscle, left forearm

M61.241 Paralytic calcification and ossification of muscle, right hand

M61.242 Paralytic calcification and ossification of muscle, left hand

M61.251 Paralytic calcification and ossification of muscle, right thigh

M61.252 Paralytic calcification and ossification of muscle, left thigh

M61.261 Paralytic calcification and ossification of muscle, right lower leg

M61.262 Paralytic calcification and ossification of muscle, left lower leg

M61.271 Paralytic calcification and ossification of muscle, right ankle and foot

M61.272 Paralytic calcification and ossification of muscle, left ankle and foot

M61.28 Paralytic calcification and ossification of muscle, other site

M61.29 Paralytic calcification and ossification of muscle, multiple sites

M88.0 Osteitis deformans of skull

M88.1 Osteitis deformans of vertebrae

M88.811 Osteitis deformans of right shoulder

M88.812 Osteitis deformans of left shoulder

M88.821 Osteitis deformans of right upper arm

M88.822 Osteitis deformans of left upper arm

M88.831 Osteitis deformans of right forearm

M88.832 Osteitis deformans of left forearm

M88.841 Osteitis deformans of right hand

M88.842 Osteitis deformans of left hand

M88.851 Osteitis deformans of right thigh

M88.852 Osteitis deformans of left thigh

M88.861 Osteitis deformans of right lower leg

M88.862 Osteitis deformans of left lower leg

M88.871 Osteitis deformans of right ankle and foot

M88.872 Osteitis deformans of left ankle and foot

M88.88 Osteitis deformans of other bones

M88.89 Osteitis deformans of multiple sites

M89.9* Disorder of bone, unspecified

M94.9* Disorder of cartilage, unspecified


T79.6XXA Traumatic ischemia of muscle, initial encounter
T79.6XXD Traumatic ischemia of muscle, subsequent encounter

T79.6XXS Traumatic ischemia of muscle, sequela

Z79.811* Long term (current) use of aromatase inhibitors

Z79.899* Other long term (current) drug therapy

Z85.3* Personal history of malignant neoplasm of breast

Z85.46* Personal history of malignant neoplasm of prostate

Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *For C79.51 and C79.52, see Documentation Requirements



*For treatment of bone loss in woman receiving adjuvant aromatase inhibitor therapy for breast cancer, ICD-10 code M89.9 or M94.9 must be reported with Z85.3 and Z79.811.


*For treatment of bone loss in men receiving androgen deprivation therapy for nonmetastatic prostate cancer, ICD-10 M89.9 or M94.9 must be reported with Z85.46 and Z79.899.


Sunday, January 22, 2017

CPT CODE 95923, 95943, 95921, 95924

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The autonomic nervous system (ANS) regulates physiologic processes, such as blood pressure, heart rate, body temperature, digestion, metabolism, fluid and electrolyte balance, sweating, urination, defecation, sexual response, and other processes. Regulation occurs without conscious control, i.e., autonomously. The ANS has two major divisions: the sympathetic and parasympathetic systems. ANS testing measures alterations in the R-R interval of the electrocardiogram (ECG) in response to parasympathetic and sympathetic system stimulation. The aim of such testing is to correlate signs and symptoms of possible autonomic dysfunction with objective measurement in a way that is clinically useful. Many organs are controlled primarily by either the sympathetic or parasympathetic system, although they may receive input from both; occasionally, functions are reciprocal (e.g., sympathetic input increases heart rate; parasympathetic decreases it).

The sympathetic nervous system is catabolic and activates fight-or-flight responses. Thus, sympathetic output increases heart rate and contractility, bronchodilation, hepatic glycogenolysis and glucose release, BMR (basal metabolism rate), and muscular strength; it also causes sweaty palms. Less immediately-life-preserving functions (e.g., digestion, renal filtration) are decreased.

The parasympathetic nervous system is anabolic; it conserves and restores. Gastrointestinal secretions and motility (including evacuation) are stimulated, heart rate is slowed, and blood pressure decreases.

Disorders of the ANS can affect any system of the body; they can originate in the peripheral or central nervous system and may be primary or secondary to other disorders. Symptoms suggesting autonomic dysfunction include orthostatic hypotension, heat intolerance, nausea, constipation, urinary retention or incontinence, nocturia, impotence, and dry mucous membranes. If a patient has symptoms suggesting autonomic dysfunction, cardiovagal, adrenergic, and sudomotor tests are usually done to help determine severity and distribution of the dysfunction.

ANS testing can be grouped into three general categories:

Cardiovagal innervation - a test that provides a standardized quantitative evaluation of vagal innervation to parasympathetic function of the heart. Responses are based on the interpretation of changes in continuous heart recordings in response to standardized maneuvers and include heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio heart rate responses to standing. A tilt table may be used, but is not required.

Vasomotor adrenergic innervation - evaluates adrenergic innervation of the circulation and of the heart in autonomic failure. The following tests are included: beat-to-beat blood pressure and R-R interval response to Valsalva maneuver, sustained hand grip, and blood pressure and heart rate responses to tilt-up or active standing and must be performed with a tilt table.

Sudomotor - function testing is used to evaluate and document neuropathic disturbances that may be associated with pain. The quantitative sudomotor axon reflex test (QSART), thermoregulatory sweat test (TST), sympathetic skin responses, and silastic sweat imprints are tests of sympathetic cholinergic sudomotor function.

Indications:

Tests are useful in defining the presence of autonomic failure, their natural history, and response to treatment. They can also define patterns of dysautonomia that are useful in helping the clinician diagnose certain autonomic conditions. Selective autonomic failure (which only one system is affected) can be diagnosed by autonomic testing. An example is chronic idiopathic anhidrosis, where only sudomotor function is affected. Among the synucleinopathies, autonomic function tests can distinguish Parkinson’s disease (PD) from multiple system atrophy (MSA). There is a gradation of autonomic failure. PD is characterized by mild autonomic failure and a length-dependent pattern of sudomotor involvement. MSA and pure autonomic failure have severe generalized autonomic failure while Dementia with Lewy Bodies ( DLB) is intermediate.

Limitations:

Syndromes of autonomic dysfunction which require formal autonomic function testing are relatively rare. Generally, only after excluding more common causes of autonomic signs or symptoms (e.g., hypotension, hyperhidrosis, and orthostatic tachycardia) may formal autonomic testing be indicated to exclude or confirm rarer autonomic disorders. Autonomic function testing is covered as reasonable and necessary when used as a diagnostic tool to evaluate symptoms indicative of vasomotor instability and the ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful and relevant medical decision making for one of the following indications:

To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic neuropathy.

To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy.

To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness.

To evaluate inadequate response to beta blockade in vasodepressor syncope.

To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose the condition.

To differentiate the cause of postural tachycardia syndrome.

To evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure.

To evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam.

To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient.

To evaluate and treat patients with recurrent unexplained syncope or demonstrate autonomic failure, after more common causes have been excluded by other standard testing.

The following indications are considered not medically reasonable and necessary and will not be covered:
Screening patients without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic or renal disease.

Testing for the sole purpose of monitoring disease intensity or treatment efficacy in diabetes, hepatic or renal disease.

Testing results that are not used in clinical decision-making or patient management.

Testing performed by physicians who do not have evidence of training, and expertise to perform and interpret these tests. (Physicians must have knowledge, training, and expertise to perform and interpret these tests, and to assess and train personnel working with them. This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered, sponsored or endorsed by an academic [institution] in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as category I credit.)

General professional standards with FDA clearance apply for all equipment used in ANS testing.

Testing with ANSAR ANX 3.0 or a similar machine is considered investigational for screening and will not be covered.

Equipment for Autonomic Nervous System Studies 

Equipment with FDA clearance for heart rate variability measurements in response to paced respirations and exercises that tests only heart rate variability does not meet the full range of testing parameters required for the performance of cardiovagal innervation (parasympathetic function) or vasomotor adrenergic innervation (sympathetic adrenergic function), and does not ensure full test requirements, such as blood pressure monitoring and blood oxygen levels; nor do they incorporate proper testing conditions, such as the use of a tilt table. Providers may be asked to supply information on the equipment used to perform autonomic nervous system studies, to ensure that all studies performed meet the requirements of the procedure.




CPT/HCPCS Codes

Group 1 Paragraph: NA

Group 1 Codes:

95921 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; CARDIOVAGAL INNERVATION (PARASYMPATHETIC FUNCTION), INCLUDING 2 OR MORE OF THE FOLLOWING: HEART RATE RESPONSE TO DEEP BREATHING WITH RECORDED R-R INTERVAL, VALSALVA RATIO, AND 30:15 RATIO

95922 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; VASOMOTOR ADRENERGIC INNERVATION (SYMPATHETIC ADRENERGIC FUNCTION), INCLUDING BEAT-TO-BEAT BLOOD PRESSURE AND R-R INTERVAL CHANGES DURING VALSALVA MANEUVER AND AT LEAST 5 MINUTES OF PASSIVE TILT

95923 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; SUDOMOTOR, INCLUDING 1 OR MORE OF THE FOLLOWING: QUANTITATIVE SUDOMOTOR AXON REFLEX TEST (QSART), SILASTIC SWEAT IMPRINT, THERMOREGULATORY SWEAT TEST, AND CHANGES IN SYMPATHETIC SKIN POTENTIAL

95924 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; COMBINED PARASYMPATHETIC AND SYMPATHETIC ADRENERGIC FUNCTION TESTING WITH AT LEAST 5 MINUTES OF PASSIVE TILT

Group 2 Paragraph: CPT code 95943 was not developed and intended to be specific to any brand/manufacturer. If a physician finds that this non-standardized component information of autonomic function testing (AFT) is useful in a patient assessment and clinical decision making given certain patient risks/signs/symptoms, this would be included in the physician’s basic evaluation and management service and not separately covered. In addition, testing patients prior to the development of symptomatic autonomic neuropathy would be screening, and there is no such screening Medicare benefit with the absence of disease.


Group 2 Codes:

95943 SIMULTANEOUS, INDEPENDENT, QUANTITATIVE MEASURES OF BOTH PARASYMPATHETIC FUNCTION AND SYMPATHETIC FUNCTION, BASED ON TIME-FREQUENCY ANALYSIS OF HEART RATE VARIABILITY CONCURRENT WITH TIME-FREQUENCY ANALYSIS OF CONTINUOUS RESPIRATORY ACTIVITY, WITH MEAN HEART RATE AND BLOOD PRESSURE MEASURES, DURING REST, PACED (DEEP) BREATHING, VALSALVA MANEUVERS, AND HEAD-UP POSTURAL CHANGE





ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: Group 1 diagnosis codes apply to codes 95921, 95922, 95923 and 95924


ICD-10 CODE DESCRIPTION

E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy

E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy

E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy

E10.44 Type 1 diabetes mellitus with diabetic amyotrophy

E10.49 Type 1 diabetes mellitus with other diabetic neurological complication

E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy

E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy

E11.44 Type 2 diabetes mellitus with diabetic amyotrophy

E11.49 Type 2 diabetes mellitus with other diabetic neurological complication

E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy

E13.41 Other specified diabetes mellitus with diabetic mononeuropathy

E13.42 Other specified diabetes mellitus with diabetic polyneuropathy

E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy

E13.44 Other specified diabetes mellitus with diabetic amyotrophy

E13.49 Other specified diabetes mellitus with other diabetic neurological complication

E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy

E85.0 Non-neuropathic heredofamilial amyloidosis

E85.1 Neuropathic heredofamilial amyloidosis

E85.3 Secondary systemic amyloidosis

E85.4 Organ-limited amyloidosis

E85.8 Other amyloidosis


G23.0 Hallervorden-Spatz disease

G23.1 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski]

G23.2 Striatonigral degeneration

G23.8 Other specified degenerative diseases of basal ganglia

G60.3 Idiopathic progressive neuropathy

G60.8 Other hereditary and idiopathic neuropathies

G90.09 Other idiopathic peripheral autonomic neuropathy

G90.3 Multi-system degeneration of the autonomic nervous system

G90.50 Complex regional pain syndrome I, unspecified

G90.511 Complex regional pain syndrome I of right upper limb
G90.512 Complex regional pain syndrome I of left upper limb

G90.513 Complex regional pain syndrome I of upper limb, bilateral

G90.521 Complex regional pain syndrome I of right lower limb

G90.522 Complex regional pain syndrome I of left lower limb
G90.523 Complex regional pain syndrome I of lower limb, bilateral

G90.59 Complex regional pain syndrome I of other specified site

I95.1 Orthostatic hypotension

R00.0 Tachycardia, unspecified
R55 Syncope and collapse

R61 Generalized hyperhidrosis

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