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

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