CMS Pub. 100-04, ch. 32
Table of Contents (Rev. 13709; Issued: 04-02-26)
40.2 – Billing Requirements
40.2.2 – Payment Requirements for Test Procedures (HCPCS Codes 64585, 64590 and 64595)
60.12 - Coverage for PET Scans for Dementia and Neurodegenerative Diseases
66 - National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage.
90 - Stem Cell Transplantation
90.1 - General
140.2 – CR Program Services Effective for Dates of Service On or After January 1, 2024
140.2.2.4 – Edits for CR Services Exceeding 36 Sessions
180.3 – Payment Requirements
180.4 - Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages
280 – Autologous Cellular Immunotherapy Treatment of Metastatic Prostate Cancer
280.1 - Policy
340.3 - Claims Processing Requirements for Mitral Valve TEER Services on Inpatient Hospital Claims
340.4 - Claims Processing Requirements for Mitral Valve TEER Services for Medicare Advantage (MA) Plan Participants
380.1 - Leadless Pacemaker Coding and Billing Requirements for Professional Claims
380.2 - Leadless Pacemaker Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Medicare Summary Notice (MSN) Messages
415.1– Coding Requirements for T-TEER
415.2– Claims Processing Instructions for T-TEER Professional Claims
415.3– Claims Processing Instructions for T-TEER Institutional Claims
416.1- Coverage
416.2- Claims Processing Instructions
416.3 Claims Processing Instructions for Cardiac Contractility Modulation (CCM) for Heart Failure (HF) Institutional Claims
416.4 Messages
417. 1 Coding Requirements
417.2 – Special Intermediary Claims Processing Requirements
417.3 – Special Professional Billing Requirements
417.4 – Messaging
418.1 Coding Requirements for Cardiac Contractility Modulation (CCM) for Heart Failure (HF)
418.2 Claims Processing Instructions for Cardiac Contractility Modulation (CCM) for Heart Failure (HF) Professional Claims
418.3 Claims Processing Instructions for Cardiac Contractility Modulation (CCM) for Heart Failure (HF) Institutional Claims
418.4 Messages
Effective April 1, 2002, a National Coverage Decision was made to allow for Medicare coverage of ABPM for those beneficiaries with suspected 'white coat hypertension' (WCH). ABPM involves the use of a non-invasive device, which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the device and are later interpreted by a physician. Suspected 'WCH' is defined as: (1) Clinic/office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; (2) At least two documented separate blood pressure measurements taken outside the clinic/office which are < 140/90 mm Hg; and (3) No evidence of end-organ damage. ABPM is not covered for any other uses. Coverage policy can be found in Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §20.19. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).
The ABPM must be performed for at least 24 hours to meet coverage criteria. Payment is not allowed for institutionalized beneficiaries, such as those receiving Medicare covered skilled nursing in a facility. In the rare circumstance that ABPM needs to be performed more than once for a beneficiary, the qualifying criteria described above must be met for each subsequent ABPM test.
Effective dates for applicable Common Procedure Coding System (HCPCS) codes for ABPM for suspected WCH and their covered effective dates are as follows:
| HCPCS | Definition | Effective Date |
|---|---|---|
| 93784 | ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report. | 04/01/2002 |
| 93786 | ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only. | 04/01/2002 |
| 93788 | ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report. | 01/01/2004 |
| HCPCS | Definition | Effective Date |
|---|---|---|
| 93790 | ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; physician review with interpretation and report. | 04/01/2002 |
In addition, one of the following diagnosis codes must be present:
| Diagnosis Code | Description | |
|---|---|---|
| If ICD-10-CM is applicable | R03.0 | Elevated blood pressure reading without diagnosis of hypertension |
The applicable types of bills acceptable when billing for ABPM services are 13X, 23X, 71X, 73X, 75X, and 85X. Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B MACs (A). The A/B MACs (A) pay for hospital outpatient ABPM services billed on a 13X type of bill with HCPCS 93786 and/or 93788 as follows: (1) Outpatient Prospective Payment System (OPPS) hospitals pay based on the Ambulatory Payment Classification (APC); (2) non-OPPS hospitals (Indian Health Services Hospitals, Hospitals that provide Part B services only, and hospitals located in American Samoa, Guam, Saipan and the Virgin Islands) pay based on reasonable cost, except for Maryland Hospitals which are paid based on a percentage of cost. Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for ABPM.
The A/B MACs (A) pay for comprehensive outpatient rehabilitation facility (CORF) ABPM services billed on a 75x type of bill with HCPCS code 93786 and/or 93788 based on the Medicare Physician Fee Schedule (MPFS) amount for that HCPCS code.
The A/B MACs (A) pay for ABPM services for critical access hospitals (CAHs) billed on a 85x type of bill as follows: (1) for CAHs that elected the Standard Method and billed HCPCS code 93786 and/or 93788, pay based on reasonable cost for that HCPCS code; and (2) for CAHs that elected the Optional Method and billed any combination of HCPCS codes 93786, 93788 and 93790 pay based on reasonable cost for HCPCS 93786 and 93788 and pay 115% of the MPFS amount for HCPCS 93790.
The A/B MACs (A) pay for ABPM services for skilled nursing facility (SNF) outpatients billed on a 23x type of bill with HCPCS code 93786 and/or 93788, based on the MPFS.
The A/B MACs (A) accept independent and provider-based rural health clinic (RHC) bills for visits under the all-inclusive rate when the RHC bills on a 71x type of bill with revenue code 052x for providing the professional component of ABPM services. The A/B MACs
(A) should not make a separate payment to a RHC for the professional component of ABPM services in addition to the all-inclusive rate. RHCs are not required to use ABPM HCPCS codes for professional services covered under the all-inclusive rate.
The A/B MACs (A) accept free-standing and provider-based federally qualified health center (FQHC) bills for visits under the all-inclusive rate when the FQHC bills on a 73x type of bill with revenue code 052x for providing the professional component of ABPM services.
The A/B MACs (A) should not make a separate payment to a FQHC for the professional component of ABPM services in addition to the all-inclusive rate. FQHCs are not required to use ABPM HCPCS codes for professional services covered under the all-inclusive rate.
The A/B MACs (A) pay provider-based RHCs/FQHCs for the technical component of ABPM services when billed under the base provider's number using the above requirements for that particular base provider type, i.e., a OPPS hospital based RHC would be paid for the ABPM technical component services under the OPPS using the APC for code 93786 and/or 93788 when billed on a 13x type of bill.
Independent and free-standing RHC/FQHC practitioners are only paid for providing the technical component of ABPM services when billed to the A/B MAC (B) following the MAC's instructions.
A/B MACs (B) pay for ABPM services billed with ICD-10-CM diagnosis code R03.0 (if ICD-10 is applicable) and HCPCS codes 93784 or for any combination of 93786, 93788 and 93790, based on the MPFS for the specific HCPCS code billed.
The A/B MACs (A and B) shall apply coinsurance and deductible to payments for ABPM services except for services billed to the A/B MAC (A) by FQHCs. For FQHCs only coinsurance applies.
(Rev 124a, 03-19-04)
(Rev. 371, Issued 11-19-04, Effective: 04-01-05, Implementation: 04-04-05)
Effective April 1, 2003, a National Coverage Decision was made to allow for Medicare coverage of Electrical Stimulation for the treatment of certain types of wounds. The type of wounds covered are chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers. All other uses of electrical stimulation for the treatment of wounds are not covered by Medicare. Electrical stimulation will not be covered as an initial treatment modality.
The use of electrical stimulation will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing. If electrical stimulation is being used, wounds must be evaluated periodically by the treating physician but no less than every 30 days by a physician. Continued treatment with electrical stimulation is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Additionally, electrical stimulation must be discontinued when the wound demonstrates a 100% epithelialized wound bed.
Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.1 (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)
The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:
| HCPCS | Definition | Effective Date |
|---|---|---|
| G0281 | Electrical Stimulation, (unattended), to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. | 04/01/2003 |
Medicare will not cover the device used for the electrical stimulation for the treatment of wounds. However, Medicare will cover the service. Unsupervised home use of electrical stimulation will not be covered.
The applicable types of bills acceptable when billing for electrical stimulation services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X. Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to FIs. FIs pay for electrical stimulation services under the Medicare Physician Fee Schedule for a hospital, Comprehensive Outpatient Rehabilitation Facility (CORF), Outpatient Rehabilitation Facility (ORF), Outpatient Physical Therapy (OPT) and Skilled Nursing Facility (SNF).
Payment methodology for independent Rural Health Clinic (RHC), provider-based RHCs, free-standing Federally Qualified Health Center (FQHC) and provider based FQHCs is made under the all-inclusive rate for the visit furnished to the RHC/FQHC patient to obtain the therapy service. Only one payment will be made for the visit furnished to the RHC/FQHC patient to obtain the therapy service. As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for these therapy services.
Payment Methodology for a Critical Access Hospital (CAH) is on a reasonable cost basis unless the CAH has elected the Optional Method and then the FI pays 115% of the MPFS amount for the professional component of the HCPCS code in addition to the technical component.
In addition, the following revenues code must be used in conjunction with the HCPCS code identified:
| Revenue Code | Description |
|---|---|
| 420 | Physical Therapy |
| 430 | Occupational Therapy |
| 520 | Federal Qualified Health Center * |
| 521 | Rural Health Center * |
| 977, 978 | Critical Access Hospital- method II CAH professional services only |
Carriers pay for Electrical Stimulation services billed with HCPCS codes G0281 based on the MPFS. Claims for Electrical Stimulation services must be billed on Form CMS-1500 or the electronic equivalent following instructions in chapter 12 of this manual (http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf).
The Medicare contractor shall apply coinsurance and deductible to payments for these therapy services except for services billed to the FI by FQHCs. For FQHCs, only co-insurance applies.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
Effective July 1, 2004, a National Coverage Decision was made to allow for Medicare coverage of electromagnetic therapy for the treatment of certain types of wounds. The type of wounds covered are chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers. All other uses of electromagnetic therapy for the treatment of wounds are not covered by Medicare. Electromagnetic therapy will not be covered as an initial treatment modality.
The use of electromagnetic therapy will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing. If electromagnetic therapy is being used, wounds must be evaluated periodically by the treating physician but no less than every 30 days. Continued treatment with electromagnetic therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Additionally, electromagnetic therapy must be discontinued when the wound demonstrates a 100% epithelialized wound bed.
Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1 section 270.1. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)
The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:
| HCPCS | Definition | Effective Date |
|---|---|---|
| G0329 | Electromagnetic Therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. | 07/01/2004 |
Medicare will not cover the device used for the electromagnetic therapy for the treatment of wounds. However, Medicare will cover the service. Unsupervised home use of electromagnetic therapy will not be covered.
The applicable types of bills acceptable when billing for electromagnetic therapy services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X. Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B MACs (A). A/B MACs (A) pay for electromagnetic therapy services under the Medicare Physician Fee Schedule for a hospital, CORF, ORF, and SNF.
Payment methodology for independent (RHC), provider-based RHCs, free-standing FQHC and provider based FQHCs is made under the all-inclusive rate for the visit furnished to the RHC/FQHC patient to obtain the therapy service. Only one payment will be made for the visit furnished to the RHC/FQHC patient to obtain the therapy service. As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for the therapy service.
Payment Methodology for a CAH is payment on a reasonable cost basis unless the CAH has elected the Optional Method and then the A/B MAC (A) pays pay 115% of the MPFS amount for the professional component of the HCPCS code in addition to the technical component.
In addition, the following revenues code must be used in conjunction with the HCPCS code identified:
| Revenue Code | Description |
|---|---|
| 420 | Physical Therapy |
| 430 | Occupational Therapy |
| 520 | Federal Qualified Health Center * |
| 521 | Rural Health Center * |
| 977, 978 | Critical Access Hospital- method II CAH professional services only |
A/B MACs (B) pay for Electromagnetic Therapy services billed with HCPCS codes G0329 based on the MPFS. Claims for electromagnetic therapy services must be billed using the ASC X12 837 professional claim format or Form CMS-1500 following instructions in chapter 12 of this manual (www.cms.hhs.gov/manuals/104_claims/clm104index.asp).
Payment information for HCPCS code G0329 will be added to the July 2004 update of the Medicare Physician Fee Schedule Database (MPFSD).
The Medicare contractor shall apply coinsurance and deductible to payments for electromagnetic therapy services except for services billed to the A/B MAC (A) by FQHCs. For FQHCs only co-insurance applies.
(Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14-22 MACs)
(Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14-22 MACs)
Effective for claims with dates of service on or after April 13, 2021, contractors shall accept and pay for autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by devices whose Food and Drug Administration-cleared indications include the management of exuding cutaneous wounds, such as diabetic ulcers, in accordance with the coverage criteria outlined in Publication 100-03, chapter 1, section 270.3, of the National Coverage Determinations (NCD) Manual.
NOTE: Coverage of PRP services for the treatment of chronic non-healing diabetic wounds that are performed more than 20 weeks after the date of the first PRP service shall be determined by the local Medicare Administrative Contractor (MAC).
Coverage of autologous PRP for the treatment of all other chronic non-healing wounds (non-diabetic) will be determined by local MACs under section 1862(a)(1)(A) of the Social Security Act.
Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0460 for PRP services for the treatment of chronic non-healing non-diabetic wounds.
Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0465 for PRP services for the treatment of chronic non-healing diabetic wounds under the conditions and criteria outlined in NCD Manual Section 270.3.
For claims with dates of service on or after April 13, 2021, PRP, for the treatment of chronic non-healing diabetic wounds must be billed reporting both an ICD-10 diagnosis code for diabetes mellitus and an ICD-10 diagnosis code for chronic ulcers.
| E08.621 | Diabetes mellitus due to underlying condition with foot ulcer |
|---|---|
| E08.622 | Diabetes mellitus due to underlying condition with other skin ulcer |
| E09.621 | Drug or chemical induced diabetes mellitus with foot ulcer |
| E09.622 | Drug or chemical induced diabetes mellitus with other skin ulcer |
| E10.621 | Type 1 diabetes mellitus with foot ulcer |
| E10.622 | Type 1 diabetes mellitus with other skin ulcer |
| E11.621 | Type 2 diabetes mellitus with foot ulcer |
| E11.622 | Type 2 diabetes mellitus with other skin ulcer |
| E13.621 | Other specified diabetes mellitus with foot ulcer |
| E13.622 | Other specified diabetes mellitus with other skin ulcer |
L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone L97.325 Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of necrosis L97.326 Non-pressure chronic ulcer of left ankle with bone involvement without evidence of necrosis L97.328 Non-pressure chronic ulcer of left ankle with other specified severity L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L97.415 Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without evidence of necrosis L97.416 Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis L97.418 Non-pressure chronic ulcer of right heel and midfoot with other specified severity L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L97.425 Non-pressure chronic ulcer of left heel and midfoot with muscle involvement without evidence of necrosis L97.426 Non-pressure chronic ulcer of left heel and midfoot with bone involvement without evidence of necrosis L97.428 Non-pressure chronic ulcer of left heel and midfoot with other specified severity L98.411 Non-pressure chronic ulcer of buttock limited to breakdown of skin L98.412 Non-pressure chronic ulcer of buttock with fat layer exposed L98.413 Non-pressure chronic ulcer of buttock with necrosis of muscle L98.414 Non-pressure chronic ulcer of buttock with necrosis of bone L98.415 Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis L98.416 Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis L98.418 Non-pressure chronic ulcer of buttock with other specified severity L98.421 Non-pressure chronic ulcer of back limited to breakdown of skin L98.422 Non-pressure chronic ulcer of back with fat layer exposed L98.423 Non-pressure chronic ulcer of back with necrosis of muscle L98.424 Non-pressure chronic ulcer of back with necrosis of bone L98.425 Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis L98.426 Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis L98.428 Non-pressure chronic ulcer of back with other specified severity L98.491 Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin L98.492 Non-pressure chronic ulcer of skin of other sites with fat layer exposed L98.493 Non-pressure chronic ulcer of skin of other sites with necrosis of muscle L98.494 Non-pressure chronic ulcer of skin of other sites with necrosis of bone
Effective for claims with dates of service on and after April 13, 2021, contractors shall cover PRP services for chronic non-healing diabetic wounds, G0465, for a maximum of 20 weeks beginning with the first week of treatment.
Effective for claims with dates of services on or after April 13, 2021, the local MACs shall have discretion to pay PRP services for chronic non-healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service when the -KX modifier is reported on the claim.
Effective for claims with dates of service on and after April 13, 2021, contractors shall have discretion to cover, and determine frequency for, PRP services for chronic non-healing non-diabetic wounds, G0460.
(Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14-22 MACs)
(Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14-22 MACs)
Payment for PRP services is as follows:
Local MACs shall pay for PRP services for hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission on an outpatient basis, TOB 13X, in accordance with the terms of the Maryland waiver.
(Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14-22 MACs)
Effective for claims with dates of service on or after August 2, 2012, place of service (POS) codes 11, 22, and 49 shall be used for PRP services.
Effective for claims with dates of service on or after April 13, 2021, POS codes 11, 19, 22, and 49 shall be used for PRP services.
(Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14-22 MACs)
Contractors shall deny claims for PRP services when provided on other than TOBs 12X, 13X, 22X, 23X, 71X, 75X, 77X, and 85X using:
MSN 21.25 - “This service was denied because Medicare only covers this service in certain settings.”
Spanish Version - “El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.”
CARC 58 - “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.
RARC N428 - “Service/procedure not covered when performed in this place of service.”
Group Code - CO (Contractual Obligation)
Contractors shall reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service when the --KX modifier is NOT included on the claim using the following messages:
CARC 119 – Benefit Maximum for this time period or occurrence has been reached.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Medicare Summary Notice (MSN) 20.5 – These services cannot be paid because your benefits are exhausted at this time.
Spanish Version: “Estos servicios no pueden ser pagados porque sus beneficios se han agotado.”
Group Code – CO (Contractual Obligation)
Contractors shall deny/reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that don’t contain the appropriate diagnosis codes as noted above and use the following messages:
Claim Adjustment Reason Code (CARC) 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.
Remittance Advice Remark Code (RARC) N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at: www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Medicare Summary Notice (MSN) 15.19 - “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare-coverage-database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor.”
Spanish Version -Usamos una Determinación de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN para el código 'CPT/HCPCS') y envíela con la información de su médico.
MSN 15.20 - 'The following polices were used when we made this decision: NCD 270.3.'
Spanish Version – 'Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 270.3.'
NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.
Group Code – Contractual Obligation (CO).
(Rev.3848, Issued: 08- 25-17, Effective: 09-26-17, Implementation: 09- 26-17)
Background: Effective for services furnished on or after March 22, 2005, a National Coverage Determination (NCD) provided for coverage of smoking and tobacco-use cessation counseling services located at Medicare National Coverage Determinations Manual, Publication 100-03 section 210.4. CMS established a related policy entitled Counseling to Prevent Tobaccos Use at NCD Manual 210.4.1 effective August 25, 2010. However, effective September 30, 2016, the conditions of Medicare Part A and Medicare Part B coverage for smoking and tobacco-use cessation counseling services (210.4) were deleted. The remaining NCD entitled Counseling to Prevent Tobacco Use (210.4.1), remains in effect, along with HCPCS codes 99406 and 99407, specifically payable for counseling to prevent tobacco use effective October 1, 2016.
(Rev. 13549; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26)
The following HCPCS codes should be reported when billing for counseling to prevent tobacco use services:
99406 - Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 - Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes
Note the above codes were effective for dates of service on or after January 1, 2008, and specifically effective for counseling to prevent tobacco use claims on or after October 1, 2016.
Contractors shall allow payment for a medically necessary E/M service on the same day as the counseling to prevent tobacco use, when it is clinically appropriate. Physicians and qualified non-physician practitioners shall use an appropriate HCPCS code, such as HCPCS 99201–99215, to report an E/M service with modifier 25 to indicate that the E/M service is a separately identifiable service from 99406 or 99407.
Contractors shall only pay for 8 counseling to prevent tobacco use sessions in a 12-month period. The beneficiary may receive another 8 sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered counseling session was performed. To start the count for the second or subsequent 12-month period, begin with the month after the month in which the first Medicare covered counseling session was performed and count until 11 full months have elapsed.
Claims for counseling to prevent tobacco use services shall be submitted with an appropriate diagnosis code.
NOTE: This decision does not modify existing coverage for minimal cessation counseling (defined as 3 minutes or less in duration) which is already considered to be covered as part of each Evaluation and Management (E/M) visit and is not separately billable.
Claims for counseling to prevent tobacco use services shall be submitted with an applicable diagnosis code:
V15.82, personal history of tobacco use, or 305.1, non-dependent tobacco use disorder 989.84, toxic effect of tobacco
F17.210, nicotine dependence, cigarettes, uncomplicated, F17.211, nicotine dependence, cigarettes, in remission, F17.213 Nicotine dependence, cigarettes, with withdrawal F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders F17.220, nicotine dependence, chewing tobacco, uncomplicated, F17.221, nicotine dependence, chewing tobacco, in remission, F17.223 Nicotine dependence, chewing tobacco, with withdrawal F17.228 Nicotine dependence, chewing tobacco, with other nicotine-induced disorders F17.229 Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders F17.290, nicotine dependence, other tobacco product, uncomplicated, F17.291, nicotine dependence, other tobacco product, in remission, or F17.293 Nicotine dependence, other tobacco product, with withdrawal F17.298 Nicotine dependence, other tobacco product, with other nicotine F17.299 Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders Z87.891, personal history of nicotine dependence, unspecified, uncomplicated. T65.211A, Toxic effect of chewing tobacco, accidental (unintentional), initial encounter T65.212A, Toxic effect of chewing tobacco, intentional self-harm, initial encounter T65.213A, Toxic effect of chewing tobacco, assault, initial encounter T65.214A, Toxic effect of chewing tobacco, undetermined, initial encounter T65.221A, Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter T65.222A, Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter T65.223A, Toxic effect of tobacco cigarettes, assault, initial encounter T65.224A, Toxic effect of tobacco cigarettes, undetermined, initial encounter T65.291A, Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter T65.292A, Toxic effect of other tobacco and nicotine, intentional self-harm, initial encounter T65.293A, Toxic effect of other tobacco and nicotine, assault, initial encounter T65.294A, Toxic effect of other tobacco and nicotine, undetermined, initial encounter Z72.0, Tobacco use effective October 1, 2024
(Rev.3848, Issued: 08- 25-17, Effective: 09-26-17, Implementation: 09- 26-17)
A/B MACs (B) shall pay for counseling to prevent tobacco use services billed with codes 99406 and 99407 for dates of service on or after October 1, 2016 A/B MACs (B) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on and after August 25, 2010, through September 30, 2016. The type of service (TOS) for each of the new codes is 1.
A/B MACs (B) pay for these services billed based on the Medicare Physician Fee Schedule (MPFS). Deductible and coinsurance are waived. Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, which means that charges to the beneficiary may be no more than 115% of the allowed amount.
Physicians or qualified non-physician practitioners shall bill the A/B MAC (B) for counseling to prevent tobacco use services using the ASC X12 837 professional claim format or the Form CMS-1500.
(Rev. 13549; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26)
The A/B MACs (A) shall pay for counseling to prevent tobacco use services with codes 99406 and 99407 for dates of service on or after October 1, 2016. A/B MACs (A) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on or after August 25, 2010, through September 30, 2016. Deductible and coinsurance are waived.
The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 77X, 83X, and 85X. Effective April 1, 2006, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for counseling to prevent tobacco use services.
Applicable revenue codes are as follows:
| Provider Type | Revenue Code |
|---|---|
| Rural Health Centers (RHCs) | 052X |
| Federally Qualified Health Centers (FQHCs) | 052X, 0519 |
| Indian Health Services (IHS) | 0510 |
| Critical Access Hospitals (CAHs) Method II | 096X, 097X, 098X |
| All Other Providers | 0942 |
NOTE: When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered 'incident to' and do not constitute a billable visit.
Payment for outpatient services is as follows:
| Type of Facility | Method of Payment |
|---|---|
| Rural Health Centers (RHCs) | All-inclusive rate (AIR) for the encounter |
| Federally Qualified Health Centers (FQHCs) | FQHC Prospective Payment System (PPS) for the encounter |
| Indian Health Service (IHS)/Tribally owned or operated hospitals and hospital-based facilities | AIR |
| IHS/Tribally owned or operated non-hospital-based facilities | Medicare Physician Fee Schedule (MPFS) |
| IHS/Tribally owned or operated Critical Access Hospitals (CAHs) | Facility Specific Visit Rate |
| Hospitals subject to the Outpatient Prospective Payment System (OPPS) | Ambulatory Payment Classification (APC) |
| Hospitals not subject to OPPS | Payment is made under current methodologies |
| Skilled Nursing Facilities (SNFs) | MPFS |
| NOTE: Included in Part A PPS for skilled patients. | |
| Home Health Agencies (HHAs) | MPFS |
| Critical Access Hospitals (CAHs) | Method I: Technical services are paid at 101% of reasonable cost. Method II: technical services are paid at 101% of reasonable cost, and Professional services are paid at 115% of the MPFS Data Base |
| Maryland Hospitals | Payment is based according to the Health Services Cost Review Commission (HSCRC). That is 94% of submitted charges subject to any unmet deductible, coinsurance, and non-covered charges policies. |
NOTE: Inpatient claims submitted with counseling to prevent tobacco use services are processed under the current payment methodologies. In addition, payment is not allowed for inpatients whose primary diagnosis is counseling to prevent tobacco use.
(Rev.3848, Issued: 08- 25-17, Effective: 09-26-17, Implementation: 09- 26-17)
Contractors shall use the appropriate claim RA(s) when denying payment for counseling to prevent tobacco use services.
The following messages are used where applicable:
(Rev.3848, Issued: 08- 25-17, Effective: 09-26-17, Implementation: 09- 26-17)
(When denying claims for counseling to prevent tobacco use services that were performed prior to the effective date of coverage, contractors shall use an appropriate MSN, such as, MSN 21.11, “This service was not covered by Medicare at the time you received it.”
When denying claims for counseling services on the basis that the coverage criteria were not met, use an appropriate MSN, such as MSN 21.21, “This service was denied because Medicare only covers this service under certain circumstances.”
When denying claims for counseling services that have dates of service exceeding the maximum benefit allowed, use an appropriate MSN, such as MSN 17.8, “Payment is denied because the maximum benefit allowance has been reached.”
(Rev.3848, Issued: 08- 25-17, Effective: 09-26-17, Implementation: 09- 26-17)
As with any claim, Medicare may decide to conduct post-payment reviews to determine that the services provided are consistent with coverage instructions. Providers must keep patient record information on file for each Medicare patient for whom a counseling claim is made. These medical records can be used in any post-payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.
(Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
The Common Working File (CWF) maintains the number of counseling sessions rendered to a beneficiary. By entering the beneficiary's Medicare beneficiary identifier, providers have the capability to view the number of sessions a beneficiary has received for this service via inquiry through CWF.
(Rev.3848, Issued: 08- 25-17, Effective: 09-26-17, Implementation: 09- 26-17)
Providers may access coverage period remaining counseling sessions and a next eligible date, when there are no remaining sessions, through the 270/271 eligibility inquiry and response transaction.
(Rev. 1876; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-05-10)
Effective for claims with dates of service on and after January 1, 2010, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) determines that kidney disease patient education services are covered when provided to patients with stage IV chronic kidney disease (CKD). See Pub. 100-02, chapter 15, section 310, for complete coverage guidelines.
Contractors shall pay for kidney disease education (KDE) services that meet the following conditions:
NOTE: A renal dialysis facility (Type of Bill (TOB) 72x) is precluded from providing KDE services.
(Rev. 1876; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-05-10)
The FI will reimburse for KDE services when services are rendered in a rural area and submitted on the following TOBs: 12X, 13X, 22X, 23X, 34X, 75X, 81X, 82X, and 85X.
NOTE: FIs shall use the actual geographic location, core based statistical area (CBSA) to identify facilities located in rural areas. In addition, KDE services are covered when claims containing the above mentioned TOBs are received from section 401 hospitals.
Revenue code 0942 should be reported when billing for KDE services in the following: SNFs, HHAs, CORFs, hospices, and CAHs.
Hospital outpatient departments bill for this service under any valid/appropriate revenue code. They are not required to report revenue code 0942.
Hospices report this service on a separate claim from any hospice services. Hospice claims billed for revenue code 0942 that contain any other services will be returned to the provider. In addition, hospices report value code 61 or G8 when billing for KDE services.
NOTE: KDE services are not covered when services are submitted on TOB 72X.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
Effective for services performed on and after January 1, 2010, the following new HCPCS codes have been created for KDE services when provided to patients with stage IV CKD.
When billing for KDE services the applicable ICD diagnosis code shall be used:
NOTE: Claims with HCPCS codes G0420 or G0421 and ICD-9 code 585.4, if applicable, or, if ICD -10 is applicable, ICD-10 code N18.4 that are billed for KDE services are not allowed on a professional and institutional claim on the same service date.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
The following messages are used by Medicare contractors when denying non-covered services associated with KDE services when provided to patients with stage IV CKD:
When denying claims for KDE services billed without diagnosis code 585.4 contractors shall use:
MSN 16.10 - Medicare does not pay for this item or service.
CARC 167 - This (these) diagnosis(es) is (are) not covered. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
When denying claims for KDE services when submitted for more than 6 sessions contractors shall use:
When denying claims for KDE services when two claims are billed (professional and institutional) on the same service date, contractors shall use:
A/B MACs (A) shall deny KDE services when rendered in an urban area unless:
A/B MACs (A) shall deny payment for KDE services when submitted on TOB 72X.
Use the following messages:
(Rev. 1876; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-05-10)
If a signed ABN was provided, contractors shall use Group Code PR (Patient Responsibility) and the liability falls to the beneficiary.
If an ABN was not provided, contractors shall use Group Code CO (Contractual Obligation) and the liability falls to the provider.
(Rev. 187, 05-28-04)
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Hyperbaric Oxygen Therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Effective April 1, 2003, a National Coverage Decision expanded the use of HBO therapy to include coverage for the treatment of diabetic wounds of the lower extremities. For specific coverage criteria for HBO Therapy, refer to the National Coverage Determinations Manual, Chapter 1, section 20.29.
NOTE: Topical application of oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.
• Billing Requirements for A/B MACs (A)
Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS-1450.
a. Applicable Bill Types
The applicable hospital bill types are 11X, 13X and 85X.
b. Procedural Coding
NOTE: Code G0277 is not available for use other than in a hospital outpatient department. In skilled nursing facilities (SNFs), HBO therapy is part of the SNF PPS payment for beneficiaries in covered Part A stays.
For hospital inpatients and critical access hospitals (CAHs) not electing Method I, HBO therapy is reported under revenue code 940 without any HCPCS code. For inpatient services, if ICD-10 is applicable, show ICD-10-PCS code 5A05121.
For CAHs electing Method I, HBO therapy is reported under revenue code 940 along with HCPCS code 99183.
c. Payment Requirements for A/B MACs (A)
Payment is as follows:
A/B MAC (A) payment is allowed for HBO therapy for diabetic wounds of the lower extremities when performed as a physician service in a hospital outpatient setting and for inpatients. Payment is allowed for claims with valid diagnosis codes as shown above with dates of service on or after April 1, 2003. Those claims with invalid codes should be denied as not medically necessary.
For hospitals, payment will be based upon the Ambulatory Payment Classification (APC) or the inpatient Diagnosis Related Group (DRG). Deductible and coinsurance apply.
Payment to Critical Access Hospitals (electing Method I) is made under cost reimbursement. For Critical Access Hospitals electing Method II, the technical component is paid under cost reimbursement and the professional component is paid under the Physician Fee Schedule.
II. A/B MAC (B) Billing Requirements
Claims for this service should be submitted using the ASC X12 837 professional claim format or Form CMS-1500.
The following HCPCS code applies:
Payment and pricing information will occur through updates to the Medicare Physician Fee Schedule Database (MPFSDB). Pay for this service on the basis of the MPFSDB. Deductible and coinsurance apply. Claims from physicians or other practitioners where assignment was not taken, are subject to the Medicare limiting charge.
Use the following MSN Messages where appropriate:
In situations where the claim is being denied on the basis that the condition does not meet our coverage requirements, use one of the following MSN Messages:
“Medicare does not pay for this item or service for this condition.” (MSN Message 16.48)
The Spanish version of the MSN message should read:
“Medicare no paga por este articulo o servicio para esta afeccion.”
In situations where, based on the above utilization policy, medical review of the claim results in a determination that the service is not medically necessary, use the following MSN message:
“The information provided does not support the need for this service or item.” (MSN Message 15.4)
The Spanish version of the MSN message should read:
“La informacion proporcionada no confirma la necesidad para este servicio o articulo.”
Use appropriate existing remittance advice remark codes and claim adjustment reason codes at the line level to express the specific reason if you deny payment for HBO therapy for the treatment of diabetic wounds of lower extremities.
CMS considers topical oxygen therapy (TOT) to be a method whereby a local supply of oxygen is applied to a wound.
Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS-1450.
As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors.
NOTE: Regardless of whether an A/B MAC (A) has made a determination to cover this service, there shall be no coverage for any separate or additional physician's professional services related to this procedure.
As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors.
NOTE: Regardless of whether an A/B MAC (B) has made a determination to cover this service, there shall be no coverage for any separate or additional physician's professional services related to this procedure.
(Rev. 125, 03-26-04)
A sacral nerve stimulator is a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire. These impulses cause the bladder muscles to contract, which gives the patient ability to void more properly.
(Rev. 125, 03-26-04)
Effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered.
The following limitations for coverage apply to all indications:
(Rev. 125, 03-26-04)
(Rev. 11789, Issued:01-19-23, Effective Date: 02-21-23, Implementation Date: 02-21-23)
64561 - Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64581 - Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64585 - Revision or removal of peripheral neurostimulator electrodes 64590 - Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling 64595 - Revision or removal of peripheral neurostimulator pulse generator or receiver A4290 - Sacral nerve stimulation test lead, each C1767 - Generator, neurostimulator (implantable) C1778 - Lead, neurostimulator (implantable) C1820 - Generator, neurostimulator (implantable), with rechargeable battery and charging system - effective 01/01/20 for NCD230.18 with CR11655 C1883 - Adaptor/extension, pacing lead or neurostimulator lead (implantable) C1897 - Lead, neurostimulator test kit (implantable) E0752 - Implantable neurostimulator electrodes, each E0756 - Implantable neurostimulator pulse generator
NOTE: The "C" codes listed above are only applicable when billing under the hospital outpatient prospective payment system (OPPS). They should be reported in place of codes A4290, E0752 and E0756.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
Payment is as follows:
Deductible and coinsurance apply.
Payment is made on a reasonable cost basis when these devices are implanted in a CAH.
Only hospital outpatient departments report these codes. Payment is made under OPPS.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
The applicable bill types for test stimulation procedures are 13X, 71X, 73X, 75X and 85X.
The RHCs and FQHCs bill you under bill type 71X and 73X for the professional component. The technical component is outside the scope of the RHC/FQHC benefit. The provider of that technical service bills their A/B MAC (B) using the ASC X12 837 professional claim format or the Form CMS-1500.
The technical component for a provider-based RHC/FQHC is typically furnished by the provider. The provider of that service bills you under bill type 13X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider number since these services are not covered as RHC/FQHC services.) Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for test stimulation procedures.
The applicable bill types for implantation procedures and devices are 11X, 13X, and 85X.
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)
The applicable revenue code for the test procedures is 920 except for RHCs/FQHCs who report these procedures under revenue code 521.
Revenue codes for the implantation can be performed in a number of revenue centers within a hospital such as operating room (360) or clinic (510). Therefore, instruct your hospitals to report these implantation procedures under the revenue center where they are performed.
The applicable revenue code for the device codes C1767, C1778, C1883, C1897, and C1820 provided in a hospital outpatient department is 272, 274, 275, 276, 278, 279, 280, 289, 290 or 624 as appropriate. The applicable revenue code for device codes A4290, E0752 and E0756 provided in a CAH is 290.
Nationwide claims processing edits for pre or post payment review of claim(s) for sacral nerve stimulation are not being required at this time. Contractors may develop local medical review policy and edits for such claim(s).
(Rev. 128, 03-26-04)
Deep brain stimulation (DBS) refers to high-frequency electrical stimulation of anatomic regions deep within the brain utilizing neurosurgically implanted electrodes. These DBS electrodes are stereotactically placed within targeted nuclei on one (unilateral) or both (bilateral) sides of the brain. There are currently three targets for DBS -- the thalamic ventralis intermedius nucleus (VIM), subthalamic nucleus (STN) and globus pallidus interna (GPi).
Essential tremor (ET) is a progressive, disabling tremor most often affecting the hands. ET may also affect the head, voice and legs. The precise pathogenesis of ET is unknown. While it may start at any age, ET usually peaks within the second and sixth decades. Beta-adrenergic blockers and anticonvulsant medications are usually the first line treatments for reducing the severity of tremor. Many patients, however, do not adequately respond or cannot tolerate these medications. In these medically refractory ET patients, thalamic VIM DBS may be helpful for symptomatic relief of tremor.
Parkinson’s disease (PD) is an age-related progressive neurodegenerative disorder involving the loss of dopaminergic cells in the substantia nigra of the midbrain. The disease is characterized by tremor, rigidity, bradykinesia and progressive postural instability. Dopaminergic medication is typically used as a first line treatment for reducing the primary symptoms of PD. However, after prolonged use, medication can become less effective and can produce significant adverse events such as dyskinesias and other motor function complications. For patients who become unresponsive to medical treatments and/or have intolerable side effects from medications, DBS for symptom relief may be considered.
(Rev. 128, 03-26-04)
Effective on or after April 1, 2003, Medicare will cover unilateral or bilateral thalamic VIM DBS for the treatment of ET and/or Parkinsonian tremor and unilateral or bilateral STN or GPi DBS for the treatment of PD only under the following conditions:
1. Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols governing Category B Investigational Device Exemption (IDE) DBS clinical trials.
2. For thalamic VIM DBS to be considered reasonable and necessary, patients must meet all of the following criteria:
a. Diagnosis of essential tremor (ET) based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor- dominant form.
b. Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy.
c. Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.
3. For STN or GPi DBS to be considered reasonable and necessary, patients must meet all of the following criteria:
a. Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia). b. Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease Rating Scale (UPDRS) part III motor subscale. c. L-dopa responsive with clearly defined "on" periods. d. Persistent disabling Parkinson's symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or disabling "off" periods) despite optimal medical therapy. e. Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.
The DBS is not reasonable and necessary and is not covered for ET or PD patients with any of the following:
1. Non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes.
2. Cognitive impairment, dementia or depression which would be worsened by or would interfere with the patient's ability to benefit from DBS.
3. Current psychosis, alcohol abuse or other drug abuse.
4. Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder.
5. Previous movement disorder surgery within the affected basal ganglion.
6. Significant medical, surgical, neurologic or orthopedic co-morbidities contraindicating DBS surgery or stimulation.
Patients who undergo DBS implantation should not be exposed to diathermy (deep heat treatment including shortwave diathermy, microwave diathermy and ultrasound diathermy) or any type of MRI which may adversely affect the DBS system or adversely affect the brain around the implanted electrodes.
The DBS should be performed with extreme caution in patients with cardiac pacemakers or other electronically controlled implants which may adversely affect or be affected by the DBS system.
For DBS lead implantation to be considered reasonable and necessary, providers and facilities must meet all of the following criteria:
1. Neurosurgeons must: (a) be properly trained in the procedure; (b) have experience with the surgical management of movement disorders, including DBS therapy; and (c) have experience performing stereotactic neurosurgical procedures
2. Operative teams must have training and experience with DBS systems, including knowledge of anatomical and neurophysiological characteristics for localizing the targeted nucleus, surgical and/or implantation techniques for the DBS system, and operational and functional characteristics of the device.
3. Physicians specializing in movement disorders must be involved in both patient selection and post-procedure care.
4. Hospital medical centers must have: (a) brain imaging equipment (MRI and/or CT) for pre-operative stereotactic localization and targeting of the surgical site(s); (b) operating rooms with all necessary equipment for stereotactic surgery; and (c) support services necessary for care of patients undergoing this procedure and any potential complications arising intraoperatively or postoperatively.
(Rev. 128, 03-26-04)
(Rev. 128, 03-26-04)
This procedure can be two fold. Implantation of the electrodes is performed in a hospital inpatient setting. Implantation of the pulse generator can be performed in an outpatient department.
(Rev. 128, 03-26-04)
(Rev. 128, 03-26-04)
Payment for the inpatient procedure is under Diagnostic Related Group (DRG). The outpatient procedure is outpatient prospective payment system. For critical access hospitals (CAH), the inpatient stay is on reasonable cost and the outpatient procedures are also based on reasonable cost.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Deep Brain Stimulation may be submitted on institutional claims using the following Types of Bill:
11X, 12X, 13X, and 85X
(Rev. 128, 03-26-04)
Revenue codes for implementation can be performed in a number of revenue centers within a hospital such as operating room (360) or clinic (510). The codes to report the pulse generator and/or electrodes are 270, 278, 279.
For CAHs that choose method II, use revenue code 98X for the professional component only.
(Rev. 128, 03-26-04)
(Rev. 12435, Issued:12-28-23, Effective:01-29-24, Implementation:01-29-24)
Deep Brain Stimulation is covered for the following diagnosis codes:
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
The following procedure codes may be present:
If ICD-10-PCS is applicable:
| ICD-10-PCS Code | Code Description |
|---|---|
| 00H00MZ | Insertion of Neurostimulator Lead into Brain, Open Approach |
| 00H03MZ | Insertion of Neurostimulator Lead into Brain, Percutaneous Approach |
| 00H04MZ | Insertion of Neurostimulator Lead into Brain, Endoscopic Approach |
| 00H60MZ | Insertion of Neurostimulator Lead into Cerebral Ventricle, Open Approach |
| 00H63MZ | Insertion of Neurostimulator Lead into Cerebral Ventricle, Percutaneous Approach |
| 00H64MZ | Insertion of Neurostimulator Lead into Cerebral Ventricle, Percutaneous Endoscopic Approach |
| 00P00MZ | Removal of Neurostimulator Lead from Brain, Open Approach |
| 00P03MZ | Removal of Neurostimulator Lead from Brain, Percutaneous Approach |
| 00P04MZ | Removal of Neurostimulator Lead from Brain, Percutaneous Endoscopic Approach |
| 00P60MZ | Removal of Neurostimulator Lead from Cerebral Ventricle, Open Approach |
| 00P63MZ | Removal of Neurostimulator Lead from Cerebral Ventricle, Percutaneous Approach |
| 00P64MZ | Removal of Neurostimulator Lead from Brain, Open Approach |
| 0H80XZZ | Division of Scalp Skin, External Approach |
|---|---|
| 0HSSXZZ | Reposition Hair, External Approach |
Coverage policy may be found in the National Coverage Determinations Manual in Chapter 1, section 160.24: Deep Brain Stimulation, using the following link: (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
The following HCPCS codes are available for use when billing for covered deep brain stimulation:
with brain neurostimulator pulse generator/ transmitter programming, first 15 minutes face-to-face time with physician or other qualified health care professional.
95984 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency (Hz), on/off cycling, burst, magnet mode, doe lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain neurostimulator pulse generator/transmitter programming, each additional 15 minutes face-to-face time with physician or other qualified health care professional.
(Rev. 128, 03-26-04)
The following HCPCS codes are approved for billing in Ambulatory Surgical Centers:
61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array - ASC Payment Group 02
61888 Revision or removal of cranial neurostimulator pulse generator or receiver - ASC Payment Group 01
NOTE: Pulse generator is payable in an ASC; implantation of electrodes are not.
(Rev. 128, 03-26-04)
We do not require nationwide standard system claims processing edits for pre and post payment review of claim(s) at this time. However, carriers and intermediaries may create local claims processing edits for the requirements listed above.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
Use appropriate existing remittance advice reason and remark codes at the line level to express the specific reason if you deny payment for DBS. If denying services as furnished before April 1, 2003, use existing ASC X 12-835 claim adjustment reason code 26 "Expenses incurred prior to coverage" at the line level.
(Rev. 128, 03-26-04)
Use the following MSN messages where appropriate:
If a claim for DBS is denied because the service was performed prior to April 1, 2003, use the MSN message:
"This service was not covered by Medicare at the time you received it." (MSN Message 21.11)
The Spanish version of the MSN message should read:
"Este servicio no estaba cubierto por Medicare cuando usted lo recibió." (MSN Message 21.11)
(Rev. 128, 03-26-04)
Contractors should notify providers of this new national coverage in their next regularly scheduled bulletin, on their Web site within 2 weeks, and in routinely scheduled training sessions.
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
The prothrombin time (PT) test is an in-vitro test to assess coagulation. PT testing and its normalized correlate, the International Normalized Ratio (INR), are the standard measurements for therapeutic effectiveness of warfarin therapy. Warfarin, Coumadin®, and others, are self-administered, oral anticoagulant, or blood thinner, medications that affect a person's Vitamin K-dependent clotting factors.
Use of the INR allows physicians to determine the level of anticoagulation in a patient independent of the laboratory reagents used. The INR is the ratio of the patient's prothrombin time compared to the mean prothrombin time for a group of normal individuals.
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
For services furnished on or after July 1, 2002, Medicare will cover the use of home INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin. The monitor and the home testing must be prescribed by a physician and the following patient requirements must be met:
For services furnished on or after March 19, 2008, the Centers for Medicare & Medicaid Services revised its national coverage determination (NCD) on PT/INR Monitoring for Home Anticoagulation Management as follows:
Medicare will cover the use of home PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a), and all of the following requirements must be met:
1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,
2. The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and,
3. The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and,
4. Self-testing with the device should not occur more frequently than once a week.
NOTE: Porcine valves are not included in this NCD, so Medicare will not make payment on home INR monitoring for patients with porcine valves unless covered by local Medicare contractors.
(Rev. 216, 06-25-04)
(Rev. 216, 06-25-04)
Payment is as follows:
Deductible and coinsurance apply.
(Rev. 216, 06-25-04)
(Rev. 216, 06-25-04)
The applicable bill types are 13X and 85X.
(Rev. 216, 06-25-04)
Hospitals may report these services under revenue code 920 or they may report HCPCS codes G0248 and G0249 under the revenue center where they are performed.
(Rev. 216, 06-25-04)
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)
For services furnished on or after the implementation of ICD-10 the applicable ICD-10-CM diagnosis codes for this benefit are:
| ICD-10-CM Code | Code Description |
|---|---|
| D68.51 | Activated protein C resistance |
| D68.52 | Prothrombin gene mutation |
| D68.59 | Other primary thrombophilia |
| D68.61 | Antiphospholipid syndrome |
| D68.62 | Lupus anticoagulant syndrome |
| I23.6 | Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction |
|---|---|
| I26.01 | Septic pulmonary embolism with acute cor pulmonale |
| I26.09 | Other pulmonary embolism with acute cor pulmonale |
| I26.90 | Septic pulmonary embolism without acute cor pulmonale |
| I26.93 | Single subsegmental pulmonary embolism without acute cor pulmonale |
| I26.94 | Multiple subsegmental pulmonary emboli without acute cor pulmonale |
| I26.99 | Other pulmonary embolism without acute cor pulmonale |
| I27.24 | Chronic thromboembolic pulmonary hypertension |
| I27.82 | Chronic pulmonary embolism |
| I48.0 | Paroxysmal atrial fibrillation |
| I48.11 | Longstanding persistent atrial fibrillation |
| I48.19 | Other persistent atrial fibrillation |
| I48.21 | Permanent atrial fibrillation |
| I67.6 | Nonpyogenic thrombosis of intracranial venous system |
| 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 |
| I80.211 | Phlebitis and thrombophlebitis of right iliac vein |
| I80.212 | Phlebitis and thrombophlebitis of left iliac vein |
| I80.213 | Phlebitis and thrombophlebitis of iliac 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 |
| I80.241 | Phlebitis and thrombophlebitis of right peroneal vein |
| I80.242 | Phlebitis and thrombophlebitis of left peroneal vein |
| I80.243 | Phlebitis and thrombophlebitis of peroneal vein, bilateral |
| I80.251 | Phlebitis and thrombophlebitis of right calf muscular vein |
| I80.252 | Phlebitis and thrombophlebitis of left calf muscular vein |
| I80.253 | Phlebitis and thrombophlebitis of calf muscular 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 |
| I82.0 | Budd-Chiari syndrome |
| I82.210 | Acute embolism and thrombosis of superior vena cava |
| I82.211 | Chronic embolism and thrombosis of superior vena cava |
| I82.220 | Acute embolism and thrombosis of inferior vena cava |
| I82.221 | Chronic embolism and thrombosis of inferior vena cava |
| I82.290 | Acute embolism and thrombosis of other thoracic veins |
| I82.291 | Chronic embolism and thrombosis of other thoracic veins |
| I82.3 | Embolism and thrombosis of renal vein |
| I82.411 | Acute embolism and thrombosis of right femoral vein |
| I82.412 | Acute embolism and thrombosis of left femoral vein |
|---|---|
| I82.413 | Acute embolism and thrombosis of femoral vein, bilateral |
| I82.421 | Acute embolism and thrombosis of right iliac vein |
| I82.422 | Acute embolism and thrombosis of left iliac vein |
| I82.423 | Acute embolism and thrombosis of iliac vein, bilateral |
| I82.431 | Acute embolism and thrombosis of right popliteal vein |
| I82.432 | Acute embolism and thrombosis of left popliteal vein |
| I82.433 | Acute embolism and thrombosis of popliteal vein, bilateral |
| I82.441 | Acute embolism and thrombosis of right tibial vein |
| I82.442 | Acute embolism and thrombosis of left tibial vein |
| I82.443 | Acute embolism and thrombosis of tibial vein, bilateral |
| I82.451 | Acute embolism and thrombosis of right peroneal vein |
| I82.452 | Acute embolism and thrombosis of left peroneal vein |
| I82.453 | Acute embolism and thrombosis of peroneal vein, bilateral |
| I82.461 | Acute embolism and thrombosis of right calf muscular vein |
| I82.462 | Acute embolism and thrombosis of left calf muscular vein |
| I82.463 | Acute embolism and thrombosis of calf muscular vein, bilateral |
| I82.491 | Acute embolism and thrombosis of other specified deep vein of right lower extremity |
| I82.492 | Acute embolism and thrombosis of other specified deep vein of left lower extremity |
| I82.493 | Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral |
| I82.511 | Chronic embolism and thrombosis of right femoral vein |
| I82.512 | Chronic embolism and thrombosis of left femoral vein |
| I82.513 | Chronic embolism and thrombosis of femoral vein, bilateral |
| I82.521 | Chronic embolism and thrombosis of right iliac vein |
| I82.522 | Chronic embolism and thrombosis of left iliac vein |
| I82.523 | Chronic embolism and thrombosis of iliac vein, bilateral |
| I82.531 | Chronic embolism and thrombosis of right popliteal vein |
| I82.532 | Chronic embolism and thrombosis of left popliteal vein |
| I82.533 | Chronic embolism and thrombosis of popliteal vein, bilateral |
| I82.541 | Chronic embolism and thrombosis of right tibial vein |
| I82.542 | Chronic embolism and thrombosis of left tibial vein |
| I82.543 | Chronic embolism and thrombosis of tibial vein, bilateral |
| I82.551 | Chronic embolism and thrombosis of right peroneal vein |
| I82.552 | Chronic embolism and thrombosis of left peroneal vein |
| I82.553 | Chronic embolism and thrombosis of peroneal vein, bilateral |
| I82.561 | Chronic embolism and thrombosis of right calf muscular vein |
| I82.562 | Chronic embolism and thrombosis of left calf muscular vein |
| I82.563 | Chronic embolism and thrombosis of calf muscular vein, bilateral |
| I82.591 | Chronic embolism and thrombosis of other specified deep vein of right lower extremity |
| I82.592 | Chronic embolism and thrombosis of other specified deep vein of left lower extremity |
| I82.593 | Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral |
|---|---|
| I82.621 | Acute embolism and thrombosis of deep veins of right upper extremity |
| I82.622 | Acute embolism and thrombosis of deep veins of left upper extremity |
| I82.623 | Acute embolism and thrombosis of deep veins of upper extremity, bilateral |
| I82.721 | Chronic embolism and thrombosis of deep veins of right upper extremity |
| I82.722 | Chronic embolism and thrombosis of deep veins of left upper extremity |
| I82.723 | Chronic embolism and thrombosis of deep veins of upper extremity, bilateral |
| I82.890 | Acute embolism and thrombosis of other specified veins |
| I82.891 | Chronic embolism and thrombosis of other specified veins |
| I82.A11 | Acute embolism and thrombosis of right axillary vein |
| I82.A12 | Acute embolism and thrombosis of left axillary vein |
| I82.A13 | Acute embolism and thrombosis of axillary vein, bilateral |
| I82.A21 | Chronic embolism and thrombosis of right axillary vein |
| I82.A22 | Chronic embolism and thrombosis of left axillary vein |
| I82.A23 | Chronic embolism and thrombosis of axillary vein, bilateral |
| I82.B11 | Acute embolism and thrombosis of right subclavian vein |
| I82.B12 | Acute embolism and thrombosis of left subclavian vein |
| I82.B13 | Acute embolism and thrombosis of subclavian vein, bilateral |
| I82.B21 | Chronic embolism and thrombosis of right subclavian vein |
| I82.B22 | Chronic embolism and thrombosis of left subclavian vein |
| I82.B23 | Chronic embolism and thrombosis of subclavian vein, bilateral |
| I82.C11 | Acute embolism and thrombosis of right internal jugular vein |
| I82.C12 | Acute embolism and thrombosis of left internal jugular vein |
| I82.C13 | Acute embolism and thrombosis of internal jugular vein, bilateral |
| I82.C21 | Chronic embolism and thrombosis of right internal jugular vein |
| I82.C22 | Chronic embolism and thrombosis of left internal jugular vein |
| I82.C23 | Chronic embolism and thrombosis of internal jugular vein, bilateral |
| O87.3 | Cerebral venous thrombosis in the puerperium |
| Z79.01 | Long term (current) use of anticoagulants |
| Z86.718 | Personal history of other venous thrombosis and embolism |
| Z95.2 | Presence of prosthetic heart valve |
Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 190.11 PT/INR. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)
For services furnished on or after July 1, 2002, and prior to March 19, 2008, the applicable HCPCS codes for this benefit are:
G0248: Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes: demonstration use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results and documentation of a patient’s ability to perform testing.
Short Description: Demonstrate use home INR mon
G0249: Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria. Includes provision of materials for use in the home and reporting of test results to physician; per 4 tests.
Short Description: Provide test material, equipm
For services furnished on or after March 19, 2008, the applicable HCPCS codes for this benefit are:
G0248: Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing prior to its use
Short Description: Demonstrate use home INR mon
G0249: Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week
Short Description: Provide INR test mater/equip
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
Effective for claims with dates of service on and after March 19, 2008, the descriptors of HCPCS Codes G0248, G0249, and G0250 were changed to reflect revised coverage policy.
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
For services furnished on or after July 1, 2002, and prior to March 19, 2008, the applicable HCPCS codes for this benefit are:
G0248: Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes: demonstration use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results and documentation of a patient’s ability to perform testing.
Short Description: Demonstrate use home INR mon
G0249: Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria. Includes provision of materials for use in the home and reporting of test results to physician; per 4 tests.
Short Description: Provide test material, equipm
G0250: Physician review; interpretation and patient management of home INR testing for a patient with mechanical heart valve(s) who meets other coverage criteria; per 4 tests (does not require face-to-face).
Short Description: MD review interpret of test
For services furnished on or after March 19, 2008, the applicable HCPCS codes for this benefit are:
G0248: Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing prior to its use
Short Description: Demonstrate use home INR mon
G0249: Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week
Short Description: Provide INR test mater/equip
G0250: Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week
Short Description: MD INR test revie inter mgmt
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)
For services furnished on or after the implementation of ICD-10 the applicable ICD-10-CM diagnosis codes for this benefit are:
| ICD-10-CM Code | Code Description |
|---|---|
| D68.51 | Activated protein C resistance |
| D68.52 | Prothrombin gene mutation |
| D68.59 | Other primary thrombophilia |
| D68.61 | Antiphospholipid syndrome |
| D68.62 | Lupus anticoagulant syndrome |
| I23.6 | Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction |
| I26.01 | Septic pulmonary embolism with acute cor pulmonale |
| I26.09 | Other pulmonary embolism with acute cor pulmonale |
| I26.90 | Septic pulmonary embolism without acute cor pulmonale |
| I26.93 | Single subsegmental pulmonary embolism without acute cor pulmonale |
| I26.94 | Multiple subsegmental pulmonary emboli without acute cor pulmonale |
|---|---|
| I26.99 | Other pulmonary embolism without acute cor pulmonale |
| I27.24 | Chronic thromboembolic pulmonary hypertension |
| I27.82 | Chronic pulmonary embolism |
| I48.0 | Paroxysmal atrial fibrillation |
| I48.11 | Longstanding persistent atrial fibrillation |
| I48.19 | Other persistent atrial fibrillation |
| I48.21 | Permanent atrial fibrillation |
| I67.6 | Nonpyogenic thrombosis of intracranial venous system |
| 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 |
| I80.211 | Phlebitis and thrombophlebitis of right iliac vein |
| I80.212 | Phlebitis and thrombophlebitis of left iliac vein |
| I80.213 | Phlebitis and thrombophlebitis of iliac 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 |
| I80.241 | Phlebitis and thrombophlebitis of right peroneal vein |
| I80.242 | Phlebitis and thrombophlebitis of left peroneal vein |
| I80.243 | Phlebitis and thrombophlebitis of peroneal vein, bilateral |
| I80.251 | Phlebitis and thrombophlebitis of right calf muscular vein |
| I80.252 | Phlebitis and thrombophlebitis of left calf muscular vein |
| I80.253 | Phlebitis and thrombophlebitis of calf muscular 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 |
| I82.0 | Budd-Chiari syndrome |
| I82.210 | Acute embolism and thrombosis of superior vena cava |
| I82.211 | Chronic embolism and thrombosis of superior vena cava |
| I82.220 | Acute embolism and thrombosis of inferior vena cava |
| I82.221 | Chronic embolism and thrombosis of inferior vena cava |
| I82.290 | Acute embolism and thrombosis of other thoracic veins |
| I82.291 | Chronic embolism and thrombosis of other thoracic veins |
| I82.3 | Embolism and thrombosis of renal vein |
| I82.411 | Acute embolism and thrombosis of right femoral vein |
| I82.412 | Acute embolism and thrombosis of left femoral vein |
| I82.413 | Acute embolism and thrombosis of femoral vein, bilateral |
| I82.421 | Acute embolism and thrombosis of right iliac vein |
| I82.422 | Acute embolism and thrombosis of left iliac vein |
| I82.423 | Acute embolism and thrombosis of iliac vein, bilateral |
| I82.431 | Acute embolism and thrombosis of right popliteal vein |
| I82.432 | Acute embolism and thrombosis of left popliteal vein |
|---|---|
| I82.433 | Acute embolism and thrombosis of popliteal vein, bilateral |
| I82.441 | Acute embolism and thrombosis of right tibial vein |
| I82.442 | Acute embolism and thrombosis of left tibial vein |
| I82.443 | Acute embolism and thrombosis of tibial vein, bilateral |
| I82.451 | Acute embolism and thrombosis of right peroneal vein |
| I82.452 | Acute embolism and thrombosis of left peroneal vein |
| I82.453 | Acute embolism and thrombosis of peroneal vein, bilateral |
| I82.461 | Acute embolism and thrombosis of right calf muscular vein |
| I82.462 | Acute embolism and thrombosis of left calf muscular vein |
| I82.463 | Acute embolism and thrombosis of calf muscular vein, bilateral |
| I82.491 | Acute embolism and thrombosis of other specified deep vein of right lower extremity |
| I82.492 | Acute embolism and thrombosis of other specified deep vein of left lower extremity |
| I82.493 | Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral |
| I82.511 | Chronic embolism and thrombosis of right femoral vein |
| I82.512 | Chronic embolism and thrombosis of left femoral vein |
| I82.513 | Chronic embolism and thrombosis of femoral vein, bilateral |
| I82.521 | Chronic embolism and thrombosis of right iliac vein |
| I82.522 | Chronic embolism and thrombosis of left iliac vein |
| I82.523 | Chronic embolism and thrombosis of iliac vein, bilateral |
| I82.531 | Chronic embolism and thrombosis of right popliteal vein |
| I82.532 | Chronic embolism and thrombosis of left popliteal vein |
| I82.533 | Chronic embolism and thrombosis of popliteal vein, bilateral |
| I82.541 | Chronic embolism and thrombosis of right tibial vein |
| I82.542 | Chronic embolism and thrombosis of left tibial vein |
| I82.543 | Chronic embolism and thrombosis of tibial vein, bilateral |
| I82.551 | Chronic embolism and thrombosis of right peroneal vein |
| I82.552 | Chronic embolism and thrombosis of left peroneal vein |
| I82.553 | Chronic embolism and thrombosis of peroneal vein, bilateral |
| I82.561 | Chronic embolism and thrombosis of right calf muscular vein |
| I82.562 | Chronic embolism and thrombosis of left calf muscular vein |
| I82.563 | Chronic embolism and thrombosis of calf muscular vein, bilateral |
| I82.591 | Chronic embolism and thrombosis of other specified deep vein of right lower extremity |
| I82.592 | Chronic embolism and thrombosis of other specified deep vein of left lower extremity |
| I82.593 | Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral |
| I82.621 | Acute embolism and thrombosis of deep veins of right upper extremity |
| I82.622 | Acute embolism and thrombosis of deep veins of left upper extremity |
| I82.623 | Acute embolism and thrombosis of deep veins of upper extremity, bilateral |
| I82.721 | Chronic embolism and thrombosis of deep veins of right upper extremity |
| I82.722 | Chronic embolism and thrombosis of deep veins of left upper extremity |
| I82.723 | Chronic embolism and thrombosis of deep veins of upper extremity, bilateral |
|---|---|
| I82.890 | Acute embolism and thrombosis of other specified veins |
| I82.891 | Chronic embolism and thrombosis of other specified veins |
| I82.A11 | Acute embolism and thrombosis of right axillary vein |
| I82.A12 | Acute embolism and thrombosis of left axillary vein |
| I82.A13 | Acute embolism and thrombosis of axillary vein, bilateral |
| I82.A21 | Chronic embolism and thrombosis of right axillary vein |
| I82.A22 | Chronic embolism and thrombosis of left axillary vein |
| I82.A23 | Chronic embolism and thrombosis of axillary vein, bilateral |
| I82.B11 | Acute embolism and thrombosis of right subclavian vein |
| I82.B12 | Acute embolism and thrombosis of left subclavian vein |
| I82.B13 | Acute embolism and thrombosis of subclavian vein, bilateral |
| I82.B21 | Chronic embolism and thrombosis of right subclavian vein |
| I82.B22 | Chronic embolism and thrombosis of left subclavian vein |
| I82.B23 | Chronic embolism and thrombosis of subclavian vein, bilateral |
| I82.C11 | Acute embolism and thrombosis of right internal jugular vein |
| I82.C12 | Acute embolism and thrombosis of left internal jugular vein |
| I82.C13 | Acute embolism and thrombosis of internal jugular vein, bilateral |
| I82.C21 | Chronic embolism and thrombosis of right internal jugular vein |
| I82.C22 | Chronic embolism and thrombosis of left internal jugular vein |
| I82.C23 | Chronic embolism and thrombosis of internal jugular vein, bilateral |
| O87.3 | Cerebral venous thrombosis in the puerperium |
| Z79.01 | Long term (current) use of anticoagulants |
| Z86.718 | Personal history of other venous thrombosis and embolism |
| Z95.2 | Presence of prosthetic heart valve |
Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 190.11 PT/INR. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
Note this test is not covered as durable medical equipment. Therefore, claims submitted to DMERCs will not be paid. It is covered under the physician fee schedule. Also note that the cost of the device and supplies is included in the payment for G0249 and therefore not separately billed to Medicare. G0249 continues to include materials for 4 tests. Additionally, G0250 continues to mean per 4 tests and should be billed no more frequently than once every 4 weeks.
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
Payment and pricing information will be in the Medicare Physician Fee Schedule Database (MPFSDB). Pay for INR on the basis of the MPFS. Deductible and coinsurance apply.
(Rev. 216, 06-25-04)
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
Use appropriate existing remittance advice reason and remark codes at the line level to express the specific reason for denying payment for PT/INR:
Remittance Advice Remark Code N386, “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have Web access, you may contact the contractor to request a copy of the NCD.”
If denying services furnished after July 1, 2002, use ASC X 12-835 claim adjustment reason code 50, “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”
(Rev. 1562, Issued: 07-25-08, Effective: 03-19-08, Implementation: 08-25-08)
If denying services furnished after July 1, 2002, use MSN message:
“The following policies [190.11] were used when we made this decision.” (MSN Message 15.20)
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Effective for dates of service on or after September 15, 2004, Medicare will cover FDG PET scans for a differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer’s disease OR; its use in a CMS-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases. Refer to Pub. 100-03, NCD Manual, section 220.6.13, for complete coverage conditions and clinical trial requirements and section 60.15 of this manual for claims processing information.
A. A/B MAC (A and B) Billing Requirements for PET Scan Claims for FDG-PET for the Differential Diagnosis of Fronto-temporal Dementia and Alzheimer’s Disease:
CPT Code for PET Scans for Dementia and Neurodegenerative Diseases
Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for dementia and neurodegenerative diseases for services performed on or after January 28, 2005.
Diagnosis Codes for PET Scans for Dementia and Neurodegenerative Diseases
The contractor shall ensure one of the following appropriate diagnosis codes is present on claims for PET Scans for AD:
Medicare contractors shall deny claims when submitted with an appropriate CPT code from section 60.3.1 and with a diagnosis code other than the range of codes listed above.
Medicare contractors shall instruct providers to issue an Advanced Beneficiary Notice to beneficiaries advising them of potential financial liability prior to delivering the service if one of the appropriate diagnosis codes will not be present on the claim.
The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
Group Code: PR (if claim is received with a GA modifier) otherwise CO
CARC: 11
RARC: N/A
MSN: 16.48
Provider Documentation Required with the PET Scan Claim
Medicare contractors shall inform providers to ensure the conditions mentioned in the NCD Manual, section 220.6.13, have been met. The information must also be maintained in the beneficiary's medical record:
B. Billing Requirements for Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease:
Effective for claims with dates of service on and after September 27, 2013, Medicare will only allow coverage with evidence development (CED) for Positron Emission Tomography (PET) beta amyloid (also referred to as amyloid-beta (Aβ)) imaging (HCPCS A9586) or (HCPCS Q9982) or (HCPCS Q9983) (one PET Aβ scan per patient).
Note: Please note that effective January 1, 2014 the following code A9599 will be updated in the IOCE and HCPCS update. This code will be contractor priced.
Note: Please note that effective January 1, 2018 the following code A9599 is end-date.
Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes
Effective for dates of service on or after September 27, 2013, contractors shall return as unprocessable/return to provider claims for PET Aβ imaging, through CED during a clinical trial, not containing the following:
And one of these additional diagnoses is required in addition to Z00.6
| F03.90 | Unspecified dementia without behavioral disturbance |
|---|---|
| F03.91 | Unspecified dementia with behavioral disturbance |
| F01.50 | Vascular dementia without behavioral disturbance |
| F01.51 | Vascular dementia with behavioral disturbance |
| F02.80 | Dementia in other diseases classified elsewhere without behavioral disturbance |
| F02.81 | Dementia in other diseases classified elsewhere with behavioral disturbance |
| G31.01 | Pick's disease |
| G31.09 | Other frontotemporal dementia |
| G31.85 | Corticobasal degeneration |
| G31.83 | Dementia with Lewy bodies |
| G31.84 | Mild cognitive impairment, so stated |
| R41.1 | Anterograde amnesia |
| R41.2 | Retrograde amnesia |
| R41.3 | Other amnesia (amnesia NOS, memory loss NOS) |
and
Contractors shall return as unprocessable claims for PET Aβ imaging using the following messages:
-Claim Adjustment Reason Code 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Remittance Advice Remark Code N519 - Invalid combination of HCPCS modifiers. Contractors shall line-item deny claims for PET Aβ, HCPCS code A9586 or Q9982 or Q9983, where a previous PET Aβ, HCPCS code A9586 or Q9982 or Q9983 is paid in history using the following messages:
Spanish Version: “Este servicio fue negado porque Medicare sólo cubre este servicio una vez en la vida.”
Group Code: PR, if a claim is received with a GA modifier
(Rev. 10229, Issued: 07-21-20 Effective: 10-01-20, Implementation: 10-05-20)
CMS is streamlining the editing for MA plans' claims when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Original fee-for-service Medicare will pay for services obtained by beneficiaries enrolled in Medicare Advantage (MA) plans in this circumstance.
Consistent with §1862 (t)(2) of the Social Security Act, Medicare Administrative Contractors will pay for identified significant cost services for Medicare beneficiaries enrolled in MA plans. In addition 42 CFR §422.109, the Medicare payment for the services or benefit is made directly by the A/B MAC to the provider furnishing the service or benefit in accordance with original Medicare payment, rules, methods, and requirements.
Beneficiaries are liable for any applicable coinsurance amounts.
Cost for NCD services legislative changes in benefits for which CMS A/B MACs will not make payment and are the responsibility of the M+C organization are:
I. Services necessary to diagnose a condition covered by the NCD or legislative changes in benefits; II. Most services furnished as follow up care to the NCD services or legislative changes in benefits; III. Any services that is already a Medicare-covered service and included in the annual M+C capitation rate or previously, adjusted payments; and IV. Any services, including costs of the NCD service or legislative change in benefits, to the extent the M+C organization is already obligated to cover it as an additional benefit under 42CFR §422.312 or supplemental benefit under 42 CFR §422.102.
(Rev. 10229, Issued: 07-21-20 Effective: 10-01-20, Implementation: 10-05-20)
A. Institutional Inpatient Billing for National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage.
The Medicare contractors shall allow Condition Code (CC) 78 on any inpatient institutional claims for Medicare Advantage beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Any current editing that doesn't allow this shall be updated to allow this scenario, unless there has been previous instructions excluding certain conditions.
Note: Condition Code 78 = Newly covered Medicare service for which an HMO doesn't pay.
B. Institutional Outpatient Billing for National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage
The Medicare contractors shall allow Condition Code (CC) 78 on any outpatient institutional claims for Medicare Advantage beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Any current editing that doesn't allow this shall be updated to allow this scenario, unless there has been previous instructions excluding certain conditions.
Note: Condition Code 78 = Newly covered Medicare service for which an HMO doesn't pay.
(Rev. 10229, Issued: 07-21-20 Effective: 10-01-20, Implementation: 10-05-20)
Services Identified as having Significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations Providers may bill the A/B MAC for these NCD services provided to a MA beneficiary.
| Services Identified as having Significant cost | |||||
|---|---|---|---|---|---|
| Service/Benefit | Revenue Code | HCPCS | ICD-10-PCS Procedure | Significant Cost Start | Significant Cost End |
| CAR-T | 0891 | Q2041, Q2042 | XW033C3 or XW043C3 | 08/07/2019 | 12/31/2020 |
(Rev. 1147, Issued: 01-05-07, Effective: 11-06-06, Implementation: 02-05-07)
On occasion, providers may receive an item (such as a device or drug) that is offered by a manufacturer/supplier free of charge. Such items, for purposes of these instructions, are considered 'no cost items.' Providers are not to seek reimbursement for no cost items as noted in Section 1862(a)(2) of the Social Security Act.
(Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09)
Practitioners typically should not bill for no cost items as there is no non-covered charges field on the claim and there are also no system edits in place to require providers to do so. However, practitioners are required to report Category A IDE devices received at no cost on claims as specified in §68.3 of this chapter (although they will not receive payment).
(Rev. 4013, Issued: 03-30-18, Effective: 01-01-09, Implementation: 06-29-18)
Generally speaking, institutional, providers should not have to report the usage of a no cost item. However, for some claims (e.g., hospital Outpatient Prospective Payment System (OPPS) claims), providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service (e.g., a specified device must be reported along with a specified implantation procedure).
For OPPS claims, when a drug is provided at no cost, claims processing edits prevent drug administration charges from being billed when the claim does not contain a covered/billable drug charge. Therefore, for drugs provided at no cost in the hospital outpatient department, providers must report the applicable drug HCPCS code and appropriate units with a token charge of less than $1.01 for the item in the covered charge field and mirror this less than $1.01 amount reported in the noncovered charge field. Providers must also bill the corresponding drug administration charge with the appropriate drug administration CPT or HCPCS code.
For OPPS claims, providers must report a token charge of less than $1.01 for the item in the covered charge field, along with the applicable HCPCS modifier (i.e., modifier –FB) appended to the procedure code that reports the service requiring
a device. For more information on billing no cost items under the OPPS, refer to Chapter 4, §20.6.9 and 61.3.1 of this manual.
By billing in this way, the provider is accomplishing four things:
1) Communicating to the contractor that the provider is not seeking payment for the no cost item;
2) Reflecting, with completeness and accuracy, all services provided to the patient;
3) Preventing the line item or claim from being rejected/denied by system edits that require an item to be billed in conjunction with an associated procedure (such as implantation or administration procedures);
4) Assuring that the patient and provider are not held liable for any charges for the no cost item.
Future updates will be issued in a Recurring Update Notification.
(Rev. 3181, Issued: 01-30-15, Effective: 07-01-15, Implementation: 07-06-15)
Currently, institutional providers that use the Healthcare Common Procedural Coding System (HCPCS) bill device HCPCS codes for no cost or full credit items with token charges in order for claims to pass OPPS claims processing edits that require certain devices to be billed with their associated procedures so that payment can be made.
Effective January 1, 2006, modifier –FB is used to indicate that an item used in a procedure was furnished without cost to the provider, and, therefore, it is not being charged to Medicare or the beneficiary. More information on billing HCPCS modifier –FB can be located in Chapter 4, §20.6.9 and 61.3.1 of this manual.
Effective April 1, 2006, two new condition codes were created for institutional use: 49 and 50 (Table 1). These new codes are used to identify and track medical devices that are provided by a manufacturer at no cost or with full credit to the hospital due to warranty for a malfunction or recall.
| Condition Code | Description | |
|---|---|---|
| 49 | Product Replacement within Product Lifecycle | Replacement of a product earlier than the anticipated lifecycle. |
| 50 | Product Replacement for Known Recall of a Product | Manufacturer or FDA has identified the product for recall and therefore replacement. |
NOTE: OPPS hospitals billing no cost/full credit devices must append modifier –FB to the procedure code for implanting the no cost/full credit device, along with the appropriate condition code if applicable (in Table 1 above), in instances when claims processing edits require that certain devices be billed with their associated procedures. The modifier identifies the procedure code line for the no cost/full credit device, while the condition code explains if the device was provided free of cost due to warranty or recall.
Effective January 1, 2014, an additional new condition code was created for institutional use: 53 (Table 2). This new code is used to identify and track medical devices that are provided by a manufacturer at no cost or with full credit to the hospital due a clinical trial or a free sample.
| Condition Code | Description | |
|---|---|---|
| 49 | Product Replacement within Product Lifecycle | Replacement of a product earlier than the anticipated lifecycle. |
| 50 | Product Replacement for Known Recall of a Product | Manufacturer or FDA has identified the product for recall and therefore replacement. |
| 53 | Initial placement of a medical device provided as part of a clinical trial or free sample | Code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample. |
NOTE: OPPS hospitals billing no cost/full credit devices are no longer required to append modifier –FB to the procedure code for implanting the no cost/full credit device, along with the appropriate condition code if applicable (in Table 2 above), in instances when claims processing edits require that certain devices be billed with their associated procedures.
(Rev. 3105, Issued: 11-06-14, Effective: 01-01-15, Implementation: 01-05-15)
See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 14 for complete Medicare coverage requirements for items and services in Category A and B IDE studies, related to these billing requirements.
NOTE: For information regarding Medicare coverage related to IDEs in Medicare Advantage plans, refer to Pub. 100-16, Medicare Managed Care Manual, chapter 4, section 10.7.2.
(Rev. 3105, Issued: 11-06-14, Effective: 01-01-15, Implementation: 01-05-15)
Institutional providers shall submit claims only for routine care items and services in Category A IDE device studies approved by CMS (or its designated entity) and listed on the CMS Coverage Website, by billing according to the clinical trial billing instructions found in §69.6 of this chapter, and as described below under subsection C (“General
Billing Requirements”). The Category A IDE device shall not be reported on institutional claims since Category A IDE devices are not eligible for payment under Medicare.
Practitioners shall submit claims for the routine care items and services in Category A IDE studies approved by CMS (or its designated entity) and listed on the CMS Coverage Website, by billing according to the clinical trial billing instructions found in §69.6 of this chapter, and as described below under subsection C (“General Billing Requirements”). The Category A IDE device shall not be reported on practitioner claims since Category A IDE devices are not eligible for payment under Medicare.
Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under coverage with evidence development (CED). This is the number assigned by the National Library of Medicine (NLM) ClinicalTrials.gov Website when a new study appears in the NLM Clinical Trials data base. This number is listed prominently on each specific study’s page and is always preceded by the letters “NCT.” Contractors verify the validity of a trial/study/registry by consulting CMS’s Coverage Website at: http://www.cms.gov/Center/Special-Topic/Medicare-Coverage-Center.html?redirect=/center/coverage.asp. Providers report the 8-digit number on the following claims locators:
CMS-1500 paper form-place in Field 19 (preceded by ‘CT’); or 837 P—Loop 2300, REF02, REF01=P4 (do not use ‘CT’ on the electronic claim)
In addition to the clinical trial number, claims shall include:
ICD-9 diagnosis code V70.7/ICD-10 diagnosis code Z00.6 (in either the primary/secondary positions)
HCPCS modifier Q0 or Q1 as appropriate
Claims submitted without a clinical trial number shall be returned as unprocessable reporting the following messages:
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)”
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.”
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
Group Code - Contractual Obligation (CO)
Effective for dates of service on or before December 31, 2007, practitioners must place a QV modifier (Item or service provided as routine care in a Medicare qualifying clinical trial) on the line for the device along with the IDE number.
Effective for dates of service on or after January 1, 2008, practitioners will no longer bill a QV modifier to identify the device. Instead, practitioners will bill a Q0 (numeral 0 versus the letter O) modifier (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) along with the IDE number.
The following table shows the designated field locations to report the Category A IDE number on practitioner claims:
| Data | CMS-1500 | 837i and 837p |
|---|---|---|
| IDE # | Item 23 | Segment 2300, REF02(REF01=LX) |
Contractors will validate the IDE number for the Category A device when modifier Q0 is submitted on the claim along with the IDE number. Claims containing an invalid IDE number will be returned to the provider using the following messages:
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption Number for FDA approved clinical trial services.”
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).”
Payment for the device may not exceed the Medicare-approved amount for a comparable device that has been already FDA-approved.
Institutional providers shall submit claims for the routine care items and services in Category B IDE studies approved by CMS (or its designated entity) and listed on the CMS Coverage Website, by billing according to the clinical trial billing instructions found in §69.6 of this chapter, and as described below under subsection D (“General Billing Requirements”).
Institutional providers must bill the Category B IDE number on a 0624 revenue code line with charges in the covered charges field. Hospital inpatient providers should not bill for the Category B IDE device if receiving the device free-of-charge.
Institutional providers shall submit claims for the routine care items and services in Category B IDE studies approved by CMS (or its designated entity) and listed on the CMS Coverage Website, by billing according to the clinical trial
billing instructions found in section 69.6 of this chapter, and as described below under subsection D (“General Billing Requirements”).
On a 0624 revenue code line, institutional providers must bill the following for Category B IDE devices for which they incur a cost:
NOTE: If the Category B IDE device is provided at no cost, outpatient prospective payment system (OPPS) providers must report a token charge in the covered charge field along with the applicable HCPCS modifier (i.e., modifier – FB) appended to the procedure code that reports the service to furnish the device, in instances when claims processing edits require that certain devices be billed with their associated procedures. For more information on billing ‘no cost items’ under the OPPS, refer to chapter 4, §§20.6.9 and 61.3.1 of this manual.
Practitioners shall submit claims for routine care items and services in Category B IDE studies approved by CMS (or its designated entity) and listed on the CMS Coverage Website, by billing according to the clinical trial billing instructions found in section 69.6 of this chapter, and as described below under subsection D (“General Billing Requirements”).
Effective for dates of service on or before December 31, 2007, practitioners must bill the Category B IDE device on a line with a QA modifier (FDA IDE) along with the IDE number. However, effective for dates of service on or after January 1, 2008, practitioners will no longer bill a QA modifier to identify a Category B device. Instead, practitioners will bill a Q0 modifier (numeral 0 versus the letter O) (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) along with the IDE number.
The following table shows the designated field locations to report the Category B IDE number on institutional and practitioner claims:
| Data | CMS-1450 | CMS-1500 | 837i and 837p |
|---|---|---|---|
| IDE # | FL 43 | Item 23 | Segment 2300, REF02(REF01=LX) |
|---|---|---|---|
Contractors will validate the IDE number for the Category B device when modifier Q0 is submitted on the claim along with the IDE number. Claims containing an invalid IDE number will be returned to the provider using the following messages:
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption Number for FDA approved clinical trial services.”
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.”
Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED. This is the number assigned by the NLM ClinicalTrials.gov Website when a new study appears in the NLM Clinical Trials data base. This number is listed prominently on each specific study’s page and is always preceded by the letters “NCT.” Contractors verify the validity of a trial/study/registry by consulting CMS’s Coverage Website at: http://www.cms.gov/Center/Special-Topic/Medicare-Coverage-Center.html?redirect=/center/coverage.asp. Providers report the 8-digit number on the following claims locators:
In addition to the clinical trial number, claims shall include:
Claims submitted without a clinical trial number shall be returned as unprocessable reporting the following messages:
Group Code-Contractual Obligation (CO)
As noted above in section 68.2, of this chapter, providers shall first notify their contractor of the IDE device trial before submitting claims for Category B IDE devices and the routine costs of clinical trials involving Category B IDE devices. Once the contractor notifies the provider that all required information for the IDE has been furnished, the provider may bill Category B IDE claims.
When billing for Category B IDEs, providers shall bill for the device and all related procedures. The Category B IDE device and the routine costs associated with its use are eligible for payment under Medicare. (Payment for the device may not exceed the Medicare-approved amount for a comparable device that has been already FDA-approved.)
Institutional providers shall submit claims for the routine costs of a clinical trial involving a Category B IDE device by billing according to the clinical trial billing instructions found in §69.6 of this chapter.
Institutional providers must bill the Category B IDE number on a 0624 revenue code line with charges in the covered charges field. Hospital inpatient providers should not bill for the Category B IDE device if receiving the device free-of-charge.
Institutional providers shall submit claims for the routine costs of a clinical trial involving a Category B IDE device by billing according to the clinical trial billing instructions found in section 69.6 of this chapter.
On a 0624 revenue code line, institutional providers must bill the following for Category B IDE devices for which they incur a cost:
NOTE: For claims prior to January 1, 2014, if the Category B IDE device is provided at no cost, outpatient prospective payment system (OPPS) providers must report a token charge in the covered charge field along with the applicable HCPCS modifier (i.e., modifier –FB) appended to the procedure code that reports the service to furnish the device, in instances when claims processing edits require that certain devices be billed with their associated procedures. For more information on billing ‘no cost items’ under the OPPS, refer to Chapter 4, §§20.6.9 and 61.3.1 of this manual.
Effective January 1, 2014, if the Category B IDE device is provided at no cost, outpatient prospective payment system (OPPS) providers must report a token charge in the covered charge field along with condition code “53” and Value Code “FD”. For more information on billing ‘no cost items’ under the OPPS, refer to Chapter 4, §§20.6.9 and 61.3.1 of this manual.
Practitioners shall submit claims for the routine costs of a clinical trial involving a Category B IDE device by billing according to the clinical trial billing instructions found in section 69.6 of this chapter.
Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED. Providers report the 8-digit number on the following claims locators:
In addition to the clinical trial number, claims shall include (in either the primary/secondary positions):
Claims submitted without a clinical trial number shall be returned as unprocessable reporting the following messages:
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)”
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.”
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
Effective for dates of service on or before December 31, 2007, practitioners must bill the Category B IDE device on a line with a QA modifier (FDA IDE) along with the IDE number. However, effective for dates of service on or after January 1, 2008, practitioners will no longer bill a QA modifier to identify a Category B device. Instead, practitioners will bill a Q0 modifier (numeral 0 versus the letter O) (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) along with the IDE number.
The following table shows the designated field locations to report the Category B IDE number on institutional and practitioner claims:
| Data | CMS-1450 | CMS-1500 | 837 institutional claim format and 837 professional claim format |
|---|---|---|---|
| IDE # | Revenue Code Description field | Item 23 | Segment 2300, REF02(REF01=LX) |
Contractors will validate the IDE number for the Category B device when modifier Q0 is submitted on the claim along with the IDE number. Claims containing an invalid IDE number will be returned to the provider using the following messages:
RARC MA50: 'Missing/incomplete/invalid Investigational Device Exemption Number for FDA approved clinical trial services.'
CARC 16: 'Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.'
Claims that are submitted without the 'Q0' modifier will be returned with the following messages:
CARC 16 - Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N822 – Missing procedure modifier(s).
(Rev. 487, Issued: 03-04-05, Effective and Implementation: N/A)
(Rev. 13551; Issued: 12-19-25; Effective: 01-21-26; Implementation: 01-21-26)
The CMS has issued a National Coverage Determination (NCD) which allows Medicare coverage for the routine costs of qualifying clinical trial services as well as reasonable, necessary items and services used to diagnose and treat complications arising from participation in all clinical trials. The coverage requirements for routine costs of qualifying clinical trial services are contained in the National Coverage Determinations Manual, Section 310.1, www.cms.gov/regulations-and-
guidance/guidance/manuals/downloads/ncd103c1_part4.pdf
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
For dates of service on or after September 19, 2000, pay for covered services furnished to beneficiaries participating in qualifying clinical trials. Payment is based on the payment methodology applicable for the service that was furnished (e.g., physician fee schedule, lab fee schedule, durable medical equipment fee schedule, reasonable charge, etc.). With the exception of managed care enrollees, applicable deductibles and coinsurance rules apply to clinical trial items and services. The Part A and Part B deductibles are assumed to be met for covered clinical trial services billed on a fee service basis for managed care enrollees.
NOTE: Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED. This is the number assigned by the National Library of Medicine (NLM) ClinicalTrials.gov Web site when a new study appears in the NLM Clinical Trials data base. This number is listed prominently on each specific study's page and is always preceded by the letters 'NCT.' Contractors verify the validity of a trial/study/registry by consulting CMS's clinical trials/registry web site at: http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/index.html.
NOTE: Contractors shall ensure value code 'D4'/amount data from their internal claims processing is mapped/populated to the 837 institutional claim format for a coordination of benefits 837 institutional claim.
(Rev. 487, Issued: 03-04-05, Effective and Implementation: N/A)
The billing provider must include in the beneficiary's medical record the following information: trial name, sponsor, and sponsor-assigned protocol number. This information does not need to be submitted with the claim but must be provided if requested for medical review.
(Rev. 487, Issued: 03-04-05, Effective and Implementation: N/A)
Do not develop new or revised LMRPs for clinical trial services. Clinical trial services that meet the requirements of the NCD are considered reasonable and necessary.
(Rev. 2955, Issued: 05-14-14, Effective, 01-01-14, Implementation, 01- 06-14)
Instruct practitioners and institutional providers to enter clinical trial and non-clinical trial services on separate line items when billing both types of services on the same claim. For services that require a Certificate of Medical Necessity (CMN), continue to require CMNs. Items and services provided free-of-charge by research sponsors generally may not be billed to be paid by Medicare, and providers are not required to submit the charge to Medicare. If it is necessary for a provider to show the items and services that are provided free-of-charge in order to receive payment for the covered routine costs (e.g. administration of a non-covered chemotherapeutic agent), providers are instructed to submit such charges as non-covered at the time of entry, while also assuring that the beneficiary is not held liable. This instruction applies to all hospitals including hospitals located in Maryland under the jurisdiction of the Health Services Cost Review Commission (HSCRC).
For OPPS claims, providers must report a token charge for a 'no cost' item in the covered charge field along with the applicable HCPCS modifier (i.e., modifier –FB) appended to the procedure code that reports the service provided to furnish the 'no cost' item, in instances when claims processing edits require that certain devices be billed with their associated procedures. For more information on billing 'no cost' items under the OPPS, refer to Chapter 4, §§20.6.9 and 61.3.1 of this manual.
NOTE: Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED.
Future updates will be issued in a Recurring Update Notification.
(Rev. 13551; Issued: 12-19-25; Effective: 01-21-26; Implementation: 01-21-26)
Routine Costs Submitted by Practitioners/Suppliers
Claims with dates of service on or after January 1, 2008:
CMS covers the cost of healthy volunteers in a qualified clinical trial if it meets the following conditions:
Claims submitted with modifier Q1 shall be returned as unprocessable if ICD-10-CM code Z00.6 is not submitted on the claim.
Contractors shall return the following messages:
Claims Adjustment Reason Code (CARC) 16: "Claim/service lacks information which is needed for adjudication. As least one Remark Code must be provided (may be comprised of either the Remittance Advice Code or NCPDP Reject Reason Code)."
Remittance Advice Remark Code (RARC) M76: "Missing/incomplete/invalid diagnosis or condition."
Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a
clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under Coverage with Evidence Development (CED.) Providers must report the 8-digit number on clinical trial number on the following claims locators:
In addition to the clinical trial number, claims should also include:
Practitioner claims submitted without a clinical trial number shall be returned as unprocessable using the following messages:
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)”
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.”
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
Group Code-Contractual Obligation (CO)
Routine Costs Submitted by Institutional Providers
Regardless of the date of service, clinical trial claims received after April 1, 2008, providers must report the 8-digit clinical trial number. To bill the 8-digit clinical trial number, institutional providers shall use value code 'D4' where the value code amount equals the 8-digit clinical trial number. Below are the claim locators in which to bill the 8-digit clinical trial number:
NOTE: Value code 'D4'/amount data from the internal claims processing is mapped/populated to the 837 institutional claim formats for a coordination of benefits 837 institutional claim
NOTE: It is mandatory to report a clinical trial number on claims for items or services provided in clinical trials, studies or registries. Institutional claims submitted without a clinical trial number shall be returned to providers.
NOTE: Modifier Q0 is used for services defined as an investigational clinical service provided in an approved clinical research study. Append this modifier on a Category B Investigational Device Exemption (IDE) code along with IDE number on the claim.
The modifier Q1 is a line item specific and must be used to identify items and services that constitute medically necessary routine patient care or treatment of complications arising from a Medicare beneficiary's participation in a Medicare covered clinical trial. Items and services that are provided solely to:
are not covered and may not be billed using modifier Q1. Items and services that are not covered by Medicare by virtue of a statutory exclusion or lack of a benefit category also may not be billed using modifier Q1. When billed in conjunction with the Z00.6 diagnosis code, modifier Q1 will serve as the provider's attestation that the service meets the Medicare coverage criteria (i.e., was furnished to a beneficiary who is participating in a Medicare qualifying clinical trial and represents routine patient care, including complications associated with qualifying clinical trial participation).
Institutional providers billing clinical trial service(s) must report ICD-10 diagnosis code Z00.6 in either the primary or secondary position and condition code 30 regardless of whether all services are related to the clinical trial or not.
NOTE: HCPCS codes are not reported on inpatient claims. Therefore, the HCPCS modifier requirements (i.e., Q0/Q1) as outlined in the outpatient clinical trial section below, are not applicable to inpatient clinical trial claims.
On all outpatient clinical trial claims, providers must do the following:
For clinical trial billing requirements for patients enrolled in a managed care plan/MAO, please refer to Section 69.9 of this chapter.
(Rev. 1418, Issued: 01-18-08, Effective: 01-01-08, Implementation: 04-07-08)
(Rev. 487, Issued: 03-04-05, Effective and Implementation: N/A)
If a service Medicare covers was billed with the appropriate clinical trial coding but was inadvertently denied (e.g., for medical necessity or utilization) and is subsequently brought to your attention, adjust the denied claim. If the denied services weren't properly coded as clinical trial services, instruct the provider to resubmit the service on a new claim with appropriate clinical trial coding.
(Rev. 13551; Issued: 12-19-25; Effective: 01-21-26; Implementation: 01-21-26)
Medicare Advantage Organizations (MAOs) are responsible for payment of claims related to the enrollees' participation in both Category A and B IDE studies that are covered by the Medicare Administrative Contractor (MAC) with jurisdiction over the MA plan's service area. The MAO is responsible for payment of routine care items and services in Centers for Medicare & Medicaid (CMS) approved Category A and Category B IDE studies. The MAO is also responsible for CMS approved Category B devices. CMS will not approve Category A devices because they are statutorily excluded from coverage.
In National Coverage Determinations (NCDs) requiring CED, Medicare covers items and services in CMS approved CED studies. MAOs are responsible for
payment of items and services in CMS approved CED studies unless CMS determines that the significant cost threshold is exceeded for that item or service (see 42 CFR 422.109).
Per Publication 100-16, Chapter 4, Section 10.7.1- 10.7.3, Medicare Advantage Organizations (MAOs) are responsible for payment of services. For additional information regarding MAO benefits refer to:
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c04.pdf
The clinical trial coding requirements for MAO claims are the same as those for regular Medicare fee for service claims. However, for beneficiaries enrolled in a MAO plan, institutional providers must not bill outpatient clinical trial services and non-clinical trial services on the same claim. If covered outpatient services unrelated to the clinical trial are rendered during the same day/stay, the provider must split bill submitting only the clinical trial services on a single claim and billed as fee-for-service. (This allows the Medicare claims processing system to not apply the deductible when the patient is found to be in a MAO plan). Any outpatient services unrelated to the clinical trial should be billed to the MAO plan
Submit clinical trial services for managed care enrollees to CWF for payment approval. CWF will not reject clinical trial claims for managed care enrollees when all services on the claim transaction record are coded as clinical trial services and the date(s) of service is (are) on or after September 19, 2000. In addition, CWF will not apply Part B deductible to clinical trial claims for managed care enrollees (i.e., CWF will process clinical trial services for managed care enrollees as if the Part B deductible has already been met).
If you send a claim transaction to CWF that includes both clinical and non-clinical trial services for a managed care enrollee, the entire claim will be rejected with the UR 5232 error code. When you receive a UR 5232 error code split the claim and resubmit the clinical trial portion to CWF. Process the non-clinical trial portion of the rejected claims in the same manner that other non-clinical trial fee for service claims for managed care enrollees are handled.
For services performed on or after October 1, 2004, Medicare will cover islet cell transplantation for patients with Type I diabetes who are participating in an NIH sponsored clinical trial. See Pub 100-04 (National Coverage Determinations Manual) section 260.3.1 for complete coverage policy.
The islet cell transplant may be done alone or in combination with a kidney transplant. Islet recipients will also need immunosuppressant therapy to prevent rejection of the transplanted islet cells. Routine follow-up care will be necessary for each trial patient. See Pub 100-04,
section 310 for further guidance relative to routine care. All other uses for islet cell services will remain non-covered.
(Rev. 261, Issued: 07-30-04, Effective: 10-01-04, Implementation: 10-04-04)
G0341: Percutaneous islet cell transplant, includes portal vein catheterization and infusion
Short Descriptor: Percutaneous islet cell trans
Type of Service: 2
G0342: Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion
Short Descriptor: Laparoscopy islet cell trans
Type of Service: 2
G0343: Laparotomy for islet cell transplant, includes portal vein catheterization and infusion
Short Descriptor: Laparotomy islet cell transp
Type of Service: 2
(Rev. 986, Issued: 06-16-06, Effective: 05-01-06, Implementation: 07-31-06)
Carriers shall instruct physicians to bill using the above procedure code(s) with modifier QR (Item or service provided in a Medicare-specified study) for all claims for islet cell transplantation and routine follow-up care related to this service.
(Rev. 261, Issued: 07-30-04, Effective: 10-01-04, Implementation: 10-04-04)
Payment and pricing information will be on the October 2004 update of the Medicare Physician Fee Schedule Database (MPFSDB). Pay for islet cell transplants on the basis of the MPFS. Deductible and coinsurance apply for fee-for-service beneficiaries.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
If ICD-10 is applicable, ICD-10-PCS codes for the clinical trial are:
| ICD-10-PCS Code | Code Description |
|---|---|
| 3E030U1 | Introduction of Nonautologous Pancreatic Islet Cells into Peripheral Vein, Open Approach |
| 3E033U1 | Introduction of Nonautologous Pancreatic Islet Cells into Peripheral Vein, Percutaneous Approach |
|---|---|
| 3E0J3U1 | Introduction of Nonautologous Pancreatic Islet Cells into Biliary and Pancreatic Tract, Percutaneous Approach |
| 3E0J7U1 | Introduction of Nonautologous Pancreatic Islet Cells into Biliary and Pancreatic Tract, Via Natural or Artificial Opening |
| 3E0J8U1 | Introduction of Nonautologous Pancreatic Islet Cells into Biliary and Pancreatic Tract, Via Natural or Artificial Opening Endoscopic |
| E10.9 | Type 1 diabetes mellitus without complications |
|---|---|
| E10.65 | Type 1 diabetes mellitus with hyperglycemia |
| E10.10 | Type 1 diabetes mellitus with ketoacidosis without coma |
| E10.69 | Type 1 diabetes mellitus with other specified complication |
| E10.21 | Type 1 diabetes mellitus with diabetic nephropathy |
| E10.22 | Type 1 diabetes mellitus with diabetic chronic kidney disease |
| E10.29 | Type 1 diabetes mellitus with other diabetic kidney complication |
| E10.311 | Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E10.319 | Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E10.3211 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E10.3212 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E10.3213 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E10.3291 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E10.3292 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E10.3293 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E10.3311 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E10.3312 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E10.3313 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E10.3391 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E10.3392 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E10.3393 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E10.3411 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E10.3412 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E10.3413 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E10.3491 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E10.3492 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E10.3493 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
| E10.3511 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E10.3512 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E10.3513 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E10.3521 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
|---|---|
| E10.3522 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E10.3523 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E10.3531 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E10.3532 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E10.3533 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E10.3541 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
| E10.3542 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
| E10.3543 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
| E10.3551 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
| E10.3552 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
| E10.3553 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
| E10.3591 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
| E10.3592 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E10.3593 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E10.37x1 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E10.37x2 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E10.37x3 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
| E10.36 | Type 1 diabetes mellitus with diabetic cataract |
| E10.39 | Type 1 diabetes mellitus with other diabetic ophthalmic complication |
| E10.40 | Type 1 diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| E10.51 | Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E10.52 | Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E10.59 | Type 1 diabetes mellitus with other circulatory complications |
| E10.618 | Type 1 diabetes mellitus with other diabetic arthropathy |
| E10.620 | Type 1 diabetes mellitus with diabetic dermatitis |
| E10.621 | Type 1 diabetes mellitus with foot ulcer |
| E10.622 | Type 1 diabetes mellitus with other skin ulcer |
| E10.628 | Type 1 diabetes mellitus with other skin complications |
| E10.630 | Type 1 diabetes mellitus with periodontal disease |
| E10.638 | Type 1 diabetes mellitus with other oral complications |
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.8 Type 1 diabetes mellitus with unspecified complications
If ICD-10 is applicable, ICD-10-CM codes for the clinical trial are:
Secondary ICD-10-CM Diagnosis requirement for Clinical Trial:
Z00.6 Encounter for examination for normal comparison and control in clinical research program
The applicable TOB is 11X. A secondary diagnosis (diagnoses positions 2 – 9) of ICD-10- CM code Z00.6 (examination of participant or control in clinical research) must be present along with condition code 30 (qualifying clinical trial) Z00.6 and condition code 30 alerts the claims processing system that this is a clinical trial. The procedure is paid under inpatient prospective payment system for hospitals with patients in the trial. Deductible and coinsurance apply for fee-for-service beneficiaries.
Inpatient hospitals participating in this trial are entitled to an add-on payment of $18,848.00 for islet isolation services. This amount is in addition to the final IPPS payment made to the hospital. Should two infusions occur during the same hospital stay, Medicare will pay for two add-ons for isolation of the islet cells, but never for more than two add-ons for a hospital stay.
Inpatient hospitals shall report charges for organ acquisition in Revenue Code 0810, 0811, 0812, 0813, or 0819. This includes charges for the pre-transplant items and services related to the acquisition and delivery of the pancreatic islet cell transplants. As is Medicare’s policy with other organ transplants, Medicare contractors deduct acquisition charges prior to processing through the IPPS Pricer. Pancreata procured for islet cell transplant are not included in the prospective payment. They are paid on a reasonable cost basis. This is a pass-through cost for which interim payments may be made.
Effective for services on or after May 1, 2006, contractors shall accept the QR modifier for islet cell transplantation follow up care when performed in an outpatient department of a hospital when the transplant was done in conjunction with an NIH-sponsored clinical trial, and when billed on type of bill 13X or 85X.
All other normal inpatient billing practices apply.
70.5 - Special Billing and Payment Requirements Medicare Advantage (MA) Beneficiaries
(Rev. 261, Issued: 07-30-04, Effective: 10-01-04, Implementation: 10-04-04)
CMS will make payment directly on a fee-for service basis for the routine costs of pancreatic islet cell transplants as well as transplantation and appropriate related items and services, for MA beneficiaries participating in an NIH-sponsored clinical trial. MA organizations will not be liable for payment for routine costs of this new clinical trial until MA payments can be appropriately adjusted to take into account the cost of this national coverage decision. Medicare contractors shall make payment on behalf of MA organizations directly to providers of these islet cell transplants in accordance with Medicare payment rules, except that beneficiaries are not responsible for the Part A and Part B deductibles. MA enrollees will be liable for any applicable coinsurance amounts MA organizations have in place for clinical trial benefits.
(Rev. 498, Issued: 03-11-05, Effective/Implementation: N/A)
Coverage Requirements - Peripheral neuropathy is the most common factor leading to amputation in people with diabetes. In diabetes, peripheral neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers; however, distal motor findings may be present in advanced cases. Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally. This leads to loss of protective sensation (LOPS), whereby a person is unable to feel minor trauma from mechanical, thermal, or chemical sources. When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.
Peripheral neuropathy with LOPS, secondary to diabetes, is a localized illness of the feet and falls within the regulation's exception to the general exclusionary rule (see 42 C.F.R. §411.15(l)(l)(i)). Foot exams for people with diabetic peripheral neuropathy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.
Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every 6 months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically. Heavily callused areas should be avoided. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.
(Rev. 2783, Issued: 09-10-13, Effective: 09-30-13, Implementation: 09-30-13)
The following providers of service may bill you for these services:
(Rev. 498, Issued: 03-11-05, Effective/Implementation: N/A)
G0245 - Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include:
1. The diagnosis of LOPS;
2. A patient history;
3. A physical examination that consists of at least the following elements: (a) visual inspection of the forefoot, hindfoot, and toe web spaces, (b) evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, (e) evaluation and recommendation of footwear, and
4. Patient education.
G0246 - Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least the following:
1. a patient history;
2. a physical examination that includes: (a) visual inspection of the forefoot, hindfoot, and toe web spaces, (b) evaluation of protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, (e) evaluation and recommendation of footwear, and
3. patient education.
G0247 - Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a LOPS to include if present, at least the following:
(1) local care of superficial (i.e., superficial to muscle and fascia) wounds; (2) debridement of corns and calluses; and (3) trimming and debridement of nails.
NOTE: Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.
The short descriptors for the above HCPCS codes are as follows:
G0245 – INITIAL FOOT EXAM PTLOPS
G0246 – FOLLOWUP EVAL OF FOOT PT LOP
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
If ICD-10-CM is applicable--Providers should report one of the following diagnosis codes in conjunction with this benefit:
ICD-10-CM ICD-10 DX Description
| E08.40 | Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified |
|---|---|
| E08.42 | Diabetes mellitus due to underlying condition with diabetic polyneuropathy |
| E09.40 | Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy |
| E09.42 | Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy |
| E10.40 | Type 1 diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| E13.40 | Other specified diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 70.2.1 Diabetic neuropathy w/ LOPs.
(http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp
(Rev. 2783, Issued: 09-10-13, Effective: 09-30-13, Implementation: 09-30-13)
Deductible and coinsurance apply.
While these physician services may be appropriately provided to patients of Comprehensive Outpatient Rehabilitation Facilities (CORFs), the CORF does not bill. The services are billed by the physician on a professional claim.
Examples of Payment calculation:
Part B Deductible Met: $900 (MPFS allowed amount) x 20 percent (co-insurance) = $720 (Medicare reimbursement). Beneficiary is responsible for $180.
Part B Deductible Not met: $900 (MPFS allowed amount) - $100 (Part B deductible) = $800 x 20 percent (co-insurance) = $640 (Medicare reimbursement). Beneficiary is responsible for $260.
Part B Deductible Met: $800 (actual charged amount) x 20 percent (co-insurance) = $640 (Medicare Reimbursement), beneficiary is responsible for $160 co-insurance.
Part B Deductible Not Met: $800 (actual charged amount) - $100 (Part B deductible) = $700 x 20 percent (co-insurance) = $560 (Medicare reimbursement). Beneficiary is responsible for $240, ($100 Part B deductible and $140 co-insurance).
Services are paid at 80 percent of the lesser of the fee schedule amount or the actual charges.
This service, when furnished in an RHC/FQHC by a physician or non-physician, is considered an RHC/FQHC service. RHCs/FQHCs bill you under bill type 71X or 73X with revenue code 940 and HCPCS G0245, G0246, and G0247.
Payment should not be made for this service unless the claim contains a related visit code. Therefore, install an edit in your system to assure payment is not made for revenue code 940 unless the claim also contains a visit revenue code (520 or 521).
The applicable revenue code is 940, except for hospitals.
This service can be performed in other revenue centers such as a clinic (510) for hospitals. Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.
(Rev. 498, Issued: 03-11-05, Effective/Implementation: N/A)
The applicable revenue code is 940, except for hospitals.
This service can be performed in other revenue centers such as a clinic (510) for hospitals. Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Edit 1 - Implement diagnosis to procedure code edits to allow payment only for the LOPS codes, G0245, G0246, and G0247 when submitted with one of the following ICD-10-CM diagnosis codes
If ICD-10-CM is applicable:
| E08.40 | Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified |
|---|---|
| E08.42 | Diabetes mellitus due to underlying condition with diabetic polyneuropathy |
| E09.40 | Drug or chemical induced diabetes mellitus with neurological complications with diabetic |
| E09.42 | Drug or chemical induced diabetes mellitus with neurological complications with diabetic |
| E10.40 | Type 1 diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| E13.40 | Other specified diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
Deny these services when submitted without one of the appropriate diagnoses. Use the same
messages you currently use for procedure to diagnosis code denials. Edit 2 – Deny G0247 if it is
not submitted on the same claim as G0245 or G0246.
Use MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.
Use RA claim adjustment reason code 107 - The related or qualifying claim/service was not identified on this claim. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
Though G0245 and G0246 have no technical or professional components, for these codes, CWF will post institutional claims with type of bill 13X as technical, and professional claims as professional. For bill type 85X with revenue code 940, CWF will post as technical. For 85X bill type with revenue code 98X, (Method II), CWF will post as technical and professional. This will allow both the facility and professional service payments to be approved by CWF for payment when the code and date of service match. Therefore, should a claim be received with the same code and same date of service for the same beneficiary, the second claim submitted will not be rejected as a duplicate.
Due to the billing and payment methodology of Rural Health Clinics - bill type 71X and Federally Qualified Health Centers - bill type 73X, CWF will post these claims as usual, which will correctly allow claims from these entities that are billed on institutional claims to reject as duplicates when the HCPCS code, date of service, and Medicare beneficiary identifier are an exact match with a claim billed on a professional claim.
Medicare contractors must react to these duplicate claims as they currently do for any other duplicates.
(Rev. 1742, Issued: 05-22-09, Effective: 06-08-09, Implementation: 06-08-09)
Edit 1 - Should CWF receive a claim from an FI for G0245 or G0246 and a second claim from a contractor for either G0245 or G0246 (or vice versa) and they are different dates of service and less than 6 months apart, the second claim will reject. CWF will edit to allow G0245 or G0246 to be paid no more than every 6 months for a particular beneficiary, regardless of who furnished the service. If G0245 has been paid, regardless of whether it was posted as a facility or professional claim, it must be 6 months before G0245 can be paid again or G0246 can be paid. If G0246 has been paid, regardless of whether it was posted as a facility or professional claim, it must be 6 months before G0246 can be paid again or G0245 can be paid. CWF will not impose limits on how many times each code can be paid for a beneficiary as long as there has been 6 months between each service.
The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation. Based on the CWF reject code, the contractors and FIs must deny the claims and return the following messages:
MSN 18.4 -- This service is being denied because it has not been __ months since your last examination of this kind (NOTE: Insert 6 as the appropriate number of months.)
RA claim adjustment reason code 96 – Non-covered charges, along with remark code M86 – Service denied because payment already made for same/similar procedure within set time frame.
The CWF will edit to allow G0247 to pay only if either G0245 or G0246 has been submitted and accepted as payable on the same date of service. CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation. Based on this reject code, contractors and FIs will deny the claims and return the following messages:
MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.
RA claim adjustment reason code 107 – The related or qualifying claim/service was not identified on this claim.
Once a beneficiary’s condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services. Those services would be considered to be included in the regular exams and treatments afforded to the beneficiary on a routine basis. The physician or provider must then just bill the routine foot care codes, per Pub 100-02, Chapter 15, §290.
The CWF will edit to reject LOPS codes G0245, G0246, and/or G0247 when on the beneficiary’s record it shows that one of the following routine foot care codes were billed and paid within the prior 6 months: 11055, 11056, 11057, 11719, 11720, and/or 11721.
The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation. Based on the CWF reject code, the contractors and FIs must deny the claims and return the following messages:
MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.
The RA claim adjustment reason code 96 – Non-covered charges, along with remark code M86 – Service denied because payment already made for same/similar procedure within set time frame.
(Rev.12533; Issued: 03-07-24 Effective: 04-08-24; Implementation:04-08-24)
Stem cell transplantation is a process in which stem cells are harvested from either a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion.
Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses. See Pub. 100-03, National Coverage Determinations Manual, section 110.23, for a complete description of covered and noncovered conditions. For Part A hospital inpatient claims processing instructions, refer to Pub. 100-04, chapter 3, section 90. The following sections contain claims processing instructions for all other claims.
| 30230G2 | Transfusion of Allogeneic Related Bone Marrow into Peripheral Vein, Open Approach |
|---|---|
| 30230G3 | Transfusion of Allogeneic Unrelated Bone Marrow into Peripheral Vein, Open Approach |
| 30233U2 | Transfusion of Allogeneic Related T-cell Depleted Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach |
| 30233U3 | Transfusion of Allogeneic Unrelated T-cell Depleted Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach |
| 30230Y2 | Transfusion of Allogeneic Related Hematopoietic Stem Cells into Peripheral Vein, Open Approach |
| 30230Y3 | Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into Peripheral Vein, Open Approach |
| 30233G2 | Transfusion of Allogeneic Related Bone Marrow into Peripheral Vein, Percutaneous Approach |
| 30233G3 | Transfusion of Allogeneic Unrelated Bone Marrow into Peripheral Vein, Percutaneous Approach |
| 30243U2 | Transfusion of Allogeneic Related T-cell Depleted Hematopoietic Stem Cells into Central Vein, Percutaneous Approach |
| 30243U3 | Percutaneous Approach |
| 30233Y2 | Transfusion of Allogeneic Related Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach |
| 30233Y3 | Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach |
| 30240G2 | Transfusion of Allogeneic Related Bone Marrow into Central Vein, Open Approach |
|---|---|
| 30240G3 | Transfusion of Allogeneic Unrelated Bone Marrow into Central Vein, Open Approach |
| 30240Y2 | Transfusion of Allogeneic Related Hematopoietic Stem Cells into Central Vein, Open Approach |
| 30240Y3 | Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into Central Vein, Open Approach |
| 30243G2 | Transfusion of Allogeneic Related Bone Marrow into Central Vein, Percutaneous Approach |
| 30243G3 | Transfusion of Allogeneic Unrelated Bone Marrow into Central Vein, Percutaneous Approach |
| 30243Y2 | Transfusion of Allogeneic Related Hematopoietic Stem Cells into Central Vein, Percutaneous Approach |
| 30243Y3 | Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into Central Vein, Percutaneous Approach |
HCPCS Code 38240
See below table for ICD-10-DX Codes:
a. For the treatment of leukemia, leukemia in remission; see table below for ICD-10-CM codes:
| C91.00 | Acute lymphoblastic leukemia not having achieved remission |
|---|---|
| C91.01 | Acute lymphoblastic leukemia, in remission |
| C91.02 | Acute lymphoblastic leukemia, in relapse |
| C91.10 | Chronic lymphocytic leukemia of B-cell type not having achieved remission |
| C91.11 | Chronic lymphocytic leukemia of B-cell type in remission |
| C91.12 | Chronic lymphocytic leukemia of B-cell type in relapse |
| C91.30 | Prolymphocytic leukemia of B-cell type not having achieved remission |
| C91.31 | Prolymphocytic leukemia of B-cell type, in remission |
| C91.32 | Prolymphocytic leukemia of B-cell type, in relapse |
| C91.50 | Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission |
| C91.51 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission |
| C91.52 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse |
| C91.60 | Prolymphocytic leukemia of T-cell type not having achieved remission |
| C91.61 | Prolymphocytic leukemia of T-cell type, in remission |
| C91.62 | Prolymphocytic leukemia of T-cell type, in relapse |
| C91.90 | Lymphoid leukemia, unspecified not having achieved remission |
| C91.91 | Lymphoid leukemia, unspecified, in remission |
| C91.92 | Lymphoid leukemia, unspecified, in relapse |
| C91.A0 | Mature B-cell leukemia Burkitt-type not having achieved remission |
| C91.A1 | Mature B-cell leukemia Burkitt-type, in remission |
|---|---|
| C91.A2 | Mature B-cell leukemia Burkitt-type, in relapse |
| C91.Z0 | Other lymphoid leukemia not having achieved remission |
| C91.Z1 | Other lymphoid leukemia, in remission |
| C91.Z2 | Other lymphoid leukemia, in relapse |
| C92.00 | Acute myeloblastic leukemia, not having achieved remission |
| C92.01 | Acute myeloblastic leukemia, in remission |
| C92.02 | Acute myeloblastic leukemia, in relapse |
| C92.10 | Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission |
| C92.11 | Chronic myeloid leukemia, BCR/ABL-positive, in remission |
| C92.12 | Chronic myeloid leukemia, BCR/ABL-positive, in relapse |
| C92.20 | Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission |
| C92.21 | Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission |
| C92.22 | Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse |
| C92.30 | Myeloid sarcoma, not having achieved remission |
| C92.31 | Myeloid sarcoma, in remission |
| C92.32 | Myeloid sarcoma, in relapse |
| C92.40 | Acute promyelocytic leukemia, not having achieved remission |
| C92.41 | Acute promyelocytic leukemia, in remission |
| C92.42 | Acute promyelocytic leukemia, in relapse |
| C92.50 | Acute myelomonocytic leukemia, not having achieved remission |
| C92.51 | Acute myelomonocytic leukemia, in remission |
| C92.52 | Acute myelomonocytic leukemia, in relapse |
| C92.60 | Acute myeloid leukemia with 11q23-abnormality not having achieved remission |
| C92.61 | Acute myeloid leukemia with 11q23-abnormality in remission |
| C92.62 | Acute myeloid leukemia with 11q23-abnormality in relapse |
| C92.90 | Myeloid leukemia, unspecified, not having achieved remission |
| C92.91 | Myeloid leukemia, unspecified in remission |
| C92.92 | Myeloid leukemia, unspecified in relapse |
| C92.A0 | Acute myeloid leukemia with multilineage dysplasia, not having achieved remission |
| C92.A1 | Acute myeloid leukemia with multilineage dysplasia, in remission |
| C92.A2 | Acute myeloid leukemia with multilineage dysplasia, in relapse |
| C92.Z0 | Other myeloid leukemia not having achieved remission |
| C92.Z1 | Other myeloid leukemia, in remission |
| C92.Z2 | Other myeloid leukemia, in relapse |
| C93.00 | Acute monoblastic/monocytic leukemia, not having achieved remission |
| C93.01 | Acute monoblastic/monocytic leukemia, in remission |
| C93.02 | Acute monoblastic/monocytic leukemia, in relapse |
| C93.10 | Chronic myelomonocytic leukemia not having achieved remission |
| C93.11 | Chronic myelomonocytic leukemia, in remission |
| C93.12 | Chronic myelomonocytic leukemia, in relapse |
| C93.30 | Juvenile myelomonocytic leukemia, not having achieved remission |
| C93.31 | Juvenile myelomonocytic leukemia, in remission |
| C93.32 | Juvenile myelomonocytic leukemia, in relapse |
| C93.90 | Monocytic leukemia, unspecified, not having achieved remission |
| C93.91 | Monocytic leukemia, unspecified in remission |
|---|---|
| C93.92 | Monocytic leukemia, unspecified in relapse |
| C93.Z0 | Other monocytic leukemia, not having achieved remission |
| C93.Z1 | Other monocytic leukemia, in remission |
| C93.Z2 | Other monocytic leukemia, in relapse |
| C94.00 | Acute erythroid leukemia, not having achieved remission |
| C94.01 | Acute erythroid leukemia, in remission |
| C94.02 | Acute erythroid leukemia, in relapse |
| C94.20 | Acute megakaryoblastic leukemia not having achieved remission |
| C94.21 | Acute megakaryoblastic leukemia, in remission |
| C94.22 | Acute megakaryoblastic leukemia, in relapse |
| C94.30 | Mast cell leukemia not having achieved remission |
| C94.31 | Mast cell leukemia, in remission |
| C94.32 | Mast cell leukemia, in relapse |
| C94.80 | Other specified leukemias not having achieved remission |
| C94.81 | Other specified leukemias, in remission |
| C94.82 | Other specified leukemias, in relapse |
| C95.00 | Acute leukemia of unspecified cell type not having achieved remission |
| C95.01 | Acute leukemia of unspecified cell type, in remission |
| C95.02 | Acute leukemia of unspecified cell type, in relapse |
| C95.10 | Chronic leukemia of unspecified cell type not having achieved remission |
| C95.11 | Chronic leukemia of unspecified cell type, in remission |
| C95.12 | Chronic leukemia of unspecified cell type, in relapse |
| C95.90 | Leukemia, unspecified not having achieved remission |
| C95.91 | Leukemia, unspecified, in remission |
| C95.92 | Leukemia, unspecified, in relapse |
| D45 | Polycythemia vera |
ii. For the treatment of aplastic anemia; see table below for ICD-10-CM codes)
| ICD-10 | Description |
|---|---|
| D60.0 | Chronic acquired pure red cell aplasia |
| D60.1 | Transient acquired pure red cell aplasia |
| D60.8 | Other acquired pure red cell aplasias |
| D60.9 | Acquired pure red cell aplasia, unspecified |
| D61.01 | Constitutional (pure) red blood cell aplasia |
| D61.09 | Other constitutional aplastic anemia |
| D61.1 | Drug-induced aplastic anemia |
| D61.2 | Aplastic anemia due to other external agents |
| D61.3 | Idiopathic aplastic anemia |
| D61.810 | Antineoplastic chemotherapy induced pancytopenia |
| D61.811 | Other drug-induced pancytopenia |
| D61.818 | Other pancytopenia |
| D61.82 | Myelophthisis |
| D61.89 | Other specified aplastic anemias and other bone marrow failure syndromes |
|---|---|
| D61.9 | Aplastic anemia, unspecified |
b. Effective for services performed on or after June 3, 1985:
c. Effective for services performed on or after August 4, 2010:
For the treatment of Myelodysplastic Syndromes (MDS) (ICD-10-CM codes D46.A, D46.B, D46.C, D46.Z, D46.0, D46.1, D46.4, D46.9, D46.20, D46.21, D46.22, and Z00.6) pursuant to Coverage with Evidence Development (CED) in the context of a Medicare- approved, prospective clinical study. Refer to Pub. 100-03, NCD Manual, chapter 1, section 110.23, for further information about this policy. See section F below for billing instructions.
d. Effective for services performed on or after January 27, 2016:
b. Allogeneic HSCT for multiple myeloma (ICD-10-CM codes C90.00, C90.01, C90.02, and Z00.6) is covered by Medicare only for beneficiaries with Durie-Salmon Stage II or III multiple myeloma, or International Staging
System (ISS) Stage II or Stage III multiple myeloma, and participating in an approved prospective clinical study. Refer to Pub. 100-03, NCD Manual, chapter 1, section 110.23, for further information about this policy. See section F below for billing instructions.
e. Allogeneic HSCT for myelofibrosis (MF) (ICD-10-CM codes C94.40, C94.41, C94.42, D47.1, D47.4, D75.81, and Z00.6) is covered by Medicare only for beneficiaries with Dynamic International Prognostic Scoring System (DIPSSplus) intermediate-2 or High primary or secondary MF and participating in an approved prospective clinical study. Refer to Pub. 100- 03, NCD Manual, chapter 1, section 110.23, for further information about this policy. See section F below for billing instructions.
f. Allogeneic HSCT for sickle cell disease (SCD) (ICD-10-CM codes D57.00, D57.01, D57.02, D57.03, D57.09, D57.1, D57.20, D57.211, D57.212, D57.213, D57.218, D57.219, D57.40, D57.411, D57.412, D57.413, D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.458, D57.459, D57.80, D57.811, D57.812, D57.813, D57.818, D57.819, and Z00.6)
is covered by Medicare only for beneficiaries with severe, symptomatic SCD who participate in an
approved prospective clinical study. Refer to Pub.100-03, NCD Manual, chapter 1, section 110.23, for further information about this policy. See section F below for billing instructions.
HCPCS Code 38241
ICD-10-PCS Procedure Codes:
| 30230C0 | Transfusion of Autologous Hematopoietic Stem/Progenitor Cells, Genetically Modified into Peripheral Vein, Open Approach |
|---|---|
| 30230G0 | Transfusion of Autologous Bone Marrow into Peripheral Vein, Open Approach |
| 30230Y0 | Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Open Approach |
| 30233G0 | Transfusion of Autologous Bone Marrow into Peripheral Vein, Percutaneous Approach |
| 30233C0 | Transfusion of Autologous Hematopoietic Stem/Progenitor Cells, Genetically Modified into Peripheral Vein, Percutaneous Approach |
| 30233Y0 | Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach |
| 30240C0 | Transfusion of Autologous Hematopoietic Stem/Progenitor Cells, Genetically Modified into Central Vein, Open Approach |
| 30240G0 | Transfusion of Autologous Bone Marrow into Central Vein, Open Approach |
| 30240Y0 | Transfusion of Autologous Hematopoietic Stem Cells into Central Vein, Open Approach |
| 30243C0 | Transfusion of Autologous Hematopoietic Stem/Progenitor Cells, Genetically Modified into Central Vein, Percutaneous Approach |
| 30243G0 | Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous Approach |
| 30243Y0 | Transfusion of Autologous Hematopoietic Stem Cells into Central Vein, Percutaneous Approach |
Below ICD-10 CM codes Cover autologous SCT (38241) no trial for acute leukemia in remission, resistant non-Hodgkins lymphomas, recurrent/refractory neuroblastoma, advanced Hodgkins Disease on or after 4/28/89, and Cover autologous SCT (38241) no trial for Durie-Salmon stage II/III responsive multiple myeloma and responsive relapse on or after 10/1/00 over autologous SCT (38241) together with high dose melphalan (HDMI) no trial for primary amyloid light chain (AL) amyloidosis on or after 3/15/05
| C81.01 | Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck |
|---|---|
| C81.02 | Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes |
| C81.03 | Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.04 | Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.05 | Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.06 | Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes |
| C81.07 | Nodular lymphocyte predominant Hodgkin lymphoma, spleen |
| C81.08 | Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites |
| C81.09 | Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites |
| C81.11 | Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.12 | Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes |
| C81.13 | Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.14 | Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.15 | Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.16 | Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes |
| C81.17 | Nodular sclerosis Hodgkin lymphoma, spleen |
| C81.18 | Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites |
| C81.19 | Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites |
| C81.21 | Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.22 | Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes |
| C81.23 | Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.24 | Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb |
|---|---|
| C81.25 | Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.26 | Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes |
| C81.27 | Mixed cellularity Hodgkin lymphoma, spleen |
| C81.28 | Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites |
| C81.29 | Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites |
| C81.31 | Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.32 | Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes |
| C81.33 | Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.34 | Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.35 | Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.36 | Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes |
| C81.37 | Lymphocyte depleted Hodgkin lymphoma, spleen |
| C81.38 | Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites |
| C81.39 | Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites |
| C81.41 | Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.42 | Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes |
| C81.43 | Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.44 | Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.45 | Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.46 | Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes |
| C81.47 | Lymphocyte-rich Hodgkin lymphoma, spleen |
| C81.48 | Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiplesites |
| C81.49 | Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites |
| C81.71 | Other Hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.72 | Other Hodgkin lymphoma, intrathoracic lymph nodes |
| C81.73 | Other Hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.74 | Other Hodgkin lymphoma, lymph nodes of axilla and upper limb |
|---|---|
| C81.75 | Other Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.76 | Other Hodgkin lymphoma, intrapelvic lymph nodes |
| C81.77 | Other Hodgkin lymphoma, spleen |
| C81.78 | Other Hodgkin lymphoma, lymph nodes of multiple sites |
| C81.91 | Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck |
| C81.92 | Hodgkin lymphoma, unspecified, intrathoracic lymph nodes |
| C81.93 | Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes |
| C81.94 | Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C81.95 | Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
| C81.96 | Hodgkin lymphoma, unspecified, intrapelvic lymph nodes |
| C81.97 | Hodgkin lymphoma, unspecified, spleen |
| C81.98 | Hodgkin lymphoma, unspecified, lymph nodes of multiple sites |
| C81.99 | Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
| C82.01 | Follicular lymphoma grade I, lymph nodes of head, face, and neck |
| C82.02 | Follicular lymphoma grade I, intrathoracic lymph nodes |
| C82.03 | Follicular lymphoma grade I, intra-abdominal lymph nodes |
| C82.04 | Follicular lymphoma grade I, lymph nodes of axilla and upper limb |
| C82.05 | Follicular lymphoma grade I, lymph nodes of inguinal region and lower limb |
| C82.06 | Follicular lymphoma grade I, intrapelvic lymph nodes |
| C82.07 | Follicular lymphoma grade I, spleen |
| C82.08 | Follicular lymphoma grade I, lymph nodes of multiple sites |
| C82.09 | Follicular lymphoma grade I, extranodal and solid organ sites |
| C82.11 | Follicular lymphoma grade II, lymph nodes of head, face, and neck |
| C82.12 | Follicular lymphoma grade II, intrathoracic lymph nodes |
| C82.13 | Follicular lymphoma grade II, intra-abdominal lymph nodes |
| C82.14 | Follicular lymphoma grade II, lymph nodes of axilla and upper limb |
| C82.15 | Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb |
| C82.16 | Follicular lymphoma grade II, intrapelvic lymph nodes |
| C82.17 | Follicular lymphoma grade II, spleen |
| C82.18 | Follicular lymphoma grade II, lymph nodes of multiple sites |
| C82.19 | Follicular lymphoma grade II, extranodal and solid organ sites |
| C82.21 | Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck |
| C82.22 | Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes |
|---|---|
| C82.23 | Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes |
| C82.24 | Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb |
| C82.25 | Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb |
| C82.26 | Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes |
| C82.27 | Follicular lymphoma grade III, unspecified, spleen |
| C82.28 | Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites |
| C82.29 | Follicular lymphoma grade III, unspecified, extranodal and solid organ sites |
| C82.31 | Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck |
| C82.32 | Follicular lymphoma grade IIIa, intrathoracic lymph nodes |
| C82.33 | Follicular lymphoma grade IIIa, intra-abdominal lymph nodes |
| C82.34 | Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb |
| C82.35 | Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb |
| C82.36 | Follicular lymphoma grade IIIa, intrapelvic lymph nodes |
| C82.37 | Follicular lymphoma grade IIIa, spleen |
| C82.38 | Follicular lymphoma grade IIIa, lymph nodes of multiple sites |
| C82.39 | Follicular lymphoma grade IIIa, extranodal and solid organ sites |
| C82.41 | Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck |
| C82.42 | Follicular lymphoma grade IIIb, intrathoracic lymph nodes |
| C82.43 | Follicular lymphoma grade IIIb, intra-abdominal lymph nodes |
| C82.44 | Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb |
| C82.45 | Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb |
| C82.46 | Follicular lymphoma grade IIIb, intrapelvic lymph nodes |
| C82.47 | Follicular lymphoma grade IIIb, spleen |
| C82.48 | Follicular lymphoma grade IIIb, lymph nodes of multiple sites |
| C82.49 | Follicular lymphoma grade IIIb, extranodal and solid organ sites |
| C82.51 | Diffuse follicle center lymphoma, lymph nodes of head, face, and neck |
| C82.52 | Diffuse follicle center lymphoma, intrathoracic lymph nodes |
| C82.53 | Diffuse follicle center lymphoma, intra-abdominal lymph nodes |
| C82.54 | Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb |
| C82.55 | Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb |
|---|---|
| C82.56 | Diffuse follicle center lymphoma, intrapelvic lymph nodes |
| C82.57 | Diffuse follicle center lymphoma, spleen |
| C82.58 | Diffuse follicle center lymphoma, lymph nodes of multiple sites |
| C82.59 | Diffuse follicle center lymphoma, extranodal and solid organ sites |
| C82.61 | Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck |
| C82.62 | Cutaneous follicle center lymphoma, intrathoracic lymph nodes |
| C82.63 | Cutaneous follicle center lymphoma, intra-abdominal lymph nodes |
| C82.64 | Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb |
| C82.65 | Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb |
| C82.66 | Cutaneous follicle center lymphoma, intrapelvic lymph nodes |
| C82.67 | Cutaneous follicle center lymphoma, spleen |
| C82.68 | Cutaneous follicle center lymphoma, lymph nodes of multiple sites |
| C82.69 | Cutaneous follicle center lymphoma, extranodal and solid organ sites |
| C82.81 | Other types of follicular lymphoma, lymph nodes of head, face, and neck |
| C82.82 | Other types of follicular lymphoma, intrathoracic lymph nodes |
| C82.83 | Other types of follicular lymphoma, intra-abdominal lymph nodes |
| C82.84 | Other types of follicular lymphoma, lymph nodes of axilla and upper limb |
| C82.85 | Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb |
| C82.86 | Other types of follicular lymphoma, intrapelvic lymph nodes |
| C82.87 | Other types of follicular lymphoma, spleen |
| C82.88 | Other types of follicular lymphoma, lymph nodes of multiple sites |
| C82.89 | Other types of follicular lymphoma, extranodal and solid organ sites |
| C82.91 | Follicular lymphoma, unspecified, lymph nodes of head, face, and neck |
| C82.92 | Follicular lymphoma, unspecified, intrathoracic lymph nodes |
| C82.93 | Follicular lymphoma, unspecified, intra-abdominal lymph nodes |
| C82.94 | Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C82.95 | Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
| C82.96 | Follicular lymphoma, unspecified, intrapelvic lymph nodes |
| C82.97 | Follicular lymphoma, unspecified, spleen |
|---|---|
| C82.98 | Follicular lymphoma, unspecified, lymph nodes of multiple sites |
| C82.99 | Follicular lymphoma, unspecified, extranodal and solid organ sites |
| C83.01 | Small cell B-cell lymphoma, lymph nodes of head, face, and neck |
| C83.02 | Small cell B-cell lymphoma, intrathoracic lymph nodes |
| C83.03 | Small cell B-cell lymphoma, intra-abdominal lymph nodes |
| C83.04 | Small cell B-cell lymphoma, lymph nodes of axilla and upper limb |
| C83.05 | Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb |
| C83.06 | Small cell B-cell lymphoma, intrapelvic lymph nodes |
| C83.07 | Small cell B-cell lymphoma, spleen |
| C83.08 | Small cell B-cell lymphoma, lymph nodes of multiple sites |
| C83.09 | Small cell B-cell lymphoma, extranodal and solid organ sites |
| C83.11 | Mantle cell lymphoma, lymph nodes of head, face, and neck |
| C83.12 | Mantle cell lymphoma, intrathoracic lymph nodes |
| C83.13 | Mantle cell lymphoma, intra-abdominal lymph nodes |
| C83.14 | Mantle cell lymphoma, lymph nodes of axilla and upper limb |
| C83.15 | Mantle cell lymphoma, lymph nodes of inguinal region and lower limb |
| C83.16 | Mantle cell lymphoma, intrapelvic lymph nodes |
| C83.17 | Mantle cell lymphoma, spleen |
| C83.18 | Mantle cell lymphoma, lymph nodes of multiple sites |
| C83.19 | Mantle cell lymphoma, extranodal and solid organ sites |
| C83.31 | Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck |
| C83.32 | Diffuse large B-cell lymphoma, intrathoracic lymph nodes |
| C83.33 | Diffuse large B-cell lymphoma, intra-abdominal lymph nodes |
| C83.34 | Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb |
| C83.35 | Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
| C83.36 | Diffuse large B-cell lymphoma, intrapelvic lymph nodes |
| C83.37 | Diffuse large B-cell lymphoma, spleen |
| C83.38 | Diffuse large B-cell lymphoma, lymph nodes of multiple sites |
| C83.39 | Diffuse large B-cell lymphoma, extranodal and solid organ sites |
| C83.51 | Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck |
| C83.52 | Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes |
| C83.53 | Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes |
| C83.54 | Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb |
| C83.55 | Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb |
| C83.56 | Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes |
|---|---|
| C83.57 | Lymphoblastic (diffuse) lymphoma, spleen |
| C83.58 | Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites |
| C83.59 | Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites |
| C83.71 | Burkitt lymphoma, lymph nodes of head, face, and neck |
| C83.72 | Burkitt lymphoma, intrathoracic lymph nodes |
| C83.73 | Burkitt lymphoma, intra-abdominal lymph nodes |
| C83.74 | Burkitt lymphoma, lymph nodes of axilla and upper limb |
| C83.75 | Burkitt lymphoma, lymph nodes of inguinal region and lower limb |
| C83.76 | Burkitt lymphoma, intrapelvic lymph nodes |
| C83.77 | Burkitt lymphoma, spleen |
| C83.78 | Burkitt lymphoma, lymph nodes of multiple sites |
| C83.79 | Burkitt lymphoma, extranodal and solid organ sites |
| C83.81 | Other non-follicular lymphoma, lymph nodes of head, face, and neck |
| C83.82 | Other non-follicular lymphoma, intrathoracic lymph nodes |
| C83.83 | Other non-follicular lymphoma, intra-abdominal lymph nodes |
| C83.84 | Other non-follicular lymphoma, lymph nodes of axilla and upper limb |
| C83.85 | Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb |
| C83.86 | Other non-follicular lymphoma, intrapelvic lymph nodes |
| C83.87 | Other non-follicular lymphoma, spleen |
| C83.88 | Other non-follicular lymphoma, lymph nodes of multiple sites |
| C83.89 | Other non-follicular lymphoma, extranodal and solid organ sites |
| C83.91 | Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck |
| C83.92 | Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes |
| C83.93 | Non-follicular (diffuse) lymphoma, unspecified, intra-abdominal lymph nodes |
| C83.94 | Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C83.95 | Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
| C83.96 | Non-follicular (diffuse) lymphoma, unspecified, intrapelvic lymph nodes |
| C83.97 | Non-follicular (diffuse) lymphoma, unspecified, spleen |
| C83.98 | Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of multiple sites |
| C83.99 | Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites |
| C84.01 | Mycosis fungoides, lymph nodes of head, face, and neck |
| C84.02 | Mycosis fungoides, intrathoracic lymph nodes |
|---|---|
| C84.03 | Mycosis fungoides, intra-abdominal lymph nodes |
| C84.04 | Mycosis fungoides, lymph nodes of axilla and upper limb |
| C84.05 | Mycosis fungoides, lymph nodes of inguinal region and lower limb |
| C84.06 | Mycosis fungoides, intrapelvic lymph nodes |
| C84.07 | Mycosis fungoides, spleen |
| C84.08 | Mycosis fungoides, lymph nodes of multiple sites |
| C84.09 | Mycosis fungoides, extranodal and solid organ sites |
| C84.11 | Sezary disease, lymph nodes of head, face, and neck |
| C84.12 | Sezary disease, intrathoracic lymph nodes |
| C84.13 | Sezary disease, intra-abdominal lymph nodes |
| C84.14 | Sezary disease, lymph nodes of axilla and upper limb |
| C84.15 | Sezary disease, lymph nodes of inguinal region and lower limb |
| C84.16 | Sezary disease, intrapelvic lymph nodes |
| C84.17 | Sezary disease, spleen |
| C84.18 | Sezary disease, lymph nodes of multiple sites |
| C84.19 | Sezary disease, extranodal and solid organ sites |
| C84.41 | Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck |
| C84.42 | Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes |
| C84.43 | Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes |
| C84.44 | Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb |
| C84.45 | Peripheral T-cell lymphoma, not classified, lymph nodes of inguinal region and lower limb |
| C84.46 | Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes |
| C84.47 | Peripheral T-cell lymphoma, not classified, spleen |
| C84.48 | Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites |
| C84.49 | Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites |
| C84.61 | Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck |
| C84.62 | Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes |
| C84.63 | Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes |
| C84.64 | Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb |
| C84.65 | Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb |
| C84.66 | Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes |
|---|---|
| C84.67 | Anaplastic large cell lymphoma, ALK-positive, spleen |
| C84.68 | Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites |
| C84.69 | Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites |
| C84.71 | Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck |
| C84.72 | Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes |
| C84.73 | Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes |
| C84.74 | Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb |
| C84.75 | Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb |
| C84.76 | Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes |
| C84.77 | Anaplastic large cell lymphoma, ALK-negative, spleen |
| C84.78 | Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites |
| C84.79 | Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites |
| C84.91 | Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face, and neck |
| C84.92 | Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes |
| C84.93 | Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes |
| C84.94 | Mature T/NK-cell lymphomas, unspecified, lymph nodes of axilla and upper limb |
| C84.95 | Mature T/NK-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb |
| C84.96 | Mature T/NK-cell lymphomas, unspecified, intrapelvic lymph nodes |
| C84.97 | Mature T/NK-cell lymphomas, unspecified, spleen |
| C84.98 | Mature T/NK-cell lymphomas, unspecified, lymph nodes of multiple sites |
| C84.99 | Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites |
| C84.A1 | Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck |
| C84.A2 | Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes |
| C84.A3 | Cutaneous T-cell lymphoma, unspecified, intra-abdominal lymph nodes |
|---|---|
| C84.A4 | Cutaneous T-cell lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C84.A5 | Cutaneous T-cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
| C84.A6 | Cutaneous T-cell lymphoma, unspecified, intrapelvic lymph nodes |
| C84.A7 | Cutaneous T-cell lymphoma, unspecified, spleen |
| C84.A8 | Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites |
| C84.A9 | Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites |
| C84.Z1 | Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck |
| C84.Z2 | Other mature T/NK-cell lymphomas, intrathoracic lymph nodes |
| C84.Z3 | Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes |
| C84.Z4 | Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb |
| C84.Z5 | Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb |
| C84.Z6 | Other mature T/NK-cell lymphomas, intrapelvic lymph nodes |
| C84.Z7 | Other mature T/NK-cell lymphomas, spleen |
| C84.Z8 | Other mature T/NK-cell lymphomas, lymph nodes of multiple sites |
| C84.Z9 | Other mature T/NK-cell lymphomas, extranodal and solid organ sites |
| C85.11 | Unspecified B-cell lymphoma, lymph nodes of head, face, and neck |
| C85.12 | Unspecified B-cell lymphoma, intrathoracic lymph nodes |
| C85.13 | Unspecified B-cell lymphoma, intra-abdominal lymph nodes |
| C85.14 | Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb |
| C85.15 | Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb |
| C85.16 | Unspecified B-cell lymphoma, intrapelvic lymph nodes |
| C85.17 | Unspecified B-cell lymphoma, spleen |
| C85.18 | Unspecified B-cell lymphoma, lymph nodes of multiple sites |
| C85.19 | Unspecified B-cell lymphoma, extranodal and solid organ sites |
| C85.21 | Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck |
| C85.22 | Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes |
| C85.23 | Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes |
|---|---|
| C85.24 | Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb |
| C85.25 | Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
| C85.26 | Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes |
| C85.27 | Mediastinal (thymic) large B-cell lymphoma, spleen |
| C85.28 | Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites |
| C85.29 | Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites |
| C85.81 | Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck |
| C85.82 | Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes |
| C85.83 | Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes |
| C85.84 | Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C85.85 | Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C85.86 | Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes |
| C85.87 | Other specified types of non-Hodgkin lymphoma, spleen |
| C85.88 | Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites |
| C85.89 | Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites |
| C85.91 | Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck |
| C85.92 | Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes |
| C85.93 | Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes |
| C85.94 | Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C85.95 | Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
| C85.96 | Non-Hodgkin lymphoma, unspecified, intrapelvic lymph nodes |
| C85.97 | Non-Hodgkin lymphoma, unspecified, spleen |
| C85.98 | Non-Hodgkin lymphoma, unspecified, lymph nodes of multiple sites |
| C85.99 | Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
| C86.0 | Extranodal NK/T-cell lymphoma, nasal type |
|---|---|
| C86.1 | Hepatosplenic T-cell lymphoma |
| C86.2 | Enteropathy-type (intestinal) T-cell lymphoma |
| C86.3 | Subcutaneous panniculitis-like T-cell lymphoma |
| C86.4 | Blastic NK-cell lymphoma |
| C86.5 | Angioimmunoblastic T-cell lymphoma |
| C86.6 | Primary cutaneous CD30-positive T-cell proliferations |
| C88.0 | Waldenstrom macroglobulinemia |
| C88.2 | Heavy chain disease |
| C88.3 | Immunoproliferative small intestinal disease |
| C88.4 | Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] |
| C88.8 | Other malignant immunoproliferative diseases |
| C88.9 | Malignant immunoproliferative disease, unspecified |
| C90.00 | Multiple myeloma not having achieved remission |
| C90.01 | Multiple myeloma in remission |
| C90.02 | Multiple myeloma in relapse |
| C90.10 | Plasma cell leukemia not having achieved remission |
| C90.11 | Plasma cell leukemia in remission |
| C90.20 | Extramedullary plasmacytoma not having achieved remission |
| C90.21 | Extramedullary plasmacytoma in remission |
| C90.22 | Extramedullary plasmacytoma in relapse |
| C90.30 | Solitary plasmacytoma not having achieved remission |
| C90.31 | Solitary plasmacytoma in remission |
| C90.32 | Solitary plasmacytoma in relapse |
| C91.01 | Acute lymphoblastic leukemia, in remission |
| C91.11 | Chronic lymphocytic leukemia of B-cell type in remission |
| C91.31 | Prolymphocytic leukemia of B-cell type, in remission |
| C91.51 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission |
| C91.61 | Prolymphocytic leukemia of T-cell type, in remission |
| C91.91 | Lymphoid leukemia, unspecified, in remission |
| C91.A1 | Mature B-cell leukemia Burkitt-type, in remission |
| C91.Z1 | Other lymphoid leukemia, in remission |
| C92.01 | Acute myeloblastic leukemia, in remission |
| C92.11 | Chronic myeloid leukemia, BCR/ABL-positive, in remission |
| C92.21 | Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission |
| C92.31 | Myeloid sarcoma, in remission |
| C92.41 | Acute promyelocytic leukemia, in remission |
| C92.51 | Acute myelomonocytic leukemia, in remission |
| C92.61 | Acute myeloid leukemia with 11q23-abnormality in remission |
| C92.91 | Myeloid leukemia, unspecified in remission |
| C92.A1 | Acute myeloid leukemia with multilineage dysplasia, in remission |
| C92.Z1 | Other myeloid leukemia, in remission |
| C93.01 | Acute monoblastic/monocytic leukemia, in remission |
|---|---|
| C93.11 | Chronic myelomonocytic leukemia, in remission |
| C93.31 | Juvenile myelomonocytic leukemia, in remission |
| C93.91 | Monocytic leukemia, unspecified in remission |
| C93.Z1 | Other monocytic leukemia, in remission |
| C94.01 | Acute erythroid leukemia, in remission |
| C94.21 | Acute megakaryoblastic leukemia, in remission |
| C94.31 | Mast cell leukemia, in remission |
| C94.81 | Other specified leukemias, in remission |
| C95.01 | Acute leukemia of unspecified cell type, in remission |
| C95.11 | Chronic leukemia of unspecified cell type, in remission |
| C95.91 | Leukemia, unspecified, in remission |
| C96.0 | Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis |
| C96.20 | Malignant mast cell neoplasm, unspecified |
| C96.21 | Aggressive systemic mastocytosis |
| C96.22 | Mast cell sarcoma |
| C96.29 | Other malignant mast cell neoplasm |
| C96.4 | Sarcoma of dendritic cells (accessory cells) |
| C96.5 | Multifocal and unisystemic Langerhans-cell histiocytosis |
| C96.6 | Unifocal Langerhans-cell histiocytosis |
| C96.9 | Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified |
| C96.A | Histiocytic sarcoma |
| C96.Z | Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue |
| D45 | Polycythemia vera |
| D47.Z9 | Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue |
| E85.4 | Organ-limited amyloidosis |
| E85.81 | Light chain (AL) amyloidosis |
| E85.89 | Other amyloidosis |
| E85.9 | Amyloidosis, unspecified |
Acute leukemia in remission who have a high probability of relapse and who have no human leucocyte antigens (HLA)- matched (ICD-10-CM diagnosis codes C91.01, C92.01, C92.41, C92.51, C92.61, C92.A1, C93.01, C94.01, C94.21, C94.41, C95.01);
Resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response (ICD-
10-CM diagnosis codes C82.01-C85.29, C85.81-C86.6, C96.4, and C96.Z-C96.9);
Recurrent or refractory neuroblastoma (see ICD-10-CM codes Neoplasm by site, malignant for the appropriate diagnosis code) following ranges are reported: C00 - C96, and D00 - D09 Resistant non- Hodgkin's lymphomas); or, Advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched donor (ICD-10-CM codes C81.01 - C81.99).
a. Effective for services performed on or after October 1, 2000:
Single AuSCT is only covered for Durie-Salmon Stage II or III multiple myeloma patients (ICD-10-CM codes C90.00, C90.01, C90.02 and D47.Z9) that fit the following requirements:
b. Effective for services performed on or after March 15, 2005:
When recognized clinical risk factors are employed to select patients for transplantation, high dose melphalan(HDM) together with AuSCT is reasonable and necessary for Medicare beneficiaries of any age group with primary amyloid light chain (AL) amyloidosis (ICD-10-CM codes E85.4, E85.81, E85.89 and E85.9) who meet the following criteria:
E85.4 Organ-limited amyloidosis
E85.81 Light chain (AL) amyloidosis
E85.89 Other amyloidosis
E85.9 Amyloidosis, unspecified
As the applicable ICD-10 CM codes E85.4, E85.81, E85.9, and E85.89 for amyloidosis do not differentiate between primary and non-primary, A/B MACs (B) should perform prepayreviews on all claims with a diagnosis of ICD-10-CM code E85.4, E85.81, E85.9, and E85.89 to determine whether payment is appropriate.
Effective for claims with dates of service on or after May 24, 1996, through January 27, 2016, allogeneic HSCT is not covered as treatment for multiple myeloma (if ICD-10-CM is applicable, ICD-10-CM codes C90.00, C90.01, C90.02 and D47.Z9).
AuSCT is not considered reasonable and necessary within the meaning of §I862(a)(1)(A) of the Act and is not covered under Medicare for the following conditions:
1. Solid tumors prior to October 1, 2000 (other than neuroblastoma) (if ICD-10-CM is applicable, ICD-10-CM codes C00.0 – C80.2 and D00.0 – D09.9);
2. Multiple myeloma prior to October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes C90.00, C90.01, C90.02 and D47.Z9);
3. Tandem transplantation, on or after October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes C90.00, C90.01, C90.02, and D47.Z9);
4. Non- primary amyloidosis on or after 10/01/00, for all Medicare beneficiaries
5. Primary AL amyloidosis effective October 1, 2000, through March 14, 2005 for Medicare beneficiaries age 64. (if ICD-10-CM is applicable, ICD-10-CM codes E85.4, E85.81, E85.9, and E85.89);
As the ICD-10-CM is applicable, as the applicable ICD-10 CM codes E85.4, E85.81, E85.9, and E85.89 for amyloidosis do not differentiate between primary and non-primary, A/B MACs (B) should perform prepay reviews on all claims witha diagnosis of ICD-10-CM code E85.4, E85.81, E85.9, and E85.89 to determine whether payment is appropriate.
All other indications for stem cell transplantation not otherwise notedabove as covered or non-covered remain at local Medicare Administrative Contractor discretion.
The contractor shall use an appropriate MSN and CARC messagesuch as the following:
MSN - 15.4, The information provided does not support the need forthis service or item;
CARC - 150, Payment adjusted because the payer deems the information submitted does not support this level of service.
Effective for services performed on or after August 4, 2010, contractors shall pay for claims for allogeneic HSCT for the treatment of Myelodysplastic Syndromes (MDS) pursuant to Coverage with Evidence Development (CED) in the context of a Medicare-approved, prospective clinical study.
Effective for services performed on or after January 27, 2016, contractors shall pay for claims for allogeneic HSCT for the treatment of multiple myeloma, myelofibrosis (MF), and for sickle cell disease (SCD) pursuant to CED, in the context of a Medicare-approved, prospective clinical study.
Refer to Pub.100-03, National Coverage Determinations Manual, Chapter 1, section 110.23, for more information about this policy, and Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, section 90.3, for information on inpatient billing of this CED.
• Adjudication Requirements
Payable Conditions. For claims with dates of service on and after August 4, 2010, contractors shall pay for claims for allogeneic HSCT for MDS when the service was provided pursuant to a Medicare-approved clinical study under CED; these services are paid only in the inpatient setting (Type of Bill (TOB) 11X), as outpatient Part B (TOB 13X), and in Method II critical access hospitals (TOB 85X).
Contractors shall require the following coding in order to pay for these claims:
If Outpatient Hospital or Professional Claims: HCPCS procedure code 38240
If ICD-10-CM is applicable, ICD-10-CM codes D46.A, D46.B, D46.C, D46.Z, D46.0, D46.1, D46.4, D46.9, D46.20, D46.21, D46.22, and Z00.6.
Payable Conditions. For claims with dates of service on and after January 27, 2016, contractors shall pay for claims for allogeneic HSCT for multiple myeloma, myelofibrosis (MF), and for sickle cell disease (SCD) when the service was provided pursuant to a Medicare-approved clinical study under CED; these services are paid only in the inpatient setting (Type of Bill (TOB) 11X), as outpatient Part B (TOB 13X), and in Method II critical access hospitals (TOB 85X).
Contractors shall require the following coding in order to pay for these claims:
Denials. Contractors shall deny claims failing to meet any of the above criteria. In addition, contractors shall apply the following requirements:
☐ Providers shall issue a hospital issued notice of non- coverage (HINN) or advance beneficiary notice (ABN) to the beneficiary if the services performed are not provided in accordance with CED. ☐ Contractors shall deny claims that do not meet the criteria for coverage with the following messages:
CARC 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.
NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code – Patient Responsibility (PR) if HINN/ABN issued, otherwise Contractual Obligation (CO)
MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/artículo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.)
MSN 15.20 – The following policies [NCD 110.23] were used when we made this decision. (Las siguientes políticas [NCD 110.23] fueron utilizadas cuando se tomó esta decisión.)
(Rev. 486, Issued: 03-04-05, Effective Date/Implementation Date: N/A)
Allogeneic Stem Cell Transplantation.
Allogeneic stem cell transplantation is a procedure in which a portion of a healthy donor's stem cells is obtained and prepared for intravenous infusion to restore normal hematopoietic function in recipients having an inherited or acquired hematopoietic deficiency or defect.
Expenses incurred by a donor are a covered benefit to the recipient/beneficiary but, except for physician services, are not paid separately. Services to the donor include physician services, hospital care in connection with screening the stem cell, and ordinary follow-up care.
Autologous Stem Cell Transplantation
Autologous stem cell transplantations is a technique for restoring stem cells using the patient's own previously stored cells. Autologous stem cell transplants are covered for certain specified diagnoses for services rendered on or after April 28, 1989.
(Rev.11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-21)
Allogeneic Stem Cell Transplantation
For the treatment of leukemia or leukemia in remission, providers shall use appropriate ICD-10 diagnosis codes noted in section 90 and HCPCS code 38240.
For the treatment of aplastic anemia, providers shall use appropriate ICD-10 diagnosis codes noted in section 90 and HCPCS code 38240.
For the treatment of severe combined immunodeficiency disease, providers shall use appropriate ICD-10 diagnosis codes noted in section 90 and HCPCS code 38240.
For the treatment of Wiskott-Aldrich syndrome, providers shall use appropriate ICD-10-CM code D82.0 and HCPCS code 38240.
Autologous Stem Cell Transplantation.--Is covered under the following circumstances effective for services performed on or after April 28, 1989:
For the treatment of patients with acute leukemia in remission who have a high probability of relapse and who have no human leucocyte antigens (HLA) matched, providers shall use appropriate ICD-10 diagnosis codes noted in section 90 for lymphoid; myeloid; monocytic; acute erythremia; erythroleukemia; unspecified cell type and HCPCS code 38241.
For the treatment of resistant non-Hodgkin's lymphomas for those patients presenting with poor prognostic features following an initial response, providers shall use appropriate ICD-10 diagnosis codes noted in section 90 and HCPCS code 38241.
For the treatment of recurrent or refractory neuroblastoma, providers shall use ICD- 10-CM codes Neoplasm by site, malignant, the appropriate HCPCS code and HCPCS code 38241.
For the treatment of advanced Hodgkin's disease for patients who have failed conventional therapy and have no HLA-matched donor, providers shall use appropriate ICD-10 diagnosis codes and HCPCS code 38241
Autologous Stem Cell Transplantation.--Is covered under the following circumstances effective for services furnished on or after October 1, 2000:
For the treatment of multiple myeloma (only for beneficiaries who are less than age 78, have Durie-Salmon stage II or III newly diagnosed or responsive multiple myeloma, and have adequate cardiac, renal, pulmonary and hepatic functioning), providers shall use appropriate ICD-10-CM code and HCPCS code 38241.
For the treatment of recurrent or refractory neuroblastoma, providers shall use appropriate code (see ICD-10-CM neoplasm by site, malignant) and HCPCS code 38241.
Effective for services performed on or after March 15, 2005, when recognized clinical risk factors are employed to select patients for transplantation, high-dose melphalan (HDM) together with autologous stem cell transplantation (HDM/AuSCT) is reasonable and necessary for Medicare beneficiaries of any age group for the treatment of primary amyloid light chain (AL) amyloidosis, ICD-10- CM codes E85.4, E85.81, E85.9, and E85.89 who meet the following criteria:
Amyloid deposition in 2 or fewer organs; and,
Cardiac left ventricular ejection fraction (EF) greater than 45%.
(Rev. 11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)
ICD-10 is applicable to services on and after the implementation of ICD-.
For services provided use the appropriate code from the ICD-10 CM codes the table below.. See §90.2 for a list of covered conditions
| ICD-10 | Description |
|---|---|
| C91.00 | Acute lymphoblastic leukemia not having achieved remission |
| C91.01 | Acute lymphoblastic leukemia, in remission |
| C91.02 | Acute lymphoblastic leukemia, in relapse |
| C91.10 | Chronic lymphocytic leukemia of B-cell type not having achieved remission |
| C91.11 | Chronic lymphocytic leukemia of B-cell type in remission |
| C91.12 | Chronic lymphocytic leukemia of B-cell type in relapse |
| C91.30 | Prolymphocytic leukemia of B-cell type not having achieved remission |
|---|---|
| C91.31 | Prolymphocytic leukemia of B-cell type, in remission |
| C91.32 | Prolymphocytic leukemia of B-cell type, in relapse |
| C91.50 | Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission |
| C91.51 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission |
| C91.52 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse |
| C91.60 | Prolymphocytic leukemia of T-cell type not having achieved remission |
| C91.61 | Prolymphocytic leukemia of T-cell type, in remission |
| C91.62 | Prolymphocytic leukemia of T-cell type, in relapse |
| C91.90 | Lymphoid leukemia, unspecified not having achieved remission |
| C91.91 | Lymphoid leukemia, unspecified, in remission |
| C91.92 | Lymphoid leukemia, unspecified, in relapse |
| C91.A0 | Mature B-cell leukemia Burkitt-type not having achieved remission |
| C91.A1 | Mature B-cell leukemia Burkitt-type, in remission |
| C91.A2 | Mature B-cell leukemia Burkitt-type, in relapse |
| C91.Z0 | Other lymphoid leukemia not having achieved remission |
| C91.Z1 | Other lymphoid leukemia, in remission |
| C91.Z2 | Other lymphoid leukemia, in relapse |
| C92.00 | Acute myeloblastic leukemia, not having achieved remission |
| C92.01 | Acute myeloblastic leukemia, in remission |
| C92.02 | Acute myeloblastic leukemia, in relapse |
| C92.10 | Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission |
| C92.11 | Chronic myeloid leukemia, BCR/ABL-positive, in remission |
| C92.12 | Chronic myeloid leukemia, BCR/ABL-positive, in relapse |
| C92.20 | Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission |
| C92.21 | Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission |
| C92.22 | Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse |
| C92.30 | Myeloid sarcoma, not having achieved remission |
| C92.31 | Myeloid sarcoma, in remission |
| C92.32 | Myeloid sarcoma, in relapse |
| C92.40 | Acute promyelocytic leukemia, not having achieved remission |
| C92.41 | Acute promyelocytic leukemia, in remission |
| C92.42 | Acute promyelocytic leukemia, in relapse |
| C92.50 | Acute myelomonocytic leukemia, not having achieved remission |
| C92.51 | Acute myelomonocytic leukemia, in remission |
| C92.52 | Acute myelomonocytic leukemia, in relapse |
| C92.60 | Acute myeloid leukemia with 11q23-abnormality not having achieved remission |
| C92.61 | Acute myeloid leukemia with 11q23-abnormality in remission |
| C92.62 | Acute myeloid leukemia with 11q23-abnormality in relapse |
| C92.90 | Myeloid leukemia, unspecified, not having achieved remission |
| C92.91 | Myeloid leukemia, unspecified in remission |
| C92.92 | Myeloid leukemia, unspecified in relapse |
| C92.A0 | Acute myeloid leukemia with multilineage dysplasia, not having achieved remission |
| C92.Z0 | Other myeloid leukemia not having achieved remission |
|---|---|
| C92.Z1 | Other myeloid leukemia, in remission |
| C92.Z2 | Other myeloid leukemia, in relapse |
| C93.00 | Acute monoblastic/monocytic leukemia, not having achieved remission |
| C93.01 | Acute monoblastic/monocytic leukemia, in remission |
| C93.02 | Acute monoblastic/monocytic leukemia, in relapse |
| C93.10 | Chronic myelomonocytic leukemia not having achieved remission |
| C93.11 | Chronic myelomonocytic leukemia, in remission |
| C93.12 | Chronic myelomonocytic leukemia, in relapse |
| C93.30 | Juvenile myelomonocytic leukemia, not having achieved remission |
| C93.31 | Juvenile myelomonocytic leukemia, in remission |
| C93.32 | Juvenile myelomonocytic leukemia, in relapse |
| C93.90 | Monocytic leukemia, unspecified, not having achieved remission |
| C93.91 | Monocytic leukemia, unspecified in remission |
| C93.92 | Monocytic leukemia, unspecified in relapse |
| C93.Z0 | Other monocytic leukemia, not having achieved remission |
| C93.Z1 | Other monocytic leukemia, in remission |
| C93.Z2 | Other monocytic leukemia, in relapse |
| C94.00 | Acute erythroid leukemia, not having achieved remission |
| C94.01 | Acute erythroid leukemia, in remission |
| C94.02 | Acute erythroid leukemia, in relapse |
| C94.20 | Acute megakaryoblastic leukemia not having achieved remission |
| C94.21 | Acute megakaryoblastic leukemia, in remission |
| C94.22 | Acute megakaryoblastic leukemia, in relapse |
| C94.30 | Mast cell leukemia not having achieved remission |
| C94.31 | Mast cell leukemia, in remission |
| C94.32 | Mast cell leukemia, in relapse |
| C94.80 | Other specified leukemias not having achieved remission |
| C94.81 | Other specified leukemias, in remission |
| C94.82 | Other specified leukemias, in relapse |
| C95.00 | Acute leukemia of unspecified cell type not having achieved remission |
| C95.01 | Acute leukemia of unspecified cell type, in remission |
| C95.02 | Acute leukemia of unspecified cell type, in relapse |
| C95.10 | Chronic leukemia of unspecified cell type not having achieved remission |
| C95.11 | Chronic leukemia of unspecified cell type, in remission |
| C95.12 | Chronic leukemia of unspecified cell type, in relapse |
| C95.90 | Leukemia, unspecified not having achieved remission |
| C95.91 | Leukemia, unspecified, in remission |
| C95.92 | Leukemia, unspecified, in relapse |
| D45 | Polycythemia vera |
III. For the treatment of aplastic anemia; see table below for ICD-10-CM codes)
| ICD-10 | Description |
|---|---|
| D60.0 | Chronic acquired pure red cell aplasia |
| D60.1 | Transient acquired pure red cell aplasia |
| D60.8 | Other acquired pure red cell aplasias |
| D60.9 | Acquired pure red cell aplasia, unspecified |
| D61.01 | Constitutional (pure) red blood cell aplasia |
| D61.09 | Other constitutional aplastic anemia |
| D61.1 | Drug-induced aplastic anemia |
| D61.2 | Aplastic anemia due to other external agents |
| D61.3 | Idiopathic aplastic anemia |
| D61.810 | Antineoplastic chemotherapy induced pancytopenia |
| D61.811 | Other drug-induced pancytopenia |
| D61.818 | Other pancytopenia |
| D61.82 | Myelophthisis |
| D61.89 | Other specified aplastic anemias and other bone marrow failure syndromes |
| D61.9 | Aplastic anemia, unspecified |
If ICD-10-CM is applicable, the following ranges of ICD-10-CM codes are also covered for AuSCT:
NOTE: The following conditions are not covered:
Also coverage for conditions other than those specifically designated as covered in §90.2 or specifically designated as non-covered in this section or in §90.3 will be at the discretion of the individual contractor.
(Rev.11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)
Autologous stem cell transplantation is not covered for the following conditions:
NOTE: Coverage for conditions other than those specifically designated as covered in 90.2 or 90.2.1 or specifically designated as non-covered in this section will be at the discretion of the individual A/B MAC (B).
(Rev.11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)
NOTE: Coverage for conditions other than those specifically designated as covered in 80.2 or specifically designated as non-covered in this section will be at the discretion of the individual A/B MAC (B).
Appropriate diagnosis to procedure code edits should be implemented for the non-covered conditions and services in 90.2, 90.2.1, and 90.3 as applicable
As the ICD-10-CM codes E85.4, E85.81, E85.89, and E85.9 amyloidosis does not differentiate between primary and non-primary, A/B MACs (B) should perform prepay reviews on all claims with a diagnosis of ICD-10-CM codes E85.4, E85.81, E85.89, and E85.9 and a HCPCS procedure code of 38241 to determine whether payment is appropriate.
(Rev.11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)
The contractor shall use an appropriate MSN and CARC messages such as the following:
MSN - 15.4, The information provided does not support the need for this service or item;
CARC - 150, Payment adjusted because the payer deems the information submitted does not support this level of service.
(Rev. 11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-21)
Myelodysplastic Syndrome (MDS) refers to a group of diverse blood disorders in which the bone marrow does not produce enough healthy, functioning blood cells. These disorders are varied with regard to clinical characteristics, cytologic and pathologic features, and cytogenetics.
On August 4, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a national coverage determination (NCD) stating that
CMS believes that the evidence does not demonstrate that the use of allogeneic hematopoietic stem cell transplantation (HSCT) improves health outcomes in Medicare beneficiaries with MDS. Therefore, allogeneic HSCT for MDS is not reasonable and necessary under
§1862(a)(1)(A) of the Social Security Act (the Act). However, allogeneic HSCT for MDS is reasonable and necessary under
§1862(a)(1)(E) of the Act and therefore covered by Medicare ONLY if provided pursuant to a Medicare-approved clinical study under Coverage with Evidence Development (CED). Refer to Pub.100-03, National Coverage Determinations Manual, Chapter 1, section 110.8.1, for more information about this policy, and Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, section 90.3.1, for information on CED.
Payable Conditions. For claims with dates of service on and after August 4, 2010, contractors shall pay for claims for HSCT for MDS when the service was provided pursuant to a Medicare-approved clinical study under CED; these services are paid only in the inpatient setting (Type of Bill (TOB) 11X), as outpatient Part B (TOB 13X), and in Method II critical access hospitals (TOB 85X). Contractors shall require the following coding in order to pay for these claims:
• Professional claims only: place of service codes 21 or 22.
Denials. Contractors shall deny claims failing to meet any of the above criteria. In addition, contractors shall apply the following requirements:
CARC 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.
NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code – Patient Responsibility (PR) if HINN/ABN issued, otherwise Contractual Obligation (CO)
MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/artículo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.)
Effective for dates of services on and after September 26, 2022, the Centers for Medicare & Medicaid Services (CMS) has expanded the coverage for cochlear implantation to cover bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss in individuals with hearing test scores equal to or less than 60% correct in the best aided listening condition on recorded tests of open-set sentence recognition and who demonstrate limited benefit from amplification. (See Publication 100-03, Chapter 1, Section 50.3, for complete coverage criteria).
In addition, CMS is covering cochlear implants for beneficiaries not meeting the coverage criteria listed under Publication 100-03, Chapter 1, Section 50.3 when performed in context with:
(Rev. 11875; Issued:02-23-23; Effective: 09-26-22; Implementation: 03-24-23)
There are no special payment methods. Existing payment methods shall apply.
(Rev. 601, Issued: 07-01-05; Effective: 04-04-05; Implementation: 07-25-05)
11X, 12X (see note below), 13X, 83X, 85X
NOTE: Surgical procedures are not acceptable on 12x bill types.
(Rev. 11875; Issued:02-23-23; Effective: 09-26-22; Implementation: 03-24-23)
NOTE: The -Q0/-Q1 modifiers do not need to be applied to these services (92601-92604, 92507 & 92521-92524).
(Rev. 601, Issued: 07-01-05; Effective: 04-04-05; Implementation: 07-25-05)
There are no special payment methods. Existing payment methods shall apply.
(Rev. 11875; Issued:02-23-23; Effective: 09-26-22; Implementation: 03-24-23)
Effective for dates of service performed on and after September 26, 2022, the following applies:
A/B MACs (Part B) shall accept claims for cochlear implantation devices and services for beneficiaries meeting the coverage criteria listed under Publication 100-03, Chapter 1, section 50.3.
A/B MACs (Part B) shall accept claims for cochlear implantation devices and all related costs for beneficiaries not meeting the coverage criteria listed under Publication 100-03, Chapter 1, Section 50.3 provided in an FDA-approved category B IDE clinical trial or a trial under the CMS Clinical Trial policy, that is billed with the -Q0 modifier. The definition of the -Q0 modifier is, “Item or service provided in a Medicare specified study.”
A/B MACs (Part B) shall accept claims for routine costs pertaining to beneficiaries not meeting the coverage criteria listed under Publication 100-03, Chapter 1, Section 50.3 who are in a clinical trial under the clinical
trial policy that is billed with the -Q1 modifier. The definition of the -Q1 modifier is, “Routine clinical service provided in a clinical research study that is in an approved clinical research study”
A/B MACs (Part B) shall accept claims for evaluation and therapeutic services related to cochlear implantation.
NOTE: The -Q0/-Q1 modifier does not need to be applied to these services (92601-92604, 92507 & 92521-92524).
These services should be billed on an approved electronic claim form or a paper CMS Form 1500.
The following HCPCS codes are some of those available for use when billing for cochlear implantation services and devices provided by audiologists or physicians, and for the service of 92507, by speech language pathologists.
69930 – Cochlear device implantation, with or without mastoidectomy
L8614 – Cochlear Device includes all internal and external components
L8619 – Cochlear implant external speech processor and controller, integrated system, replacement
L7510 – Repair of prosthetic device, repair or replace minor parts
92507 – Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual
92521 – Evaluation of speech fluency (e.g. stuttering, cluttering)
92522 – Evaluation of speech sound production (e.g. articulation, phonological process, apraxia, dysarthria)
92523 – Evaluation of speech sound production (e.g. articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g. receptive and expressive language).
92524 – Behavioral and qualitative analysis of voice and resonance
92601 – Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming
(Codes 92601 and 92603 describe post-operative analysis and fitting of previously placed external devices, connection to the cochlear implant, and programming of the stimulator. Codes 92602 and 92604 describe subsequent sessions for measurements and adjustment of the external transmitter and re-programming of the internal stimulator.)
92602 – Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent programming. (Do not report 92602 in addition to 92601.)
92603 – Diagnostic analysis of cochlear implant, age 7 years or older; with programming
92604 – Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming
A complete list of audiology codes can be found in Pub 100-4, chapter12, section 30.3.
(Rev. 11875; Issued:02-23-23; Effective: 09-26-22; Implementation: 03-24-23)
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for cochlear implantation devices and services for beneficiaries with moderate-to-profound hearing loss in patients with hearing test scores ≤ 40% through 9/25/22; ≤ 60% effective 9/26/22.
Use the following messages when denying services on claims:
CARC 50 - “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer”
RARC N386 - “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
MSN 15.20 = “The following policies were used when we made this decision: NCD 50. 3”
Spanish translation: “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 50.3”)
Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:
MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD.
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-MEDICARE (1-800-633-4227).
NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.
Group Code: CO (Contractual Obligation) assigning financial liability to the provider
A/B MACs (Part A) shall deny for any covered dx audiology/therapy services related to cochlear implantation with the following messages:
Use the following messages when denying services on claims:
CARC 50 - “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer”
RARC N386 - “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
MSN 15.20 = “The following policies were used when we made this decision: NCD 50. 3”
Spanish translation: “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 50.3”)
Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:
MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD.
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-MEDICARE (1-800-633-4227).
NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.
Group Code: CO (Contractual Obligation) assigning financial liability to the provider
A/B/MACs (Part B) shall deny claims for evaluation and therapeutic services related to cochlear implantation. NOTE: Modifiers -Q0/-Q1 do not need to be applied to these services (92601– 92604, 92521-92524 or any applicable audiology codes).
Use the following messages when denying services on claims:
CARC 50 - “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer”
RARC N386 - “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
MSN 15.20 - “The following policies were used when we made this decision: NCD 50. 3”
Spanish translation: “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 50.3”)
Group Code - CO (Contractual Obligation) assigning financial liability to the provider
An ultrasonic osteogenic stimulator is a non-invasive device that emits low intensity, pulsed ultrasound. This device is applied to the surface of the skin at the fracture site and ultrasound waves are emitted via a conductive coupling gel to stimulate fracture healing. The ultrasonic osteogenic stimulators are not to be used concurrently with other non-invasive osteogenic devices.
Effective for dates of service on and after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of nonunion bone fractures prior to surgical intervention. In demonstrating nonunion fractures, CMS expects:
For further coverage information, please refer to the National Coverage Determinations Manual, Pub. 100-03, chapter 1, section 150.2.
The RHHIs will pay for ultrasonic osteogenic stimulators only when services are submitted on type of bills (TOBs) listed under Pub. 100-04, Medicare Claims Processing Manual, chapter 32, section 100.3.
Fiscal intermediaries (FIs) must educate hospitals that there are no covered services for Ultrasonic Osteogenic Stimulation for which hospitals can be paid by the FI.
NOTE: Hospitals can not bill for Ultrasonic Osteogenic Stimulators.
(Rev. 597, Issued: 06-24-05, Effective: 04-27-05, Implementation: 08-01-05)
Only the following TOBs can bill for Ultrasonic Osteogenic Stimulators: 32X, 33X, 34X, which is payable under the DMEPOS Fee Schedule.
NOTE: Ultrasonic Osteogenic Stimulators must be in the patient’s home health plan of care if billed on TOBs 32X or 33X.
(Rev. 597, Issued: 06-24-05, Effective: 04-27-05, Implementation: 08-01-05)
Effective for dates of service on or after April 27, 2005, contractors shall allow payment for ultrasonic osteogenic stimulators with the following current procedural terminology (CPT) code:
(Rev. 816, Issued: 01-20-06, Effective: 04-27-05, Implementation: 04-03-06)
Effective for dates of service on or after April 27, 2005, DMERCs shall allow payment for ultrasonic osteogenic stimulators with the following HCPCS codes:
E0760 for low intensity ultrasound (include modifier “KF”), or;
E1399 for other ultrasound stimulation (include modifier “KF”)
(Rev. 1228; Issued: 04-27-07; Effective: 01-22-07; Implementation: 05-29-07)
Per CMS Ruling 05-01, issued May 3, 2005, Medicare will allow beneficiaries to pay additional charges associated with insertion of a P-C IOL following cataract surgery.
Per CMS-1536-Ruling, effective for services on and after January 22, 2007, Medicare will allow beneficiaries to pay additional charges (which are non-covered by Medicare as these additional charges are not part of a Medicare benefit category) for insertion of an A-C IOL.
A list of A-C IOLs and P-C IOLs can be accessed online at http://www.cms.hhs.gov/HospitalOutpatientPPS/01_overview.asp
(Rev. 1430; Issued: 02-01-08; Effective: 01-01-08; Implementation: 03-03-08)
For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital Outpatient Prospective Payment System (OPPS) or the Inpatient Prospective Payment System (IPPS), respectively; or in a Medicare-approved ambulatory surgical center (ASC) that is paid under the ASC fee schedule:
• There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a P-C or A-C IOL following removal of a cataract that exceeds the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.
A physician shall bill for a conventional IOL, regardless of a whether a conventional, P-C IOL, or A-C IOL is inserted (see section 120.2, General Billing Requirements)
There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the physician charges for services and supplies for the insertion and adjustment of a conventional IOL.
There is no Medicare benefit category that allows payment of physician charges for subsequent treatments, service and supplies required to examine and monitor a beneficiary following removal of a cataract with insertion of a P-C or A-C IOL that exceed physician charges for services and supplies to examine and monitor a beneficiary following removal of a cataract with insertion of a conventional IOL.
A physician may not bill Medicare for a P-C or A-C IOL inserted during a cataract procedure performed in a hospital setting because the payment for the lens is included in the payment made to the facility for the surgical procedure.
There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the physician charges for services and supplies required for the insertion of a conventional IOL.
(Rev. 1430; Issued: 02-01-08; Effective: 01-01-08; Implementation: 03-03-08)
Physicians and hospitals must report one of the following Current Procedural Terminology (CPT) codes on the claim:
66982 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic development stage.
• 66983 - Intracapsular cataract with insertion of intraocular lens prosthesis (one stage procedure) • 66984 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)
In addition, physicians inserting a P-C IOL or A-C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL. Medicare will make payment for the lens based on reasonable cost for a conventional IOL. Place of Service (POS) = 11.
Effective for dates of service on and after January 1, 2006, physician, hospitals and ASCs may also bill the non-covered charges related to the P-C function of the IOL using HCPCS code V2788. Effective for dates of service on and after January 22, 2007 through January 1, 2008, non-covered charges related to A-C function of the IOL can be billed using HCPCS code V2788. The type of service indicator for the non-covered billed charges is Q. (The type of service is applied by the Medicare carrier and not the provider). Effective for A-C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 rather than V2788 to report any additional charges that accrue.
When denying the non-payable charges submitted with V2787 or V2788, contractors shall use an appropriate Medical Summary Notice (MSN) such as 16.10 (Medicare does not pay for this item or service) and an appropriate claim adjustment reason code such as 96 (non-covered charges) for claims submitted with the non-payable charges.
Hospitals and physicians may use the proper CPT code(s) to bill Medicare for evaluation and management services usually associated with services following cataract extraction surgery, if appropriate.
The hospital applicable bill types are 12X, 13X, 83X and 85X.
Hospitals shall continue to pay CAHs method 2 claims under current payment methodologies for conditional IOLs.
(Rev. 1228; Issued: 04-27-07; Effective: 01-22-07; Implementation: 05-29-07)
When a beneficiary requests insertion of a P-C or A-C IOL instead of a conventional IOL following removal of a cataract:
The P-C or A-C functionality of a P-C or A-C IOL does not fall into a Medicare benefit category, and, therefore, is not covered. Therefore, the facility and physician are not required to provide an Advanced Beneficiary Notice to beneficiaries who request a P-C or A-C IOL.
Although not required, CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to clearly identify the non-payable aspects of a P-C or A-C IOL insertion. This notice may be found in English at http://cms.hhs.gov/medicare/bni/20007_English.pdf
(Rev. 1228; Issued: 04-27-07; Effective: 01-22-07; Implementation: 05-29-07)
When a beneficiary requests insertion of a P-C or A-C IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the beneficiary is responsible for payment of facility and physician charges for services and supplies attributable to the P-C or A-C functionality of the P-C or A-C IOL:
(Rev. 898, Issued: 03-31-06; Effective/Implementation Dates: 03-31-06)
Commonly referred to as enhanced external counterpulsation, is a non-invasive outpatient treatment for coronary artery disease refractory medical and/or surgical therapy. Effective for dates of service July 1, 1999, and after, Medicare will cover ECP when its use is in patients with stable angina (Class III or Class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass, because:
(Refer to Publication 100-03, section 20.20 for further coverage criteria.)
(Rev. 12109; Issued:06-29-23; Effective: 10-02-23; Implementation: 10-02-23)
Effective for dates of service on or after January 1, 2000, use HCPCS code G0166 (External counterpulsation, per session) to report ECP services. The codes for external cardiac assist (92971), ECG rhythm strip and report (93040 or 93041), pulse oximetry (94760 or 94761) and plethysmography (93922 or 93923) or other monitoring tests for examining the effects of this treatment are not clinically necessary with this service and
should not be paid on the same day, unless they occur in a clinical setting not connected with the delivery of the ECP. Daily evaluation and management service, e.g., 99201- 99205, 99211-99215, 99217-99220, 99241-99245, and G0463 cannot be billed with the ECP treatments. Any evaluation and management service must be justified with adequate documentation of the medical necessity of the visit. Deductible and coinsurance apply.
Note: Please note that effective December 31, 2020 evaluation and management service code 99201 is end-dated. Effective December 31, 2022 codes 99217,99218,99219,99220 and 99241 are end dated. For Part A, remove CPT codes 99202-99215, 99242-99245 and replace with G0463 (the OPPS equivalent of E/M codes) effective retroactive to 10/1/2015.
(Rev. 898, Issued: 03-31-06; Effective/Implementation Dates: 03-31-06)
Payment is made to hospitals for the facility costs it incurs under Part B on a reasonable cost basis. Payment is also made to PPS-exempt hospitals for the facility costs it incurs on a reasonable cost basis. Deductible and coinsurance apply.
Applicable bill types are 12X, 13X, 83X or 85X.
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
Cardiac rehabilitation (CR) means a physician or nonphysician practitioner supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Intensive cardiac rehabilitation (ICR) program means a physician or nonphysician practitioner supervised program that furnishes CR and has shown, in peer-reviewed published research, that it improves patients' cardiovascular disease through specific outcome measurements described in 42 CFR 410.49(c). Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social Security Act (the Act).
Effective January 1, 2024, Medicare Part B pays for CR/ICR if specific criteria are met by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is administered, and the physician administering the program.
Pulmonary rehabilitation (PR) means a physician or nonphysician practitioner supervised program for chronic obstructive pulmonary disease (COPD) and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Act.
Effective January 1, 2024, Medicare Part B pays for PR if specific criteria are met by the Medicare beneficiary, the PR program itself, the setting in which it is administered, and the physician administering the program, as outlined below.
(Rev. 11426; Issued: 05-20-22; Effective: 01-01-22; Implementation: 07-05-22)
Medicare covers CR exercise programs for patients who meet the following criteria:
Effective for dates of services on or after March 22, 2006, services provided in connection with a CR exercise program may be considered reasonable and necessary for up to 36 sessions. Patients generally receive 2 to 3 sessions per week for 12 to 18 weeks. The contractor has discretion to cover CR beyond 18 weeks. Coverage must not exceed a total of 72 sessions for 36 weeks.
CR programs shall be performed incident to physician's services in outpatient hospitals, or outpatient settings such as clinics or offices. Follow the policies for services incident to the services of a physician as they apply in each setting. For example, see Pub. 100-02, Chapter 6, §2.4.1, and Pub. 100-02, Chapter 15, §60.1. (Refer to Publication 100-03, §20.10 for further coverage guidelines.)
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
The following are the applicable Healthcare Common Procedure Coding System (HCPCS) codes:
93797 - Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session); and
93798 - Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session).
Note: The above HCPCS descriptors are effective January 1, 2013.
Effective for dates of service on or after January 1, 2008, and before January 1, 2010, providers and practitioners may report more than one unit of CPT code 93797 or 97398 for a date of service if more than one CR session lasting at least 1 hour each is provided on the same day. In order to report more than one session for a given date of service, each session must last a minimum of 60 minutes. For example, if the CR provided on a given day total 1 hour and 50 minutes, then only one session should be billed to report the CR provided on that day.
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
As specified at 42 CFR 410.49, Medicare Part B covers CR for beneficiaries who have experienced one or more of the following:
CR must include all of the following components:
Medicare Part B pays for CR in a physician's office or a hospital outpatient setting. All settings must have a physician or nonphysician practitioner immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician or nonphysician practitioner meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42 CFR 410.27. Note: Nonphysician practitioners are eligible to supervise CR effective January 1, 2024.
As specified at 42 CFR 410.49(f)(1), the number of CR sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the Medicare Administrative Contractor (MAC).
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
The following are the applicable Current Procedural Technology (CPT) codes for CR services:
93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (Per Session)
93798 Physician or other qualified care health professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (Per Session)
Note: The above HCPCS descriptors are effective January 1, 2013.
Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session of CR in a day, the duration of treatment must be at least 31 minutes. Two sessions of CR may only be reported in the same day if the duration of treatment is at least 91 minutes. In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes if two sessions are reported. If several shorter periods of CR are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.
Example: If the patient receives 20 minutes of CR in the day, no CR session may be reported because less than 31 minutes of services were furnished.
Example: If a patient receives 20 minutes of CR in the morning and 35 minutes of CR in the afternoon of a single day, the hospital or practitioner would report 1 session of CR under 1 unit of the appropriate CPT code for the total duration of 55 minutes of CR on that day.
Example: If the patient receives 70 minutes of CR in the morning and 25 minutes of CR in the afternoon of a single day, the hospital or practitioner would report two sessions of CR under the appropriate CPT code(s) because the total duration of CR on that day of 95 minutes exceeds 90 minutes.
Example: If the patient receives 70 minutes of CR in the morning and 85 minutes of CR in the afternoon of a single day, the hospital or practitioner would report two sessions of CR under the appropriate CPT code(s) for the total duration of CR of 155 minutes. A maximum of two sessions per day may be reported, regardless of the total duration of CR.
sessions after 36 (to include completed ICR sessions prior to switch). In these cases, and consistent with the information above, the -KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch.
See Pub. 100-06, Medicare Financial Management Manual, chapter 6, section 420, and Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 232, and Pub. 100-08, Medicare Program Integrity Manual, chapter 10, section 10.2.2.5 for detailed information regarding CR and ICR policy and claims processing.
NOTE: A beneficiary may switch from an ICR program to a CR program. The beneficiary is limited to a one-time switch, multiple switches are not allowable. Once the beneficiary switches from ICR to CR he or she will be limited to the number of sessions remaining in the program. For example, a beneficiary who switches from ICR to CR after 12 sessions will have 24 sessions of CR remaining, (i.e., 12 sessions of ICR + 24 sessions of CR = total of 36 sessions). Should a beneficiary experience more than one indication simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., a patient who had a MI within 12 months and currently experiences stable angina is entitled to one series of CR sessions, up to 36 1-hour sessions with contractor discretion for an additional 36 sessions; or one series of ICR sessions, up to 72 1-hour sessions over a period up to 18 weeks). Beneficiaries may not switch from CR to ICR. Upon completion of a CR or ICR program, beneficiaries must experience another indication in order to be eligible for coverage of more CR or ICR.
Contractors shall accept the inclusion of the -KX modifier on the claim line(s) as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy or, for ICR, that any further sessions beyond 72 sessions within a 126-day period counting from the date of the first session, or for any sessions provided after 126 days from the date of the first session, meet the requirements of the medical policy. Beneficiaries who switch from ICR to CR may also be eligible for up to 72 combined sessions with contractor discretion for CR sessions after 36 (to include completed ICR sessions prior to switch). In these cases, and consistent with the information above, the -KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch.
See Pub. 100-06, Medicare Financial Management Manual, chapter 6, section 420, and Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 232, and Pub. 100-08, Medicare Program Integrity Manual, chapter 10, section 10.2.2.5 for detailed information regarding CR and ICR policy and claims processing.
(Rev. 3058, Issued: 08-29-14, Effective: 02-18-14, Implementation: 08-18-14)
Effective for claims with dates of service on and after January 1, 2010, place of service (POS) code 11 shall be used for CR and ICR services provided in a physician's office and POS 22 shall be used for services provided in a hospital outpatient setting. All other POS codes shall be denied. Contractors shall adjust their prepayment procedure edits as appropriate.
The following messages shall be used when contractors deny CR and ICR claims for POS:
Claim Adjustment Reason Code (CARC) 171 – Payment is denied when performed/billed by this type of provider in this type of facility.
NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.
Remittance Advice Remark Code (RARC) N428 - Service/procedure not covered when performed in this place of service.
Medicare Summary Notice (MSN) 21.25 - This service was denied because Medicare only covers this service in certain settings.
Group Code PR (Patient Responsibility) - Where a claim is received with the GA modifier indicating that a signed ABN is on file.
Group Code CO (Contractor Responsibility) – Where a claim is received with the GZ modifier indicating that no signed ABN is on file.
(Rev. 3084, Issued: 10-03-14, Effective: 05-06-14, Implementation: 11-04-14)
Effective for claims with dates of service on and after January 1, 2010, contractors shall pay for CR and ICR services when submitted on Types of Bill (TOBs) 13X and 85X only. All other TOBs shall be denied.
The following messages shall be used when contractors deny CR and ICR claims for TOBs other than 13X and 85X:
Claim Adjustment Reason Code (CARC) 171 – Payment is denied when performed/billed by this type of provider in this type of facility. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Remittance Advice Remark Code (RARC) N428 - Service/procedure not covered when performed in this place of service.
Medicare Summary Notice (MSN) 21.25 - This service was denied because Medicare only covers this service in certain settings.
Group Code PR (Patient Responsibility) – Where a claim is received with the GA modifier indicating that a signed ABN is on file.
Group Code CO (Contractor Responsibility) – Where a claim is received with the GZ modifier indicating that no signed ABN is on file.
(Rev. 11426; Issued: 05-20-22; Effective: 01-01-22; Implementation: 07-05-22)
Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all CR claims (both professional and institutional claims) that exceed 2 units per date of service for CR and 6 units per date of service for ICR.
The following messages shall be used when contractors deny CR and ICR claims for exceeding units per date of service:
CARC 119 - Benefit maximum for this time period or occurrence has been reached.
RARC N362 - The number of days or units of service exceeds our acceptable maximum.
MSN 20.5 - These services cannot be paid because your benefits are exhausted at this time.
Spanish Version - Estos servicios no pueden ser pagados porque sus beneficios se han agotado.
Group Code PR – Where a claim is received with the GA modifier indicating that a signed ABN is on file.
Group Code CO – Where a claim is received with the GZ modifier indicating that no signed ABN is on file.
Contractors shall not research and adjust CR claims (HCPCS 93797 and 93798) paid for more than 2 units on the same date of service processed prior to the implementation of edits. However, contractors may adjust claims brought to their attention.
Contractors shall not research and adjust ICR claims (HCPCS G0422 and G0423) paid for more than 6 units on the same date of service processed prior to the implementation of edits. However, contractors may adjust claims brought to their attention.
(Rev. 11426; Issued: 05-20-22; Effective: 01-01-22; Implementation: 07-05-22)
Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all claims with HCPCS 93797 and 93798 (both professional and institutional claims) that exceed 36 CR sessions when a -KX modifier is not included on the claim line.
The following messages shall be used when contractors deny CR claims that exceed 36 sessions, when a -KX modifier is not included on the claim line:
-CARC-) 119 – Benefit maximum for this period or occurrence has been reached.
RARC N435 - Exceeds number/frequency approved/allowed within time period without support documentation. MSN 23.17- Medicare won’t cover these services because they are not considered medically necessary.
Spanish Version - Medicare no cubrirá estos servicios porque no son considerados necesarios por razones médicas.
Group Code PR – Where a claim is received with the GA modifier indicating that a signed ABN is on file.
Group Code CO – Where a claim is received with the GZ modifier indicating that no signed ABN is on file.
Contractors shall not research and adjust CR claims paid for more than 36 sessions processed prior to the implementation of Common Working File (CWF) edits. However, contractors may adjust claims brought to their attention.
Effective for claims with dates of service on and after January 1, 2010, CWF shall reject ICR claims (G0422 and G0423) that exceed 72 sessions or where any billed sessions were provided after 126 days from the date of the first session and a KX modifier is not included on the claim line.
The following messages shall be used when contractors deny ICR claims that exceed 72 sessions or where any billed sessions were received after the 126 days from the date of the first session:
Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached.
RARC N435 - Exceeds number/frequency approved/allowed within time period without support documentation.
MSN 20.5 - These services cannot be paid because your benefits are exhausted at this time.
Spanish Version - Estos servicios no pueden ser pagados porque sus beneficios se han agotado.
Group Code PR (Patient Responsibility) – Where a claim is received with the GA modifier indicating that a signed ABN is on file.
Group Code CO (Contractor Responsibility) – Where a claim is received with the GZ modifier indicating that no signed ABN is on file.
Contractors shall not research and adjust ICR claims paid for more than 72 sessions or where any billed sessions were received after 126 days from the date of the first session that were processed prior to the implementation of CWF edits. However, contractors may adjust claims brought to their attention.
Effective for claims with dates of service on and after January 1, 2010, contractors shall pay for ICR services when submitted by providers enrolled as the new supplier specialty code 31 for ICR. ICR services submitted by providers enrolled as other than the new supplier specialty code 31 for ICR are to be denied using the following messages:
CARC 8: “The procedure code is inconsistent with the provider type/specialty (taxonomy). NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
RARC N95: “This provider type may not bill this service.”
MSN 21.18 – “This item or service is not covered when performed or ordered by this provider.”
Spanish Version: Este servicio no está cubierto cuando es ordenado o rendido por este proveedor.
Group Code PR (Patient Responsibility) – Where a claim is received with the GA modifier indicating that a signed ABN is on file.
Group Code CO (Contractor Responsibility) – Where a claim is received with the GZ modifier indicating that no signed ABN is on file.
As specified at 42 CFR 410.49, Medicare Part B covers ICR for beneficiaries who have experienced one or more of the following:
ICR must include all of the following components:
A list of approved ICR programs, identified through the NCD process, will be listed in the Federal Register and is available on the CMS website at https://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/ICR. In order to be approved, a program must demonstrate through peer-reviewed, published research that it has accomplished one or more of the following for its patients:
An ICR program must also demonstrate through peer-reviewed published research that it accomplished a statistically significant reduction in 5 or more of the following measures for patients from their levels before CR services to after CR services:
• Triglycerides. • Body mass index. • Systolic blood pressure. • Diastolic blood pressure. • The need for cholesterol, blood pressure, and diabetes medications.
Medicare Part B pays for ICR in a physician's office or a hospital outpatient setting. All settings must have a physician or nonphysician practitioner immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician or nonphysician practitioner meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42 CFR 410.27. Note: Nonphysician practitioners are eligible to supervise ICR effective January 1, 2024.
As specified at 42 CFR 410.49(f)(2), ICR sessions are limited to 72 1-hour sessions (as defined in section 1848(b)(5) of the Act), up to 6 sessions per day, over a period of up to 18 weeks.
(Rev. 11426; Issued: 05-20-22; Effective: 01-01-22; Implementation: 07-05-22)
The following are the applicable HCPCS codes for ICR:
G0422 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring, with exercise, per hour, per session)
G0423 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring, without exercise, per hour, per session)
Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 6 1-hour sessions per day. In order to report one session of ICR in a day, the duration of treatment must be at least 31 minutes. Additional sessions of ICR beyond the first session may only be reported in the same day if the duration of treatment is 31 minutes or greater beyond the hour increment. In other words, in order to report 6 sessions of ICR on a given date of service, the first five sessions would account for 60 minutes each and the sixth session would account for at least 31 minutes. If several shorter periods of ICR are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.
Example: If the patient receives 20 minutes of ICR in the day, no ICR session may be reported because less than 31 minutes of services were furnished.
Example: If a patient receives 20 minutes of ICR in the morning and 35 minutes of ICR in the afternoon of a single day, the hospital or practitioner would report 1 session of ICR under 1 unit of the appropriate HCPCS code for the total duration of 55 minutes of ICR on that day.
Example: If the patient receives 70 minutes of ICR in the morning and 25 minutes of ICR in the afternoon of a single day, the hospital or practitioner would report two sessions of ICR under the appropriate HCPCS code(s) because the total duration of ICR on that day of 95 minutes exceeds 90 minutes.
Example: If the patient receives 70 minutes of ICR in the morning and 85 minutes of ICR in the afternoon of a single day, the hospital or practitioner would report three sessions of ICR under the appropriate HCPCS code(s) because the total duration of ICR on that day is 155 minutes, which exceeds 150 minutes and is less than 211 minutes.
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:
PR must include all of the following components:
Medicare Part B pays for PR in a physician’s office or a hospital outpatient setting. All settings must have the following: (i) A physician or nonphysician practitioner immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician or nonphysician practitioner meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42 CFR 410.27, and, (ii) The necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and defibrillator) to treat chronic respiratory disease.
Note: Nonphysician practitioners are eligible to supervise PR effective January 1, 2024.
As specified at 42 CFR 410.47(e), the number of PR sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the MACs.
(Rev. 11426; Issued: 05-20-22; Effective: 01-01-22; Implementation: 07-05-22)
The following are the applicable HCPCS codes for PR:
Effective January 1, 2010 through December 31, 2021
G0424 (Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session)
Effective January 1, 2022
94625 (Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session))
94626 (Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session))
Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session of PR in a day, the duration of treatment must be at least 31 minutes. Two sessions of PR may only be reported in the same day if the duration of treatment is at least 91 minutes. In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes, if two sessions are reported. If several shorter periods of PR are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.
Example: If the patient receives 20 minutes of PR in the day, no PR session may be reported because less than 31 minutes of services were furnished.
Example: If a patient receives 20 minutes of PR in the morning and 35 minutes of PR in the afternoon of a single day, the hospital or practitioner would report 1 session of PR under 1 unit of HCPCS code/CPT code for the total duration of 55 minutes of PR on that day.
Example: If the patient receives 70 minutes of pulmonary rehabilitation services in the morning and 25 minutes of pulmonary rehabilitation services in the afternoon of a single day, the hospital or practitioner would report two sessions of pulmonary rehabilitation services under the HCPCS G-code/CPT codes because the total duration of pulmonary rehabilitation services on that day of 95 minutes exceeds 90 minutes.
Example: If the patient receives 70 minutes of pulmonary rehabilitation services in the morning and 85 minutes of pulmonary rehabilitation services in the afternoon of a single day, the hospital or practitioner would report two sessions of pulmonary rehabilitation services under the HCPCS G-code/CPT codes for the total duration of pulmonary rehabilitation services of 155 minutes. A maximum of two sessions per day may be reported, regardless of the total duration of pulmonary rehabilitation services.
(Rev. 1966, Issued: 05-07-10, Effective: 01-01-10, Implementation: 10-04-10)
Effective for claims with dates of service on and after January 1, 2010, place of service (POS) code 11 shall be used for pulmonary rehabilitation (PR) services provided in a physician’s office and POS 22 shall be used for services provided in a hospital outpatient setting. All other POS codes shall be denied. Medicare contractors shall adjust their prepayment procedure edits as appropriate.
The following messages shall be used when Medicare contractors deny PR claims for POS:
CARC 96: “Non-covered charge(s).”
RARC N428: “Service/procedure not covered when performed in this place of service.”
Medicare Summary Notice (MSN) 21.25: “This service was denied because Medicare only covers this service in certain settings.”
Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.”
NOTE: This is a new MSN message.
Contractors shall use Group Code PR (Patient `Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
Effective for claims with dates of service on and after January 1, 2010, Medicare contractors shall pay for PR services when submitted on a type of bill (TOB) 13X and 85X only, along with revenue code 0948. All other TOBs shall be denied.
The following messages shall be used when Medicare contractors deny PR claims for TOB:
CARC 96: “Non-covered charge(s).”
RARC N428: “Service/procedure not covered when performed in this place of service.”
Medicare Summary Notice (MSN) 21.25: “This service was denied because Medicare only covers this service in certain settings.”
Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.”
NOTE: This is a new MSN message.
Contractors shall use Group Code PR (Patient `Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
Effective for claims with dates of service on or after January 1, 2010, Medicare contractors shall deny all PR claims (both professional and institutional claims) that exceed two units on the same date of service.
The following messages shall be used when Medicare contractors deny PR claims for exceeding the daily frequency limit:
CARC 119: “Benefit maximum for this time period or occurrence has been reached.”
RARC N362: “The number of days or units of service exceeds our acceptable maximum.”
MSN 20.5: “These services cannot be paid because your benefits are exhausted at this time.”
Spanish Version: “Estos servicios no pueden ser pagados porque sus beneficios se han agotado.”
Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
(Rev. 1966, Issued: 05-07-10, Effective: 01-01-10, Implementation: 10-04-10)
When a beneficiary has reached 37 PR sessions, CWF shall reject the claims to the contractors if the KX modifier is not included on the claim line. Effective for claims with dates of service on or after January 1, 2010, Medicare contractors shall deny all claims (both professional and institutional claims) that exceed 36 PR sessions without a KX modifier included on the claim line.
The following messages shall be used when Medicare contractors deny PR claims that exceed 36 sessions, without the KX modifier on the claim line:
CARC 151: “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.”
MSN 23.17: “Medicare won’t cover these services because they are not considered medically necessary.”
Spanish Version: “Medicare no cubrirá estos servicios porque no son considerados necesarios por razones médicas.”
Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
Effective for claims with dates of service on and after January 1, 2010, through December 31, 2021, CWF shall reject PR claims that exceed 72 sessions. Medicare contractors shall deny PR claims that exceed 72 sessions regardless of whether the -KX modifier is submitted on the claim line.
The following messages shall be used when Medicare contractors deny PR claims that exceed 72 sessions:
CARC 119: “Benefit maximum for this time period or occurrence has been reached.”
RARC N362: “The number of days or units of service exceeds our acceptable maximum.”
MSN 20.5: “These services cannot be paid because your benefits are exhausted at this time.”
Spanish Version: “Estos servicios no pueden ser pagados porque sus beneficios se han agotado.”
Contractors shall use Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
Effective for claims with dates of service on and after January 1, 2022, Medicare Contractors shall deny PR claims that exceed 72 sessions only when the -KX modifier is not submitted on the claim line.
(Rev. 931, Issued: 04-28-06, Effective: 02-21-06, Implementation: 05-30-06 Carrier/10-02-06 FI)
(Rev. 2841, Issued: 12-23-13, Effective: 09-24-13, Implementation: 12-17-13)
Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body-mass index (BMI) ≥35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility. A list of approved facilities may be found at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Bariatric-Surgery.html
Effective for services performed on and after February 12, 2009, Medicare has determined that Type 2 diabetes mellitus is a co-morbidity for purposes of processing bariatric surgery claims.
Effective for dates of service on and after September 24, 2013, the Centers for Medicare & Medicaid Services (CMS) has removed the certified facility requirements for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.
Please note the additional national coverage determinations related to bariatric surgery will be consolidated and subsumed into Publication 100-03, Chapter 1, section 100.1. These include sections 40.5, 100.8, 100.11 and 100.14.
Open Roux-en-Y gastric bypass (RYGBP)
Laparoscopic Roux-en-Y gastric bypass (RYGBP)
Laparoscopic adjustable gastric banding (LAGB)
Open biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS)
Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS)
Laparoscopic sleeve gastrectomy (LSG) (Effective June 27, 2012, covered at Medicare Administrative Contractor (MAC) discretion.
For services on or after February 21, 2006, the following HCPCS procedure codes are covered for bariatric surgery:
43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).
43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).
43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847.)
43845 - Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoeostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch).
43846 - Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less Roux-en-Y gastroenterostomy. (For greater than 150 cm, use 43847.) (For laparoscopic procedure, use 43644.)
43847 - With small intestine reconstruction to limit absorption.
43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) (Effective June 27, 2012, covered at contractor's discretion.)
For services on or after February 21, 2006, the following HCPCS procedure codes are non-covered for bariatric surgery:
43842 - Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty NOC code 43999 used to bill for:
Laparoscopic vertical banded gastroplasty
Open sleeve gastrectomy
Open adjustable gastric banding
(Rev. 12683 Issued: 06-13-24; Effective: 01-01-20; Implementation: 07-15-24)
For services on or after October 1, 2015, the following independent ICD-10 procedure codes are covered for bariatric surgery:
| 0D164ZL | Bypass Stomach to Transverse Colon, Percutaneous Endoscopic Approach |
|---|---|
| 0D16079 | Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open Approach |
| 0D1607A | Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Approach |
| 0D1607B | Bypass Stomach to Ileum with Autologous Tissue Substitute, Open Approach |
| 0D1607L | Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Open Approach |
| 0D160J9 | Bypass Stomach to Duodenum with Synthetic Substitute, Open Approach |
| 0D160JA | Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach |
| 0D160JB | Bypass Stomach to Ileum with Synthetic Substitute, Open Approach |
| 0D160JL | Bypass Stomach to Transverse Colon with Synthetic Substitute, Open Approach |
| 0D160K9 | Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Open Approach |
| 0D160KA | Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Open Approach |
| 0D160KB | Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Open Approach |
| 0D160KL | Bypass Stomach to Transverse Colon with Non-autologous Tissue Substitute, Open Approach |
| 0D160Z9 | Bypass Stomach to Duodenum, Open Approach |
| 0D160ZA | Bypass Stomach to Jejunum, Open Approach |
| 0D160ZB | Bypass Stomach to Ileum, Open Approach |
| 0D160ZL | Bypass Stomach to Transverse Colon, Open Approach |
| 0D16879 | Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D1687A | Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D1687B | Bypass Stomach to Ileum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D1687L | Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
|---|---|
| 0D168J9 | Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168JA | Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168JB | Bypass Stomach to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168JL | Bypass Stomach to Transverse Colon with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168K9 | Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168KA | Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168KB | Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168KL | Bypass Stomach to Transverse Colon with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic |
| 0D168Z9 | Bypass Stomach to Duodenum, Via Natural or Artificial Opening Endoscopic |
| 0D168ZA | Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic |
| 0D168ZB | Bypass Stomach to Ileum, Via Natural or Artificial Opening Endoscopic |
| 0D168ZL | Bypass Stomach to Transverse Colon, Via Natural or Artificial Opening Endoscopic |
| 0DV64CZ | Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach |
To describe either laparoscopic or open BPD with DS or GRDS, one code from each of the following three groups must be on the claim:
Group 1:
| 0DB60Z3 | Excision of Stomach, Open Approach, Vertical |
|---|---|
| 0DB60ZZ | Excision of Stomach, Open Approach |
| 0DB63Z3 | Excision of Stomach, Percutaneous Approach, Vertical |
| 0DB63ZZ | Excision of Stomach, Percutaneous Approach |
0DB67Z3 Excision of Stomach, Via Natural or Artificial Opening, Vertical 0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening 0DB68Z3 Excision of Stomach, Via Natural or Artificial Opening Endoscopic, Vertical
Group 2:
(Note: One code from A-C below is required for a correct equivalent)
0DB80ZZ Excision of Small Intestine, Open Approach – A 0DB84ZZ Excision of Small Intestine, Perc Endo Approach – A (Effective 01-01-20) 0DB90ZZ Excision of Duodenum, Open Approach – A 0DB93ZZ Excision of Duodenum, Percutaneous Approach – A (Effective 01-01-20) 0DBB0ZZ Excision of Ileum, Open Approach – A 0DBB3ZZ Excision of Ileum, Percutaneous Approach – A (Effective 01-01-20) 0D160ZB Bypass Stomach to Ileum, Open Approach – B 0D164ZB Bypass Stomach to Ileum, Percutaneous Endoscopic Approach – B (Effective 01-01-20) 0F190Z3 Bypass Common Bile Duct to Duodenum, Open Approach – C 0F194Z3 Bypass Common Bile Duct to Duodenum, Perc Endo Approach – C (Effective 01-01-20)
Group 3:
0D19079 Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Open Approach 0D1907A Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Open Approach 0D1907B Bypass Duodenum to Ileum with Autologous Tissue Substitute, Open Approach 0D190J9 Bypass Duodenum to Duodenum with Synthetic Substitute, Open Approach 0D190JA Bypass Duodenum to Jejunum with Synthetic Substitute, Open Approach 0D190JB Bypass Duodenum to Ileum with Synthetic Substitute, Open Approach 0D190K9 Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute, Open Approach 0D190KA Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute, Open Approach 0D190KB Bypass Duodenum to Ileum with Non-autologous Tissue Substitute, Open Approach 0D190Z9 Bypass Duodenum to Duodenum, Open Approach 0D190ZA Bypass Duodenum to Jejunum, Open Approach 0D190ZB Bypass Duodenum to Ileum, Open Approach 0D19479 Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach
0D1947A Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach0D1947B Bypass Duodenum to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach0D194J9 Bypass Duodenum to Duodenum with Synthetic Substitute, Percutaneous Endoscopic Approach0D194JA Bypass Duodenum to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach0D194JB Bypass Duodenum to Ileum with Synthetic Substitute, Percutaneous Endoscopic Approach0D194K9 Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach0D194KA Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach0D194KB Bypass Duodenum to Ileum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach0D194Z9 Bypass Duodenum to Duodenum, Percutaneous Endoscopic Approach0D194ZA Bypass Duodenum to Jejunum, Percutaneous Endoscopic Approach0D194ZB Bypass Duodenum to Ileum, Percutaneous Endoscopic Approach0D19879 Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D1987A Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D1987B Bypass Duodenum to Ileum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D198J9 Bypass Duodenum to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic0D198JA Bypass Duodenum to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic0D198JB Bypass Duodenum to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic0D198K9 Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D198KA Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic
0D198KB Bypass Duodenum to Ileum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D198Z9 Bypass Duodenum to Duodenum, Via Natural or Artificial Opening Endoscopic 0D198ZA Bypass Duodenum to Jejunum, Via Natural or Artificial Opening Endoscopic 0D198ZB Bypass Duodenum to Ileum, Via Natural or Artificial Opening Endoscopic 0D1A07A Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Open Approach 0D1A07B Bypass Jejunum to Ileum with Autologous Tissue Substitute, Open Approach 0D1A0JA Bypass Jejunum to Jejunum with Synthetic Substitute, Open Approach 0D1A0JB Bypass Jejunum to Ileum with Synthetic Substitute, Open Approach 0D1A0KA Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Open Approach 0D1A0KB Bypass Jejunum to Ileum with Non-autologous Tissue Substitute, Open Approach 0D1A0ZA Bypass Jejunum to Jejunum, Open Approach 0D1A0ZB Bypass Jejunum to Ileum, Open Approach 0D1A47A Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1A47B Bypass Jejunum to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1A4JA Bypass Jejunum to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach 0D1A4JB Bypass Jejunum to Ileum with Synthetic Substitute, Percutaneous Endoscopic Approach 0D1A4KA Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1A4KB Bypass Jejunum to Ileum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1A4ZA Bypass Jejunum to Jejunum, Percutaneous Endoscopic Approach 0D1A4ZB Bypass Jejunum to Ileum, Percutaneous Endoscopic Approach 0D1A87A Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic
0D1A87B Bypass Jejunum to Ileum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D1A8JA Bypass Jejunum to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic0D1A8JB Bypass Jejunum to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic0D1A8KA Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D1A8KB Bypass Jejunum to Ileum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D1A8ZA Bypass Jejunum to Jejunum, Via Natural or Artificial Opening Endoscopic0D1A8ZB Bypass Jejunum to Ileum, Via Natural or Artificial Opening Endoscopic0D1A8ZH Bypass Jejunum to Cecum, Via Natural or Artificial Opening Endoscopic0D1B07B Bypass Ileum to Ileum with Autologous Tissue Substitute, Open Approach0D1B0JB Bypass Ileum to Ileum with Synthetic Substitute, Open Approach0D1B0KB Bypass Ileum to Ileum with Non-autologous Tissue Substitute, Open Approach0D1B0ZB Bypass Ileum to Ileum, Open Approach0D1B47B Bypass Ileum to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach0D1B4JB Bypass Ileum to Ileum with Synthetic Substitute, Percutaneous Endoscopic Approach0D1B4KB Bypass Ileum to Ileum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach0D1B4ZB Bypass Ileum to Ileum, Percutaneous Endoscopic Approach0D1B87B Bypass Ileum to Ileum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic0D1B8JB Bypass Ileum to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic
0D1B8KB Bypass Ileum to Ileum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D1B8ZB Bypass Ileum to Ileum, Via Natural or Artificial Opening Endoscopic 0D1B8ZH Bypass Ileum to Cecum, Via Natural or Artificial Opening Endoscopic
NOTE: There is no distinction between open and laparoscopic BPD with DS or GRDS for the inpatient setting. For either approach, one code from each of the above three groups must appear on the claim to be covered.
Effective October 1, 2015, the following ICD-10 procedure code is covered for bariatric surgery at contractor discretion:
0DB64Z3 Excision of stomach, percutaneous endoscopic approach, vertical.
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
For services on or after October 1, 2015, the following ICD-10 diagnosis code is covered for bariatric surgery if certain other conditions are met:
E66.01 - Morbid (severe) obesity due to excess calories
E66.812 - Obesity, class 2, effective October 1, 2024
E66.813 – Obesity, class 3, effective October 1, 2024
Effective for services performed on and after February 12, 2009, type 2 diabetes mellitus (T2DM) is considered a comorbid condition related to morbid obesity for covered bariatric surgery procedures in Medicare beneficiaries with a BMI ≥35. When T2DM is the comorbid condition related to morbid obesity, the claim must include a covered ICD procedure code, ICD diagnosis code E66.01, E66.812 or E66.813 as a primary diagnosis, a covered ICD diagnosis code indicating T2DM as a secondary diagnosis, and an ICD diagnosis code indicating a BMI ≥ 35 as a secondary diagnosis.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
The following ICD-10 diagnosis codes identify BMI ≥35:
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
| E11.9 | Type 2 diabetes mellitus without complications |
|---|---|
| E13.9 | Other specified diabetes mellitus without complications |
| E11.65 | Type 2 diabetes mellitus with hyperglycemia |
| E13.10 | Other specified diabetes mellitus with ketoacidosis without coma |
| E11.69 | Type 2 diabetes mellitus with other specified complication |
| Note: E11.69 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E11.00 | Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) |
| E11.01 | Type 2 diabetes mellitus with hyperosmolarity with coma |
| E13.00 | Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) |
| E13.01 | Other specified diabetes mellitus with hyperosmolarity with coma |
| Note: E11.00 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E11.641 | Type 2 diabetes mellitus with hypoglycemia with coma |
| E13.11 | Other specified diabetes mellitus with ketoacidosis with coma |
| E13.641 | Other specified diabetes mellitus with hypoglycemia with coma |
| Note: E11.01 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E11.21 | Type 2 diabetes mellitus with diabetic nephropathy |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| E11.29 | Type 2 diabetes mellitus with other diabetic kidney complication |
| E13.21 | Other specified diabetes mellitus with diabetic nephropathy |
| E13.22 | Other specified diabetes mellitus with diabetic chronic kidney disease |
| E13.29 | Other specified diabetes mellitus with other diabetic kidney complication |
| Note: E11.21 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E11.3211 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E11.3212 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E11.3213 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E11.3591 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
| E11.3592 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E11.3593 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E11.37X1 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E11.37X2 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E11.37X3 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
|---|---|
| E11.3291 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E11.3292 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E11.3293 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E11.3311 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E11.3312 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E11.3313 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E11.3391 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E11.3392 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E11.3393 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E11.3411 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E11.3412 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E11.3413 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E11.3491 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E11.3492 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E11.3493 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
| E11.3511 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E11.3512 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E11.3513 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E11.3521 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
| E11.3522 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E11.3523 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E11.3531 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E11.3532 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E11.3533 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E11.3591 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
|---|---|
| E11.3592 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E11.3593 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E11.37X1 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E11.37X2 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E11.37X3 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
| E13.311 | Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E13.319 | Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E13.3211 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E13.3212 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E13.3213 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E13.3291 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E13.3292 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E13.3293 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E13.3311 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E13.3312 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E13.3313 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E13.3391 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E13.3392 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E13.3393 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E13.3411 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E13.3412 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E13.3413 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E13.3491 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E13.3492 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E13.3493 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
|---|---|
| E13.3511 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E13.3512 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E13.3513 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E13.3521 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
| E13.3522 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E13.3523 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E13.3531 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E13.3532 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E13.3533 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E13.3541 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
| E13.3542 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
| E13.3543 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
| E13.3551 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
| E13.3552 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
| E13.3553 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
| E13.3591 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
| E13.3592 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E13.3593 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E13.36 | Other specified diabetes mellitus with diabetic cataract |
| E13.39 | Other specified diabetes mellitus with other diabetic ophthalmic complication |
| E11.311 | Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema OR |
| E11.319 | Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema OR |
| E11.36 | Type 2 diabetes mellitus with diabetic cataract OR |
| E11.39 | Type 2 diabetes mellitus with other diabetic ophthalmic complication AND |
| Note: E11.39 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy | |
|---|---|
| E13.37X1 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E13.37X2 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E13.37X3 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| E13.40 | Other specified diabetes mellitus with diabetic neuropathy, unspecified |
| 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 |
| Note: E11.40 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E11.51 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E11.52 | Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E11.59 | Type 2 diabetes mellitus with other circulatory complications |
| E13.51 | Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E13.52 | Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E13.59 | Other specified diabetes mellitus with other circulatory complications |
| Note: E11.51 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E11.618 | Type 2 diabetes mellitus with other diabetic arthropathy |
| E11.620 | Type 2 diabetes mellitus with diabetic dermatitis |
| E11.621 | Type 2 diabetes mellitus with foot ulcer |
| E11.622 | Type 2 diabetes mellitus with other skin ulcer |
| E11.628 | Type 2 diabetes mellitus with other skin complications |
| E11.630 | Type 2 diabetes mellitus with periodontal disease |
| E11.638 | Type 2 diabetes mellitus with other oral complications |
| E11.649 | Type 2 diabetes mellitus with hypoglycemia without coma |
| E13.618 | Other specified diabetes mellitus with other diabetic arthropathy |
| E13.620 | Other specified diabetes mellitus with diabetic dermatitis |
| E13.621 | Other specified diabetes mellitus with foot ulcer |
|---|---|
| E13.622 | Other specified diabetes mellitus with other skin ulcer |
| E13.628 | Other specified diabetes mellitus with other skin complications |
| E13.630 | Other specified diabetes mellitus with periodontal disease |
| E13.638 | Other specified diabetes mellitus with other oral complications |
| E13.649 | Other specified diabetes mellitus with hypoglycemia without coma |
| E13.65 | Other specified diabetes mellitus with hyperglycemia |
| E13.69 | Other specified diabetes mellitus with other specified complication |
| Note: E11.69 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. | |
| E13.8 | Other specified diabetes mellitus with unspecified complications |
| E11.8 | Type 2 diabetes mellitus with unspecified complications |
| Note: E11.8 with E11.65 are a cluster BUT since each code on its own justifies the service, the combination is not required together for this policy. |
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
Contractors shall process covered bariatric surgery claims as follows:
Contractors identify inpatient bariatric surgery claims by the presence of ICD-10 diagnosis code E66.01, E66.812 or E66.813 as the primary diagnosis (for morbid obesity) and one of the covered ICD-10 procedure codes listed in §150.3.
Contractors identify practitioner bariatric surgery claims by the presence of ICD-10 diagnosis code E66.01, E66.812 or E66.813 as the primary diagnosis (for morbid obesity) and one of the covered HCPCS procedure codes listed in §150.2.
A list of approved facilities is found at the link noted in section 150.1, section A, above.
The A/B MAC medical director may define the appropriate method for addressing the obesity-related co-morbid requirement.
Effective for dates of service on and after September 24, 2013, CMS has removed the certified facility requirements for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.
NOTE: If ICD-10 diagnosis code E66.01, E66.812 or E66.813 is present, but a covered procedure code (listed in §150.2 or §150.3) is/are not present, the claim is not for bariatric surgery and should be processed under normal procedures.
When rejecting/denying claims because bariatric surgery procedures were performed in an unapproved facility use:
When rejecting/denying claims for non-covered bariatric surgery procedures use:
When rejecting/denying claims for covered bariatric surgery procedures because the patient did not meet the conditions for coverage use:
In addition to the codes listed above, afford appeal rights to all denied parties.
(Rev. 2841, Issued: 12-23-13, Effective: 09-24-13, Implementation: 12-17-13)
The A/MAC billing requirements will pay for bariatric surgery only when the services are submitted on the following type of bill (TOB): 11X. Type of facility and setting determines the basis of payment:
(Rev. 1233, Issued: 04-27-07, Effective: 02-21-06, Implementation: 05-29-07)
Physicians must be advised that the physician is liable for charges if the surgery is performed in an unapproved facility, unless the beneficiary was informed that he or she would be financially responsible prior to performance for the procedure. The provider must have the beneficiary sign an advance beneficiary notice (ABN) if the bariatric surgery is performed in an unapproved facility. Note that the ABN is the appropriate notice for Part B services.
The HINN model language should be adapted to this situation in the sections addressing: description of the care at issue if the surgery is performed on an inpatient basis, in an unapproved facility, to avoid being liable, the provider must issue a HINN. Other content requirements of HINN still apply. Use the HINN letter most appropriate to the overall situation.
(Rev. 1042, Issued: 08-25-06; Effective: 03-17-05; Implementation: 10-02-06)
Effective July 1, 2001, Medicare covers percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stent placement when furnished in accordance with the Food and Drug Administration (FDA) protocols governing Category B Investigational Device Exemption (IDE) studies.
The billing for this procedure is based upon how the service is delivered. There are several CPT codes that may be billed depending upon how the procedure is performed. Contractor medical directors should consider what provider education information is needed to assist providers on the billing for this service.
Contractors must review their local coverage determinations to ensure that payment is provided for claims for PTA in an FDA-approved clinical study.
As a requirement for Category B IDE coverage, providers must bill a six-digit IDE Number that begins with a “G” (i.e., G123456). To identify the line as an IDE line, institutional providers must bill this IDE Number on a 0624 Revenue Code line while practitioners must bill this IDE Number along with a Q0 modifier.
Effective October 12, 2004, under section B3 of NCD 20.7, Medicare covers PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent and an FDA-approved or –cleared embolic protection device (effective December 9, 2009) for an FDA-approved indication when furnished in accordance with FDA-approved protocols governing post-approval studies. Also included in the currently covered population of patients participating in FDA-approved post-approval studies are patients participating in post-approval extension studies and patients participating in studies following FDA 510k approval of these devices.
Billing post-approval studies is similar to normal Category B IDE billing procedures, except that under post-approval coverage, providers must bill the Pre-Market Approval (PMA) number assigned to the stent system by the FDA. PMA numbers are like typical IDE Numbers in that they have six-digits, but they begin with a “P” (i.e., P123456) instead of a “G.”
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
As the post-approval studies began to end, CMS received requests to extend coverage for the post-approval studies. CMS has reviewed the extension requests and has determined that patients participating in post-approval extension studies are also included in the currently covered population of patients participating in FDA-approved post-approval studies.
To grant approval for post-approval studies, the FDA reviews each study protocol. Once approval is granted, the FDA issues a formal approval letter to the study sponsor.
Extensions of post-approval studies are not subject to approval by the FDA because they surpass the post-approval study requirements identified in the conditions of approval for post-approval studies. Since the FDA cannot approve these extension studies, individual Post-Market Approval (PMA) numbers cannot be issued to separately identify each study. Currently, in order to receive reimbursement for procedures performed as part of a carotid artery stenting post-approval study, providers must include the FDA-issued PMA number on each claim to indicate participation in a specific study.
CMS has determined that all extension studies must be reviewed by the FDA. The FDA will issue an acknowledgement letter stating that the extension study is scientifically valid and will generate clinically relevant post-market data. Upon receipt of this letter and review of the extension study protocol, CMS will issue a letter to the study sponsor indicating that the study under review will be covered by Medicare. Since an individual PMA number cannot be assigned by the FDA to each extension study, these studies will use the PMA number assigned to the original FDA-approved post-approval study (i.e., CAPTURE 2 shall use the PMA number assigned to CAPTURE 1).
In order to receive Medicare coverage for patients participating in post-approval extension studies, providers shall submit both the FDA acknowledgement letter and the CMS letter providing coverage for the extension study to their contractor. Additionally, providers shall submit any other materials contractors would require for FDA-approved post- approval studies.
In response, contractors will issue a letter assigning an effective date for each facility’s participation in the extension study. Providers may bill for procedures performed in the extension study for dates of service on and after the assigned effective date. Providers billing A/B MACs (A) must bill using the most current ICD-10-CM is applicable, Indications for PTA of the Carotid Artery Concurrent with Stenting (must bill one of these primary codes to meet coverage under 20.7B2, 20.7B3, 20.7B4)
| I63.031 | Cerebral infarction due to thrombosis of right carotid artery |
|---|---|
| I63.032 | Cerebral infarction due to thrombosis of left carotid artery |
| I63.033 | Cerebral infarction due to thrombosis of bilateral carotid arteries |
| I63.131 | Cerebral infarction due to embolism of right carotid artery |
| I63.132 | Cerebral infarction due to embolism of left carotid artery |
| I63.133 | Cerebral infarction due to embolism of bilateral carotid arteries |
| I63.231 | Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries |
| I63.232 | Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries |
| I63.233 | Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries |
| I65.21 | Occlusion and stenosis of right carotid artery |
| I65.22 | Occlusion and stenosis of left carotid artery |
| I65.23 | Occlusion and stenosis of bilateral carotid arteries |
ICD-10-PCS codes may be used.
| 037G34Z | Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
|---|---|
| 037G35Z | Dilation of Intracranial Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037G36Z | Dilation of Intracranial Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037G37Z | Dilation of Intracranial Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037G3DZ | Dilation of Intracranial Artery with Intraluminal Device, Percutaneous Approach |
| 037G3EZ | Dilation of Intracranial Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037G3FZ | Dilation of Intracranial Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037G3GZ | Dilation of Intracranial Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037G44Z | Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037G45Z | Dilation of Intracranial Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G46Z | Dilation of Intracranial Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G47Z | Dilation of Intracranial Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G4DZ | Dilation of Intracranial Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037G4EZ | Dilation of Intracranial Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G4FZ | Dilation of Intracranial Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G4GZ | Dilation of Intracranial Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
|---|---|
| 037H34Z | Dilation of Right Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037H35Z | Dilation of Right Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037H36Z | Dilation of Right Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037H37Z | Dilation of Right Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037H3DZ | Dilation of Right Common Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037H3EZ | Dilation of Right Common Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037H3FZ | Dilation of Right Common Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037H3GZ | Dilation of Right Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037H44Z | Dilation of Right Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037H45Z | Dilation of Right Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H46Z | Dilation of Right Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H47Z | Dilation of Right Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H4DZ | Dilation of Right Common Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037H4EZ | Dilation of Right Common Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H4FZ | Dilation of Right Common Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H4GZ | Dilation of Right Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J34Z | Dilation of Left Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037J35Z | Dilation of Left Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037J36Z | Dilation of Left Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037J37Z | Dilation of Left Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037J3DZ | Dilation of Left Common Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037J3EZ | Dilation of Left Common Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037J3FZ | Dilation of Left Common Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037J3GZ | Dilation of Left Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037J44Z | Dilation of Left Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037J45Z | Dilation of Left Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J46Z | Dilation of Left Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J47Z | Dilation of Left Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
|---|---|
| 037J4DZ | Dilation of Left Common Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037J4EZ | Dilation of Left Common Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J4FZ | Dilation of Left Common Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J4GZ | Dilation of Left Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K34Z | Dilation of Right Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037K35Z | Dilation of Right Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037K36Z | Dilation of Right Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037K37Z | Dilation of Right Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037K3DZ | Dilation of Right Internal Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037K3EZ | Dilation of Right Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037K3FZ | Dilation of Right Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037K3GZ | Dilation of Right Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037K44Z | Dilation of Right Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037K45Z | Dilation of Right Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K46Z | Dilation of Right Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K47Z | Dilation of Right Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K4DZ | Dilation of Right Internal Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037K4EZ | Dilation of Right Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K4FZ | Dilation of Right Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K4GZ | Dilation of Right Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L34Z | Dilation of Left Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037L35Z | Dilation of Left Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037L36Z | Dilation of Left Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037L37Z | Dilation of Left Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037L3DZ | Dilation of Left Internal Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037L3EZ | Dilation of Left Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037L3FZ | Dilation of Left Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037L3GZ | Dilation of Left Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
|---|---|
| 037L44Z | Dilation of Left Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037L45Z | Dilation of Left Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L46Z | Dilation of Left Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L47Z | Dilation of Left Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L4DZ | Dilation of Left Internal Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037L4EZ | Dilation of Left Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L4FZ | Dilation of Left Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L4GZ | Dilation of Left Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M34Z | Dilation of Right External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037M35Z | Dilation of Right External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037M36Z | Dilation of Right External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037M37Z | Dilation of Right External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037M3DZ | Dilation of Right External Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037M3EZ | Dilation of Right External Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037M3FZ | Dilation of Right External Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037M3GZ | Dilation of Right External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037M44Z | Dilation of Right External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037M45Z | Dilation of Right External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M46Z | Dilation of Right External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M47Z | Dilation of Right External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M4DZ | Dilation of Right External Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037M4EZ | Dilation of Right External Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M4FZ | Dilation of Right External Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M4GZ | Dilation of Right External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N34Z | Dilation of Left External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037N35Z | Dilation of Left External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037N36Z | Dilation of Left External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
|---|---|
| 037N37Z | Dilation of Left External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037N3DZ | Dilation of Left External Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037N3EZ | Dilation of Left External Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037N3FZ | Dilation of Left External Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037N3GZ | Dilation of Left External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037N44Z | Dilation of Left External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037N45Z | Dilation of Left External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N46Z | Dilation of Left External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N47Z | Dilation of Left External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N4DZ | Dilation of Left External Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037N4EZ | Dilation of Left External Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N4FZ | Dilation of Left External Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N4GZ | Dilation of Left External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
On October 11, 2023, CMS issued a reconsideration of NCD 20.7. The updated NCD covers PTA of the carotid artery concurrent with stenting with the placement of an FDA-approved carotid stent with an FDA-approved or cleared embolic protection device, for Medicare beneficiaries with symptomatic carotid artery stenosis ≥50% and asymptomatic carotid artery stenosis ≥70%. The NCD also sets forth requirements regarding neurological assessments, imaging, shared decision-making, and retains institutional and physician standards but removes the requirement that facilities that perform CAS procedures must be approved by CMS. Additionally, CMS revised section D of NCD 20.7 to allow MACs to make reasonable and necessary determinations under section 1862(a)(1)(A) for any other beneficiary seeking coverage for PTA of the carotid artery concurrent with stenting.
Effective for claims with dates of services on or after October 11, 2023, contractors shall cover PTA of the carotid artery concurrent with stenting with the placement of an FDA-approved carotid stent with an FDA-approved or cleared embolic protection device, for Medicare beneficiaries under the following conditions:
Also effective for claims with dates of service on or after October 11, 2023, beneficiaries no longer have to be enrolled in a clinical trial for this service. Contractors may also pay for claims for PTA of the carotid artery
concurrent with stenting not otherwise addressed in The National Coverage Determinations Manual, Chapter 1, part 1, section 20.7 at local discretion.
Effective March 17, 2005, through October 10, 2023, Medicare covered PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent with embolic protection under specific patient indications found in Pub. 100-03, Medicare National Coverage Determinations Manual, part 1, section 20.7. Coverage was limited to procedures performed using FDA-approved CAS systems and FDA-approved or – cleared (effective December 9, 2009) embolic protection devices (EPDs). If deployment of the EPD was not technically possible, and not performed, then the procedure was not covered.
In addition to the specific patient indications, CMS determined that CAS with embolic protection was reasonable and necessary only if performed in facilities that had been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. CMS created a list of minimum standards modeled in part on professional society statements on competency. All facilities were required to at least meet CMS’s standards in order to receive coverage for CAS for high-risk patients. Facilities were required to recertify every 2 years in order to maintain coverage of CAS procedures.
In the past, PTA to treat obstructive lesions of the cerebral arteries was non-covered by Medicare because the safety and efficacy of the procedure had not been established. This national coverage determination (NCD) meant that the procedure was also non-covered for beneficiaries participating in Food and Drug Administration (FDA)-approved investigational device exemption (IDE) clinical trials.
On February 9, 2006, a request for reconsideration of this NCD initiated a national coverage analysis. CMS reviewed the evidence and determined that intracranial PTA with stenting is reasonable and necessary under §1862(a)(1)(A) of the Social Security Act for the treatment of cerebral vessels (as specified in The National Coverage Determinations Manual, Chapter 1, part 1, section 20.7) only when furnished in accordance with FDA- approved protocols governing Category B IDE clinical trials. All other indications for intracranial PTA with stenting remain non-covered.
Providers of covered intracranial PTA with stenting shall use Category B IDE billing requirements, as listed above in section 68.4. In addition to these requirements, providers must bill the appropriate procedure and diagnosis codes for the date of service to receive payment.
See the below ICD-10-CM diagnosis codes list applies, depending on the date of service. Indications for PTA and Stenting of Intracranial Arteries (must bill I67.2 and one of these primary codes to meet coverage under 20.7B5)
If ICD-10-CM is applicable:
| I67.2 Cerebral atherosclerosis |
|---|
| I66.01 | Occlusion and stenosis of right middle cerebral artery |
|---|---|
| I66.02 | Occlusion and stenosis of left middle cerebral artery |
| I66.03 | Occlusion and stenosis of bilateral middle cerebral arteries |
| I66.11 | Occlusion and stenosis of right anterior cerebral artery |
| I66.12 | Occlusion and stenosis of left anterior cerebral artery |
| I66.13 | Occlusion and stenosis of bilateral anterior cerebral arteries |
| I66.21 | Occlusion and stenosis of right posterior cerebral artery |
| I66.22 | Occlusion and stenosis of left posterior cerebral artery |
| I66.23 | Occlusion and stenosis of bilateral posterior cerebral arteries |
| I66.8 | Occlusion and stenosis of other cerebral arteries |
| I63.59 | Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery |
If ICD-10-PCS is applicable, ICD-10-PCS procedure codes.
That is, under Part A, providers must bill intracranial PTA using if ICD-10-PCS procedure codes is applicable.
| 037G34Z | Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
|---|---|
| 037G35Z | Dilation of Intracranial Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037G36Z | Dilation of Intracranial Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037G37Z | Dilation of Intracranial Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037G3DZ | Dilation of Intracranial Artery with Intraluminal Device, Percutaneous Approach |
| 037G3EZ | Dilation of Intracranial Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037G3FZ | Dilation of Intracranial Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037G3GZ | Dilation of Intracranial Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037G44Z | Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037G45Z | Dilation of Intracranial Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G46Z | Dilation of Intracranial Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G47Z | Dilation of Intracranial Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G4DZ | Dilation of Intracranial Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037G4EZ | Dilation of Intracranial Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G4FZ | Dilation of Intracranial Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037G4GZ | Dilation of Intracranial Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H34Z | Dilation of Right Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037H35Z | Dilation of Right Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
|---|---|
| 037H36Z | Dilation of Right Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037H37Z | Dilation of Right Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037H3DZ | Dilation of Right Common Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037H3EZ | Dilation of Right Common Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037H3FZ | Dilation of Right Common Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037H3GZ | Dilation of Right Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037H44Z | Dilation of Right Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037H45Z | Dilation of Right Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H46Z | Dilation of Right Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H47Z | Dilation of Right Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H4DZ | Dilation of Right Common Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037H4EZ | Dilation of Right Common Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H4FZ | Dilation of Right Common Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037H4GZ | Dilation of Right Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J34Z | Dilation of Left Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037J35Z | Dilation of Left Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037J36Z | Dilation of Left Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037J37Z | Dilation of Left Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037J3DZ | Dilation of Left Common Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037J3EZ | Dilation of Left Common Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037J3FZ | Dilation of Left Common Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037J3GZ | Dilation of Left Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037J44Z | Dilation of Left Common Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037J45Z | Dilation of Left Common Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J46Z | Dilation of Left Common Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
|---|---|
| 037J47Z | Dilation of Left Common Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J4DZ | Dilation of Left Common Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037J4EZ | Dilation of Left Common Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J4FZ | Dilation of Left Common Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037J4GZ | Dilation of Left Common Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K34Z | Dilation of Right Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037K35Z | Dilation of Right Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037K36Z | Dilation of Right Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037K37Z | Dilation of Right Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037K3DZ | Dilation of Right Internal Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037K3EZ | Dilation of Right Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037K3FZ | Dilation of Right Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037K3GZ | Dilation of Right Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037K44Z | Dilation of Right Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037K45Z | Dilation of Right Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K46Z | Dilation of Right Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K47Z | Dilation of Right Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K4DZ | Dilation of Right Internal Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037K4EZ | Dilation of Right Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K4FZ | Dilation of Right Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037K4GZ | Dilation of Right Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L34Z | Dilation of Left Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037L35Z | Dilation of Left Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037L36Z | Dilation of Left Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037L37Z | Dilation of Left Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
|---|---|
| 037L3DZ | Dilation of Left Internal Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037L3EZ | Dilation of Left Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037L3FZ | Dilation of Left Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037L3GZ | Dilation of Left Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037L44Z | Dilation of Left Internal Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037L45Z | Dilation of Left Internal Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L46Z | Dilation of Left Internal Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L47Z | Dilation of Left Internal Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L4DZ | Dilation of Left Internal Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037L4EZ | Dilation of Left Internal Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L4FZ | Dilation of Left Internal Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037L4GZ | Dilation of Left Internal Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M34Z | Dilation of Right External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037M35Z | Dilation of Right External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037M36Z | Dilation of Right External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037M37Z | Dilation of Right External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037M3DZ | Dilation of Right External Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037M3EZ | Dilation of Right External Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037M3FZ | Dilation of Right External Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037M3GZ | Dilation of Right External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037M44Z | Dilation of Right External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037M45Z | Dilation of Right External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M46Z | Dilation of Right External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M47Z | Dilation of Right External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M4DZ | Dilation of Right External Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
|---|---|
| 037M4EZ | Dilation of Right External Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M4FZ | Dilation of Right External Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037M4GZ | Dilation of Right External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N34Z | Dilation of Left External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Approach |
| 037N35Z | Dilation of Left External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037N36Z | Dilation of Left External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037N37Z | Dilation of Left External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Approach |
| 037N3DZ | Dilation of Left External Carotid Artery with Intraluminal Device, Percutaneous Approach |
| 037N3EZ | Dilation of Left External Carotid Artery with Two Intraluminal Devices, Percutaneous Approach |
| 037N3FZ | Dilation of Left External Carotid Artery with Three Intraluminal Devices, Percutaneous Approach |
| 037N3GZ | Dilation of Left External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Approach |
| 037N44Z | Dilation of Left External Carotid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach |
| 037N45Z | Dilation of Left External Carotid Artery with Two Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N46Z | Dilation of Left External Carotid Artery with Three Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N47Z | Dilation of Left External Carotid Artery with Four or More Drug-eluting Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N4DZ | Dilation of Left External Carotid Artery with Intraluminal Device, Percutaneous Endoscopic Approach |
| 037N4EZ | Dilation of Left External Carotid Artery with Two Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N4FZ | Dilation of Left External Carotid Artery with Three Intraluminal Devices, Percutaneous Endoscopic Approach |
| 037N4GZ | Dilation of Left External Carotid Artery with Four or More Intraluminal Devices, Percutaneous Endoscopic Approach |
Under Part B, providers must bill HCPCS procedure code 37799. If above ICD-10-CM is applicable.
NOTE: ICD- codes are subject to modification. Providers must always ensure they are using the latest and most appropriate codes.
(Rev. 992, Issued: 06-23-06, Effective: 05-16-06, Implementation: Carriers 07-17-06/FIs 10-01-06)
(Rev. 1340, Issued: 09-21-07, Effective: 08-14-07, Implementation: 10-01-07)
Effective for services performed from May 16, 2006 through August 13, 2007, the Centers for Medicare & Medicaid Services (CMS) made the decision that lumbar artificial disc replacement (LADR) with the Charite™ lumbar artificial disc is non-covered for Medicare beneficiaries over 60 years of age. See Pub. 100-03, Medicare National Coverage Determinations Manual, section 150.10, for more information about the non-covered determination.
Effective for services performed on or after August 14, 2007, CMS made the decision that LADR with any lumbar artificial disc is non-covered for Medicare beneficiaries over 60 years of age, (i.e., on or after a beneficiary's 61st birthday).
For Medicare beneficiaries 60 years of age and younger, there is no national coverage determination for LADR, leaving such determinations to continue to be made by the local contractors.
(Rev. 11902; Issued:03-16-23; Effective: 04-17-23; Implementation: 04-17-23)
Effective for services performed on or after May 16, 2006 through December 31, 2006, carriers shall deny claims, for Medicare beneficiaries over 60 years of age, submitted with the following Category III Codes:
Effective for services performed on or after January 1, 2007 through August 13, 2007, for Medicare beneficiaries over 60 years of age, LADR with the Charite™ lumbar artificial disc, carriers shall deny claims submitted with the following codes:
Carriers shall continue to follow their normal claims processing criteria for IDEs for LADR performed with an implant eligible under the IDE criteria.
For dates of service May 16, 2006 through August 13, 2007, Medicare coverage under the investigational device exemption (IDE) for LADR with a disc other than the Charite™ lumbar disc in eligible clinical trials is not impacted.
Effective for services performed on or after August 14, 2007, carriers shall deny claims for LADR surgery, for Medicare beneficiaries over 60 years of age, (i.e., on or after a beneficiary's 61st birthday) submitted with the following codes:
22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace
0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace NOTE: Effective December 31, 2022, code 0163T is end dated.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
The A/B MAC (A) will pay for LADR when approved under the IDE/clinical trial criteria only when submitted with ICD-9-CM procedure code 84.65 if ICD-9 is applicable, with condition code 30 and if ICD-9-CM is applicable, ICD-9-CM diagnosis code V70.7 when submitted on type of bill (TOB) 11X from May 16, 2006 through August 13, 2007.
Special Billing instructions:
For services performed on TOB 11X in critical access hospitals (CAH), the payment will be 101% of reasonable cost.
For services performed on TOB 11X Indian Health Services (IHS) inpatient hospitals will pay under the inpatient prospective payment system (IPPS) based on the DRG.
For services performed on TOB 11X, IHS CAHs will pay under 101% facility specific per diem rate.
NOTE: The ICD-9-CM procedure code 84.65 is not payable for beneficiaries over 60 years of age, with the Charite™ lumbar artificial disc, which is the only one that is FDA approved for any diagnosis. If a different manufacture's disc is used in an approved clinical trials or is an approved IDE, then condition code 30 and ICD-9-CM diagnosis code V70.7 must be on the claim for it to be payable.
Effective for discharges on or after August 14, 2007, CMS has found that LADR is not reasonable and necessary for the Medicare population over 60 years of age. Therefore, LADR is non-covered for Medicare beneficiaries over 60 years of age as identified in section 150.10, of Pub.100-03, the NCD Manual. A/B MACS (A) shall deny claims with ICD-9-CM procedure code 84.65 for Medicare beneficiaries over 60 years of age.
For Medicare beneficiaries 60 years of age and younger, there is no NCD, leaving such determinations to continue to be made by the local contractors.
(Rev. 1340, Issued: 09-21-07, Effective: 08-14-07, Implementation: 10-01-07)
Contractors shall use the following messages when denying claims for Medicare beneficiaries over 60 years of age (i.e. on or after a beneficiary's 61st birthday).
21.24 "This service is not covered for patients over age 60."
"Este servicio no está cubierto en pacientes mayores de 60 años."
Use an appropriate Claim Adjustment Reason Code:
96 "Non-covered charge(s)."
Use an appropriate Remittance Advice Remark Code:
N386 "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have Web access, you may contact the contractor to request a copy of the NCD."
(Rev. 1340, Issued: 09-21-07, Effective: 08-14-07, Implementation: 10-01-07)
Providers must be advised that the provider is liable for charges if the lumbar artificial disc replacement is used in the surgery, unless the beneficiary was informed that he/she would be financially responsible prior to performance of the procedure. To avoid this liability the provider should have the beneficiary sign an ABN.
The HINN model language should be adapted to this situation in the sections addressing description of the care at issue if the surgery is performed on an inpatient basis. Unless the beneficiary was informed prior to the admission that he/ she would be financially liable for the admission, the provider is liable. To avoid this liability the provider must issue a HINN. Other content requirements of a HINN still apply. Use the HINN letter most appropriate to the overall situation.
(Rev. 1111, Issued: 11-09-06, Effective: 04-01-07, Implementation: 04-02-07)
Cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CAP), destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the prostate gland.
(Rev. 1111, Issued: 11-09-06, Effective: 04-01-07, Implementation: 04-02-07)
Medicare covers cryosurgery of the prostate gland effective for claims with dates of service on or after July 1, 1999. The coverage is for:
1. Primary treatment of patients with clinically localized prostate cancer, Stages T1 – T3 (diagnosis code is 185 – malignant neoplasm of prostate).
2. Salvage therapy (effective for claims with dates of service on or after July 1, 2001 for patients: a. Having recurrent, localized prostate cancer; b. Failing a trial of radiation therapy as their primary treatment; and c. Meeting one of these conditions: State T2B or below; Gleason score less than 9 or; PSA less than 8 ng/ml.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
Claims for cryosurgery for the prostate gland are to be submitted on the ASC X12 837, or, in exceptional circumstances, on a hard copy Form CMS – 1450. This procedure can be rendered in an inpatient or outpatient hospital setting (types of bill (TOBs) 11x 13x, 83x, and 85x).
The A/B MAC (A) will look for the following when processing claims with cryosurgery services:
(Rev. 1111, Issued: 11-09-06, Effective: 04-01-07, Implementation: 04-02-07)
This service may be paid as a primary treatment for patients with clinically localized prostate cancer, Stages T1 – T3. The ultrasonic guidance associated with this procedure will not be paid for separately, but is bundled into the payment for the surgical procedure. When one provider has furnished the cryosurgical ablation and another the ultrasonic guidance, the provider of the ultrasonic guidance must seek compensation from the provider of the cryosurgical ablation.
Effective July 1, 2001, cryosurgery performed as salvage therapy, will be paid only according to the coverage requirements described above.
Type of facility and setting determines the basis of payment:
For services performed on an inpatient basis in short term acute care hospitals, (including those in Guam, America Samoa, Virgin Islands, Saipan, and Indian Health Services Hospitals) TOB 11x: the FI will pay the DRG payment minus any applicable deductible and coinsurance.
For services performed on an outpatient basis in hospitals subject to the Outpatient PPS, TOB 13x: the FI will pay the assigned APC minus any applicable deductible and coinsurance.
For services performed on an inpatient basis: the hospitals exempt from inpatient acute care PPS shall be paid on reasonable cost basis, minus any applicable deductible and coinsurance.
(Rev 2544, Issued: 09-13-2012, Effective: 10-01-2012, Implementation: 10-01-2012)
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavioral counseling sessions:
NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.
NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.
NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.
○ Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
○ Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.
• Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a 12-month period, and denying alcohol misuse counseling sessions HCPCS code G0443 more than four times in the same 12-month period:
○ Medicare Summary Notice (MSN) 20.5 – These services cannot be paid because your benefits are exhausted at this time.
○ Claim Adjustment Reason Code (CARC) 119 – Benefit maximum for this time period or occurrence has been reached.
○ Remittance Advice Remark Code (RARC) N362 – The number of Days or Units of service exceeds our acceptable maximum.
○ Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
○ Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.
• Denying claims for alcohol misuse counseling session HCPCS code G0443 when there is no claim in history for the screening service HCPCS code G0442 in the prior 12 months:
○ Medicare Summary Notice (MSN) 16.26 – Medicare does not pay for services or items related to a procedure that has not been approved or billed.
○ Claim Adjustment Reason Code (CARC) B15 – This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
○ Remittance Advice Remark Code (RARC) M16 – Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.
○ Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a modifier indicating a signed ABN is on file.
○ Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received without a modifier indicating no signed ABN is on file.
(Rev 2544, Issued: 09-13-2012, Effective: 10-01-2012, Implementation: 10-01-2012)
NOTE: If G0442 is not paid, the beneficiary is not eligible for G0443.
When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening. Additionally, CWF shall create an edit to allow alcohol misuse brief behavioral counseling, HCPCS G0443, no more than 4 times in a 12-month period. CWF shall also count four alcohol misuse counseling sessions HCPCS G0443 in the same 12-month period used for G0442 counting from the date the G0442 screening session was billed.
When applying frequency limitations to G0442 screening on the same date of service as G0443 counseling, CWF shall allow both a claim for the professional service and a claim for a facility fee. CWF shall identify the following institutional claims as facility fee claims for screening services: TOB 13X, TOB 85X when the revenue code is not 096X, 097X, or 098X. CWF shall identify all other claims as professional service claims for screening services (professional claims, and institutional claims with TOB 71X, 77X, and 85X when the revenue code is 096X, 097X, or 098X). NOTE: This does not apply to RHCs and FQHCs.
(Rev. 3050, Issued: 08-22-14, Effective: 09-23-14, ICD-10: Upon Implementation of ICD-10, Implementation: 09-23-14, ICD-10: Upon Implementation of ICD-10)
Effective for dates of services on and after December 19, 2006, Medicare has expanded coverage for extracorporeal photopheresis for patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment and patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment. (See the National Coverage Determinations (NCD) Manual, Pub. 100-03, Chapter 1, part 2, section 110.4, for complete coverage guidelines.)
Effective for claims with dates of service on or after April 30, 2012, the Centers for Medicare & Medicaid Services has expanded coverage for extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study that meets specific requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation. Further coverage criteria is outlined in Pub. 100-03, Chapter 1, part 2, section 110.4 of the NCD Manual.
(Rev. 1206; Issued: 03-16-07; Effective: December 19, 2006; Implementation: 04-02-07)
11X, 13X, or 85X
(Rev. 12822; Issued:09-05-024; Effective:10-01-23 Implementation:11-07-24)
The following HCPCS procedure code is used for billing extracorporeal photopheresis:
Effective for claims with dates of service on or after Oct 1, 2015, the following are the applicable ICD-10-CM procedure codes for the new expanded coverage:
NOTE: Contractors shall edit for an appropriate oncological and autoimmune disorder diagnosis for payment of extracorporeal photopheresis according to the NCD.
Effective for claims with dates of service on or after Oct 1, 2015, in addition to HCPCS 36522, the following ICD-10-CM codes are applicable for extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study as outlined in above sections 190 and 190.2 Healthcare Common Procedural Coding System (HCPCS) codes, and applicable diagnosis codes as below::
A reference listing of ICD-10-CM coding and descriptions is listed below:
C84.01 Mycosis fungoides, lymph nodes of head, face, and neck C84.02 Mycosis fungoides, intrathoracic lymph nodes C84.03 Mycosis fungoides, intra-abdominal lymph nodes C84.04 Mycosis fungoides, lymph nodes of axilla and upper limb C84.05 Mycosis fungoides, lymph nodes of inguinal region and lower limb C84.06 Mycosis fungoides, intrapelvic lymph nodes C84.07 Mycosis fungoides, spleen C84.08 Mycosis fungoides, lymph nodes of multiple sites C84.09 Mycosis fungoides, extranodal and solid organ sites C84.11 Sézary disease, lymph nodes of head, face, and neck C84.12 Sézary disease, intrathoracic lymph nodes C84.13 Sézary disease, intra-abdominal lymph nodes C84.14 Sézary disease, lymph nodes of axilla and upper limb C84.15 Sézary disease, lymph nodes of inguinal region and lower limb C84.16 Sézary disease, intrapelvic lymph nodes C84.17 Sézary disease, spleen C84.18 Sézary disease, lymph nodes of multiple sites C84.19 Sezary disease, extranodal/solid organ sites C84.A0 Cutaneous T-cell lymphoma, unspecified, unspecified site C84.A1 Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck C84.A2 Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes C84.A3 Cutaneous T-cell lymphoma, unspecified, intra-abdominal lymph nodes C84.A4 Cutaneous T-cell lymphoma, unspecified, lymph nodes of axilla and upper limb C84.A5 Cutaneous T-cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb C84.A6 Cutaneous T-cell lymphoma, unspecified, intrapelvic lymph nodes C84.A7 Cutaneous T-cell lymphoma, unspecified, spleen C84.A8 Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites C84.A9 Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites
| D89.811 | Chronic graft-versus-host disease |
|---|---|
| D89.812 | Acute on chronic graft-versus-host disease |
| D89.813 | Graft-versus-host disease, unspecified |
| T86.01 | Bone marrow transplant rejection |
| T86.02 | Bone marrow transplant failure |
| T86.03 | Bone marrow transplant infection |
| T86.21 | Heart transplant rejection |
| T86.22 | Heart transplant failure |
| T86.23 | Heart transplant infection |
| T86.290 | Cardiac allograft vasculopathy |
| T86.31 | Heart-lung transplant rejection |
| T86.32 | Heart-lung transplant failure |
| T86.33 | Heart-lung transplant infection |
| T86.5 | Complications of stem cell transplant |
| Z94.3 | Heart and lungs transplant status |
| Z94.81 | Bone marrow transplant status |
| J42 | Unspecified chronic bronchitis |
|---|---|
| J44.0 | Chronic obstructive pulmonary disease with (acute) lower respiratory infection |
| J44.1 | Chronic obstructive pulmonary disease with (acute) exacerbation |
| J44.81 | Bronchiolitis obliterans and bronchiolitis obliterans syndrome - Effective 10/1/23 |
| J44.9 | Chronic obstructive pulmonary disease, unspecified |
| T86.810 | Lung transplant rejection |
| T86.811 | Lung transplant failure |
| T86.812 | Lung transplant infection |
| T86.818 | Other complications of lung transplant |
| T86.819 | Unspecified complication of lung transplant |
| Z94.2 | Lung transplant status |
| Z00.6 | Encounter for examination for normal comparison and control in clinical research program |
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)
Contractors shall continue to use the appropriate existing messages that they have in place when denying claims submitted that do not meet the Medicare coverage criteria for extracorporeal photopheresis.
Medicare coverage for extracorporeal photopheresis is restricted to the inpatient or outpatient hospital settings specifically for BOS, and not for the other covered diagnosis (including chronic graft versus host disease) which remain covered in the hospital inpatient, hospital outpatient, and non-facility (physician-directed clinic or office settings) settings.
Contractors shall deny claims for extracorporeal photopheresis for BOS when the service is not rendered to an inpatient or outpatient of a hospital, including critical access hospitals using the following codes:
Advice Remark Code that is not an ALERT.) NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
B. Group Code CO (Contractual Obligations) or PR (Patient Responsibility) dependent on liability.
Contractors shall return to provider/ return as unprocessable claims for BOS containing HCPCS procedure code 36522 along with one of the allowable ICD-10 codes if the claim is missing diagnosis code Z00.6 (as primary/secondary diagnosis, institutional only), condition code 30 (institutional claims only), clinical trial modifier Q0/Q1, and value code D4 with an 8-digit clinical trial identifier number (A/MACs only). Use the following messages:
When diagnosis code Z00.6 is missing, use:
When Condition Code 30 is missing, use CARC 16 and
When Clinical Trial modifier Q0/Q1 is missing, use CARC 16 and
When Clinical Trial Number is missing, use CARC 16 and
When Value Code D4 is missing, use CARC 16 and
(Rev. 1206; Issued: 03-16-07; Effective: December 19, 2006; Implementation: 04-02-07)
If this service is not reasonable and necessary under 1862(a)(1)(A) of the Act (falls outside the scope of the revised NCD found in Pub. 100-03, chapter 1, section 110.4), contractors shall advise physicians and/or hospital outpatient departments, including critical access hospitals (CAHs), that they will be held liable for charges unless the physician and/or hospital has the beneficiary sign an Advance Beneficiary Notice in advance of providing the service.
If this service is provided to a hospital inpatient, including CAHs, for a reason unrelated to the admission (outside of the bundled payment) contractors shall advise hospitals billing for inpatient services that they will be held liable for charges unless the hospital has the beneficiary sign a Hospital Issued Notice of Noncoverage letter 11 in advance of providing the service.
(Rev. 1271, Issued: 06-22-07; Effective: 05-04-07; Implementation: 07-23-07)
(Rev. 1271, Issued: 06-22-07; Effective: 05-04-07; Implementation: 07-23-07)
VNS is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus nerve via the lead. These signals are in turn sent to the brain. FDA approved VNS for treatment of refractory epilepsy in 1999. Further coverage guidelines can be found in the National Coverage Determination Manual (Publication 100-03), Chapter 1, Section 160.18. Since the HCPCS codes for VNS can also be used for other indications, contractors must determine if the service being billed are for VNS and make a determination to pay or deny. CMS guidance on payment is listed below.
(Rev. 12435, Issued:12-28-23, Effective:01-29-24, Implementation:01-29-24)
One of the following diagnosis codes must be reported as appropriate, when billing for Vagus Nerve Stimulation:
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
(Rev. 1271, Issued: 06-22-07; Effective: 05-04-07; Implementation: 07-23-07)
Effective for services performed on or after July 1, 1999, contractors are accepting claims submitted for vagus nerve stimulation for epilepsy and recurrent seizures.
Effective for services performed on or after July 1, 1999, CMS determined that vagus nerve stimulation is not reasonable and necessary for all other types of seizures which are refractory and for whom surgery is not recommended or for whom surgery has failed.
Effective for services performed on or after May 4, 2007, contractors will deny claims submitted for vagus nerve stimulation for resistant depression. Contractors need to update their local coverage determination policy to include this new NCD determination. There is no coverage for vagus nerve stimulation for patient with resistant depression.
(Rev. 1271, Issued: 06-22-07; Effective: 05-04-07; Implementation: 07-23-07)
Effective for services performed on or after July 1, 1999, contractors are accepting claims submitted for vagus nerve stimulation for epilepsy and recurrent seizures.
Effective for services performed on or after July 1, 1999, CMS determined that vagus nerve stimulation is not reasonable and necessary for all other types of seizures which are refractory and for whom surgery is not recommended or for whom surgery has failed.
Effective for services performed on or after May 4, 2007, contractors will reject claims submitted for vagus nerve stimulation for resistant depression.
(Rev.11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)
The following messages are used by Medicare contractors when denying non-covered VNS services:
MSN: 16.10 'Medicare does not pay for this item or service.'
CARC: 50 'These are non-covered services because this is not deemed a'medical necessity' by the payer.'
The following RARC messages can be used depending on liability:
M27 Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. You, the provider, are ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were notreasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered.You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date youreceive this notice. You must make the request through this office.
Or
M38 Alert: The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay.
Contractors will also include group code CO (contractual obligation) or PR (patient responsibility) depending on liability.
(Rev. 1271, Issued: 06-22-07; Effective: 05-04-07; Implementation: 07-23-07)
Physicians are liable for non-covered VNS procedures unless they issue an appropriate advance beneficiary notice (ABN). The following language should be included in the ABN:
Items or Service Section:
“Vagas Nerve Stimulation”.
Because Section:
“As specified in section 160.18 of Pub.100-03, Medicare National Coverage Determination Manual, Medicare will not pay for this procedure as it is not a reasonable and necessary treatment for (select either “your type of seizure disorder” or “resistant depression.”)
Note that the ABN is the appropriate notice for Part B services and is valid whether the language above is inserted or not.
(Rev.)
(Rev. 1646, Issued: 12-09-08, Effective: 09-29-08, Implementation: 01-05-09)
(Rev. 1646, Issued: 12-09-08, Effective: 09-29-08, Implementation: 01-05-09)
Effective for services on or after September 29, 2008, the Center for Medicare & Medicaid Services (CMS) made the decision that Thermal Intradiscal Procedures (TIPs) are not reasonable and necessary for the treatment of low back pain. Therefore, TIPs are non-covered. Refer to Pub.100-03, Medicare National Coverage Determination (NCD) Manual Chapter 1, Part 2, Section 150.11, for further information on the NCD.
(Rev. 1646, Issued: 12-09-08, Effective: 09-29-08, Implementation: 01-05-09)
The following Healthcare Common Procedure Coding System (HCPCS) codes will be nationally non-covered by Medicare effective for dates of service on and after September 29, 2008:
22526: Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level
22527: Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels
0062T: Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; single level
0063T: Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; one or more additional levels
NOTE: The change to add the non-covered indicator for the above HCPCS codes will be part of the January 2009 Medicare Physician Fee Schedule Update. The change to the status indicator to non-cover the above HCPCS will be part of the January Integrated Outpatient Code Editor (IOCE) update.
Claims submitted with the non-covered HCPCS codes on or after September 29, 2008, will be denied by Medicare contractors.
(Rev. 1646, Issued: 12-09-08, Effective: 09-29-08, Implementation: 01-05-09)
The following messages are used by Medicare contractors when denying non-covered TIP services:
N386 “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/med/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
(Rev. 1646, Issued: 12-09-08, Effective: 09-29-08, Implementation: 01-05-09)
Providers are liable for charges if TIPS is used in surgery, unless the beneficiary was informed that he/she would be financially responsible prior to performance of the procedure. To avoid this liability the provider should have the beneficiary sign an ABN.
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
The Centers for Medicare & Medicaid Services (CMS) internally generated a request for a national coverage analysis (NCA) to establish national coverage determinations (NCDs) addressing Medicare coverage of Wrong Surgical or Other Invasive Procedures Performed on a Patient, Surgical or Other Invasive Procedures Performed on the Wrong Body Part, and Surgical or Other Invasive Procedures Performed on the Wrong Patient. Information regarding these NCDs can be found in Publication (Pub.) 100-03, Chapter 1, sections 140.6, 140.7, and 140.8, respectively.
Inpatient Claims
Hospitals are required to bill two claims when a surgical error is reported and a covered service is also being reported:
NOTE: Both the covered and non-covered claim shall have a matching Statement Covers Period.
For discharges prior to October 1, 2009, the non-covered TOB 110 must indicate on the 837 institutional claim format, or in the Remarks field of the Form CMS1450 one of the applicable erroneous surgery(s) two-digit codes (entered exactly as specified below):
For discharges on or after October 1, 2009, the non-covered TOB 110 must have one of the following diagnosis codes reported in diagnosis position 2-9, instead of billing the aforementioned two-digit codes in Remarks:
If ICD-9-CM Is Applicable
NOTE: The above codes shall not be reported in the External Cause of Injury (E-code) field.
If ICD-10-CM Is Applicable
Outpatient, Ambulatory Surgical Centers, and Practitioner Claims
Providers are required to append one of the following applicable HCPCS modifiers to all lines related to the erroneous surgery(s):
All claims
Claim/Lines submitted with a surgical error will be denied/line-item denied using the following:
Medicare Summary Notice
23.17 – Medicare won’t cover these services because they are not considered medically necessary.”
23.17 – Medicare no cubrirá estos servicios porque no son considerados necesarios por razones médicas.
CARC 50 – These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
CO – Contractual Obligation
Generally, beneficiary liability notices such an Advance Beneficiary Notice of Non-coverage (ABN) or a Hospital Issued Notice of Non-coverage (HINN) is appropriate when a provider is furnishing an item or service that the provider reasonably believes Medicare will not cover on the basis of §1862(a)(1). An ABN must include all of the elements described in Pub. 100-04, Claims Processing Manual (CPM), Ch. 30, §50.6.3, in order to be considered valid. For example, the ABN must specifically describe the item or service expected to be denied (e.g. a left leg amputation) and must include a cost estimate for the non-covered item or service. Similarly, HINNs must specifically describe the item or service expected to be denied (e.g. a left leg amputation) and must include all of the elements described in the instructions found in the CPM Ch. 3.0 §200. Thus, a provider cannot shift financial liability for the non-covered services to the beneficiary, unless the ABN or the HINN satisfies all of the applicable requirements in the CPM Ch. 30, §50.6.3 and §200, respectively. Given these requirements, CMS cannot envision a scenario in which HINNs or ABNs could be validly delivered in these NCD cases. However, an ABN or a HINN could be validly delivered prior to furnishing services related to the follow-up care for the non-covered surgical error that would not be considered a related service to the non-covered surgical error.
Claims for some services for beneficiaries with transgender, ambiguous genitalia, and hermaphrodite issues, may inadvertently be denied due to sex related edits unless these services are billed properly.
The National Uniform Billing Committee (NUBC) has approved condition code 45 (Ambiguous Gender Category) as a result of the increasing number of claims received that are denied due to sex/diagnosis and sex/procedure edits. This claim level condition code should be used by institutional providers to identify these unique claims and alerts the fiscal intermediary that the gender/procedure or gender/diagnosis conflict is not an error allowing the sex related edits to be by-passed.
The KX modifier (Requirements specified in the medical policy have been met) is now a multipurpose informational modifier and will also be used identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses. Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries. Therefore, if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an error and will allow the claim to continue with normal processing.
Institutional providers are to report condition code 45 on any inpatient or outpatient claim related to transgender, ambiguous genitalia, or hermaphrodite issues.
The KX modifier is to be billed on the detail line only with the procedure code(s) that is gender specific for transgender, ambiguous genitalia, and hermaphrodite beneficiaries. (NOTE: The KX modifier is a multipurpose informational modifier, and may also be used in conjunction with other medical policies.)
(Rev. 1889, Issued: 01-08-10; Effective Date: 08-03-09; Implementation Date: 04-05-10)
(Rev. 1889, Issued: 01-08-10; Effective Date: 08-03-09; Implementation Date: 04-05-10)
Effective August 3, 2009, pharmacogenomic testing to predict warfarin responsiveness is covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin; i.e., 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 only then in the context of a prospective, randomized, controlled clinical study when that study meets certain criteria as outlined in Pub 100-03, section 90.1, of the NCD Manual.
NOTE: A new temporary HCPCS Level II code effective August 3, 2009, G9143, warfarin responsiveness testing by genetic technique using any method, any number of specimen(s), was developed to enable implementation of CED for this purpose.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Institutional clinical trial claims for pharmacogenomic testing for warfarin response are identified through the presence of all of the following elements:
Practitioner clinical trial claims for pharmacogenomic testing for warfarin response are identified through the presence of all of the following elements:
NOTE: This NCD does not determine coverage to identify CYP2C9 or VKORC1 alleles for other purposes beside warfarin responsiveness, nor does it determine national coverage to identify other alleles to predict warfarin responsiveness. These decisions are made at the local MAC level.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Beginning April 5, 2010, for claims with dates of service on and after August 3, 2009, the Medicare Shared System will track the number of times a beneficiary receives pharmacogenomic testing for warfarin response. When a claim is received for pharmacogenomic testing for warfarin response, and the shared system has determined that the beneficiary has already received the test in his/her lifetime, it will generate a Medicare line-item denial and the Medicare contractor will provide the following messages to enforce the one-time limitation for the test:
Claim Adjustment Reason Code (CARC) 50 – These are non-covered services because this is not deemed a ‘medical necessity’ by the payer. This change to be effective April 1, 2010: These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
NOTE: Refer to the 835 Healthcare Policy Identification Segment, if present.
Remittance Advice Remark Code (RARC) N362 – The number of Days or Units of Service exceeds our acceptable maximum.
Group Code CO – Contractual Obligation
Medicare Summary Notice (MSN) 16.76 – This service/item was not covered because you have exceeded the lifetime limit for getting this service/item. (Este servicio/articulo no fue cubierto porque usted ya se ha pasado del limite permitido de por vida, para recibirlo.).
The Medicare shared system and the A/B MACs (B) will also ensure that pharmacogenomic testing for warfarin response is billed in accordance with clinical trial reporting requirements. In other words, the shared system and the A/B MACs (B) will return to provider/return as unprocessable lines for pharmacogenomic testing for warfarin response when said line is not billed with HCPCS modifier Q0 and ICD-10- CM diagnosis code if applicable, ICD-10-CM Z00.6 is not present as a secondary diagnosis. When the system or the A/B MAC (B) initiates the line- item return to provider or returns the claim as unprocessable, the Medicare contractor will respond with the following messages:
For a missing Q0 modifier:
CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.
For a missing Z00.6 diagnosis code when a HCPCS Q0 modifier is reported with HCPCS G9143:
CARC 16 - Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Remark Code M64 - Missing/incomplete/invalid other diagnosis.
For either a missing Q0 modifier and/or a missing ICD-10-CM Z00.6 diagnosis code:
Group Code CO- Contractual Obligation
MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/articulo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.)
(Rev. 2105, Issued: 11-24-10, Effective: 03-23-10, Implementation: 07-06-10)
(Rev. 2105, Issued: 11-24-10, Effective: 03-23-10, Implementation: 07-06-10)
The Centers for Medicare & Medicaid Services (CMS) received a request for national coverage of treatments for facial lipodystrophy syndrome (LDS) for human immunodeficiency virus (HIV)-infected Medicare beneficiaries. Facial LDS is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks. This fat loss can arise as a complication of HIV and/or highly active antiretroviral therapy. Due to their appearance and stigma of the condition, patients with facial LDS may become depressed, socially isolated, and in some cases may stop their HIV treatments in an attempt to halt or reverse this complication.
Effective for claims with dates of service on and after March 23, 2010, dermal injections for facial LDS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration for this purpose, and then only in HIV-infected beneficiaries who manifest depression secondary to the physical stigmata of HIV treatment.
See Pub. 100-03, National Coverage Decision manual, section 250.5, for detailed policy information concerning treatment of LDS.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
A - Hospital Outpatient Claims
For hospital outpatient claims, hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:
1. A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March 23, 2010,
NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014 HCPCS update.
2. A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,
3. If ICD-10-CM is applicable, ICD-10-CM diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 Lipodystrophy, not elsewhere classified
The applicable NCD is 250.5 Facial Lipodystrophy.
For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026 and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800, instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.
NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014, HCPCS update.
Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:
C. Discharge date on or after March 23, 2010,
D. If ICD-10-PCS is applicable,
E. If ICD-10-CM is applicable on or after 10/01/2015,
A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractor’s policy.
(Rev. 2105, Issued: 11-24-10, Effective: 03-23-10, Implementation: 07-06-10)
(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)
For hospital outpatient claims, hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:
A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March 23, 2010,
A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,
The applicable NCD is 250.5 Facial Lipodystrophy.
B - Outpatient Prospective Payment System (OPPS) Hospitals or Ambulatory Surgical Centers (ASCs):
For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026 and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800, instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.
C - Hospital Inpatient Claims
Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:
A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractor's policy.
260.2.2 – Practitioner Billing Instructions
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Practitioners must bill covered claims for dermal injections for treatment of facial LDS by having all of the required elements on the claim:
Performed in a non-facility setting:
NOTE: Q2027 is replaced with Q2028 effective 1/1/14 per the 2014 HCPCS update.
51 If ICD-10-CM applies, diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 (Lipodystrophy not elsewhere classified). Both diagnoses are required on the claim.
NOTE: A diagnosis code for a comorbidity of depression may also be required for coverage based on the individual Medicare contractor's policy.
52 A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,
53 If ICD-10 CM- applies, ICD-10-CM diagnosis codes B20 Human immunodeficiency Virus (HIV) disease and E88.1 (Lipodystrophy not elsewhere classified). Both diagnoses are required on the claim.
NOTE: A diagnosis code for a comorbidity of depression may also be required for coverage based on the individual Medicare contractor's policy.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Hospitals and practitioners billing for dermal injections for treatment of facial LDS prior to the coverage date of March 23, 2010, will receive the following messages upon their Medicare denial:
NOTE: Outpatient hospitals and beneficiaries that received services in a hospital outpatient setting may receive different message as established by their particular Medicare contractor processing the claim.)
Medicare beneficiaries whose provider bills Medicare for dermal injections for treatment of facial LDS prior to the coverage date of March 23, 2010, will receive the following Medicare Summary Notice (MSN) message upon the Medicare denial:
Hospitals and practitioners billing for dermal injections for treatment of facial LDS on patients that do not have a comorbidity of HIV and lipodystrophy (or even depression if deemed required by the Medicare contractor) will receive the following messages upon their Medicare denial:
CARC 50: These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at
http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Medicare beneficiaries who do not meet Medicare comorbidity requirements of HIV and lipodystrophy (or even depression if deemed required by the Medicare contractor) and whose provider bills Medicare for dermal injections for treatment of facial LDS will receive the following MSN message upon the Medicare denial:
15.4 - The information provided does not support the need for this service or item. (Spanish Version: La información proporcionada no confirma la necesidad para este servicio oículo.)
Coverage Requirements- The implantable automatic defibrillator is an electronic device designed to detect and treat life threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating.
See §20.4 -Medicare National Coverage Determinations (NCD) Manual for the complete list of covered indications.
The following are the applicable HCPCS procedure codes for implantable automatic defibrillators:
For inpatient hospitals claims, if ICD-9 CM is applicable use procedure code 37.94. If ICD-10-PCS is applicable the following applies.
More than one ICD-10-PCS code (a cluster) is required. There are two possible clusters:
FIRST CLUSTER: Use 1 code from the first list and one code from the second list.
Cluster 1 first list:
0JH608Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH638Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH808Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH838Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Cluster 1 second list:
02H60KZ Insertion of Defibrillator Lead into Right Atrium, Open Approach
02H63KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach
02H64KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Approach
02H70KZ Insertion of Defibrillator Lead into Left Atrium, Open Approach
02H73KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Approach
02H74KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Approach
02HK0KZ Insertion of Defibrillator Lead into Right Ventricle, Open Approach
02HK3KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach
02HK4KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic Approach
02HL0KZ Insertion of Defibrillator Lead into Left Ventricle, Open Approach
02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach
02HL4KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Approach
SECOND CLUSTER:
Use 1 code from 1st list & 1 code from the 4th list; also add one code from each of the 2nd & 3rd lists if doing a replacement instead of initial insertion.
Cluster 2 first list:
0JH608Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH638Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH808Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH838Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Cluster 2 second list:
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
02PA0MZ Removal of Cardiac Lead from Heart, Open Approach
02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous Approach
02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic Approach
02PAXMZ Removal of Cardiac Lead from Heart, External Approach
02H60KZ Insertion of Defibrillator Lead into Right Atrium, Open Approach
02H63KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach
02H64KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Approach
02H70KZ Insertion of Defibrillator Lead into Left Atrium, Open Approach
02H73KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Approach
02H74KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Approach
02HK0KZ Insertion of Defibrillator Lead into Right Ventricle, Open Approach
02HK3KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach
02HK4KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic Approach
02HL0KZ Insertion of Defibrillator Lead into Left Ventricle, Open Approach
02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach
02HL4KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Approach
(Rev.11759, Issued:12-21-2022, Effective:01-23-2023, Implementation:01-23-2023)
Effective for dates of service on or after April 1, 2005, Medicare required that patients receiving a defibrillator for the primary prevention of sudden cardiac arrest be enrolled in a qualifying data collection system. Providers shall use modifier Q0 to identify patients whose data is being submitted to a data collection system.
The following diagnosis codes identify non-primary prevention (secondary prevention) patient or replacement implantations (e.g. due to recalled devices):
If ICD-9-CM is applicable, select from the following diagnosis codes:
427.1 Ventricular tachycardia
427.41 Ventricular fibrillation
427.42 Ventricular flutter
427.5 Cardiac arrest
427.9 Cardiac dysrhythmia, unspecified
V12.53 Personal history of sudden cardiac arrest
996.04 Mechanical complication of cardiac device, implant, and graft, due to automatic implantable cardiac defibrillator
V53.32 Fitting and adjustment of other device, automatic implantable cardiac defibrillator
If ICD-10-CM is applicable, select from the following list:
I47.0 Re-entry Ventricular Arrhythmia
I47.2 Ventricular Tachycardia select - end date September 30, 2022
I47.20 Ventricular Tachycardia, unspecified - effective October 1, 2022
I47.21 Torsades De Pointes - effective October 1, 2022
I47.29 Other Ventricular Tachycardia - effective October 1, 2022
I49.3 Ventricular Premature depolarization
I49.01 Ventricular Fibrillation
I49.02 Ventricular Flutter
I46.2 Cardiac arrest due to underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition
I46.9 Cardiac arrest, cause unspecified
I49.9 Cardiac arrhythmia, unspecified
T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter
T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter
T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter
T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter
T82.120A Displacement of cardiac electrode, initial encounter
T82.121A Displacement of cardiac pulse generator (battery), initial encounter
T82.128A Displacement of other cardiac electronic device, initial encounter
T82.129A Displacement of unspecified cardiac electronic device, initial encounter
T82.190A Other mechanical complication of cardiac electrode, initial encounter
T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter
T82.198A Other mechanical complication of other cardiac electronic device, initial encounter
T82.199A Other mechanical complication of unspecified cardiac device, initial encounter
Z86.74 Personal history of sudden cardiac arrest
Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator
When any of the above codes appear on a claim, the Q0 modifier is not required. The Q0 modifier may be appended to claims for secondary prevention indications when data is being entered into a qualifying data collection system.
(Rev. 2380, Issued: 01-06-12, Effective: 06-30-11, Implementation: 08-08-11)
Effective for services furnished on or after June 30, 2011, a National Coverage Determination (NCD) provides coverage of sipuleucel-T (PROVENGE®) for patients with asymptomatic or minimally symptomatic metastatic, castrate-resistant (hormone refractory) prostate cancer. Conditions of Medicare Part A and Medicare Part B coverage for sipuleucel-T are located in the Medicare NCD Manual, Publication 100-03, section 110.22.
(Rev. 2380, Issued: 01-06-12, Effective: 06-30-11, Implementation: 08-08-11)
Effective for claims with dates of service on June 30, 2011, Medicare providers shall report one of the following HCPCS codes for PROVENGE®:
NOTE: Contractors shall continue to process claims for HCPCS code C9273, J3490, and J3590, with dates of service June 30, 2011, as they do currently.
Effective for claims with dates of service on and after July 1, 2011, Medicare providers shall report the following HCPCS code:
For claims with dates of service on and after July 1, 2011, for PROVENGE®, the on-label indication of asymptomatic or minimally symptomatic metastatic, castrate-resistant (hormone refractory) prostate cancer, must be billed using ICD-9 code 185 (malignant neoplasm of prostate) and at least one of the following ICD-9 codes:
| ICD-9 code | Description |
|---|---|
| 196.1 | Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes |
| 196.2 | Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes |
| 196.5 | Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb |
| 196.6 | Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes |
| 196.8 | Secondary and unspecified malignant neoplasm of lymph nodes of multiple sites |
| 196.9 | Secondary and unspecified malignant neoplasm of lymph node site unspecified - The spread of cancer to and establishment in the lymph nodes. |
| 197.0 | Secondary malignant neoplasm of lung – Cancer that has spread from the original (primary) tumor to the lung. The spread of cancer to the lung. This may be from a primary lung cancer, or from a cancer at a distant site. |
| 197.7 | Malignant neoplasm of liver secondary - Cancer that has spread from the original (primary) tumor to the liver. A malignant neoplasm that has spread to the liver from another (primary) anatomic site. Such malignant neoplasms may be carcinomas (e.g., breast, colon), lymphomas, melanomas, or sarcomas. |
| 198.0 | Secondary malignant neoplasm of kidney - The spread of the cancer to the kidney. This may be from a primary kidney cancer |
| involving the opposite kidney, or from a cancer at a distant site. | |
|---|---|
| 198.1 | Secondary malignant neoplasm of other urinary organs |
| 198.5 | Secondary malignant neoplasm of bone and bone marrow – Cancer that has spread from the original (primary) tumor to the bone. The spread of a malignant neoplasm from a primary site to the skeletal system. The majority of metastatic neoplasms to the bone are carcinomas. |
| 198.7 | Secondary malignant neoplasm of adrenal gland |
| 198.82 | Secondary malignant neoplasm of genital organs |
The use of PROVENGE® off-label for the treatment of prostate cancer is left to the discretion of the Medicare Administrative Contractors. Claims with dates of service on and after July 1, 2011, for PROVENGE® paid off-label for the treatment of prostate cancer must be billed using either ICD-9 code 233.4 (carcinoma in situ of prostate), or ICD-9 code 185 (malignant neoplasm of prostate) in addition to HCPCS Q2043. Effective with the implementation date for ICD-10 codes, off-label PROVENGE® services must be billed with either ICD-10 code D075(carcinoma in situ of prostate), or C61 (malignant neoplasm of prostate) in addition to HCPCS Q2043.
Contractors shall note the appropriate ICD-10 code(s) that are listed below for future implementation. Contractors shall track the ICD-10 codes and ensure that the updated edit is turned on as part of the ICD-10 implementation effective October 1, 2013.
| ICD-10 | Description |
|---|---|
| C61 | Malignant neoplasm of prostate (for on-label or off-label indications) |
| D075 | Carcinoma in situ of prostate (for off-label indications only) |
| C77.1 | Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes |
| C77.2 | Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes |
| C77.4 | Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes |
| C77.5 | Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes |
| C77.8 | Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions |
| C77.9 | Secondary and unspecified malignant neoplasm of lymph node, unspecified |
|---|---|
| C78.00 | Secondary malignant neoplasm of unspecified lung |
| C78.01 | Secondary malignant neoplasm of right lung |
| C78.02 | Secondary malignant neoplasm of left lung |
| C78.7 | Secondary malignant neoplasm of liver |
| C79.00 | Secondary malignant neoplasm of unspecified kidney and renal pelvis |
| C79.01 | Secondary malignant neoplasm of right kidney and renal pelvis |
| C79.02 | Secondary malignant neoplasm of left kidney and renal pelvis |
| C79.10 | Secondary malignant neoplasm of unspecified urinary organs |
| C79.11 | Secondary malignant neoplasm of bladder |
| C79.19 | Secondary malignant neoplasm of other urinary organs |
| C79.51 | Secondary malignant neoplasm of bone |
| C79.52 | Secondary malignant neoplasm of bone marrow |
| C79.70 | Secondary malignant neoplasm of unspecified adrenal gland |
| C79.71 | Secondary malignant neoplasm of right adrenal gland |
| C79.72 | Secondary malignant neoplasm of left adrenal gland |
| C79.82 | Secondary malignant neoplasm of genital organs |
(Rev. 2380, Issued: 01-06-12, Effective: 06-30-11, Implementation: 08-08-11)
The applicable TOBs for PROVENGE® are: 12X, 13X, 22X, 23X, 71X, 77X, and 85X.
On institutional claims, TOBs 12X, 13X, 22X, 23X, and 85X, use revenue code 0636 - drugs requiring detailed coding.
(Rev. 2380, Issued: 01-06-12, Effective: 06-30-11, Implementation: 08-08-11)
Payment for PROVENGE® is as follows:
For Medicare Part B practitioner claims, payment for PROVENGE® is based on ASP + 6%.
Contractors shall not pay separately for routine costs associated with PROVENGE®, HCPCS Q2043, except for the cost of administration. (Q2043 is all-inclusive and represents all routine costs except for its cost of administration).
(Rev. 2394, Issued: 01-25-12, Effective: 06-30-11 for-(claims with dates of service on or after 07-01-11 processed on or after July 02-12, Implementation: 07-02-12)
Contractors shall use the following messages when denying claims for the on-label indication for PROVENGE®, HCPCS Q2043, submitted without ICD-9-CM diagnosis code 185 and at least one diagnosis code from the ICD-9 table in Section 280.2 above:
MSN 14.9 - Medicare cannot pay for this service for the diagnosis shown on the claim.
Spanish Version - Medicare no puede pagar por este servicio debido al diagnóstico indicado en la reclamación.
RARC 167 - This (these) diagnosis (es) are not covered. Note: Refer to the 835 Healthcare Policy Identification segment (loop 2110 Service Payment Information REF), if present.
Group Code – CO (Contractual Obligation)
Contractors shall use the following messages when denying claims for the off-label indication for PROVENGE®, HCPCS Q2043, submitted without ICD-9-CM diagnosis code 233.4:
MSN 14.9 - Medicare cannot pay for this service for the diagnosis shown on the claim.
Spanish Version - Medicare no puede pagar por este servicio debido al diagnóstico indicado en la reclamación.
RARC 167 - This (these) diagnosis (es) are not covered. Note: Refer to the 835 Healthcare Policy Identification segment (loop 2110 Service Payment Information REF), if present.
Group Code – CO (Contractual Obligation)
For claims with dates of service on or after July 1, 2012, processed on or after July 2, 2012, when denying claims for PROVENGE®, HCPCS Q2043® that exceed three (3) services in a patient’s lifetime, contractors shall use the following messages:
MSN 20.5 - These services cannot be paid because your benefits are exhausted at this time.
Spanish Version - Estos servicios no pueden ser pagados porque sus beneficios se han agotado.
RARC N362 - The number of Days or Units of Service exceeds our acceptable maximum.
CARC 149 - Lifetime benefit maximum has been reached for this service/benefit category.
(Rev. 10179, Issued: 06-10-20, Effective: 06-21-19, Implementation: 06-12-20)
Transcatheter aortic valve replacement (TAVR - also known as TAVI or transcatheter aortic valve implantation) is used in the treatment of aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the aortic valve.
The most recent reconsideration of the TAVR policy is effective for claims with dates of service on and after June 21, 2019. It makes changes to the criteria for the heart team and the hospital, and to the trial outcomes and the registry questions/criteria. Please see Publication 100-03, National Coverage Determination Manual Part 1, section 20.32, for complete national policy criteria.
HISTORICAL NOTE: CR 7897, Transmittal (TR) 2552, issued September 24, 2012, implemented the initial NCD for TAVR, effective May 1, 2012. CR 8168, TR 2628, issued January 7, 2013, implemented replacement coding to TAVR effective January 1, 2013. CR 8255, TR 2737, issued July 11, 2013, implemented clinical trial number reporting effective July 1, 2013. CR 8537, TR 2827, issued November 29, 2013, implemented replacement CPT coding effective January 1, 2013.
(Rev. 10179, Issued: 06-10-20, Effective: 06-21-19, Implementation: 06-12-20)
The following are the applicable Current Procedural Terminology (CPT) codes for TAVR:
0256T: Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach
0257T: Implantation of catheter-delivered prosthetic aortic heart valve; open thoracic approach (eg, transapical, transventricular)
0258T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; without cardiopulmonary bypass
0259T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; with cardiopulmonary bypass
The following are the International Classification of Diseases (ICD)-9 procedure codes applicable for TAVR:
35.05: Endovascular replacement of aortic valve
35.06: Transapical replacement of aortic valve
The following are the ICD-10 procedure codes applicable for TAVR:
35.05: 02RF37Z, 02RF38Z, 02RF3JZ, 02RF3KZ
35.06: 02RF37H, 02RF38H, 02RF3JH, 02RF3KH
(Rev. 10179, Issued: 06-10-20, Effective: 06-21-19, Implementation: 06-12-20)
Beginning January 1, 2013, the following are the applicable CPT codes for TAVR:
33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral approach
33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach
33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (e.g., median sternotomy, mediastinotomy)
0381T Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical approach (e.g., left thoracotomy)
Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014, shall instead use permanent CPT code 33366.
(Rev. 10179, Issued: 06-10-20, Effective: 06-21-19, Implementation: 06-12-20)
Effective for claims with dates of service on and after May 1, 2012, place of service (POS) code 21 shall be used for TAVR services. All other POS codes shall be denied.
The following messages shall be used when Medicare contractors deny TAVR claims for POS:
Claim Adjustment Reason Code (CARC) 58: 'Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.'
Remittance advice remark code (RARC) N428: 'Not covered when performed in this place of service.' Beginning January 2, 2020, contractors shall no longer report RARC N428 for claims denied for invalid POS.
Medicare Summary Notice (MSN) 21.25: 'This service was denied because Medicare only covers this service in certain settings.'
Spanish Version: 'El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.'
For TAVR claims with dates of service on or after July 1, 2013, contractors shall pay claim lines with 33361, 33362, 33363, 33364, 33365 & 0318T only when billed with modifier -62. Claim lines billed without modifier -62 shall be returned as unprocessable.
Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with
dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.
The following messages shall be used when Medicare contractors return TAVR claims billed without modifier -62 as unprocessable:
CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
RARC N29: “Missing documentation/orders/notes/summary/report/chart.” Beginning January 2, 2020, contractors shall no longer report RARC N29 on remittance for claims billed without modifier -62 and returned as unprocessable.
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
Professional Claims Modifier -Q0
For claims with dates of service on or after January 1 , 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with modifier-Q0. Claim lines billed without modifier -Q0 shall be returned as unprocessable.
Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014, shall instead use permanent CPT code 33366.
The following messages shall be used when Medicare contractors return TAVR claims billed without modifier -Q0 as unprocessable:
CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
RARC N29: “Missing documentation/orders/notes/summary/report/chart.” Beginning January 2, 2020, contractors shall no longer report RARC N29 on remittance for claims billed without modifier –Q0 and returned as unprocessable.
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
Diagnosis Coding
For claims with dates of service on or after July 1, 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with diagnosis code V70.7 (ICD-10 Z00.6). Claim lines billed without diagnosis code V70.7 (ICD-10 Z00.6) shall be returned as unprocessable.
Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.
The following messages shall be used when Medicare contractors return TAVR claims billed without diagnosis code V70.7 (ICD-10 Z00.6) as unprocessable:
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason
Code, or Remittance Advice Remark Code that is not an ALERT)."
RARC M76: “Missing/incomplete/invalid diagnosis or condition”
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
Group Code – Contractual Obligation (CO): Beginning January 2, 2020, contractors shall no longer report Group Code CO on remittances for claims billed without ICD-10 dx Z00.6 and returned as unprocessable.
MSN 16.77: This service/item was not covered because it was not provided as part of a qualifying trial/study. Spanish version: Este servicio/articulo no fue cubierto porque no estaba incluido como parte de un ensayo clinic/studio calificado. Beginning January 2, 2020, contractors shall no longer report MSN 16.77 on remittances for claims billed without ICD-10 diagnosis Z00.6 and returned as unprocessable.
Professional Claims 8-digit ClinicalTrials.gov Identifier Number
For claims with dates of service on or after July 1, 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with the numeric, 8-digit clinicaltrials.gov identifier number preceded by the two alpha characters “CT” when placed in Field 19 of paper Form CMS-1500, or when entered without the “CT” prefix in the electronic 837P in Loop 2300REF02(REF01=P4). Claim lines billed without an 8-digit clinicaltrials.gov identifier number shall be returned as unprocessable.
Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.
The following messages shall be used when Medicare contractors return TAVR claims billed without an 8-digit clinicaltrials.gov identifier number as unprocessable:
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).”
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.”
RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
NOTE: Clinicaltrials.gov identifier numbers for TAVR are listed on our website: (http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Transcatheter-Aortic-Valve-Replacement-TAVR-.html)
(Rev. 10179, Issued: 06-10-20, Effective: 06-21-19, Implementation: 06-12-20)
Inpatient hospitals shall bill for TAVR on an 11X TOB effective for discharges on or after May 1, 2012. Refer to Section 69 of this chapter for further guidance on billing under CED. Inpatient hospital discharges for TAVR shall be covered when billed with:
• ICD-9 V70.7 through September 30, 2015, ICD-10 Z00.6 for dates of service on or after October 1, 2015, and Condition Code 30. • An 8-digit clinicaltrials.gov identifier number listed on the CMS website (effective July 1, 2013)
Inpatient hospital discharges for TAVR shall be rejected when billed without:
• ICD-9 V70.7 through September 30, 2015, ICD-10 Z00.6 for dates of service on or after October 1, 2015, and Condition Code 30. • An 8-digit clinicaltrials.gov identifier number listed on the CMS website (effective July 1, 2013)
Claims billed by hospitals not participating in the trial/registry shall be rejected with the following messages:
CARC 50: These are non-covered services because this is not deemed a “medical necessity” by the payer.
RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code: Contractual Obligation (CO)
MSN 16.77: This service/item was not covered because it was not provided as part of a qualifying trial/study. Spanish version: Este servicio/artículo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.
(Rev. 3898, Issued: 10-27-17; Effective: 04-01- 15, Implementation: 04-02-18)
MA plans are responsible for payment of TAVR services for MA plan participants. Medicare coverage for TAVR is not included under section 310.1 of the NCD Manual (Routine Costs in Clinical Trials).
(Rev. 2728, Issued: 06-14-13-Effective: 04-03-13, Implementation: 07-16-13)
Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic diseases; specifically, for age-related macular degeneration (AMD), a common eye disease among the elderly. OPT involves the infusion of an intravenous photosensitizing drug called Verteporfin, followed by exposure to a laser. For complete Medical coverage guidelines, see National Coverage Determinations (NCD) Manual (Pub 100-03) § 80.2 through 80.3.1.
(Rev. 2728, Issued: 06-14-13, Effective: 04-03-13, Implementation: 07-16-13)
The following are applicable Current Procedural Terminology (CPT) codes for OPT with Verteporfin:
67221- Destruction of localized lesion of choroid (e.g. choroidal neovascularization); photodynamic therapy (includes intravenous infusion)
67225- Destruction of localized lesion of choroid (e.g. choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment)
The following are applicable Healthcare Common Procedure Coding System (HCPCS) code for OPT with Verteporfin:
J3396- Injection, Verteporfin, 0.1 mg
OPT with Verteporfin is a covered service when billed with the below ICD-10-CM codes Nationally Covered ICD-10-CM codes
| H35.3210 | Exudative age-related macular degeneration, right eye, stage unspecified |
|---|---|
| H35.3211 | Exudative age-related macular degeneration, right eye, with active choroidal neovascularization |
| H35.3212 | Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization |
| H35.3213 | Exudative age-related macular degeneration, right eye, with inactive scar |
| H35.3220 | Exudative age-related macular degeneration, left eye, stage unspecified |
| H35.3221 | Exudative age-related macular degeneration, left eye, with active choroidal neovascularization |
| H35.3222 | Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization |
| H35.3223 | Exudative age-related macular degeneration, left eye, with inactive scar |
| H35.3230 | Exudative age-related macular degeneration, bilateral, stage unspecified |
| H35.3231 | Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization |
| H35.3232 | Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization |
| H35.3233 | Exudative age-related macular degeneration, bilateral, with inactive scar |
ICD-10- Codes for OPT with Verteporfin for other ocular indications are eligible for local coverage determinations through individual contractor discretion.
| B39.4 | Histocapsulati, unspecified |
|---|---|
| (Translates to combination of both B39.4 & H32) | |
| B39.5 | Histoplasmosis duboisii |
| (Requires H32 coverage) | |
| B39.9 | Histoplasmosis, unspecified |
| (Requires H32 coverage) |
| H32 | Chorioretinal disorders in diseases classified elsewhere |
|---|---|
| (Requires B39.4 coverage) | |
| H44.2A1 | Degenerative myopia with choroidal neovascularization, right eye |
| H44.2A2 | Degenerative myopia with choroidal neovascularization, left eye |
| H44.2A3 | Degenerative myopia with choroidal neovascularization, bilateral eye |
| H44.2B1 | Degenerative myopia with macular hole, right eye |
| H44.2B2 | Degenerative myopia with macular hole, left eye |
| H44.2B3 | Degenerative myopia with macular hole, bilateral eye |
| H44.2C1 | Degenerative myopia with retinal detachment, right eye |
| H44.2C2 | Degenerative myopia with retinal detachment, left eye |
| H44.2C3 | Degenerative myopia with retinal detachment, bilateral eye |
| H44.2D1 | Degenerative myopia with foveoschisis, right eye |
| H44.2D2 | Degenerative myopia with foveoschisis, left eye |
| H44.2D3 | Degenerative myopia with foveoschisis, bilateral eye |
| H44.2E1 | Degenerative myopia with other maculopathy, right eye |
| H44.2E2 | Degenerative myopia with other maculopathy, left eye |
| H44.2E3 | Degenerative myopia with other maculopathy, bilateral eye |
| H44.21 | Degenerative Myopia, right eye |
| H44.22 | Degenerative Myopia, left eye |
| H44.23 | Degenerative Myopia, bilateral |
| H35.711 | Central serous chorioretinopathy, right eye |
| H35.712 | Central serous chorioretinopathy, left eye |
| H35.713 | Central serous chorioretinopathy, bilateral |
Coverage is denied when billed with the below Nationally Non-Covered ICD-10-CM codes Nationally Non-Covered ICD-10-CM codes:
| H35.30 | Unspecified macular degeneration |
|---|---|
| H35.3110 | Nonexudative age-related macular degeneration, right eye, stage unspecified |
| H35.3111 | Nonexudative age-related macular degeneration, right eye, early dry stage |
| H35.3112 | Nonexudative age-related macular degeneration, right eye, intermediate dry stage |
| H35.3113 | Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement |
| H35.3114 | Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement |
| H35.3120 | Nonexudative age-related macular degeneration, left eye, stage unspecified |
| H35.3121 | Nonexudative age-related macular degeneration, left eye, early dry stage |
| H35.3122 | Nonexudative age-related macular degeneration, left eye, intermediate dry stage |
| H35.3123 | Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement |
| H35.3124 | Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement |
| H35.3130 | Nonexudative age-related macular degeneration, bilateral, stage unspecified |
|---|---|
| H35.3131 | Nonexudative age-related macular degeneration, bilateral, early dry stage |
| H35.3132 | Nonexudative age-related macular degeneration, bilateral, intermediate dry stage |
| H35.3133 | Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement |
| H35.3134 | Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement |
Payment for OPT service (CPT code 67221/67225) must be billed on the same claim as the drug (J3396) for the same date of service.
Claims for OPT with Verteporfin for dates of service prior to April 3, 2013, are covered at the initial visit as determined by a fluorescein angiogram (FA) CPT code 92235. Subsequent follow-up visits also require a FA prior to treatment.
For claims with dates of service on or after April 3, 2013, contractors shall accept and process claims for subsequent follow-up visits with either a FA, CPT code 92235, or optical coherence tomography (OCT), CPT codes 92133, 92134 or 92137 (effective 01/01/2025) prior to treatment.
Regardless of the date of service of the claim, the FA or OCT is not required to be submitted on the claim for OPT and can be maintained in the patient’s file for audit purposes.
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Inpatient facilities shall report ICD-10-CM codes H35.3210-H35.3233 (Exudative Age-related Macular Degeneration) and ICD-10-PCS codes 085E3ZZ (Destruction of Right Retina, Percutaneous Approach) and 085F3ZZ (Destruction of Left Retina, Percutaneous Approach)
(Rev. 2728, Issued: 06-14-13, Effective: 04-03-13, Implementation: 07-16-13)
The following message shall be used to notify beneficiaries and providers of denial situations that may occur:
MSN 14.9: “Medicare cannot pay for this service for the diagnosis shown on the claim.” (English version) or “Medicare no puede pagar por este servicio debido al diagnostic indicado en la reclamacion.” (Spanish Version)
Claims Adjustment Reason Code B22: “This payment is adjusted based on the diagnosis.”
(Rev. 2743, Issued: 07-25-13, Effective: 07-01-01-13, Implementation, 08-26-13)
Effective May 17, 2007, Transesophageal Doppler used for cardiac monitoring is covered for ventilated patients in the ICU and operative patients with a need for intra-operative fluid
optimization was deemed reasonable and necessary. See National Coverage Determinations Manual (Pub. 100-03) §220.5, for complete coverage guidelines.
A new Healthcare Common Procedure Coding System (HCPCS) code, G9157, Transesophageal Doppler used for cardiac monitoring, will be made effective for use for dates of service on or after January 1, 2013.
(Rev. 2743, Issued: 07-25-13, Effective: 07-01-01-13, Implementation, 08-26-13)
Prior to January 1, 2013, the applicable HCPCS code for Transesophageal Doppler cardiac monitoring is:
HCPCS 76999 (billed with modifier -26) when performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for intra-operative fluid optimization.
If globally billed using code 76999, it shall be returned as unprocessable to the provider using a claim adjustment reason code (CARC) such as:
CARC 58: 'Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.'
HCPCS 76999 (billed with modifier -TC) shall be denied when performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for intra-operative fluid optimization with a message such as:
CARC 58: 'Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.'
RARC M77: 'Missing/incomplete/invalid place of service.'
MSN 17.9: 'Medicare (Part A/Part B) pays for this service. The provider must bill the correct Medicare contractor.' (English version) or 'Este servicio es pagado por Medicare (Parte A/Parte B). El proveedor debe enviar la facture al contratista de Medicare correcto.' (Spanish version).
HCPCS 76999 (billed globally or with -26 or -TC) when performed in an ASC setting for operative patients with a need for intra-operative fluid optimization, ultrasound diagnostic procedures are covered when performed by an entity other than the ASC.
(Rev. 2743, Issued: 07-25-13, Effective: 07-01-01-13, Implementation, 08-26-13)
After January 1, 2013, the applicable HCPCS code for Transesophageal Doppler cardiac monitoring is:
HCPCS G9157: Transesophageal Doppler used for cardiac monitoring
Contractors shall allow HCPCS G9157 to be billed when services are provided in POS 21 for ventilated patients in the ICU or for operative patients with a need for intra-operative fluid optimization.
Contractors shall deny HCPCS 76999 when billed for Esophageal Doppler for ventilated patients in the ICU or for operative patients with a need for intra-operative fluid optimization using the following messages:
CARC 189: “Not otherwise classified” or ‘unlisted’ procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.”
RARC M20: “Missing/incomplete/invalid HCPCS.”
MSN 16.13: “The code(s) your provider used is/are not valid for the date of service billed.” (English version) or “El/los código(s) que usó su proveedor no es/son válido(s) en la fecha de servicio facturada.” (Spanish version).
Group Code: Contractual Obligation (CO)
Contractors shall pay for Transesophageal Doppler cardiac monitoring, G9157, only when services are provided at POS 21.
Contractors shall deny HCPCS G9157 when billed globally in any POS other than 21 for ventilated patients in the ICU or for operative patients with a need for intra-operative fluid optimization using the following messages:
CARC 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
MSN 16.2: This service cannot be paid when provided in this location/facility.
Effective for claims with dates of service on or after December 1, 2020, as a result of a reconsideration of National Coverage Determination (NCD) 20.9 of the Medicare NCD Manual, coverage determinations for artificial hearts and related devices shall be made by the Medicare Administrative Contractors.
Effective for discharges before May 1, 2008, Medicare does not cover the use of artificial hearts, either as a permanent replacement for a human heart or as a temporary life-support system until a human heart becomes available for transplant (often referred to a 'bridge to transplant').
Effective for discharges on or after May 1, 2008, the use of artificial hearts will be covered by Medicare under Coverage with Evidence Development (CED) when beneficiaries are enrolled in a clinical study that meets all of the criteria listed in IOM Pub. 100-03, Medicare NCD Manual, section 20.9.
For claims with dates of service on or after May 1, 2008, artificial hearts in the context of an approved clinical study for a Category A IDE, refer to section 69 in this manual for more detail on CED billing. Appropriate ICD-10 diagnosis and procedure codes are included below:
| ICD-10 Diagnosis Code | Definition | Discharges Effective |
|---|---|---|
| I09.81 | Rheumatic heart failure | On or After ICD-10 Implementation |
| I11.0 | Hypertensive heart disease with heart failure | |
| I13.0 | Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease | |
| I13.2 | Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease | |
| I20.0 | Unstable angina | |
| I21.01 | ST elevation (STEMI) myocardial infarction involving left main coronary artery | |
| I21.02 | ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery | |
| 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 | |
| I21.21 | ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery | |
| 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 | |
| I22.0 | Subsequent ST elevation (STEMI) myocardial infarction of anterior wall | |
| I22.1 | Subsequent ST elevation (STEMI) myocardial infarction of inferior wall | |
| I22.2 | Subsequent non-ST elevation (NSTEMI) myocardial infarction | |
| I22.8 | Subsequent ST elevation (STEMI) myocardial infarction of other sites | |
| I22.9 | Subsequent ST elevation (STEMI) myocardial infarction of unspecified site | |
| I24.0 | Acute coronary thrombosis not resulting in myocardial infarction | |
| I24.1 | Dressler's syndrome | |
| I24.8 | Other forms of acute ischemic heart disease | |
| I24.9 | Acute ischemic heart disease, unspecified |
| I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris |
|---|---|
| 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 |
| I25.5 | Ischemic cardiomyopathy |
| I25.6 | Silent myocardial ischemia |
| 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 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.720 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris |
| I25.721 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm |
| I25.728 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.729 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.730 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris |
| I25.731 | 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 pectoris |
| I25.751 | Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm |
| I25.758 | Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris |
| I25.759 | Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris |
| I25.760 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina pectoris |
| I25.761 | 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 |
| I25.810 | Atherosclerosis of coronary artery bypass graft(s) without angina pectoris |
| I25.811 | Atherosclerosis of native coronary artery of transplanted heart without angina pectoris |
| I25.812 | Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris |
| I25.89 | Other forms of chronic ischemic heart disease |
| I25.9 | Chronic ischemic heart disease, unspecified |
| I34.0 | Nonrheumatic mitral (valve) insufficiency |
| I34.1 | Nonrheumatic mitral (valve) prolapse |
| I34.2 | Nonrheumatic mitral (valve) stenosis |
| I34.8 | Other nonrheumatic mitral valve disorders |
| I34.9 | Nonrheumatic mitral valve disorder, unspecified |
| I35.0 | Nonrheumatic aortic (valve) stenosis |
| I35.1 | Nonrheumatic aortic (valve) insufficiency |
| I35.2 | Nonrheumatic aortic (valve) stenosis with insufficiency |
| I35.8 | Other nonrheumatic aortic valve disorders |
| I35.9 | Nonrheumatic aortic valve disorder, unspecified |
| I36.0 | Nonrheumatic tricuspid (valve) stenosis |
| I36.1 | Nonrheumatic tricuspid (valve) insufficiency |
| I36.2 | Nonrheumatic tricuspid (valve) stenosis with insufficiency |
| I36.8 | Other nonrheumatic tricuspid valve disorders |
| I36.9 | Nonrheumatic tricuspid valve disorder, unspecified |
| I37.0 | Nonrheumatic pulmonary valve stenosis |
| I37.1 | Nonrheumatic pulmonary valve insufficiency |
| I37.2 | Nonrheumatic pulmonary valve stenosis with insufficiency |
| I37.8 | Other nonrheumatic pulmonary valve disorders |
| I37.9 | Nonrheumatic pulmonary valve disorder, unspecified |
| I38 | Endocarditis, valve unspecified |
| I39 | Endocarditis and heart valve disorders in diseases classified elsewhere |
| I42.0 | Dilated cardiomyopathy |
| I42.2 | Other hypertrophic cardiomyopathy |
| I42.3 | Endomyocardial (eosinophilic) disease |
| I42.4 | Endocardial fibroelastosis |
| I42.5 | Other restrictive cardiomyopathy |
| I42.6 | Alcoholic cardiomyopathy |
| I42.7 | Cardiomyopathy due to drug and external agent |
| I42.8 | Other cardiomyopathies |
| I42.9 | Cardiomyopathy, unspecified |
| I43 | Cardiomyopathy in diseases classified elsewhere |
|---|---|
| I46.2 | Cardiac arrest due to underlying cardiac condition |
| I46.8 | Cardiac arrest due to other underlying condition |
| I46.9 | Cardiac arrest, cause unspecified |
| I47.0 | Re-entry ventricular arrhythmia |
| I47.1 | Supraventricular tachycardia |
| I47.2 | Ventricular tachycardia |
| I47.9 | Paroxysmal tachycardia, unspecified |
| I48.0 | Atrial fibrillation |
| I48.1 | Atrial flutter |
| I49.01 | Ventricular fibrillation |
| I49.02 | Ventricular flutter |
| I49.1 | Atrial premature depolarization |
| I49.2 | Junctional premature depolarization |
| I49.3 | Ventricular premature depolarization |
| I49.40 | Unspecified premature depolarization |
| I49.49 | Other premature depolarization |
| I49.5 | Sick sinus syndrome |
| I49.8 | Other specified cardiac arrhythmias |
| I49.9 | Cardiac arrhythmia, unspecified |
| I50.1 | Left ventricular failure |
| I50.20 | Unspecified systolic (congestive) heart failure |
| I50.21 | Acute systolic (congestive) heart failure |
| I50.22 | Chronic systolic (congestive) heart failure |
| I50.23 | Acute on chronic systolic (congestive) heart failure |
| I50.30 | Unspecified diastolic (congestive) heart failure |
| I50.31 | Acute diastolic (congestive) heart failure |
| I50.32 | Chronic diastolic (congestive) heart failure |
| I50.33 | Acute on chronic diastolic (congestive) heart failure |
| I50.40 | Unspecified combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.41 | Acute combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.42 | Chronic combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.43 | Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.9 | Heart failure, unspecified |
| I51.4 | Myocarditis, unspecified |
| I51.9 | Heart disease, unspecified |
| I52 | Other heart disorders in diseases classified elsewhere |
| I97.0 | Postcardiotomy syndrome |
| I97.110 | Postprocedural cardiac insufficiency following cardiac surgery |
| I97.111 | Postprocedural cardiac insufficiency following other surgery |
| I97.120 | Postprocedural cardiac arrest following cardiac surgery |
| I97.121 | Postprocedural cardiac arrest following other surgery |
| I97.130 | Postprocedural heart failure following cardiac surgery |
| I97.131 | Postprocedural heart failure following other surgery |
| I97.190 | Other postprocedural cardiac functional disturbances following cardiac surgery |
| I97.191 | Other postprocedural cardiac functional disturbances following other surgery |
| I97.710 | Intraoperative cardiac arrest during cardiac surgery |
| I97.711 | Intraoperative cardiac arrest during other surgery |
| I97.790 | Other intraoperative cardiac functional disturbances during cardiac surgery |
|---|---|
| I97.791 | Other intraoperative cardiac functional disturbances during other surgery |
| I97.88 | Other intraoperative complications of the circulatory system, not elsewhere classified |
| I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
| M32.11 | Endocarditis in systemic lupus erythematosus |
| O90.89 | Other complications of the puerperium, not elsewhere classified |
| Q20.0 | Common arterial trunk |
| Q20.1 | Double outlet right ventricle |
| Q20.2 | Double outlet left ventricle |
| Q20.3 | Discordant ventriculoarterial connection |
| Q20.4 | Double inlet ventricle |
| Q20.5 | Discordant atrioventricular connection |
| Q20.6 | Isomerism of atrial appendages |
| Q20.8 | Other congenital malformations of cardiac chambers and connections |
| Q20.9 | Congenital malformation of cardiac chambers and connections, unspecified |
| Q21.0 | Ventricular septal defect |
| Q21.1 | Atrial septal defect |
| Q21.2 | Atrioventricular septal defect |
| Q21.3 | Tetralogy of Fallot |
| Q21.4 | Aortopulmonary septal defect |
| Q21.8 | Other congenital malformations of cardiac septa |
| Q21.9 | Congenital malformation of cardiac septum, unspecified |
| Q22.0 | Pulmonary valve atresia |
| Q22.1 | Congenital pulmonary valve stenosis |
| Q22.2 | Congenital pulmonary valve insufficiency |
| Q22.3 | Other congenital malformations of pulmonary valve |
| Q22.4 | Congenital tricuspid stenosis |
| Q22.5 | Ebstein's anomaly |
| Q22.6 | Hypoplastic right heart syndrome |
| Q22.8 | Other congenital malformations of tricuspid valve |
| Q22.9 | Congenital malformation of tricuspid valve, unspecified |
| Q23.0 | Congenital stenosis of aortic valve |
| Q23.1 | Congenital insufficiency of aortic valve |
| Q23.2 | Congenital mitral stenosis |
| Q23.3 | Congenital mitral insufficiency |
| Q23.4 | Hypoplastic left heart syndrome |
| Q23.8 | Other congenital malformations of aortic and mitral valves |
| Q23.9 | Congenital malformation of aortic and mitral valves, unspecified |
| Q24.0 | Dextrocardia |
| Q24.1 | Levocardia |
| Q24.2 | Cor triatriatum |
| Q24.3 | Pulmonary infundibular stenosis |
| Q24.4 | Congenital subaortic stenosis |
| Q24.5 | Malformation of coronary vessels |
| Q24.6 | Congenital heart block |
| Q24.8 | Other specified congenital malformations of heart |
| Q24.9 | Congenital malformation of heart, unspecified |
| R00.1 | Bradycardia, unspecified |
|---|---|
| R57.0 | Cardiogenic shock |
| T82.221A | Breakdown (mechanical) of biological heart valve graft, initial encounter |
| T82.222A | Displacement of biological heart valve graft, initial encounter |
| T82.223A | Leakage of biological heart valve graft, initial encounter |
| T82.228A | Other mechanical complication of biological heart valve graft, initial encounter |
| T82.512A | Breakdown (mechanical) of artificial heart, initial encounter |
| T82.514A | Breakdown (mechanical) of infusion catheter, initial encounter |
| T82.518A | Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter |
| T82.519A | Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.522A | Displacement of artificial heart, initial encounter |
| T82.524A | Displacement of infusion catheter, initial encounter |
| T82.528A | Displacement of other cardiac and vascular devices and implants, initial encounter |
| T82.529A | Displacement of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.532A | Leakage of artificial heart, initial encounter |
| T82.534A | Leakage of infusion catheter, initial encounter |
| T82.538A | Leakage of other cardiac and vascular devices and implants, initial encounter |
| T82.539A | Leakage of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.592A | Other mechanical complication of artificial heart, initial encounter |
| T82.594A | Other mechanical complication of infusion catheter, initial encounter |
| T82.598A | Other mechanical complication of other cardiac and vascular devices and implants, initial encounter |
| T82.599A | Other mechanical complication of unspecified cardiac and vascular devices and implants, initial encounter |
| T86.20 | Unspecified complication of heart transplant |
| T86.21 | Heart transplant rejection |
| T86.22 | Heart transplant failure |
| T86.23 | Heart transplant infection |
| T86.290 | Cardiac allograft vasculopathy |
| T86.298 | Other complications of heart transplant |
| T86.30 | Unspecified complication of heart-lung transplant |
| T86.31 | Heart-lung transplant rejection |
| T86.32 | Heart-lung transplant failure |
| T86.33 | Heart-lung transplant infection |
| T86.39 | Other complications of heart-lung transplant |
| Z48.21 | Encounter for aftercare following heart transplant |
| Z48.280 | Encounter for aftercare following heart-lung transplant |
| Z94.1 | Heart transplant status |
| Z94.3 | Heart and lungs transplant status |
| Z95.9 | Presence of cardiac and vascular implant and graft, unspecified |
| Q24.0 | Dextrocardia |
| Q24.1 | Levocardia |
| Q24.2 | Cor triatriatum |
|---|---|
| Q24.3 | Pulmonary infundibular stenosis |
| Q24.4 | Congenital subaortic stenosis |
| Q24.5 | Malformation of coronary vessels |
| Q24.6 | Congenital heart block |
| Q24.8 | Other specified congenital malformations of heart |
| Q24.9 | Congenital malformation of heart, unspecified |
| R00.1 | Bradycardia, unspecified |
| R57.0 | Cardiogenic shock |
| T82.221A | Breakdown (mechanical) of biological heart valve graft, initial encounter |
| T82.222A | Displacement of biological heart valve graft, initial encounter |
| T82.223A | Leakage of biological heart valve graft, initial encounter |
| T82.228A | Other mechanical complication of biological heart valve graft, initial encounter |
| T82.512A | Breakdown (mechanical) of artificial heart, initial encounter |
| T82.514A | Breakdown (mechanical) of infusion catheter, initial encounter |
| T82.518A | Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter |
| T82.519A | Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.522A | Displacement of artificial heart, initial encounter |
| T82.524A | Displacement of infusion catheter, initial encounter |
| T82.528A | Displacement of other cardiac and vascular devices and implants, initial encounter |
| T82.529A | Displacement of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.532A | Leakage of artificial heart, initial encounter |
| T82.534A | Leakage of infusion catheter, initial encounter |
| T82.538A | Leakage of other cardiac and vascular devices and implants, initial encounter |
| T82.539A | Leakage of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.592A | Other mechanical complication of artificial heart, initial encounter |
| T82.594A | Other mechanical complication of infusion catheter, initial encounter |
| T82.598A | Other mechanical complication of other cardiac and vascular devices and implants, initial encounter |
| T82.599A | Other mechanical complication of unspecified cardiac and vascular devices and implants, initial encounter |
| T86.20 | Unspecified complication of heart transplant |
| T86.21 | Heart transplant rejection |
| T86.22 | Heart transplant failure |
| T86.23 | Heart transplant infection |
| T86.290 | Cardiac allograft vasculopathy |
| T86.298 | Other complications of heart transplant |
| T86.30 | Unspecified complication of heart-lung transplant |
| T86.31 | Heart-lung transplant rejection |
| T86.32 | Heart-lung transplant failure |
| T86.33 | Heart-lung transplant infection |
| T86.39 | Other complications of heart-lung transplant |
| Z48.21 | Encounter for aftercare following heart transplant |
| Z48.280 | Encounter for aftercare following heart-lung transplant | |
|---|---|---|
| Z94.1 | Heart transplant status | |
| Z94.3 | Heart and lungs transplant status | |
| Z95.9 | Presence of cardiac and vascular implant and graft, unspecified |
| ICD-10 Procedure Code | Definition | Discharges Effective |
|---|---|---|
| 02RK0JZ | Replacement of Right Ventricle with Synthetic Substitute, Open Approach | On or After ICD-10 Implementation |
| 02RL0JZ | Replacement of Left Ventricle with Synthetic Substitute, Open Approach | |
| 02WA0JZ | Revision of Synthetic Substitute in Heart, Open Approach |
NOTE: Total artificial heart is reported with a “cluster” of 2 codes for open replacement with synthetic substitute of the right and left ventricles- 02RK0JZ + 02RL0JZ
(Rev.10837; Issued: 06-11-21; Effective: 12-01-20; Implementation: 07-27-21)
Medicare may cover a Ventricular Assist Device (VAD). A VAD is surgically attached to one or both intact ventricles and is used to assist or augment the ability of a damaged or weakened native heart to pump blood. Improvement in the performance of the native heart may allow the device to be removed. Refer to the Internet Only Manual Publication 100-03, National Coverage Determination (NCD) Manual, section 20.9.1, for coverage criteria.
(Rev.10837; Issued: 06-11-21; Effective: 12-01-20; Implementation: 07-27-21)
Post-cardiotomy is the period following open-heart surgery. VADs used for support of blood circulation post-cardiotomy are covered only if they have received approval from the Food and Drug Administration (FDA) for that purpose, and the VADs are used according to the FDA-approved labeling instructions.
(Rev.10837; Issued: 06-11-21; Effective: 12-01-20; Implementation: 07-27-21)
Effective for claims with dates of service on or after December 1, 2020, Left ventricular assist devices (LVADs) are covered if they are FDA-approved for short-term (e.g., bridge-to-recovery and bridge-to-transplant) or long-term (e.g., destination therapy) mechanical circulatory support for heart failure patients who meet specific clinical criteria outlined in NCD 20.9.1.
(Rev. 13549; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26)
All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the NCD Manual.
Appropriate ICD-10 diagnosis and procedure codes are included below:
| ICD-10 Diagnosis Code | Definition |
|---|---|
| I09.81 | Rheumatic heart failure |
| I11.0 | Hypertensive heart disease with heart failure |
| I13.0 | Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I13.2 | Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease |
| I20.0 | Unstable angina |
| I20.2 | Refractory angina pectoris |
| I21.01 | ST elevation (STEMI) myocardial infarction involving left main coronary artery |
| I21.02 | ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery |
| 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 |
|---|---|
| I21.21 | ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery |
| 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 |
| I22.0 | Subsequent ST elevation (STEMI) myocardial infarction of anterior wall |
| I22.1 | Subsequent ST elevation (STEMI) myocardial infarction of inferior wall |
| I22.2 | Subsequent non-ST elevation (NSTEMI) myocardial infarction |
| I22.8 | Subsequent ST elevation (STEMI) myocardial infarction of other sites |
| I22.9 | Subsequent ST elevation (STEMI) myocardial infarction of unspecified site |
| I24.0 | Acute coronary thrombosis not resulting in myocardial infarction |
| I24.1 | Dressler's syndrome |
| I24.81 | Acute coronary microvascular dysfunction Effective 10/1/23 |
| ICD-10 Diagnosis Code | Definition |
|---|---|
| I24.89 | Other forms of acute ischemic heart disease Effective 10/1/23 |
| I24.9 | Acute ischemic heart disease, unspecified |
| I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris |
| 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 |
| I25.112 | Atherosclerotic heart disease of native coronary artery with refractory angina pectoris |
| 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 |
| I25.5 | Ischemic cardiomyopathy |
| I25.6 | Silent myocardial ischemia |
| 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 |
| I25.702 | Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris |
| 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 |
| I25.712 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris |
|---|---|
| I25.718 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.719 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.720 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris |
| I25.721 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm |
| I25.722 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris |
| I25.728 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.729 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.730 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris |
| I25.731 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm |
| ICD-10 Diagnosis Code | Definition |
|---|---|
| I25.732 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with refractory angina pectoris |
| 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 |
| I25.752 | Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris |
| I25.758 | Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris |
| I25.759 | Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris |
| I25.760 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina |
| I25.761 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm |
| I25.762 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris |
| 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 |
|---|---|
| I25.792 | Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris |
| 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 |
| I25.810 | Atherosclerosis of coronary artery bypass graft(s) without angina pectoris |
| I25.811 | Atherosclerosis of native coronary artery of transplanted heart without angina pectoris |
| I25.812 | Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris |
| I25.89 | Other forms of chronic ischemic heart disease |
| I25.9 | Chronic ischemic heart disease, unspecified |
| I34.0 | Nonrheumatic mitral (valve) insufficiency |
| I34.1 | Nonrheumatic mitral (valve) prolapse |
| I34.2 | Nonrheumatic mitral (valve) stenosis |
| I34.81 | Nonrheumatic mitral (valve) |
| I34.89 | Other nonrheumatic mitral valve disorders |
| I34.9 | Nonrheumatic mitral valve disorder, unspecified |
| I35.0 | Nonrheumatic aortic (valve) stenosis |
| I35.1 | Nonrheumatic aortic (valve) insufficiency |
| I35.2 | Nonrheumatic aortic (valve) stenosis with insufficiency |
| I35.8 | Other nonrheumatic aortic valve disorders |
| I35.9 | Nonrheumatic aortic valve disorder, unspecified |
| ICD-10 Diagnosis Code | Definition |
|---|---|
| I36.0 | Nonrheumatic tricuspid (valve) stenosis |
| I36.1 | Nonrheumatic tricuspid (valve) insufficiency |
| I36.2 | Nonrheumatic tricuspid (valve) stenosis with insufficiency |
| I36.8 | Other nonrheumatic tricuspid valve disorders |
| I36.9 | Nonrheumatic tricuspid valve disorder, unspecified |
| I37.0 | Nonrheumatic pulmonary valve stenosis |
| I37.1 | Nonrheumatic pulmonary valve insufficiency |
| I37.2 | Nonrheumatic pulmonary valve stenosis with insufficiency |
| I37.8 | Other nonrheumatic pulmonary valve disorders |
| I37.9 | Nonrheumatic pulmonary valve disorder, unspecified |
| I38 | Endocarditis, valve unspecified |
| I39 | Endocarditis and heart valve disorders in diseases classified elsewhere |
|---|---|
| I42.0 | Dilated cardiomyopathy |
| I42.2 | Other hypertrophic cardiomyopathy |
| I42.3 | Endomyocardial (eosinophilic) disease |
| I42.4 | Endocardial fibroelastosis |
|---|---|
| I42.5 | Other restrictive cardiomyopathy |
| I42.6 | Alcoholic cardiomyopathy |
| I42.7 | Cardiomyopathy due to drug and external agent |
| I42.8 | Other cardiomyopathies |
| I42.9 | Cardiomyopathy, unspecified |
| I43 | Cardiomyopathy in diseases classified elsewhere |
| I46.2 | Cardiac arrest due to underlying cardiac condition |
| I46.8 | Cardiac arrest due to other underlying condition |
| I46.9 | Cardiac arrest, cause unspecified |
| I47.0 | Re-entry ventricular arrhythmia |
| I47.10 | Supraventricular tachycardia, unspecified Effective 10/1/23 |
| I47.11 | Inappropriate sinus tachycardia, so stated Effective 10/1/23 |
| I47.19 | Other supraventricular tachycardia Effective 10/1/23 |
| I47.20 | Ventricular tachycardia, unspecified |
| I47.21 | Torsades de pointes |
| I47.29 | Other ventricular tachycardia |
| I47.9 | Paroxysmal tachycardia, unspecified |
| I48.0 | Atrial fibrillation |
| I48.11 | Longstanding persistent atrial fibrillation |
| I48.19 | Other persistent atrial fibrillation |
| I49.01 | Ventricular fibrillation |
| I49.02 | Ventricular flutter |
| I49.1 | Atrial premature depolarization |
| I49.2 | Junctional premature depolarization |
| ICD-10 Diagnosis Code | Definition |
|---|---|
| I49.3 | Ventricular premature depolarization |
| I49.40 | Unspecified premature depolarization |
| I49.49 | Other premature depolarization |
| I49.5 | Sick sinus syndrome |
| I49.8 | Other specified cardiac arrhythmias |
| I49.9 | Cardiac arrhythmia, unspecified |
| I50.1 | Left ventricular failure |
| I50.20 | Unspecified systolic (congestive) heart failure |
| I50.21 | Acute systolic (congestive) heart failure |
| I50.22 | Chronic systolic (congestive) heart failure |
| I50.23 | Acute on chronic systolic (congestive) heart failure |
|---|---|
| I50.30 | Unspecified diastolic (congestive) heart failure |
| I50.31 | Acute diastolic (congestive) heart failure |
| I50.32 | Chronic diastolic (congestive) heart failure |
| I50.33 | Acute on chronic diastolic (congestive) heart failure |
| I50.40 | Unspecified combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.41 | Acute combined systolic (congestive) and diastolic (congestive) heart failure |
|---|---|
| I50.42 | Chronic combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.43 | Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.84 | End-stage heart failure |
| I50.9 | Heart failure, unspecified |
| I51.4 | Myocarditis, unspecified |
| I51.9 | Heart disease, unspecified |
| I52 | Other heart disorders in diseases classified elsewhere |
| I5A | Non-ischemic myocardial injury (non-traumatic) |
| I97.0 | Postcardiotomy syndrome |
| I97.110 | Postprocedural cardiac insufficiency following cardiac surgery |
| I97.111 | Postprocedural cardiac insufficiency following other surgery |
| I97.120 | Postprocedural cardiac arrest following cardiac surgery |
| I97.121 | Postprocedural cardiac arrest following other surgery |
| I97.130 | Postprocedural heart failure following cardiac surgery |
| I97.131 | Postprocedural heart failure following other surgery |
| I97.190 | Other postprocedural cardiac functional disturbances following cardiac surgery |
| I97.191 | Other postprocedural cardiac functional disturbances following other surgery |
| I97.710 | Intraoperative cardiac arrest during cardiac surgery |
| I97.711 | Intraoperative cardiac arrest during other surgery |
| I97.790 | Other intraoperative cardiac functional disturbances during cardiac surgery |
| I97.791 | Other intraoperative cardiac functional disturbances during other surgery |
| I97.88 | Other intraoperative complications of the circulatory system, not elsewhere classified |
| I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
| ICD-10 Diagnosis Code | Definition |
|---|---|
| M32.11 | Endocarditis in systemic lupus erythematosus |
| R00.1 | Bradycardia, unspecified |
| R57.0 | Cardiogenic shock |
| T82.221A | Breakdown (mechanical) of biological heart valve graft, initial encounter |
| T82.222A | Displacement of biological heart valve graft, initial encounter |
| T82.223A | Leakage of biological heart valve graft, initial encounter |
| T82.228A | Other mechanical complication of biological heart valve graft, initial encounter |
| T82.512A | Breakdown (mechanical) of artificial heart, initial encounter |
| T82.514A | Breakdown (mechanical) of infusion catheter, initial encounter |
| T82.518A | Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter |
|---|---|
| T82.522A | Displacement of artificial heart, initial encounter |
| T82.528A | Displacement of other cardiac and vascular devices and implants, initial encounter |
| T82.529A | Displacement of unspecified cardiac and vascular devices and implants, initial encounter |
| T82.532A | Leakage of artificial heart, initial encounter |
| T82.538A | Leakage of other cardiac and vascular devices and implants, initial encounter |
| T82.592A | Other mechanical complication of artificial heart, initial encounter |
| T82.598A | Other mechanical complication of other cardiac and vascular devices and implants, initial encounter |
| T86.20 | Unspecified complication of heart transplant |
| T86.21 | Heart transplant rejection |
| T86.22 | Heart transplant failure |
| T86.23 | Heart transplant infection |
| T86.290 | Cardiac allograft vasculopathy |
| T86.298 | Other complications of heart transplant |
| T86.30 | Unspecified complication of heart-lung transplant |
| T86.31 | Heart-lung transplant rejection |
| T86.32 | Heart-lung transplant failure |
| T86.33 | Heart-lung transplant infection |
| T86.39 | Other complications of heart-lung transplant |
| Z48.21 | Encounter for aftercare following heart transplant |
| Z48.280 | Encounter for aftercare following heart-lung transplant |
| Z94.1 | Heart transplant status |
| Z94.3 | Heart and lungs transplant status |
| Z95.811 | Presence of heart assist device effective 12/01/20 |
This policy does not address coverage of VADs for right ventricular support, biventricular support, use in beneficiaries under the age of 18, use in beneficiaries with complex congenital heart disease, or use in beneficiaries with acute heart failure without a history of chronic heart failure. Coverage under section 1862(a) (1) (A) of the Social Security Act for VADs in these situations will be made by local Medicare Administrative Contractors (MACs) within their respective jurisdictions.
Effective April 1, 2013, claims for replacement of accessories and supplies for VADs implanted in patients who were not eligible for coverage under Medicare Part A or had other insurance that paid for the device and hospital stay at the time that the device was implanted, but are now eligible for coverage of the replacement supplies and accessories under Part B, should be submitted using HCPCS code Q0509. Those claims will be manually reviewed.
In rare instances it may be appropriate to pay for replacement of supplies and accessories for external VADs used by patient who are discharged from the hospital. In addition, in some rare instances, it may be necessary for a patient to have an emergency back-up controller for an external VAD. Coverage of these items is at the discretion of the contractor. Claims for replacement of supplies and accessories used with an external VAD that are furnished by suppliers should be billed to the Part B MACs. Claims for replacement of supplies and accessories used with an external VAD that are furnished by hospitals and other providers should be billed to the Part AMACs. Effective April 1, 2013, these items should be billed using code Q0507 so that the claims can be manually reviewed.
Claims for replacement supplies or accessories used with VADs that do not have specific HCPCS codes and do not meet the criteria of codes Q0507 and Q0509 should be billed using code Q0508.
| HCPCS | Definition | Effective Date |
|---|---|---|
| Q0507 | Miscellaneous Supply Or Accessory For Use With An External Ventricular Assist Device | April 1, 2013 |
| Q0508 | Miscellaneous Supply or Accessory For Use With An Implanted Ventricular Assist Device | April 1, 2013 |
| Q0509 | Miscellaneous Supply Or Accessory For Use With Any Implanted Ventricular Assist Device For Which Payment Was Not Made Under Medicare Part A | April 1, 2013 |
Q0480:Driver for use with pneumatic ventricular assist device, replacement only
Q0481:Microprocessor control unit for use with electric ventricular assist device, replacement only
Q0482:Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only
Q0483:Monitor/display module for use with electric ventricular assist device, replacement only
Q0484:Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0485:Monitor control cable for use with electric ventricular assist device, replacement only
Q0486:Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only
Q0487:Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only
Q0488:Power pack base for use with electric ventricular assist device, replacement only
Q0489:Power pack base for use with electric/pneumatic ventricular assist device, replacement only
Q0490:Emergency power source for use with electric ventricular assist device, replacement only
Q0491:Emergency power source for use with electric/pneumatic ventricular assist device, replacement only
Q0492:Emergency power supply cable for use with electric ventricular assist device, replacement only
Q0493:Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only
Q0494:Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0495:Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0496:Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0497:Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0498:Holster for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0499:Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only
Q0500:Filters for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0501:Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0502:Mobility cart for pneumatic ventricular assist device, replacement only
Q0503:Battery for pneumatic ventricular assist device, replacement only, each
Q0504:Power adapter for pneumatic ventricular assist device, replacement only, vehicle type
Q0506:Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only
NOTE: When determined to be medically necessary, dressings used with VADs are covered under the prosthetic device benefit as a supply necessary for the effective use of the VAD/prosthetic device. Claims for dressings necessary for the
effective use of a VAD should be billed using the appropriate miscellaneous VAD supply code, depending upon whether the patient was eligible for coverage under Medicare Part A at the time that the VAD was implanted. The claims processing jurisdiction for dressings used with VADs is identical to that of other VAD replacement supplies and accessories and does not fall under Durable Medical Equipment MAC jurisdiction.
(Rev. 2959, Issued: 05-16-14, Effective: 01-09-14, Implementation: 10-06-14)
PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. This is a procedure proposed as a treatment for symptomatic LSS unresponsive to conservative therapy. This procedure is generally described as a non-invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic, CT) with the assistance of contrast media to identify and monitor the compressed area via epiduragram. For complete Medical coverage guidelines, see National Coverage Determinations (NCD) Manual (Pub 100-03) §150.13.
(Rev. 13709; Issued:04-02-26, Effective: 06-02-26; Implementation: 06-02-26)
For claims with dates of service on or after January 9, 2014, PILD (procedure code 0275T - end date 12/31/25) is a covered service when billed as part of a clinical trial approved by CMS.
The description for CPT 0275T end date 12/31/25 is : “Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy”, any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar” .
CPT 62330 describes percutaneous image-guided lumbar decompression (PILD) for spinal stenosis, involving the removal of the ligamentum flavum and laminotomy, with imaging (CT or fluoroscopy) and epidurography.
Effective January 1, 2026, 62330 is replacing the former CPT code (0275T – end date effective 12/31/25).
For claims with dates of service on or after January 1, 2015, PILD (procedure code G0276) is a covered service when billed as part of a clinical trial approved by CMS. HCPCS G0276 is “Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD), or placebo control, performed in an approved coverage with evidence development (CED) clinical trial”.
Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS-approved prospective longitudinal study for PILD procedures using a FDA-approved/cleared device that completed a CMS-approved randomized, controlled clinical trial (RCT) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).
The claim may only contain one of these procedure codes, not both. To report G0276, the procedure must be performed within a CMS approved CED clinical trial that is randomized, blinded, and includes a placebo control arm of the trial. CMS will cover procedure code 0275T (end date effective 12/31/25) for PILD only when the procedure is performed
within any other CED approved clinical trial. Regardless of the type of CED approved clinical trial (e.g. G0276 vs 0275T (end date effective 12/31/25)), PILD is only covered when billed for the ICD-9 diagnosis of 724.01-724.03 or the ICD-10 diagnosis of M48.05-M48.07, when billed in places of service 19 (Off Campus-Outpatient Hospital (effective 01/01/16), 22 (Outpatient) or 24 (Ambulatory Surgical Center), when billed along with V70.7 (ICD-9) or Z00.6 (ICD-10) in either the primary/secondary positions, and when billed with modifier Q0.
Additionally, per Transmittal 2805 (Change Request 8401), issued October 30, 2013, all claims for clinical trials must contain the 8-digit clinical trial identifier number.
The following message(s) shall be used to notify providers of return situations that may occur:
For PILD claims with procedure code 0275T (end date 12/31/25) with dates of service on or after January 9, 2014, or claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD only when billed with the numeric, 8-digit clinical trial identifier number preceded by the two alpha characters “CT” when placed in Field 19 of paper Form CMS-1500, or when entered without the “CT” prefix in the electronic 837P in Loop 2300 REF02 (REF01=P4). Claims for PILD which are billed without an 8-digit clinical trial identifier number shall be returned as un-processable.
Note: Effective January 1, 2026, CPT 62330 is replacing the former CPT code (0275T – end date effective 12/31/25).
The following messages shall be used when Medicare contractors return PILD claims billed without an 8-digit clinical trial identifier number as un-processable:
Claims Adjustment Reason Code 16: “Claim/service lacks information or has submission/billing error(s) which is needed for adjudication”.
Remittance Advice Remark Code N721: “This service is only covered when performed as part of a clinical trial.”
Remittance Advice Remark Code MA50: “Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.”
Remittance Advice Remark Code N704: “Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.”
For PILD claims with procedure code 62330 effective 01/01/26 or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed in place of service 19, 22 or 24. Claims for PILD which are billed in any other place of service shall be returned as un-processable.
The following messages shall be used when Medicare contractors return PILD claims not billed in place of service 19, 22 or 24:
Claims Adjustment Reason Code 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.”
Remittance Advice Remark Code N704: “Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.”
For PILD claims with procedure code 0275T has an end date 12/31/25, with dates of service on or after January 9, 2014, (note: 0275T is being replaced with 62330 effective 01/01/26) or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed with modifier Q0. Claims for PILD which are billed without modifier Q0 shall be returned as un-processable.
The following messages shall be used when Medicare contractors return PILD claims billed without modifier Q0 as un-processable:
Claims Adjustment Reason Code 4: 'The procedure code is inconsistent with the modifier used or a required modifier is missing.'
Remittance Advice Remark Code N657: 'This should be billed with the appropriate code for these services.'
Remittance Advice Remark Code N704: 'Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.'
For PILD claims with procedure code 0275T end date 12/31/25, with dates of service on or after January 9, 2014 (note: 0275T is being replaced with 62330 effective 01/01/26), or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed with the ICD-9 diagnosis of 724.01-724.03 or the ICD-10 diagnosis of M48.05-M48.07.
The following messages shall be used when Medicare contractors return PILD claims, billed without the covered diagnosis, as un-processable:
Claims Adjustment Reason Code B22: 'This payment is adjusted based on the diagnosis.'
Remittance Advice Remark Code N704: 'Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.'
For PILD claims with procedure code 0275T and end date 12/31/25 with dates of service on or after January 9, 2014, (note 0275T is being replaced with 62330 effective 01/01/26), or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD only when billed with the ICD-9 diagnosis of V70.7 (ICD-9) or Z00.6 (ICD-10) in either the primary or secondary positions. The following messages shall be used when Medicare contractors return PILD claims, billed without the clinical trial diagnosis, as un-processable:
Claims Adjustment Reason Code B22: 'This payment is adjusted based on the diagnosis.'
Remittance Advice Remark Code N704: 'Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.'
(Rev. 13709; Issued:04-02-26, Effective: 06-02-26; Implementation: 06-02-26)
Hospital Outpatient facilities shall bill for percutaneous image-guided lumbar decompression (PILD) procedure code 0275T end date 12/31/25 effective on or after January 9, 2014 (note 0275T is being replaced with 62330 effective 01/01/26), or procedure code G0276 effective on or after January 1, 2015, for lumbar spinal stenosis (LSS) on a 13X or 85X TOB. Refer to Section 69 of this chapter for further guidance on billing under CED.
Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS-approved prospective longitudinal study for PILD procedures using a FDA-approved/cleared device that completed a CMS-approved randomized, controlled clinical trial (RCT) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).
Hospital outpatient procedures for PILD shall be covered when billed with:
Hospital outpatient procedures for PILD shall be rejected when billed without:
Claims billed by hospitals not participating in the trial /registry, shall be rejected with the following message:
CARC: 50 -These are non-covered services because this is not deemed a “medical necessity” by the payer.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code –Contractual Obligation (CO)
MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/articulo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.)
(Rev. 10985; Issued:09-08-21, Effective:01-19-21; Implementation:10-08-21)
Transcatheter Edge-to-Edge Repair (TEER) of the mitral valve (previously named Transcatheter Mitral Valve Repair (TMVR)) is used in the treatment of mitral regurgitation (MR). TEER approximates the anterior and posterior mitral valve leaflets by grasping them with a clipping device in an approach similar to a treatment developed in cardiac surgery called the Alfieri stitch.
The most recent reconsideration of NCD 20.33 (TEER for Mitral Valve Regurgitation (previously named TMVR)) is effective for claims with dates of service on and after January 19, 2021. It expands coverage of mitral valve TEER procedures for the treatment of functional MR and maintains coverage of TEER for the treatment of degenerative MR, through coverage with evidence development (CED) and with mandatory registry participation. It also makes changes to the criteria for the heart team and hospital, and to the registry questions/criteria and the trial requirements and outcomes. For more detailed information see Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 20.33.
For services furnished between August 7, 2014 and January 19, 2021, the CMS covered TMVR for MR when furnished under CED when the treatment was furnished for an FDA-approved indication with an FDA-approved device as follows: (1) Treatment of significant, symptomatic, degenerative MR when furnished according to an FDA-approved indication and all CMS coverage criteria are met, and, (2) TMVR for MR uses not expressly listed as FDA-approved indications but only within the context of an FDA-approved, randomized clinical trial that meets all CMS coverage criteria. TMVR was non-covered outside CED or for non-MR indications.
Historical Note: For claims processing instructions from August 7, 2014, through January 19, 2021, please see the following links:
Change request (CR) 9002, Transmittal (TN) 178, issued December 5, 2014, informed Medicare Administrative Contractors to pay for TMVR under CED and revised the NCD manual to add NCD 20.33: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R178NCD.pdf.
CR 9002, TR 3142, issued December 5, 2014, implemented the initial NCD for TMVR, effective August 7, 2014. TR 3241 rescinded and replaced TN 3142 on April 25, 2014: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3241CP.pdf.
ICD-10 Coding Updates: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10
(Rev. 10985; Issued:09-08-21, Effective:01-19-21; Implementation:10-08-21)
CPT code 33418, Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis, effective January 1, 2015.
CPT code 33419, Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis (es) during same session, effective January 1, 2015. (List separately in addition to code for primary procedure).
0345T - Transcatheter mitral valve repair percutaneous approach via the coronary sinus
02UG3JZ – Supplement mitral valve with synthetic substitute, percutaneous approach
02UG3JH – Supplemental mitral valve with synthetic substitute, transapical, percutaneous approach
I34.0 – Nonrheumatic mitral (valve) insufficiency, or,
I34.1 – Nonrheumatic mitral (valve) prolapse, and,
Z00.6 – Encounter for examination for normal comparison and control in clinical research program
Effective for claims with dates of service on and after August 7, 2014, place of service (POS) code 21 shall be used for mitral valve TEER services. All other POS codes shall be denied.
The following messages shall be used when Medicare contractors deny mitral valve TEER claims for POS:
Claim Adjustment Reason Code (CARC) 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
Group Code: CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file.)
Medicare Summary Notice (MSN) 21.25: “This service was denied because Medicare only covers this service in certain settings.”
Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.”
Effective for claims with dates of service on or after August 7, 2014, contractors shall pay claim lines for mitral valve TEERs billed with the most recent CPT codes 33418, 33419, and 0345T in a clinical trial when billed with modifier -Q0. Mitral valve TEER claim lines in a clinical trial billed without modifier -Q0 shall be returned as unprocessable.
The following messages shall be used when Medicare contractors return mitral valve TEER claim lines in a clinical trial billed without modifier -Q0 as unprocessable:
CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code: CO “(Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file.)”
Effective for claims with dates of service on or after August 7, 2014 contractors shall pay claim lines for mitral valve TEERs billed with the most recent CPT codes 33418, 33419 and 0345T in a clinical trial when billed with the most recent ICD-10 diagnosis codes ICD-10 I34.0 or I34.1 and Z00.6. Mitral valve TEER claim lines in a clinical trial billed without ICD-10 diagnosis code I34.0 or I34.1 and Z00.6 shall be denied.
*Note: Effective 01/01/25, ICD-10 I34.0 or I34.1 codes are no longer required to be listed as primary, along with clinical trial ICD-10 Z00.6 as secondary. These codes can be reported in any position. See IOM 100-03-chapter 1, section NCD 20.33 for additional information.
The following messages shall be used when Medicare contractors deny mitral valve TEER claim lines in a clinical trial billed without ICD-10 diagnosis code Z00.6:
CARC 50: These are non-covered services because this is not deemed a “medical necessity” by the payer.
RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD Group Code: CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file.)
MSN 15.20: The following policies [NCD 20.33] were used when we made this decision
Spanish Version: MSN 15.20: Las siguientes políticas [NCD 20.33] fueron utilizadas cuando se tomó esta decisión.
Effective for claims with dates of service on or after August 7, 2014, contractors shall pay mitral valve TEER claim lines billed with the most recent CPT codes 33418, 33419, and 0345T in a clinical trial only when billed with an 8-digit national clinical trial (NCT) number. Contractors shall accept the numeric, 8-digit NCT number preceded by the two alpha characters of “CT” when placed in Field 19 of paper Form CMS-1500, or when entered WITHOUT the “CT” prefix in the electronic 837P in Loop 2300 REF02 (REF01=P4). NOTE: The “CT” prefix is required on a paper claim, but it is not required on an electronic claim. Mitral valve TEER claim lines in a clinical trial billed without an 8-digit NCT number shall be returned as unprocessable.
The following messages shall be used when Medicare contractors return mitral valve TEER claim lines as unprocessable when billed without an 8-digit NCT number:
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)”
RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.”
Group Code: CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file.)
(Rev. 10985; Issued:09-08-21, Effective:01-19-21; Implementation:10-08-21)
Inpatient hospitals shall bill for mitral valve TEER on an 11X type of bill (TOB) effective for discharges on or after August 7, 2014. Refer to Section 69 of this chapter for further guidance on billing under CED.
In addition to the ICD-10 procedure and diagnosis codes mentioned above, inpatient hospital discharges for mitral valve TEER shall be covered when billed with the following clinical trial coding:
Secondary ICD-10 diagnosis code Z00.6
Condition Code 30
Inpatient hospital discharges for mitral valve TEERs shall be denied when billed without the ICD-10 diagnosis, procedure codes and clinical trial coding mentioned above. Claims that do not include these required codes shall be rejected with the following messages:
CARC 50: These are non-covered services because this is not deemed a “medical necessity” by the payer.
RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code: CO (Contractual Obligation) assigning financial liability to the provider
MSN 15.20: The following policies [NCD 20.33] were used when we made this decision
Spanish Version: MSN 15.20 - Las siguientes políticas [NCD 20.33] fueron utilizadas cuando se tomó esta decisión.
(Rev. 10985; Issued:09-08-21, Effective:01-19-21; Implementation:10-08-21)
MA plans are responsible for payment of mitral valve TEER services for MA plan participants. Medicare coverage for mitral valve TEERs is not included under section 310.1 of the NCD Manual (Routine Costs in Clinical Trials).
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
The conditions for payment for services furnished in a foreign country can be found in 42 CFR 424.120-127, Subpart H - Special Conditions: Emergency Services Furnished In a Foreign Country. The payment exclusion for services furnished outside the U.S. is located at 42 CFR 411.9 and 42 CFR 411.9(a)(2) describes the applicability of the payment exclusion when services are furnished on board a ship.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Payment may be made for certain Part A inpatient and Part B outpatient hospital services provided in a nonparticipating U.S. hospital where they are necessary to prevent the death or serious impairment of the health of the individual. Because of the threat to the life or health of the individual, the use of the most accessible hospital equipped to furnish such services is necessary. Items and services furnished in a domestic nonparticipating hospital may be reimbursed if the following apply:
The hospital meets the definition of an emergency hospital. (See §350.3.)
The services meet the definition of emergency services. (See §350.2.)
The hospital is substantially more accessible from the site of the emergency than is the nearest participating hospital. (See §350.4.)
Items and services furnished outside the United States and certain services rendered on board a ship are excluded from coverage except for the following services:
Emergency inpatient hospital services where the emergency occurred:
Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's United States residence than the nearest participating United States hospital that was adequately equipped to deal with, and available to provide treatment for the illness or injury.
Physician and ambulance services furnished in connection with a covered foreign hospitalization. Program payment may not be made for any other Part B medical and other health services, including outpatient services furnished outside the United States.
Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished in United States territorial waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of United States registry.
The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered on a ship, includes the territorial waters adjoining the land areas of the United States.
A hospital that is not physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is owned or operated by the United States Government.
When the physician's office is inside of the United States, the contractor designated to process the shipboard claim is determined by the beneficiary's residence.
When the physician's office is outside of the United States, the contractor designated to process the shipboard claim is determined by the beneficiary's residence.
Services provided aboard a ship are covered only when the ship is in United States waters. In addition, the service must be provided by a doctor licensed to practice in the United States.
Servicios proporcionados abordo de un barco son cubiertos solamente cuando el barco está en aguas territoriales de los Estados Unidos. Además, el servicio debe ser proporcionado por un médico con licencia para practicar en los Estados Unidos.
Payment may not be made for any item provided or delivered to the beneficiary outside the United States, even though the beneficiary may have contracted to purchase the item while he or she was within the United States or purchased the item from an American firm.
Under the Railroad Retirement Act, payment is made to qualified Railroad Retirement beneficiaries (QRRBs) by the RRB for covered hospital services furnished in Canadian hospitals as well as in the U.S. Physician and ambulance services are not covered by the Railroad Retirement Act; however, under an agreement between CMS and RRB, if the QRRB claims payment for Part B services in connection with Canadian hospitalization, RRB processes the Part B claim. In such cases the RRB determines:
Whether the requirements are met for the inpatient services; and
Whether the physician and/or ambulance services were furnished in connection with the services.
Services for an individual who has elected religious nonmedical health care status may be covered if the above requirements are met but this revokes the religious nonmedical health care institution election.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Claims for emergency services must be accompanied by a physician's statement describing the nature of the emergency and stating that the services were necessary to prevent the death, or the serious impairment of, the beneficiary. A statement that an emergency existed is not sufficient. In addition, when inpatient services are involved, the statement must include the date when, in the physicians' judgment, the emergency ceased.
The finding of whether the patient's condition required emergency diagnosis or treatment is ordinarily based upon the physician's evaluation of the patient's condition immediately upon the beneficiary's arrival at the hospital.
However, the emergency nature of the situation may have been assessed by a physician who attended the patient where the incident resulting in hospitalization occurred (for example, a heart attack or an automobile accident). In these cases, the attending physician who ordered the hospitalization may substantiate the claim that emergency hospitalization was necessary.
Most emergencies are of relatively short duration so that only one bill is submitted. Generally, only one physician's statement is necessary. However, in the rare situation where an emergency continued over an extended period, subsequent requests for payment must be accompanied by a physician's statement containing sufficient information to indicate clearly that the emergency situation still existed. A statement that the emergency continued to exist is not acceptable.
Additional information to support a finding that the services were emergency services from the physician, the hospital, and others (e.g., the police department at the scene of an accident) may be requested.
Medical necessity can be documented by the physician on a CMS-1771, Attending Physician's Statement and Documentation of Medicare Emergency or by the beneficiary's medical records. The CMS-1771 can be obtained from:
Centers for Medicare & Medicaid Services
Or, the form can be downloaded from http://cms.hhs.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
An emergency services hospital is a nonparticipating hospital that meets the requirements of the law's definition of a "hospital" relating to full-time nursing services and licensure under State or applicable local law. (A federal hospital need not be licensed under state or local licensing laws to meet this definition.) In addition, the hospital must be primarily engaged in providing, under the supervision of doctors of medicine or osteopathy, services of the type described in defining the term hospital.
The hospital must not be primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care. Psychiatric hospitals can qualify as emergency hospitals.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
The following requirements must be met for payment to be made for emergency services received by Medicare beneficiaries in foreign hospitals:
The foreign hospital must be closer to or substantially more accessible from the site of the emergency than the nearest U.S. hospital that was adequately equipped and available to treat the illness or injury.
If the individual was physically present in the U.S. at the time the emergency occurred, the individual's reason for departure from the U.S. must have been specifically to obtain treatment at the foreign hospital. Services are not covered where the person's departure from the U.S. is part of a trip abroad and the foreign hospital is more accessible simply because the individual was in the process of travel. For example, the airplane on which the individual was traveling could not readily return to permit the person's removal.
If the emergency occurred in Canada, the beneficiary must have been traveling, without unreasonable delay, by the most direct route between Alaska and another state. Benefits are not payable if the emergency occurred while a beneficiary was vacationing. The requirement of travel without unreasonable delay by the most direct route will be considered met if the emergency occurred while the beneficiary was enroute between Alaska and another state by the shortest practicable route, or while making a necessary stopover in connection with such travel.
NOTE: An emergency occurring within the Canadian inland waterway between the States of Washington and Alaska is considered to have occurred in Canada.
Ordinarily, the "shortest practicable route" is the one that results in the least amount of travel in Canada, consistent with the mode of travel used between the point of entry into Canada and the intended point of departure. The amount of travel in the U.S., prior to entering Canada is not pertinent. A route involving greater travel within Canada may be considered the "shortest practicable route" if the additional travel resulted in a saving of time or was necessary because of such factors as:
However, the individual would be considered to have deviated from the "shortest practicable route" if the detour was unrelated to the purpose of reaching their destination (e.g., for the principal purpose of sightseeing or vacationing).
The term "necessary stopover" means a routine stopover for rest, food, or servicing of the vehicle, and a non-routine stopover (even though of significant duration) caused by such factors as unsuitable road or weather conditions, the age, health, or physical condition of the traveler, the need to make suitable travel arrangements, or to obtain acceptable accommodations.
Coverage is provided for inpatient hospital services furnished in a foreign hospital that is closer to, or substantially more accessible from, the beneficiary's U.S. residence than the nearest available participating U.S. hospital that is adequately equipped to deal with the illness or injury, whether or not an emergency existed and without regard to where the illness or injury occurred.
"Residence" means the beneficiary's fixed and permanent home to which they intend to return whenever they are away or a dwelling where the beneficiary periodically spends some time (e.g., a summer home).
The foreign hospital must meet accreditation requirements equivalent to Joint Commission standards. For example, the Canadian Council on Hospital Accreditation (CCHA) has equivalent requirements. Thus, Canadian hospitals accredited by the CCHA meet the qualifying requirements. In the case of Mexican hospitals, the Dallas or San Francisco RO makes the determination, depending upon the hospital's location. Claims for services provided in countries other than Canada or Mexico should be sent to the MAC that is responsible for the state or territory where the emergency arose. In other words, the foreign claim would be processed similarly to how claims are processed in the state or territory where the emergency arose.
See §350.11.4 below for discussion of accessibility criteria.
Some claims for services furnished in a foreign hospital nearest to the beneficiary's U.S. residence will not be "emergency." In these nonemergency situations, it may be necessary to deny payment in whole or part, (even though it has been approved with regard to accessibility) because the services are not medically reasonable and necessary or involve custodial care (i.e., exclusions under §§1862(a)(1) and (9)). However, in the case of denials under the medical
necessity and custodial care exclusions, the MAC applies the limitation on liability considerations under §1879 of the Act before issuing the denial notice.
The MAC examines claims involving medical necessity or custodial care denials to determine if there is any evidence that the beneficiary (or the person acting on behalf of the beneficiary) was aware that the beneficiary did not require, or no longer required, a covered level of care. The foreign hospital, since it is not participating, is not under any obligation to furnish a written notice of noncoverage to a beneficiary in order to protect itself from being held liable under the §1879 waiver of liability provision. However, there may be instances where the medical records of the denied foreign claim show that the beneficiary was advised that the beneficiary did not require, or no longer required, Medicare covered services, (e.g., written notice of noncoverage from the hospital's staff or a prior CMS denial notice). It will probably be rare where a finding is made that the beneficiary had knowledge of noncoverage, so that, generally, payments are made under the waiver of liability provision. The MAC uses appropriate Medicare Summary Notice (MSN) and Remittance Advice denial messages for determinations involving the limitation on liability provision. For additional information regarding the application of the §1879 liability provisions, see Pub 100-04, chapter 30.
Payment is made for necessary physician and ambulance services that meet the other coverage requirements of the Medicare program, and are furnished in connection with a covered foreign hospitalization.
Where inpatient services in a foreign hospital are covered, payment may also be made for:
Physicians' services furnished to the beneficiary while he/she is an inpatient,
Physicians' services furnished to the beneficiary outside the hospital on the day of his/her admission as an inpatient, provided the services were for the same condition for which the beneficiary was hospitalized (including the services of a physician who furnishes emergency services in Canadian waters on the day the patient is admitted to a Canadian hospital for a covered emergency stay) and,
Ambulance services, where necessary, for the trip to the hospital in conjunction with the beneficiary's admission as an inpatient. Return trips from a foreign hospital are not covered.
In cases involving foreign ambulance services, the general requirements in chapter 15 are also applicable, subject to the following special rules:
If the foreign hospitalization was determined to be covered on the basis of emergency services, the medical necessity requirements outlined in chapter 15 are considered met.
The definition of 'physician,' for purposes of coverage of services furnished outside the U.S., is expanded to include a foreign practitioner, provided the practitioner is legally licensed to practice in the country in which the services are furnished.
Only the beneficiary may file for Part B benefits. The assignment method may not be used. However, where the beneficiary is deceased, the rule for settling Part B underpayments is applicable, i.e., payment may be made to the foreign physician or ambulance company on the basis of an unpaid bill, provided the physician or ambulance company accepts the MACs reasonable charge determination as the full charge.
The regular deductible and coinsurance requirements apply to physician and ambulance services.
All claims for hospital and/or related physician or ambulance services furnished in Canada to qualified railroad retirement beneficiaries (QRRB's) are forwarded first to the Railroad Retirement Board (RRB). Under the Railroad Retirement Act, payment is made by the RRB to Qualified Railroad Retirement Beneficiaries (QRRB) for covered hospital services furnished in Canadian hospitals as well as in the U.S. The Railroad Retirement Act does not cover physician and ambulance services; however, under an agreement between CMS and RRB, if the QRRB claims payment for Part B services in connection with Canadian hospitalization, RRB processes the Part B claim. In such cases the RRB determines:
If either is not met, RRB denies the claim and notifies the beneficiary. If met, RRB refers the claim to the RRB MAC, Palmetto GBA, to determine if the coverage criteria for physician and/or ambulance services are met.
The hospital must forward all claims for services furnished QRRBs in Canada to:
Retirement Medicare Section U.S. Railroad Retirement Board 844 North Rush Street Chicago, IL 60611-2092
If a QRRB is a resident of Canada, Medicare payments are reduced by the amount of payment made for the same services by the Canadian Provincial Health Insurance Plan.
B. Claims for services furnished in other foreign countries
The RRB does not pay for health care services furnished in Mexico or any foreign countries other than Canada.
All claims for inpatient hospital services and/or related physician or ambulance services furnished in Mexico to QRRB's should be forwarded directly to the Railroad Retirement Board. If the Railroad Retirement Board determines that the requirements in §350.6.A are not met, the Railroad Retirement Board will deny the claim and send notice to the beneficiary. If the requirements in §350.6.A or B are met, the Railroad Retirement Board will hold any potentially allowable Part B claim until an MAC determination regarding the coverage of Part A services has been made. When the information regarding Part A coverage is available, the Railroad Retirement Board will send the Part B claim, together with pertinent information regarding the Part A determination, to Palmetto Government Benefits for consideration of whether the other requirements for Part B coverage are met, and further processing.
Services furnished by a laboratory that does not meet the hospital laboratory conditions of participation and is operated under a lease arrangement in a domestic emergency hospital are covered only if they are emergency inpatient services reimbursable under Part A.
A MAC may send a claim from such a laboratory and identify it as an "Emergency Lead." The MAC checks its files to see if a claim for emergency services was filed and, if so, determines whether the laboratory services were furnished
during the period of emergency. If the emergency claim was forwarded to the appropriate MAC for processing, it enters the date received on the laboratory claim.
If no emergency claim was filed, or laboratory services were not furnished in the period covered by the emergency claim, the MAC develops the claim as a possible emergency. It includes the laboratory claim with any subsequent claim.
If no emergency is alleged, the MAC records on the claim that no emergency existed and disallows it.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Nonemergency services to Medicare beneficiaries may be paid for if the coverage requirements for the services are met, and are not covered as Part A emergency inpatient services.
Program payment may be made for the following Part B medical and other health services furnished by a U.S. nonparticipating hospital on a nonemergency basis:
Emergency coverage, particularly Part B emergency outpatient coverage, is broader than the nonemergency Part B Medical and Other Health Services coverage provisions. When the emergency requirements are met, program payment may be made to the hospital for the full range of outpatient hospital services. In addition to the nonemergency coverage list, emergency coverage includes hospital services (including drugs and biologicals - blood is a biological - which cannot be self-administered), "incident to physicians' services rendered to outpatients," and outpatient physical therapy and speech-language pathology. The latter two services are not covered under the nonemergency provisions. Payment for "incident to" services can be only under the emergency rather than the nonemergency provisions.
Whether Part B payment is made under the emergency or nonemergency provisions, it may be made for diagnostic laboratory tests furnished by an emergency hospital only if the hospital meets the conditions of participation relating to hospital laboratories. It may be made only for radiology services furnished by an emergency hospital if the hospital meets the conditions of participation relating to radiology departments. Part B payment may be made for diagnostic laboratory tests furnished by a nonparticipating hospital which is not an emergency hospital only if the hospital
laboratory meets the conditions of coverage of independent laboratories and for radiology services furnished by it, only if it meets the conditions of participation relating to radiology departments.
C. Claims Processing
The hospital enters the annotation "nonemergency-hospital accepts assignment" in Remarks of the Form CMS-1450. If it is determined that some or all of the services are not covered under the nonemergency provisions, the claim is returned to it (if hospital-filed) or to the beneficiary (if patient-filed) to determine whether the services might be covered as emergency services.
350.10 - Elections to Bill for Services Rendered By Nonparticipating Hospitals (Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
A. Nonparticipating U.S. Hospitals
As a nonparticipating U.S. hospital meeting emergency requirements, the hospital has the option to bill the program during a calendar year by filing an election with its MAC. If it files an election, it should submit claims for the following services furnished all Medicare beneficiaries throughout the year:
In addition, the hospital may not bill any beneficiary beyond deductibles, coinsurance, and noncovered services in that calendar year. It must agree to refund any monies incorrectly collected. It may not file an election for the calendar year if it has already charged any beneficiary for covered services furnished in that year.
If the hospital does not file a billing election, the beneficiary can file a claim. The beneficiary may request information from the hospital or the MAC as appropriate.
During November of each year, the MAC will send the non-participating hospital a letter (see §360.3.1). Also, during November of each year, the MAC will send a letter to each domestic hospital, giving it an opportunity to elect to bill Medicare if it has not been doing so (§360.3.2).
If during the year the hospital requests to bill the program, its MAC will send the model letter in §360.3.3.
B. Billing for Services Furnished Prior to Certification
The following rules apply if a bill is submitted for services rendered before and after a hospital's certification (participation) date:
It should annotate in the upper right hand corner of the claim "Emergency Conversion."
C. Foreign Hospitals
Foreign hospitals may submit a statement to the appropriate MAC stating that they will bill for all claims. If they do not, the beneficiary may claim the payment. When the MAC is aware that a hospital is willing to bill the program for all covered services, it solicits the hospital's agreement to:
A hospital may not file an election for a calendar year if it has charged any beneficiary for covered services during that year.
D. Submitting Claims
The beneficiary or the hospital that has elected to bill the program may submit emergency claims for payment to the appropriate MAC for evaluation of accessibility or emergency factors.
The hospital completes the claim (Form CMS-1450 or electronic equivalent) according to billing instructions in chapter 25. It enters "hospital filed emergency admission" in Item 94 "Remarks." It sends the completed bill and the necessary emergency documentation (Form CMS-1771, Attending Physicians Statement and Documentation of Medicare Emergency) or medical records to substantiate the emergency to the appropriate MAC.
NOTE: See §360.2, "Designated Contractors."
If the hospital submits a claim but has not filed an election to bill the program, the MAC will contact the hospital to determine if it is qualified and wish to bill the program. If it declines, the claim will be denied. A claim will be solicited from the beneficiary.
If the hospital has filed a billing election and the beneficiary files a claim, the beneficiary's claim is denied and the MAC contacts the hospital regarding the claim.
350.11 - Processing Claims
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
All claims are subject to development to determine whether the Medicare secondary payer provisions apply. (See Pub. 100-05, Medicare Secondary Payer Manual.)
A. Nonparticipating Hospitals
The processing MAC is responsible for making accessibility and medical emergency determinations for physician and ambulance services.
1. Claims Subject to Technical Denials
The following claims are subject to technical denial:
◦ The hospital rendering the service does not meet Joint Commission or equivalent accreditation requirements set by a hospital approval program of the country in which it is located. ◦ The accessibility requirements are not met. (See §350.11.4.) • Canadian travel claims when the requirements in §350.4 are not met. • Emergency services claims for which the hospital does not meet the definition of an emergency hospital. • Claims for which the query response shows the beneficiary is not entitled to benefits. • Any foreign claim when Part A benefits are exhausted and Part B physician or ambulance claims are not involved.
2. Either the Accessibility or Medical Emergency Requirements are Not Met
Claim is denied but retained in case of an appeal by the beneficiary.
NOTE: Even though Part A or Part B emergency services furnished by U.S. hospitals are denied, Part B payment may be possible for Medical and Other Health Services specified in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6. Claim is retained in case of an appeal by the beneficiary.
3. Emergency Services Partially Denied
When the medical emergency is approved but not for the entire period, the claim is processed and payment made for the covered period.
B. Foreign Part B Physician and Ambulance Claims
The hospital must attach any Part B claim for foreign physician and ambulance services to the corresponding Part A claim and forward to the MAC.
If the MAC determines that the inpatient services were covered, it sends the physician and/or independent ambulance claim to the designated MAC for processing and payment. (See §350.6.)
If the Part A claim is denied on the basis of accessibility of medical emergency, the MAC denies the Part B claim, and sends a MSN to the beneficiary. It retains copies in case of an appeal by the beneficiary.
NOTE: Even though Part A benefits are totally or partially exhausted, payment may be made by the MAC for physician and independent ambulance services furnished if all coverage requirements are met.
If a Part A claim was partially denied because the emergency terminated, the MAC makes a decision on the claim and any provider-based ambulance claim. It sends copies to the appropriate MAC for processing.
350.11.1 - Contractors Designated to Process Foreign Claims (Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Per contractor Statement of Work (SOW) all contractors are designated to process claims for physicians' and ambulance services furnished in connection with a covered foreign hospital stay for their beneficiaries who reside in the states/areas for which they process claims.
All contractors are designated to determine whether the requirements in §350.6 are met for claims for inpatient services based upon the geographic location of the foreign hospitals furnishing the services.
All contractors are designated to process these claims if there is evidence that the Part B services were furnished in connection with covered foreign inpatient hospital services. If there is no evidence, the Contractor must send a front-end rejection notice in accordance with §350.11.2.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Per contractor Statement of Work (SOW) all contractors are responsible for processing foreign, emergency and shipboard claims for their beneficiaries who reside in the states/areas for which they process claims.
The A/B MAC determines whether the requirements in §350.6.A are met. If these requirements are not met, the A/B MAC denies the Part A claim and related Part B claim and notifies the beneficiary. Where the A/B MAC determines that the requirements in §350.6.A are met, the A/B MAC determines whether other applicable Part A coverage requirements are met. If the A/B MAC disallows the Part A claim, it denies the related Part B claim and notifies the beneficiary. However, the A/B MAC will not be involved in the processing of foreign claims if, for any reason, the related Part A claim is denied.
If the claim does not show that the beneficiary was hospitalized, the A/B MAC sends the beneficiary a front-end rejection notice. In filling out the Notification of Medicare Determination, the A/B MACs should check “other” and include the following explanation: “Foreign physician or ambulance services are not covered unless they were furnished in connection with a covered inpatient stay.”
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
For Canadian services, the Medicare approved charge will be the lower of:
1. The allowed amount for the same service in the U.S. locality closest to where the service was furnished (as determined by the designated MAC), or
Therefore, the designated MAC must obtain the most recent schedule of fees published by the appropriate Canadian Province. Most of the designated MACs deal with only one Provincial schedule.
For Mexican services, the maximum charge is the Medicare allowed amount for the same service in the locality closest to where the service was furnished (as determined by the designated MAC).
(Rev. 4111, Issued: 08-10-18, Effective: 9-11-18, Implementation: 9-11-18)
The MAC uses the same criteria in domestic and foreign emergency claims. This includes services in a foreign religious non-medical health care institution and Canadian Travel claims. (See §350.4 and §350.9.)
Emergency determinations take into account such matters as relative distances of a participating hospital, and road conditions. The MAC considers whether the nature of the emergency required immediate transportation to the nearest available hospital (i.e., the nonparticipating hospital) or, without hazard to the patient, would have permitted the additional transportation time to take the patient to a more distant participating hospital in the same general area.
The MAC does not consider in its determination such factors involving selection of a hospital which reflect the personal preferences of the individual or physician, (e.g., physician does not have staff privileges at the participating hospital) nearness to beneficiary's residence, presence of previous medical records at the nonparticipating hospital, cost, or type of accommodations available.
The following sections discuss documentation of the accessibility requirement and provide guidelines for making a determination where the participating hospital is:
In urban and suburban areas, where both participating and nonparticipating hospitals are similarly available, it is presumed, in the absence of clear and convincing evidence to the contrary, that the services could have been provided in the participating hospital.
1. Participating Hospital Closer to Site of Emergency
If there is an adequately equipped participating hospital with available beds closer to the site of the emergency than the nonparticipating hospital, accessibility is not met. Claim is denied unless extenuating circumstances were present that necessitated admission to the nonparticipating hospital, e.g., because of road or traffic conditions additional travel time would have been needed.
2. Participating Hospital 15 or Fewer Miles Farther From the Location of the Emergency Than the Admitting Nonparticipating Hospital
In this situation the accessibility is provisionally not met. The claim is reviewed to determine if the nature of the emergency required the immediate transportation to the nonparticipating hospital. If the review indicates that the nature of the emergency would have allowed the additional transportation time needed to take the patient to the participating hospital without undue hazard, the accessibility requirement is not met. The claim is denied.
3. Participating Hospital More than 15 Miles Farther From the Location of the Emergency Than the Admitting Nonparticipating Hospital
The accessibility requirement is deemed met.
B. Foreign Nonemergency Claims
The following presumptions are applied to the relative accessibility of the nearest participating U.S. and foreign hospitals.
1. Admitting Foreign Hospital is Closer to the Beneficiary's Residence Than the Nearest Participating U.S. Hospital
The accessibility requirement is met.
The accessibility requirement is not met unless evidence establishes the practical necessity for the beneficiary's admission. This requirement is met if the use of a closer participating U.S. hospital was impractical, e.g., non-availability of beds, needed equipment or personnel, or transportation not available.
In determining whether a foreign hospital is more accessible than a participating hospital, the MAC does not consider the personal preference of the beneficiary, physician, or others in the selection of a hospital, the type of accommodations available, or the nonavailability of staff privileges to the attending physician.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Reimbursement for emergency inpatient hospital services is permitted only for those periods during which the patient's state of injury or disease is such that a health or life-endangering emergency existed and continued to exist, requiring immediate care that could be provided only in a hospital. The allegation that an emergency existed must be substantiated by sufficient medical information from the physician or hospital. If the physician's statement does not provide it, or is not supplemented by adequate clinical corroboration of this allegation, it does not constitute sufficient evidence.
Death of the patient does not necessarily establish the existence of a medical emergency, since in some chronic, terminal illnesses, time is available to plan admission to a participating hospital. The lack of adequate care at home or lack of transportation to a participating hospital does not constitute a reason for emergency hospital admission, without an immediate threat to the life and health of the patient. Since the existence of medical necessity for emergency services is based upon the physician's assessment of the patient prior to admission, serious medical conditions developing after a non-emergency admission are not 'emergencies' under the emergency services provisions of the Act.
The emergency ceases when it becomes safe, from a medical standpoint, to move the individual to a participating hospital, another institution, or to discharge the individual.
Since the decision that a medical emergency existed can be a matter of subjective medical judgment involving the entire gamut of disease and accident situations, it is impossible to provide arbitrary guidelines.
An emergency condition is an unanticipated deterioration of a beneficiary's health which requires the immediate provision of inpatient hospital services because the patient's chances of survival, or regaining prior health status, depends upon the speed with which medical or surgical procedures are, or can be, applied. While many diagnoses (e.g., myocardial infarction, acute appendicitis) are normally considered emergencies, the hospital must check medical documentation for internal consistencies (e.g., signs and symptoms upon admission, notations concerning changes in a preexisting condition, results of diagnostic tests).
EXAMPLE: If the diagnosis is given as 'coronary,' the physician's statement is 'coronary,' without further explanatory remarks, and the statement of services rendered gives no indication that an electrocardiogram was taken, or that the patient required intensive care, etc., further information is required. On the other hand, if the diagnosis is one that ordinarily indicates a medical and/or surgical emergency, and the treatment, diagnostic procedures, and period of hospitalization are consistent with the diagnosis, further documentation may be unnecessary. An example is: admitting
diagnosis - appendicitis; discharge diagnosis - appendicitis; surgical procedures - appendectomy; period of inpatient stay - 7 days.
If an emergency existed at the time of admission and the patient subsequently expires, the claim is allowed for emergency services if the period of coverage is reasonable. However, death of the patient is not prima facie evidence that an emergency existed; e.g., death can occur as a result of elective surgery or in the case of a chronically ill patient who has a long terminal hospitalization. Such claims are denied.
The fact that the beneficiary's attending physician does not have staff privileges at a participating hospital has no bearing on the emergency services determination. If the lack of staff privileges in an accessible participating hospital is the governing factor in the decision to admit the beneficiary to an 'emergency hospital,' the claim is denied irrespective of the seriousness of the medical situation.
The claim is denied if the beneficiary chooses to be admitted to a non-participating hospital as a personal preference (e.g., participating hospital is on the other side of town) when a bed for the required service is available in an accessible, participating hospital.
The patient who cannot be cared for adequately at home does not necessarily require emergency services. The claim is denied in the absence of an injury, the appearance of a disease or disorder, or an acute change in a pre-existing disease state which poses an immediate threat to the life or health of the individual and which necessitates the use of the most accessible hospital equipped to furnish emergency services.
Lack of transportation to a participating hospital does not, in and of itself, constitute a reason for emergency services. The availability of suitable transportation can be considered only when the beneficiary's medical condition contraindicates taking the time to arrange transportation to a participating hospital. The claim is denied if there is no immediate threat to the life or health of the individual, and time could have been taken to arrange transportation to a participating hospital.
Program payment cannot be made for emergency services furnished by a nonparticipating hospital when the emergency condition arises after a non-emergency admission. An example: treatment of postoperative complications following an elective surgical procedure or treatment of a myocardial infarction that occurred during a hospitalization for an elective surgical procedure. The existence of medical necessity for emergency services is based upon the physician's initial assessment of the apparent condition of the patient at the time of the patient's arrival at the hospital, i.e., prior to admission.
If the patient enters a nonparticipating hospital under an emergency situation and subsequently has other injuries, diseases or disorders, or acute changes in preexisting disease conditions, related or unrelated to the condition for which the patient entered, which pose an immediate threat to life or health, emergency services coverage continues.
Emergency services coverage ends when it becomes safe from a medical standpoint to move the patient to an available bed in a participating institution or to discharge the patient, whichever occurs first.
Claims for emergency services by a non-participating hospital should be accompanied by an Attending Physician's Statement and Documentation of Medicare Emergency, Form CMS-1771 or its equivalent. This form describes the nature of the emergency, furnishing relevant clinical information about the patient, and certifying that the services rendered were required as emergency services. However, a copy of the patient's hospital records may be submitted instead. It should include history, physical, and admission notes, the medical record admission sheet, nurses' notes, doctors' orders, discharge summary, and all progress notes. A statement that an emergency existed, or the listing of diagnoses, without supporting information, is not sufficient. In addition, the statement must include the date, in the physician's judgment, the emergency ceased. The physician who attended the patient at the hospital makes the statement concerning emergency services. Only in exceptional situations, with appropriate justification, may another physician having full knowledge of the case, make the certification.
In Canadian travel claims, the beneficiary's statement is considered in making a determination regarding medical necessity for emergency services; i.e., whether an emergency occurred while a beneficiary was traveling between Alaska and another State by the most direct route without unreasonable delay. (See §350.4.)
The regular time limits apply to requests and claims for payment for emergency hospital services and hospital services outside the U.S., for physician and ambulance services furnished in connection with foreign hospitalization, and for nonemergency services furnished by a domestic nonparticipating hospital. See chapter 1 for a description of these requirements.
MACs shall send denial letters for non-covered foreign related claims.
Part B MACs will send an MSN for covered foreign emergency and shipboard claims related to a covered Part A foreign claim. An MSN is also sent for shipboard services provided within US territories.
No payment will be made for inpatient or outpatient emergency services rendered after a reasonable period of medical care in relation to the emergency condition in question. Some services may be covered in a domestic nonparticipating hospital as Part B Medical and Other Health Services. (See the Medicare Benefit Policy Manual, chapter 6.) If, based upon all information, the total period claimed for emergency services coverage does not exceed the time required for a reasonable period of emergency medical care, the entire inpatient stay is covered. The fact that a medical record or other information states that the patient showed definite improvement several days prior to discharge is not necessarily an indication that the need for emergency services ceased as of that date. The concept of a reasonable period of emergency medical care is most easily applied when relatively short-term medical care is followed by the patient's progressive improvement. There are situations or conditions in which the determination of the end of covered emergency services may be more difficult because the patient's impairment is prolonged, there is no progressive improvement, or the
patient’s course may be progressively downhill, even though the condition is not critical. The stroke patient may be in this category. In such cases the need for emergency medical care usually ceases before the need for medical care in an institutional setting (i.e., hospital or SNF) ceases. Thus, the reasonable period of emergency care does not include the entire hospital stay if the stay was prolonged beyond the point when major diagnostic evaluation and treatment were carried out.
The MAC will make the determination based upon all information available. As a general rule, if the period claimed for emergency services exceeds by more than 3 to 5 days the date on which the record definitely indicates that there was substantial improvement in the patient’s condition so that the patient could possibly have been moved to a participating facility or discharged without damage to health, the period beyond the 3 to 5 days is denied. If the total period claimed for emergency services exceeds by no more than 3 to 5 days the date on which the record indicates substantial improvement in the patient’s condition, the entire period is allowed.
This rule is intended to screen out short stay emergency hospitalization cases in which the patient was either discharged or transferred to a participating provider within a reasonable time after the medical record definitely indicated substantial improvement in the patient’s condition.
The reasonable period of emergency care is that period required to provide relief of acute symptoms or for initial management of the condition while arrangements are made for definitive treatment. Two examples:
In acute urinary retention, the reasonable period of emergency medical care includes the period required for catheterization and stabilization of the patient. The patient could then be transferred to a participating hospital for surgery or other required treatment. For the suicidal or homicidal patient, a reasonable period of emergency medical care includes the time required for initial management of the case while arrangements are made for transfer (by commitment or otherwise) to a participating hospital. A period of 24 to 48 hours of emergency care is usually sufficient in both cases.
Medicare payment may not be made for items and services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service.
The CWF must establish an auxiliary file based on enrollment data contained in the Enrollment Data Base maintained by the Centers for Medicare & Medicaid Services in order to appropriately edit the claims specifically associated with alien beneficiaries. The auxiliary file will be the basis for an edit that rejects claims for a beneficiary that was not lawfully present in the U.S. on the date of service. MACs and DMACs must deny claims for items and services, rejected by CWF on the basis that the beneficiary was not lawfully present in the U.S. on the date of service. MACs and DMACs must refer to the CWF documentation on this subject for the error code MSN Message 5.7, assigned to this editing.
Upon receipt of an error code MSN Message 5.7, A/B MACs, DME MACs, and A/B MACs (HHH) must deny the claim and use reason code (CARC) 177 – “Patient has not met the required eligibility requirements.” When CWF rejects a claim, MACs and DMACs must use MSN message 5.7, “Medicare payment may not be made for the item or service because, on the date of service, you were not lawfully present in the United States.” 5.7, Medicare no puede pagar por este artículo o servicio porque, en la fecha en que lo recibió, usted no estaba legalmente en los Estados Unidos.
A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis that the beneficiary was lawfully present in the United States on the date of service. In addition, this same information must be published in your next regularly scheduled bulletin. If you have a listserv that targets the affected provider communities, you must use it to notify subscribers that information “Medicare Services for Alien Beneficiaries Lawfully present the United States” is available on your Web site.
NOTE: Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), codified at 8 U.S.C. §1611, prohibits aliens who are not “qualified aliens” from receiving Federal public benefits including Medicare.
However, Section 5561 of the Balanced Budget Act of 1997 (BBA) amended Section 401 of the PRWORA to create a Medicare exemption to the prohibition on eligibility for non-qualified alien beneficiaries, who are lawfully present in the United States and who meet certain other conditions. Specifically, payment may be made for services furnished to an alien who is lawfully present in the United States (and provided that with respect to benefits payable under Part A of Title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], who was authorized to be employed with respect to any wages attributable to employment which are counted for purposes of eligibility for Medicare benefits). The definition for “lawfully present in the United States” is found at 8 CFR 1.3.
When a MAC receives a beneficiary appeal of a claim submitted by the beneficiary for services provided by a non-participating provider, the MAC will process the appeal in accordance with the guidelines in Pub. 100-04 chapter 29.
When a MAC receives an appeal from a non-participating provider of a claim that was submitted by, or on behalf of, a beneficiary, the MAC shall dismiss the appeal request as the non-participating provider is not a proper party. The MAC shall send a copy of the dismissal to the beneficiary. A non-participating provider does not have standing to file an appeal for the individual claims for payment it submits on behalf of a beneficiary, or for claims the beneficiary submits for services it has furnished. See, 42 CFR 405.906(a)(3) and 405.902 (for the definition of provider); Pub. 100-04, chapter 29, §210 and the glossary in Pub. 100-04, chapter 29, §110 (for the definition of provider). Only a beneficiary (or the beneficiary’s authorized representative, or an appointed representative on behalf of the beneficiary) can appeal claim determinations for services furnished by a non-participating provider.
NOTE: Non-participating providers have appeal rights under the provider and supplier enrollment appeals process in 42 CFR Part 498 for MAC determinations related to the non-participating provider’s election to file claims (see §350.10).
NOTE: The RRB conducts Part B redeterminations under the Railroad Retirement Act for services rendered in Canada.
The condition of payment regulations for emergency services received in Nonparticipating Providers can be found in the 42 CFR 424.100-109, Subpart G—Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital.
The Form CMS-1450 or its electronic equivalent must be used.
The payment rate for inpatient claims is 100 percent of the nonparticipating provider's customary charges (see 42 C.F.R. 413.74(b) and 42 C.F.R. 424.104(a)(3)).
The cost of the services is adjusted by any applicable deductible and coinsurance amounts for which the beneficiary is responsible.
Payment will be made to Federal hospitals that furnish emergency services, on an inpatient basis, to individuals entitled to hospital benefits. Payment will be based on the lower of the actual charges from the hospital or rates published for Federal hospitals in the "Federal Register" under Office of Management and Budget - Cost of Hospital and Medical Care and Treatment Furnished by the United States; Certain Rates Regarding Recovery from Tortiously Liable Third Persons.
Medicare will not pay federal hospitals for emergency items or services furnished to veterans, retired military personnel or eligible dependents. However, Medicare can pay for the inpatient deductible charged by VA hospitals, or credit that amount to the Medicare Part A deductible, for emergency services furnished to veterans. If a Part A claim is denied, a denial notice will be forwarded to the beneficiary from the MAC. The beneficiary can use this notice to forward to their private insurer, if applicable.
The VA or Department Of Defense hospital must file a statement of election for each calendar year to receive direct payment from Medicare for all claims filed that year.
2. Outpatient Services
The amount paid by Medicare for emergency outpatient claims is obtained as follows:
3. Part B Medical and Other Health Services
Part B medical and other health services, including hospital-based ambulance services whether hospital or beneficiary filed, may be covered and paid on a non-emergency basis. To calculate the amount paid by Medicare, the hospital subtracts the Part B deductible from the total covered charges and applies the 80 percent payment rate.
4. Special Letters for Partially or Totally Denied (Hospital-Filed) Claims for Emergency Inpatient Services
The patient receives a notice from CMS covering the emergency payment of a partially denied claim. A denial letter and a Part B explanation of benefits is sent to the patient. The MAC includes its address on this letter.
B. Beneficiary Filed Claim
1. Emergency Inpatient Claims
The payment computation follows:
Any noncovered accommodation charge is subtracted from the total accommodation charges. The amount of the inpatient deductible or coinsurance met on this bill is subtracted. Any remainder is multiplied by 60 percent.
The total noncovered ancillary charge is subtracted from the total ancillary charge. Any inpatient deductible or coinsurance that remains is subtracted. The remainder is multiplied by 80 percent.
2. Emergency Outpatient Services
To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total covered charges and apply the 80 percent payment rate.
3. Part B Medical and Other Health Services
Part B medical and other health services furnished by nonparticipating hospitals, including hospital-based ambulance services, may be covered and paid on a non-emergency basis.
To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total covered charges and apply an 80 percent payment rate.
4. Special Letters for Patient-Filed Claims for Emergency Inpatient Services
For emergency admissions to nonparticipating hospitals where direct payment is made to the patient, the MAC sends the beneficiary one of the letters described below, as appropriate.
The letter explains the Part A payments made. Part B payments are made for ancillary services not covered by Part A and are also explained in a letter. This letter also explains the beneficiary's right of appeal.
The MAC retains a duplicate of all notices sent for documentation in any appeals process. It enters the date the notice is released on both copies of all notices.
Sample paragraphs:
"Medicare is able to pay 60 percent of the charges for your room and board, 80 percent of the charges for other separately identified charges, and 66 2/3 percent of the other charges which were not separately identified on the hospital bill."
"If you believe that the determination is not correct, you may request a reconsideration for hospital insurance (or a review for medical insurance). You may make the request by mail to the address shown on this letter. If you come in person, please bring this notice with you."
“This check includes a medical insurance payment for 80 percent of the charges for certain nonroutine hospital services which you received from _ through _. These services are listed on the enclosed form.”
When payment cannot be made under hospital insurance, medical insurance covers some, but not all, of the hospital services. Room and board and certain other services are not covered by medical insurance.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
The condition of payment regulations for emergency services received in Nonparticipating Providers can be found in the 42 CFR 424.100-109, Subpart G—Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital
A foreign hospital that elects to bill the Medicare program receives 100 percent of its customary charges, subject to applicable deductible and coinsurance amounts. The hospital establishes its customary charges for the services by submitting an itemized bill with each claim. This eliminates the need to file a cost report.
Regardless of the billing form used, the MAC must:
The nonparticipating hospital must file a statement of election for each calendar year to receive direct payment from Medicare for all claims filed that year.
Payment is subject to the official exchange rate on the date the patient is discharged.
To calculate the amount paid by Medicare for Part B Hospital-Based Ambulance Claims, the hospital must subtract any unmet Part B deductible from the total covered charges and apply the 80 percent payment rate.
Payment to the beneficiary is subject to the official exchange rate on the date of discharge.
(Rev. 4111, Issued: 08-10-18, Effective: 9-11-18, Implementation: 9-11-18)
Form CMS-1771 - go to https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
Per Contractor Statement of Work (SOW) all contractors are designated to process claims for physicians' and ambulance services furnished in connection with a covered hospital stay in Canada and Mexico for their beneficiaries who reside in the states/areas for which they process claims.
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
(Rev.3287, Issued: 6-30-15, Effective:04-21-15, Implementation: 04-21-15)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
REFER TO:
Identification Number: _____
Dear _____:
Your election to bill the Medicare program for emergency services furnished to Medicare beneficiaries will expire on December 31. Payment for emergency services can be made to a nonparticipating hospital only if the hospital elects to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year.
If you elect to bill the program, please return to us in the enclosed self-addressed envelope a statement signed by an authorized official of your hospital stating that you elect to claim payment under the Medicare program. An election to bill cannot be withdrawn during the year. If a statement is not received by December 31, we will assume that you do not wish to continue to bill the program at this time. However, you still retain the right to elect to bill the program at any time during the coming year if, when you make your election, you have not yet charged any Medicare beneficiary in that year for emergency hospital services rendered to him.
Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting the MAC serving nonparticipating hospitals in your State. If you do not elect to bill, the beneficiary may apply for reimbursement by submitting an itemized bill.
Please contact us if you need any further information. In addition, if at any time you decide to request full participation as a provider of hospital services under the Medicare program, please contact your Medicare MAC for complete particulars.
Sincerely,
(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
REFER TO:
Identification Number: _____
Dear _____:
Under the Medicare program, hospital benefits ordinarily can be paid only for care furnished to patients of hospitals that are participating in the program. However, the program can also pay for hospital services furnished to a beneficiary who is admitted to a nonparticipating hospital in an emergency. To receive payments for emergency services, a nonparticipating hospital must meet certain conditions specified in the law. We have determined that your hospital meets these conditions.
Payment for emergency services can be made to a nonparticipating hospital only if the hospital elects to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year. Although your hospital did not elect to bill the program for the current calendar year, you may wish to bill for the coming year. If you so choose, please have an authorized official of your hospital sign a statement to this effect and return in the enclosed self-addressed envelope. Retain a copy for your records. An election to bill cannot be withdrawn during the year.
If we have not received a statement from you by December 31, we will assume that you do not wish to bill the program at this time. However, you still retain the right to elect to bill the program at any time during the coming year if, when you make your election, you have not yet charged any Medicare beneficiary in that year for emergency hospital services rendered to him.
Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting us. If a hospital does not elect to bill, the beneficiary may apply for reimbursement by submitting an itemized bill.
If at any time you decide to request full participation as a provider of hospital services under the Medicare program, please contact your Medicare intermediary for complete particulars.
Sincerely,
360.3.3 - Model Letter to Nonparticipating Hospital That Requests to Bill the Program (Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
REFER TO:
Identification Number: _____
Dear _____:
This refers to your inquiry concerning payment for emergency hospital services rendered to a Medicare beneficiary in a hospital which is not participating in the Medicare program. Under the Medicare program, hospital benefits ordinarily can be paid only for care furnished to patients of hospitals that are participating in the program. However, the program can also pay for hospital services furnished to a beneficiary who is admitted to a nonparticipating hospital in an emergency. To receive payments for emergency services, a nonparticipating hospital must meet certain conditions specified in the law. We have determined that your hospital meets these conditions.
Payment for emergency services can be made to a nonparticipating hospital only if you elect to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year. Your hospital may now choose to bill the program for all emergency services furnished to Medicare beneficiaries during the current calendar year, if you have not yet charged any Medicare beneficiary this year for emergency hospital services rendered to him.
If you so choose, please have an authorized official of your hospital sign a statement to this effect and return in the enclosed self-addressed envelope. Retain a copy for your records. An election to bill cannot be withdrawn during the year.
Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting us. If you do not elect to bill, the beneficiary may apply for reimbursement by submitting an itemized bill.
If at any time you decide to request full participation as a provider of hospital services under the Medicare program, please contact your Medicare intermediary for complete particulars.
Sincerely,
(Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
Contractors shall include beneficiary appeal rights language and include in the mailing a redetermination request form where applicable.
(MAC'S NAME AND ADDRESS)
Date: ___
Beneficiary: ___
Claim Number ___
We are sorry, but payment cannot be made for your stay from _ through _ at (hospital). This is because the (hospital) does not participate in the Medicare program and it has been determined that your treatment there does not qualify as emergency care.
Under the law, payment for services received in a nonparticipating hospital can be made only if you go, or are brought to, the hospital to receive emergency care. Emergency care under Medicare is defined as:
a. Care which is necessary to prevent the death or serious impairment to the health of the individual; and b. Which, because of threat to the life or health of the individual, requires the use of the nearest hospital (in miles or travel time) that has a bed available and is equipped to handle the emergency.
The medical facts of your hospital admission and stay have been carefully reviewed. Based upon this review, we have found that, although it was necessary for you to be hospitalized, a medical emergency did not exist. There would have been time for you to have been admitted to a hospital participating in Medicare.
If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS-20027 or on a written request that includes all of the elements listed below.
You may send the request to our address above. Please keep a copy of any written correspondence for your files.
Sincerely,
(Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
(MAC'S NAME AND ADDRESS)
Date: ___
Beneficiary: ___
Claim Number ___
This refers to your request for payment under Medicare for the services received while a patient at (hospital), from _ through _.
Payment can be made under the hospital insurance part of Medicare only for the costs of your hospitalization from _ to _.
The (hospital) does not participate in the Medicare program. Under the law, payment for services received in a nonparticipating hospital can be made only if you go, or are brought to, the hospital to receive emergency care. Emergency care under Medicare is defined as:
a. Care which is necessary to prevent the death or serious impairment to the health of the individual; and
b. Which, because of threat to the life or health of the individual, requires the use of the nearest hospital (in miles or travel time) which has a bed available and is equipped to handle the emergency.
Payment for emergency services stops when the emergency ends and it is permissible, from a medical standpoint, either to transfer the patient to a participating hospital or to discharge him.
The medical facts of your hospital admission and stay have been carefully reviewed. Based upon this review, we have found that an emergency condition existed when you were admitted. However, the medical information indicates that this emergency condition ended on _. At that time, your condition had improved to the extent that you could have been transferred to a hospital participating in the Medicare program.
If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days of the date you receive this notice. A request for a redetermination must be filed either on Form CMS-20027 or on a written request that includes all of the elements listed below.
You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.
Sincerely,
360.3.6 - Denial - Military Personnel/Eligible Dependents (Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
MODEL DENIAL NOTICE A (MAC'S NAME AND ADDRESS)
Date: ___
Beneficiary: ___
Claim Number ___
DETERMINATION ON EMERGENCY HOSPITAL SERVICES
We are sorry, but payment cannot be made for your stay from _ through _ at (hospital).
Under the law, medical services that have been furnished by a federal hospital to retired members of the armed services, or their eligible dependents, are not covered under the Medicare program.
If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS-20027 or on a written request that includes all of the elements listed below.
You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.
Sincerely,
(Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
(MAC'S NAME AND ADDRESS)
Date: _____
Beneficiary: _____
Claim Number: _____
We are sorry, but medical services provided on the (vessel/ship's name) cruise ship are not covered. The Medicare program can make payment for medically necessary shipboard services only if all of the following requirements are met:
1. The services are furnished while the ship is within the territorial waters of the United States (in a U.S. port, or within 6 hours of departure or arrival at a U.S. port).
2. The services are furnished to an individual who is entitled to Part B benefits;
3. The services are furnished in connection with covered inpatient hospital services;
4. The services furnished on the ship are for the same condition that required inpatient admission;
5. The physician is legally authorized to practice in the country where he or she furnishes the services.
If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they cover these services and what procedures you should follow in submitting your claim.
If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS-20027 or on a written request that includes all of the elements listed below.
You may send the request to our address listed above. Please keep a copy of any written correspondence for your files. Sincerely,
(Rev. 4203, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
NOTICE (MAC'S NAME AND ADDRESS)
Date: _____
Beneficiary: _____
Claim Number: _____
We are sorry, but payment cannot be made for your stay from __ through __ at (hospital) in (country).
Medicare law prohibits payment for items and services furnished outside the United States except in certain limited circumstances. The term "outside the U.S." means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
There are three situations when Medicare may pay for certain types of health care services rendered in a foreign hospital (a hospital outside the U.S.):
1. You're in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.
2. You're traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as "without unreasonable delay" on a case-by-case basis.
3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it's an emergency.
In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.
If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they cover these services and what procedures you should follow in submitting your claim.
If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS-20027 or on a written request that includes all of the elements listed below.
You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.
Sincerely,
(Rev. 3265, Issued: 05-22-15, Effective: 01-13-15, Implementation: 06-23-15)
On March 21, 2006, the Centers for Medicare & Medicaid Services (CMS) began national coverage of microvolt T-wave Alternans (MTWA) diagnostic testing when it was performed using only the spectral analysis (SA) method for the evaluation of patients at risk for sudden cardiac death (SCD) from ventricular arrhythmias and patients who may be candidates for Medicare coverage of the placement of an implantable cardiac defibrillator (ICD).
Effective for claims with dates of service on and after January 13, 2015, Medicare Administrative Contractors (MACs) may determine coverage of MTWA diagnostic testing when it is performed using methods of analysis other than SA for the evaluation of patients at risk for SCD from ventricular arrhythmias. Further information can be found at Publication 100-03, section 20.30, of the National Coverage Determinations Manual.
(Rev. 12396; Issued: 12-07-23; Effective: 01-09-24; Implementation: 01-09-24)
Effective for claims with dates of service on and after March 21, 2006, MACs shall accept CPT 93025 (MTWA for assessment of ventricular arrhythmias) for MTWA diagnostic testing for the evaluation of patients at risk for SCD with the SA method of analysis only. All other methods of analysis for MTWA are non-covered.
Effective for claims with dates of service on and after January 13, 2015, MACs shall at their discretion determine coverage for CPT 93025 for MTWA diagnostic testing for the evaluation of patients at risk for SCD with methods of analysis other than SA. The –KX modifier shall be used as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the MTWA was performed using a method of analysis other than SA for the evaluation of patients at risk for SCD from ventricular arrhythmias and that all other NCD criteria was met.
NOTE: The –KX modifier is NOT required on MTWA claims for the evaluation of patients at risk for SCD if the SA analysis method is used.
NOTE: This diagnosis code list/translation was approved by CMS/Coverage. It may or may not be a complete list of covered indications/diagnosis codes that are covered but should serve as a finite starting point.
As this policy indicates, individual A/B MACs within their respective jurisdictions have the discretion to make coverage determinations they deem reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act. Therefore, A/B MACs may have additional covered diagnosis codes in their individual policies where contractor discretion is appropriate.
ICD-10-Codes:
| ICD-10 CM | ICD-10 DX Description |
|---|---|
| I21.01 | ST elevation (STEMI) myocardial infarction involving left main coronary artery |
| I21.02 | ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery |
| 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 |
| I21.21 | ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery |
| 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 |
| I21.A1 | Myocardial infarction type 2 |
| I21.B | Myocardial infarction with coronary microvascular dysfunction |
| I22.0 | Subsequent ST elevation (STEMI) myocardial infarction of anterior wall |
| I22.1 | Subsequent ST elevation (STEMI) myocardial infarction of inferior wall |
| I22.2 | Subsequent non-ST elevation (NSTEMI) myocardial infarction |
| I22.8 | Subsequent ST elevation (STEMI) myocardial infarction of other sites |
| I22.9 | Subsequent ST elevation (STEMI) myocardial infarction of unspecified site |
| I24.81 | Acute coronary microvascular dysfunction |
| I24.89 | Other forms of acute ischemic heart disease |
| I24.9 | Acute ischemic heart disease, unspecified |
| I47.0 | Re-entry ventricular arrhythmia |
| I47.2 | Ventricular tachycardia |
| I49.01 | Ventricular fibrillation |
| I49.02 | Ventricular flutter |
|---|---|
| R55 | Syncope and collapse |
(Rev. 3265, Issued: 05-22-15, Effective: 01-13-15, Implementation: 06-23-15)
Effective for claims with dates of service on and after January 13, 2015, MACs shall deny claims for MTWA CPT 93025 with methods of analysis other than SA without modifier -KX using the following messages:
CARC 4: 'The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.'
RARC N657 – This should be billed with the appropriate code for these services.
Group Code: CO (Contractual Obligation) assigning financial liability to the provider
MSN 15.20 - The following policies [NCD 20.30] were used when we made this decision
Spanish Equivalent - 15.20 - Las siguientes políticas [NCD 20.30] fueron utilizadas cuando se tomó esta decisión.
(Rev. 3815, Issued: 07-28-17, Effective: 01-18-18, Implementation: 08-29-17 - for MAC local edits; January 2, 2018 - for MCS shared edits)
Effective for dates of service on or after January 18, 2017, contractors shall cover leadless pacemakers through Coverage with Evidence Development (CED) when procedures are performed in CMS-approved CED studies. Please refer to the National Coverage Determinations Manual (Publication 100-03, Section 20.8.4) for more information.
(Rev. 3815, Issued: 07-28-17, Effective: 01-18-18, Implementation: 08-29-17 - for MAC local edits; January 2, 2018 - for MCS shared edits)
Effective for dates of service on or after January 18, 2017, contractors shall allow the following procedure codes on claims for leadless pacemakers:
0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular
0389T Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system.
0390T Peri-procedural device evaluation (in person) and programming of device system parameters before or after surgery, procedure or test with analysis, review and report, leadless pacemaker system.
0391T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system.
Effective for dates of service on or after January 18, 2017, contractors shall allow the following ICD-10 diagnosis codes on claims for leadless pacemakers:
Z00.6 – Encounter for examination for normal comparison and control in clinical research program.
(Rev. 3815, Issued: 07-28-17, Effective: 01-18-18, Implementation: 08-29-17 - for MAC local edits; January 2, 2018 - for MCS shared edits)
Effective for dates of service on or after January 18, 2017, contractors shall only pay claims for leadless pacemakers when services are provided in one of the following places of service (POS):
POS 06 – Indian Health Service Provider Based Facility
POS 21 – Inpatient Hospital
POS 22 - On Campus-Outpatient Hospital
POS 26 – Military Treatment Facility
(Rev. 3815, Issued: 07-28-17, Effective: 01-18-18, Implementation: 08-29-17 - for MAC local edits; January 2, 2018 - for MCS shared edits)
Effective for claims with dates of service on or after January 18, 2017, modifier Q0 – Investigational clinical service provided in a clinical research study that is an approved clinical research study, must also be included.
(Rev. 3815, Issued: 07-28-17, Effective: 01-18-18, Implementation: 08-29-17 - for MAC local edits; January 2, 2018 - for MCS shared edits)
The professional claim must also contain the 8-digit clinical trial identifier in item 23 of the CMS-1500 form or the electronic equivalent.
(Rev. 3815, Issued: 07-28-17, Effective: 01-18-18, Implementation: 08-29-17 - for MAC local edits; January 2, 2018 - for MCS shared edits)
Effective for claims with dates of service on or after January 18, 2017, contractors shall deny professional claim lines for leadless pacemakers that do not contain an appropriate POS code and use the following messages:
CARC 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at
http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
MSN 21.25: “This service was denied because Medicare only covers this service in certain settings.”
Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.”
Group Code –Contractual Obligation (CO).
CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
RARC N572: This procedure not payable unless appropriate non-payable reporting.
Group Code – Contractual Obligation (CO).
CARC 16 - Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC M76 - Missing/incomplete/invalid diagnosis or condition.
CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)”
RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.
Group Code – Contractual Obligation (CO).
Effective for claims with dates of service on or after May 25, 2017, the Centers for Medicare and Medicaid Services (CMS) will cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD). Up to 36 sessions over a 12 week period are covered if all of the following components of a SET program are met:
The SET program must:
Beneficiaries must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.
SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary attending physician.
Please refer to the National Coverage Determinations Manual (Publication 100-03, Section 20.35) for more information.
(Rev. 4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)
Effective for claims with date of services on or after May 25, 2017, contractors shall pay claims for SET for beneficiaries with IC for the treatment of symptomatic PAD, with a referral from the physician responsible for PAD treatment.
Medicare Administrative Contractors (MACs) have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time. Contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the services that documentation is on file verifying that further treatment beyond the 36 sessions of SET over a 12 week period meets the requirements of the medical policy.
(Rev. 4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)
I70.211 –right leg
I70.212 – left leg
I70.213 – bilateral legs
I70.218 – other extremity
I70.311 – right leg
I70.312 – left leg
I70.313 – bilateral legs
I70.318 – other extremity
I70.611 – right leg
I70.612 – left leg
I70.613 – bilateral legs
I70.618 – other extremity
I70.711 – right leg
I70.712 – left leg
I70.713 – bilateral legs
I70.718 – other extremity
(Rev.4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)
Contractors shall pay claims for SET services containing CPT code 93668 on Types of Bill (TOBs) 13X under OPPS and 85X based on reasonable cost.
Contractors shall pay claims for SET services containing CPT 93668 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or the submitted charge.
(Rev.4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)
CWF shall create a new edit for CPT 93668 to reject claims when a beneficiary has reached 36 SET sessions within 84 days after the date of the first SET session and the KX modifier is not included on the claim or to reject any SET session provided after 84 days from the date of the first session and the KX modifier is not included on the claim.
CWF shall determine the remaining SET sessions.
The CWF determination, to parallel claims processing, shall include all applicable factors including:
CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation.
CWF shall display the remaining SET sessions on all CWF provider query screens.
The Multi-Carrier System Desktop Tool (MCSDT) shall display the remaining SET sessions in a format equivalent to the CWF HIMR screen(s).
(Rev.4049, Issued: 05- 11-18, Effective: 05-25-17, Implementation: 07-02-18)
MSN 15.20: “The following policies NCD 20.35 were used when we made this decision.”
Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”
(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-MEDICARE (1800-633-4227).
Claim Adjustment Reason Code (CARC) 58:
“Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.
Remittance advice remark code (RARC) N386: This decision was based on a National Coverage Determination (NCD) 20.35. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
MSN 15.20: “The following policies NCD 20.35 were used when we made this decision.”
Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”
(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-MEDICARE (1800-633-4227).
CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
96- Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.)
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
N640 Exceeds number/frequency approved/allowed within time period.
Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line-item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).
MSN 15.20: “The following policies NCD 20.35 were used when we made this decision.”
Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”
(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y
enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-MEDICARE (1800-633-4227).
CARC 119: “Benefit maximum for this time period or occurrence has been reached.”
RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32 with or without a GA modifier or a claim-line is received with a GA modifier indicating a signed ABN is on file)
Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line-item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present
MSN 15.20: “The following policies NCD 20.35 were used when we made this decision.”
Spanish Version – “Las siguientes políticas NCD 20.35 fueron utilizadas cuando se tomó esta decisión.”
(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800- MEDICARE (1800-633-4227).
CARC 119: “Benefit maximum for this time period or occurrence has been reached.”
RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.”
Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32 with or without a GA modifier or a claim-line is received with a GA modifier indicating a signed ABN is on file)
Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line-item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).
(Rev. 11721; Issued: 11-28-22; Effective: 01-01-23; Implementation: 01-03-23)
T-cells employ a number of mechanisms to fight abnormal cells such as cancer. One type of therapy that leverages the immune system, immunotherapy, is Chimeric Antigen Receptor (CAR) T-cell therapy. CAR T-cells have been genetically altered in order to improve the ability of the T-cells to fight cancer.
(Rev. 11721; Issued: 11-28-22; Effective: 01-01-23; Implementation: 01-03-23)
Effective for services performed on or after August 7, 2019, the Centers for Medicare & Medicaid Services (CMS) covers autologous treatment for cancer with T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the Food and Drug Administration (FDA) risk evaluation and mitigation strategies (REMS) and used for a medically accepted indication as defined at Social Security Act (the Act) section 1861(t)(2), i.e., is used for either an FDA-approved indication (according to the FDA-approved label for that product), or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia. See Publication 100-03, National Coverage Determination (NCD) Manual 110.24 for complete coverage criteria. See the following websites for specific REMS facility information:
Kymriah® https://www.us.kymriah.com/treatment-center-locator
Yescarta® https://www.yescarta.com/find-a-treatment-center
Tecartus™ https://www.tecartus.com/hcp/treatment-center-locator
Breyanzi® https://www.celltherapy360.com/locations
ABECMA® https://www.celltherapy360.com/locations
CARVYKTI™ https://www.carvyktihcp.com/treatment-centers
NOTE: The use of allogenic T-cells from healthy donors are not autologous CAR T-cell treatments and shall not be billed as autologous CAR T-cell treatments.
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
Effective for dates of service on or after August 7, 2019, contractors shall pay for line-item professional claims from approved providers for the administration of autologous treatment for cancer with T-cells expressing at least one CAR with Current Procedural Terminology (CPT) code 0540T end date 12/31/24 replaced with 38228 effective 01/01/25.
Contractors shall not require the NCD 110.24 -KX modifier and diagnosis codes for clinical trials under NCD 310.1. These claims shall bill with the NCT number for the specific trial, the -Q0 clinical trial modifier, and the Z00.6 clinical trial diagnosis code on the 0540T claim line effective for dates of service on or after August 7, 2019. (0540T end date 12/31/24 and replaced with 38228 effective 01/01/25.)
For Part A Outpatient (OPPS) contractors shall not require NCD 110.24 REMS facility and diagnosis codes for CAR T-cell therapy CPT code 0540T in clinical trials under NCD 310.1 billed with the NCT number for the specific trial, the -Q0 clinical trial modifier, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after August 7, 2019. (0540T end date 12/31/24 and replaced with 38228 effective 01/01/25.)
(Rev. 10891, Issued: 07-20-21, Effective: 08-07-19, Implementation: 09-20-21)
Valid type of bills (TOBs) for billing inpatient CAR T-cell therapy services may include (but are not necessarily limited to):
011x – Inpatient Hospital
012x – Inpatient Ancillary Hospital
Valid TOBs for billing outpatient CAR T-cell therapy services may include (but are not necessarily limited to):
085x – Critical Access Hospital
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
The following Revenue Codes are used for billing inpatient and outpatient CAR T-cell therapy services:
0871 – Cell Collection w/CPT code 0537T end date 12/31/24 and replaced with 38225 effective 01/01/25.
0872 – Specialized Biologic Processing and Storage – Prior to Transport w/CPT code 0538T end date 12/31/24 and replaced with 38226 effective 01/01/25.
0873 – Storage and Processing after Receipt of Cells from Manufacturer w/CPT code 0539T end date 12/31/24 and replaced with 38227 effective 01/01/25.
0874 – Infusion of Modified Cells w/CPT code 0540T end date 12/31/24 and replaced with 38228 effective 01/01/25.
0891 – Special Processed Drugs – FDA Approved Cell Therapy w/ Healthcare Common Procedure Coding System (HCPCS) codes Q2041, Q2042, C9073 (replaced with Q2053 April 1, 2021), C9076 (replaced with Q2054 October 1, 2021), C9081 (replaced with Q2055 January 1, 2022), C9098 (replaced with Q2056 October 1, 2022), or C9399
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
The following HCPCS/CPT procedure codes are used for billing outpatient CAR T-cell therapy services:
HCPCS Code Q2041 for Axicabtagene Ciloleucel
HCPCS Code Q2042 for Tisagenlecleucel
HCPCS Code Q2053 for Brexucabtagene Autoleucel (effective April 1, 2021)
HCPCS Code Q2054 for Lisocabtagene Maraleucel (effective October 1, 2021)
HCPCS Code Q2055 for Idecabtagene Vicleucel (effective January 1, 2022)
HCPCS Code Q2056 for Ciltacabtagene Autoleucel (effective October 1, 2022)
HCPCS Code C9073 for Brexucabtagene Autoleucel (prior to April 1, 2021)
HCPCS Code C9076 for Lisocabtagene maraleucel (prior to October 1, 2021)
HCPCS Code C9081 for Idecabtagene Vicleucel (prior to January 1, 2022)
HCPCS Code C9098 for Ciltacabtagene Autoleucel (prior to October 1, 2022)
HCPCS Code C9399, J3490, J3590, or J9999 for unclassified drugs or biologicals when dose of CAR T-cell therapy exceeds code descriptor or when other CAR T-cell therapy obtains FDA approval but has not yet received a specific HCPCS code
CPT Code 0537T collection/handling* end date 12/31/24 and replaced with 38225 effective 01/01/25.
CPT Code 0538T preparation for transport* end date 12/31/24 and replaced with 38226 effective 01/01/25.
CPT Code 0539T receipt and preparation* end date 12/31/24 and replaced with 38227 effective 01/01/25.
CPT Code 0540T the provider (physician/NPP) procedure to administer CAR T-cells end date 12/31/24 and replaced with 38228 effective 01/01/25.
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
The following places of service (POS) are covered for CAR T-cells product HCPCS codes (Q2041, Q2042, Q2053-Q2056, J3490, J3590, and J9999):
11 (Office)
49 (Independent clinic)
Professional claims for the procedure to administer CAR T-cells (0540T) end date 12/31/24 and replaced with 38228 effective 01/01/25 may include (but are not necessarily limited to):
11 (Office)
19 (Off Campus-Outpatient Hospital)
21 (Inpatient Hospital)
22 (On Campus-Outpatient Hospital)
49 (Independent Clinic)
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
Please see NCD spreadsheet for the applicable International Classification of Disease (ICD)-10-CM diagnosis codes for CAR T-cell therapy coverage.
The following are the applicable ICD-10-PCS procedure codes for CAR T-cell therapy coverage for inpatient claims:
For dates of service on or after October 1, 2021:
CARVYKTI™ - XW033A7: Introduction of Ciltacabtagene Autoleucel into Peripheral Vein, Percutaneous Approach, New Technology Group 7
CARVYKTI™ - XW043A7: Introduction of Ciltacabtagene Autoleucel into Central Vein, Percutaneous Approach, New Technology Group 7
When other CAR T-cell therapy obtains FDA approval but has not yet received a specific PCS code, and for use in clinical trials FDA-approved under NCD 310.1 – XW033C7: Introduction of Autologous Engineered Chimeric Antigen Receptor T-cell Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7
When other CAR T-cell therapy obtains FDA approval but has not yet received a specific PCS code, and for use in clinical trials FDA-approved under NCD 310.1 – XW043C7: Introduction of Autologous Engineered Chimeric Antigen Receptor T-cell Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7
Yescarta® - XW033H7: Introduction of Axicabtagene Ciloleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7
Yescarta® - XW043H7: Introduction of Axicabtagene Ciloleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7
Kymriah® - XW033J7: Introduction of Tisagenlecleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7
Kymriah® - XW043J7: Introduction of Tisagenlecleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7
ABECMA® - XW033K7: Introduction of Idecabtagene Vicleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7
ABECMA® - XW043K7: Introduction of Idecabtagene Vicleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7
Tecartus™ - XW033M7: Introduction of Brexucabtagene Autoleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7
Tecartus™ - XW043M7: Introduction of Brexucabtagene Autoleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7
Breyanzi® - XW033N7: Introduction of Lisocabtagene Maraleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7
Breyanzi® - XW043N7: Introduction of Lisocabtagene Maraleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7
Aucatzyl® - XW0338A: Introduction of Obecabtagene Autoleucel into Peripheral Vein, Percutaneous Approach, New Technology Group 10 (FDA Approval date of November 8, 2024). This code is covered in a clinical trial, see below.
Aucatzyl® - XW0438A: Introduction of Obecabtagene Autoleucel into Central Vein, Percutaneous Approach, New Technology Group 10 (FDA Approval date of November 8, 2024). This code is covered in a clinical trial, see below.
For dates of service prior to October 1, 2021:
Yescarta®, ABECMA®, Kymriah® - XW033C3: Introduction of Engineered Autologous Chimeric Antigen
Receptor T-cell Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 3
Yescarta®, ABECMA®, Kymriah® - XW043C3: Introduction of Engineered Autologous Chimeric Antigen Receptor T-cell Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 3
Tecartus™ - XW23346 - Transfusion of Brexucabtagene Autoleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 6
Tecartus™ - XW24346 - Transfusion of Brexucabtagene Autoleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 6
Breyanzi® - XW23376 – Transfusion of lisocabtagene maraleucel immunotherapy into peripheral vein, percutaneous approach, new technology group 6
Breyanzi®- XW24376 – Transfusion of lisocabtagene maraleucel immunotherapy into central vein, percutaneous approach, new technology 6
NOTE: Since allogenic T-cells are by definition not autologous CAR T-cells, it is inappropriate to use any of the above autologous CAR T-cell ICD-10 PCS procedure codes for allogenic T-cell treatments.
For Part A Inpatient contractors shall not require NCD 110.24 REMS facility and diagnosis codes for autologous CAR T-cell therapy ICD-10-PCS codes XW033A7/XW043A7, XW033H7/XW043H7, XW033J7/XW043J7, XW033K7/XW043K7, XW033M7/XW043M7, XW033N7/XW043N7, and XW0338A/XW0438A in clinical trials under NCD 310.1 billed with the NCT number for the specific trial, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after August 7, 2019.
(Rev. 11721; Issued: 11-28-22; Effective: 01-01-23; Implementation: 01-03-23)
Professional claims for CAR T-cell therapy and related services are billed using the Form CMS-1500 or 837P following instructions in chapter 12 of this manual (www.cms.hhs.gov/manuals/104_claims/clm104index.asp).
Contractors shall pay professional claims for CAR T-cell therapy when the service is administered at a healthcare facility that is enrolled in the REMS program as a REMS participating site. Contractors shall use the CMS HCPCS Website for current HCPCS codes, https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update, and the individual REMS facility websites noted at section 400.1.
Contractors shall create an edit that only allows CAR T-cell therapy services to be submitted by, or performed in, an FDA REMS approved facility when the line item has a -KX modifier appended. Note: When a provider submits a -KX modifier on CAR T-cell therapy services, they are acknowledging that the service is being submitted by or performed in an FDA REMS approved facility.
Contractors shall create an edit that only allows CAR T-cell therapy services when the line item has a -LU modifier appended in addition to a -KX modifier. Note: When a provider submits an -LU modifier on a CAR T-cell claim, it informs the MAC that the service is fractionated. The total units shall not exceed 1 unit.
Contractors shall set up their systems to allow fractionated units on multiple claims for CAR T-cell products on the same DOS. These claims should suspend for proper adjudication of payment.
The total payment will be divided by 10 and the provider will need to bill in 0.1 unit fractions. The provider will need to bill a total of 10 fractional units to reach the total Medicare allowed payment amount.
Example: CAR T-cell product allowed payment $445,000:
0.2 units = \$89,000.06 0.2 units = \$89,000.00 0.2 units = \$88,999.99 0.2 units = \$88,999.98 0.2 units = \$88,999.97
Note: Contractors shall only pay up to 1 unit, anything exceeding 1 unit must be denied.
For CAR T-cell products when the dose exceeds the code descriptor, use HCPCS code J3490, J3590, or J9999 for the exceeded dosage. Include the CAR T-cell product name and the exceeded dosage in Block 19 of the 1500 claim form or its electronic equivalent.
Example: CAR T-cell product with dose exceeded allowed payment $150,000:
0.5 units = $74,999.00
For CAR T-cell products when the dose exceeds the code descriptor, the provider would bill a total of 1 unit of the Q code plus a total of 1 unit of the J code.
For example, Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T- cells. If the provider gives 300 million cells, they will bill:
Q2041 for 0.1 fraction $42,294.00 x10 for 200 million cells (total $422,940.00)
J9999 for 0.2 fractions $42,294.00 x5 for 100 million cells (total $211,470.00)
NOTE: The FDA labels for CAR T-cell products state the maximum number of cells that are to be infused. The HCPCS code descriptors for Q2041, Q2042, Q2053, Q2054, Q2055, and Q2056 all align with the FDA label maximum number of cells that are to be infused. If a provider exceeds the HCPCS code descriptor number of cells, this is off label use. This should be extremely rare.
Contractors shall allow a -76 modifier (repeat procedure or service by same physician or other qualified healthcare professional) on subsequent claims billed on the same date of service to assist with preventing duplicate denials.
(Rev. 13608; Issued: 01-29-26; Effective: 08-25-25; Implementation: 08-25-25)
The A/ B MAC billing requirements will allow for CAR T-cell therapy when the services are submitted on the following TOB: 11X. Type of facility and setting determines the basis of payment:
For services performed in inpatient hospitals, TOB 11X, under the Inpatient PPS is based on the Medicare Severity-Diagnosis Related Group (MS-DRG).
For services performed in Critical Access Hospital (CAH) inpatient TOB 11X, payment is based on 101% of reasonable cost.
The A/B MAC billing requirements will pay for CAR T-cell therapy when the services are submitted on the TOBs: 13X and 85x. Type of facility and setting determines the basis of payment:
For services performed in hospital outpatient departments (HOPDs), TOBs 13X, or inpatient ancillary TOB 12X, payment is based on OPPS.
For services performed in CAH OPDs, TOB 85X, payment is based on reasonable cost.
For services performed in CAH Method II with revenue code 096X, 097X, and 098X, TOB 85X, payment is based on the lesser of the actual charge or the Medicare Physician Fee Schedule (115% of the lesser of the fee schedule amount and submitted charge).
HOPDs may report CPT codes 0537T, 0538T, and 0539T (end date 12/31/24 replaced with 38225, 38226, and 38227 effective 01/01/25) to allow tracking of these services when furnished in the outpatient setting. Medicare will reject these lines as Medicare does not separately pay for these services under the OPPS.
These following scenarios present further clarification on how to report items and services related to CAR-T in various clinical scenarios.
In instances when you administer the CAR-T drug in the HOPD setting, report CPT code 0540T (end date 12/31/24 and replaced with 38228 effective 01/01/25) for the administration and HCPCS Q2041, Q2042, Q2053 (effective April 1, 2021), C9073 (prior to April 1, 2021), C9076, or, if a more specific code is unavailable, the most appropriate unclassified drug code (e.g., C9399 for unclassified drugs or biologicals). NOTE: the drug codes will be denied as a Part A service even if billed with the administration.) For specific instructions on billing unclassified drug codes, refer to Chapter 26, Section 10.4 of the “Medicare Claims Processing Manual” on the CMS website at: Regulations-and-Guidance.Ch26. As discussed in the Calendar Year (CY) 2019 OPPS/Ambulatory Surgery Center final rule (83 FR 58904), the procedures described by CPT 0537T (collection/handling), 0538T (preparation for transport), and 0539T (receipt and preparation) (0537T, 0538T, and 0539T end date 12/31/24 and replaced with 38225, 38226, and 38227 effective 01/01/25) represent the various steps required to collect and prepare the genetically modified T-cells, and these steps are not paid separately under the OPPS. However, you may report the charges for these various steps to collect and prepare the CAR T-cells separately and Medicare will reject them on the HOPD claim, or they may be included in the charge reported for the biological.
Note: When including the charges for collection and preparation of the CAR-T cells in the charge for the CAR-T product, outpatient providers should code the CAR-T product service on the date that the CAR-T administration took place and not on the date when the cells were collected.
In instances when the CAR-T drug is not ultimately administered to the beneficiary, but the CAR-T preparation services are initiated or performed in the HOPD facility, the hospital may not report the drug Q code (which only applies when the T-cells are administered in the HOPD setting). HOPDs may report CPT 0537T, 0538T, and 0539T (as appropriate) and (0537T, 0538T, and 0539T end date 12/31/24 and replaced with 38225, 38226, and 38227 effective 01/01/25) the charges associated with each code under the appropriate revenue code on the HOPD claim. Medicare will reject these codes.
When CAR T-cell preparation services are initiated and furnished in the HOPD setting, but the CAR T-cells are administered in the inpatient setting, the hospital may not report the drug Q code (which only applies when the T-cells are administered in the HOPD setting). Report the charge associated with the various steps to collect and prepare the CAR T-cells on the inpatient claim (TOB 11x) separately using revenue codes 0871, 0872, or 0873. Alternatively, the hospital may include the charges for these various steps in the charge reported for the biological using revenue code 0891 – Special Processed Drugs – FDA (U.S. Food and Drug Administration) Approved Cell Therapy – Charges for Modified cell therapy.
Note: When the cells are collected in the HOPD setting and the CAR-T is administered in the hospital inpatient setting, inpatient providers should report the date that the CAR-T administration took place and not the date the cells were collected.
The A/B MAC billing requirements will pay for CAR T-cell therapy when the services are submitted on the Form CMS-1500 or electronic 837P.
In instances when you administer the CAR-T drug in the physician office setting or other non-hospital clinic setting that is enrolled in the REMS program as a REMS participating site, report CPT code 0540T (end date 12/31/24 and replaced with 38228 effective 01/01/25) for the administration and HCPCS Q2041, Q2042, Q2053 (effective April 1, 2021), C9073 (prior to April 1, 2021), C9076, or, if a more specific code is unavailable, the most appropriate unclassified drug code (e.g., J3590 for unclassified biologics). For specific instructions on billing unclassified drug codes, refer to Chapter 26, Section 10.4 of the “Medicare Claims Processing Manual” on the CMS website at: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c26pdf.pdf
The procedures described by CPT 0537T (collection/handling), 0538T (preparation for transport), and 0539T (receipt and preparation) represent the various steps required to collect and prepare the genetically modified T-cells, and these steps are not paid separately under the MPFS. However, you may report them separately, and Medicare will reject them on the professional claim. (0537T, 0538T, and 0539T end date 12/31/24 and replaced with 38225, 38226, and 38227 effective 01/01/25.)
Note: Practitioners should code the CAR-T product service on the date that the CAR-T administration took place and not on the date when the cells were collected.
In instances when the CAR-T drug is not ultimately administered to the beneficiary, but the CAR-T preparation services are initiated or performed in the physician office or other non-hospital clinic facility, the practitioner may not report the drug HCPCS code (which only applies when the T-cells are administered in the setting). The practitioner may report CPT 0537T, 0538T, and 0539T. (0537T, 0538T, and 0539T end date 12/31/24 and replaced with 38225, 38226, and 38227 effective 01/01/25.)
When CAR T-cell preparation services are initiated and furnished in the physician office or other non-hospital clinic setting, but the CAR T cells are administered in the hospital inpatient setting, the practitioner may not report the drug HCPCS code (which only applies when viable T-cells are administered in the setting). The hospital that administers the T-cells will report the charge associated with the various steps to collect and prepare the CAR T-cells on the inpatient claim (TOB 11x) separately using revenue codes 0871, 0872, or 0873. Alternatively, the hospital may include the charges for these various steps in the charge reported for the biological using revenue code 0891 – Special Processed Drugs – FDA (U.S. Food and Drug Administration) Approved Cell Therapy – Charges for Modified cell therapy.
Note: When the cells are collected in the physician office setting and the CAR T-cell is administered in the hospital inpatient setting, inpatient providers shall report the date that the CAR T-cell administration took place and not the date the cells were collected.
Contractors shall continue to use the appropriate existing messages that they have in place when denying claims submitted that do not meet the Medicare coverage criteria for CAR T-cell therapy.
--Contractors shall deny claims for CAR T-cell therapy when the service is not administered through healthcare facilities that are enrolled in the FDA REMS requirements using the following messages:
CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 – This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code CO (Contractual Obligations).
MSN 16.2 – This service cannot be paid when provided in this location/facility.
Spanish Version – Este servicio no se puede pagar cuando es suministrado en esta sitio/facilidad.
In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.
--When denying claims for covered CAR T-cell therapy procedures because the appropriate ICD-10 coding was not used, use the following messages:
CARC 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code CO or PR dependent upon liability.
MSN 15.20 - “The following polices were used when we made this decision: NCD 110.24.”
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 110.24.”
CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code CO or PR (Patient Responsibility) dependent upon liability. (Use PR when the GA modifier is appended to the line item).
MSN 09.040 - This item or service was denied because information required to make payment was incorrect.
MSN 15.20 - “The following polices were used when we made this decision: NCD 110.24.”
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 110.24.”
CARC 4 - The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code CO
MSN 15.20 - “The following polices were used when we made this decision: NCD 110.24.”
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 110.24.”
CARC 151 - Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
Group Code CO
MSN 15.060 - The information provided does not support the need for this many services or items within this period of time.
Spanish Version - (La información proporcionada no confirma la necesidad de estos servicios o artículos en este periodo de tiempo.)
-- Contractors shall reject claims for allogeneic CAR T-cell therapy ICD-10-PCS codes XW033G7 and XW043G7 and autologous CAR T-cell therapy ICD-10-PCS codes XW033C7 and XW043C7 when not billed for clinical trials under NCD 310.1 with the NCT number for the specific trial, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after October 1, 2021, using the following messages:
CARC 55: Procedure/treatment/drug is deemed experimental/investigational by the payor.
Group Code: CO
MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study.
Spanish Version – (Este servicio/artículo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.)
In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.
(Rev. 11721; Issued: 11-28-22; Effective: 01-01-23; Implementation: 01-03-23)
Medicare edits CAR T-cell therapy claims based on requirements found in NCD 110.24.
Effective for claims with dates of service on and after August 7, 2019, CMS determined that the NCD requiring coverage of CAR T-cell therapy for cancer is a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. As a result, for CYs 2019 (beginning August 7, 2019) and 2020 only, original fee-for-service Medicare will pay for CAR T-cell therapy for cancer obtained by beneficiaries enrolled in Medicare Advantage (MA) plans when the coverage criteria outlined in the NCD are met. Plans should account for CAR T-cell therapy for cancer items and services in their contract year 2021 bids.
Consistent with §1862 (t)(2) of the Act, MACs will pay for CAR T-cell therapy for cancer for Medicare beneficiaries enrolled in MA plans in CYs 2019 (beginning August 7, 2019) and 2020.
(Rev. 10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06-24 - 20 - A/B MACs; 10-05-20-SSM Edits; 01- 04-21 - BR 13 CWF only)
Acupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or “needling,” or other “non-needling” techniques focused on these points.
(Rev. 10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06-24 - 20 - A/B MACs; 10-05-20-SSM Edits; 01- 04-21 - BR 13 CWF only)
Effective for services on or after January 21, 2020, the Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:
All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.
(Rev. 10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06-24 - 20 - A/B MACs; 10-05-20-SSM Edits; 01- 04-21 - BR 13 CWF only)
Effective for claims with dates of service (DOS) on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported with CPT codes 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under National Coverage Determination (NCD) 30.3.3 no more than 20 times per annum.
NOTE: If the 1st service is performed on March 21, 2020, the next service beginning a new year cannot be performed until March 1, 2021, 11 full months following the 1st service.
The attached includes the International Classification of Diseases (ICD)-10 diagnosis codes are applicable and must be reported for acupuncture for cLBP services:
Contractors shall accept and process acupuncture for cLBP claims with the -KX modifier for the 13th through 20th service per annum.
NOTE: The 1st through 12th service over a 90-day period do not require the –KX modifier. There is a 20 service maximum per annum for this benefit.
NOTE: By applying the -KX modifier to the claim, the therapy provider is confirming that the additional services are medically necessary as justified by appropriate documentation in the medical record.
(Rev. 10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06-24 - 20 - A/B MACs; 10-05-20-SSM Edits; 01- 04-21 - BR 13 CWF only)
Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported on institutional claims on types of bill (TOBs) 12X, 13X, 71X, 77X, and 85X (and revenue codes not equal to 096X, 097X, and 098X for CAH Method I).
Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported with Revenue Code 0940 on institutional claims.
Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported on institutional claims on TOB 12X, 71X, 77X 85X CAH Method II with revenue codes 096X, 097X, and 098X.
(Rev. 10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06-24 - 20 - A/B MACs; 10-05-20-SSM Edits; 01- 04-21 - BR 13 CWF only)
Effective for claims with DOS on or after January 21, 2020, contractors shall reject/deny claims that do not contain the appropriate diagnosis/procedure coding noted in section 410.2 and use these messages:
Claim Adjustment Reason Code (CARC) 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.
Remittance Advice Remark Code (RARC) M64 – Missing/incomplete/invalid other diagnosis.
Group Code CO (Contractual Obligations) or PR (Patient Responsibility) dependent on liability.
MSN 15.20 - 'The following polices were used when we made this decision: NCD 30.3.3.'
Spanish Version – 'Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 30.3.3.'
NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.
In addition to the codes noted in section 410.2, contractors shall afford appeal rights to all denied parties.
Contractors shall return to provider/return as unprocessable claims for acupuncture for cLBP for services 13 through 20 per annum without the -KX modifier and use these messages:
CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N657 - This should be billed with the appropriate code for these services.
Group Code CO
Contractors shall reject/deny more than 20 claims per annum for acupuncture for cLBP and use the following messages:
CARC 96 - Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N640 - Exceeds number/frequency approved/allowed within time period.
Group Code - CO (Contractual Obligation)
MSN 15.20 - “The following polices were used when we made this decision: NCD 30.3.3.”
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 30.3.3.”
MSN 15.19: “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare-coverage-database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor.”
Spanish Version - Usamos una Determinación de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN para el código 'CPT/HCPCS') y envíela con la información de su médico.
NOTE: Due to system requirements, the Fiscal Intermediary Shared System has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.
(Rev. 10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06-24 - 20 - A/B MACs; 10-05-20-SSM Edits; 01- 04-21 - BR 13 CWF only)
The Common Working File (CWF) shall create a new reject for claims with DOS on and after January 21, 2020, for claims received on or after October 5, 2020, to not allow payment for more than 20 acupuncture for cLBP claims per annum.
For acupuncture for cLBP claims CWF, FISS and the Multi-Carrier System (MCS) shall apply appropriate updates to the Next Eligibility Date file for DOS on or after January 21, 2020.
NOTE: Appropriate updates include modifications to HUQA, and Extract Records on the Next Generation Desktop (NGD) and the Medicare Beneficiary Database (MBD) for next eligible date and services remaining.
CWF shall count 11 full months starting with the month of a beneficiary’s 1st acupuncture for cLBP service. EX: If 1st date of service is October 15, 2020, the next eligible date beginning a new year would be October 1, 2021.
NOTE: A new cLBP auxiliary (AUX) file will be created and HIMR will be updated to post the previous acupuncture for cLBP HCPCS 97810, 97811, 97813, 97814, 20560, or 20561.
For acupuncture for cLBP claims with DOS on and after January 21, 2020, the Multi-Carrier System Desktop Tool shall display the acupuncture for cLBP visits in a format equivalent to the CWF HIMR screen.
Effective for claims with DOS on and after January 21, 2020, received on and after October 5, 2020, CWF shall post acupuncture for cLBP HCPCS codes 97810, 97811, 97813, 97814, 20560, and 20561, reported on institutional claims, TOBs 12X, 13X, 71X, 77X, and 85X (and revenue code not equal to 096X, 097X, 098X), as the technical component on the new cLBP AUX file.
NOTE: 1 TECH and 1 PROF on same DOS represents 1 service.
NOTE: CWF shall post the Part B Professional claim line as TECH/PROF for the HCPCS if the modifier is blank.
CWF shall create a new reject for HCPCS 97810, 97811, 97813, 97814, 20560, and 20561 when a beneficiary has reached 20 acupuncture for cLBP sessions and the -KX modifier is not included on the claim line for sessions 13 through 20 (the reject will apply for both PROF and TECH sessions).
CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation
CWF shall create a new HICR function for the new cLBP AUX file.
(Rev. 10269, Issued: 08-07-2020, Effective: 01-01-2021, Implementation: 01-04-2021)
(Rev. 10269, Issued: 08-07-2020, Effective: 01-01-2021, Implementation: 01-04-2021)
Effective beginning on January 1, 2021, the Medicare home infusion therapy benefit covers the professional services, including nursing services, furnished in accordance with the plan of care, patient training and education (not otherwise covered under the durable medical equipment benefit), remote monitoring, and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier. Home infusion therapy means the items and services furnished by a qualified home infusion therapy supplier, which are furnished in the individual’s home. Payment is for an “infusion drug administration calendar day,” which means the day on which home infusion therapy services are furnished by skilled professionals in the individual’s home on the day of infusion drug administration. The skilled services provided on such day must be so inherently complex that they can only be safely and effectively performed by, or under the supervision of, professional or technical personnel.
(Rev. 10269, Issued: 08-07-2020, Effective: 01-01-2021 Implementation: 01-04-2021)
Payment for an “infusion drug administration calendar day” is only made if a beneficiary is furnished certain drugs and biologicals administered through an item of covered DME, and payable only to suppliers enrolled in Medicare as a “qualified home infusion therapy supplier.” The beneficiary must be under the care of an applicable provider, defined as a physician, nurse practitioner, or physician’s assistant, and must be under the care of a physician-established plan of care that prescribes the type, amount, and duration of infusion therapy services. A “qualified home infusion therapy supplier” is a pharmacy, physician, or other provider of services or supplier licensed by the state in which supplies or services are furnished. Qualified home infusion therapy suppliers must furnish infusion therapy to individuals with acute or chronic conditions requiring administration of home infusion drugs; ensure the safe and effective provision and administration of home infusion therapy on a 7-day-a-week, 24-hour-a-day basis; and be accredited by an organization designated by the Secretary. The supplier may subcontract with a pharmacy, physician, other qualified supplier or provider of services in order to meet these requirements.
(Rev. 11430; Issued: 05-24-22; Effective: 07-01-22; Implementation: 07-05-22)
The home infusion therapy services payment is intended to cover the professional services needed for the administration of certain home infusion drugs covered as supplies necessary for the effective use of external infusion pumps. This payment separately and explicitly pays for the services related to the administration of the drugs identified on the DME LCD for External Infusion Pumps, when such services are furnished in the individual’s home. Section 1861(iii)(3)(C) of the Act defines “home infusion drug” as a parenteral drug or biological administered intravenously, or subcutaneously for an
administration period of 15 minutes or more, in the home of an individual through a pump that is an item of durable medical equipment (as defined in section 1861(n) of the Act). Such term does not include insulin pump systems or self-administered drugs or biologicals on a self-administered drug exclusion list.
Home infusion drugs are assigned to three payment categories, as determined by the HCPCS J-code. Payment category 1 includes certain intravenous antifungals and antivirals, uninterrupted long-term infusions, pain management, inotropic, chelation drugs. Payment category 2 includes subcutaneous immunotherapy and other certain subcutaneous infusion drugs. Payment category 3 includes certain chemotherapy drugs. CMS will continue to use the G-codes, established for the temporary transitional payments in CYs 2019 and 2020, for the professional services furnished on an infusion drug administration calendar day for each payment category. CMS has established a single payment amount for each of the three categories for professional services furnished for each infusion drug administration calendar day. Each payment category will be paid at amounts in accordance with infusion codes and units for such codes under the physician fee schedule for each infusion drug administration calendar day in the individual's home for drugs assigned to such category. The payment amounts are equal to 5 hours of infusion therapy in a physician's office. Further policy information can be found in Publication 100-02, Chapter 15, Section 320.
| Category 1 | |
|---|---|
| J-Code | Description |
| J0133 | Injection, acyclovir, 5 mg |
| J0285 | Injection, amphotericin b, 50 mg |
| J0287 | Injection, amphotericin b lipid complex, 10 mg |
| J0288 | Injection, amphotericin b cholesteryl sulfate complex, 10 mg |
| J0289 | Injection, amphotericin b liposome, 10 mg |
| J0895 | Injection, deferoxamine mesylate, 500 mg |
| J1170 | Injection, hydromorphone, up to 4 mg |
| J1250 | Injection, dobutamine hydrochloride, per 250 mg |
| J1265 | Injection, dopamine hcl, 40 mg |
| J1325 | Injection, epoprostenol, 0.5 mg |
|---|---|
| J1455 | Injection, foscarnet sodium, per 1000 mg |
| J1457 | Injection, gallium nitrate, 1 mg |
| J1570 | Injection, ganciclovir sodium, 500 mg |
| J2175 | Injection, meperidine hydrochloride, per 100 mg |
| J2260 | Injection, milrinone lactate, 5 mg |
| J2270 | Injection, morphine sulfate, up to 10 mg |
| J3010 | Injection, fentanyl citrate, 0.1 mg |
| J3285 | Injection, treprostinil, 1 mg |
| Category 2 | |
| J-Code | Description |
| J1551 JB | Injection, immune globulin (cutaquig), 100mg |
| J1555 JB | Injection, immune globulin (cuvitru), 100 mg |
| J1558 JB | Injection, immune globulin (xembify), 100mg |
| J1559 JB | Injection, immune globulin (hizentra), 100mg |
| J1561 JB | Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
| J1562 JB | Injection, immune globulin (vivaglobin), 100 mg |
| J1569 JB | Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg |
| J1575 JB | Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immune globulin |
| J7799 JB | This NOC code may be used to identify the subcutaneous immune globulin (cutaquig) |
| Category 3 | |
| J-Code | Description |
| J9000 | Injection, doxorubicin hydrochloride, 10 mg |
| J9039 | Injection, blinatumomab, 1 microgram |
| J9040 | Injection, bleomycin sulfate, 15 units |
| J9065 | Injection, cladribine, per 1 mg |
| J9100 | Injection, cytarabine, 100 mg |
| J9190 | Injection, fluorouracil, 500 mg |
| J9360 | Injection, vinblastine sulfate, 1 mg |
| J9370 | Injection, vincristine sulfate, 1 mg |
It is important to note that this list is not static. The payment category may be determined by the contractor for any new home infusion drug additions to the Local Coverage Determination (LCD) for External Infusion Pumps as identified by the following not-otherwise-classified (NOC) codes:
Table 1 shows the time increments providers should report visit length in 15-minute increments (15 minutes = 1 unit). See the table below for the rounding of units:
Table 1: Time Increments
| Unit | Time |
|---|---|
| 1 | <23 minutes |
| 2 | = 23 minutes to <38 minutes |
| 3 | = 38 minutes to <53 minutes |
| 4 | = 53 minutes to <68 minutes |
| 5 | = 68 minutes to <83 minutes |
| 6 | = 83 minutes to <98 minutes |
| 7 | = 98 minutes to <113 minutes |
| 8 | = 113 minutes to <128 minutes |
| 9 | = 128 minutes to <143 minutes |
| 10 | = 143 minutes to <158 minutes |
Table 2 shows the use of the three G-codes established for the home infusion therapy benefit, and reflects the therapy type and complexity of the drug administration.
Table 2: Payment Categories for Home Infusion Therapy Professional Services (G-Codes)
| Category 1 | Category 2 | Category 3 | |
|---|---|---|---|
| Description | Intravenous anti-infective, pain management, chelation, pulmonary hypertension, inotropic, and other certain intravenous infusion drugs | Subcutaneous immunotherapy and other certain Subcutaneous infusion drugs | Chemotherapy and other certain highly complex intravenous drugs |
| G-Code | |||
| Initial Visit | G0088 | G0089 | G0090 |
| Subsequent Visit | G0068 | G0069 | G0070 |
Table 3 provides a list of J-codes associated with the home infusion drugs that fall within each category.
Table 3: Payment Categories for Home Infusion Drugs (J-Codes)
| Category 1 | |
|---|---|
| J-Code | Description |
| J0133 | Injection, acyclovir, 5 mg |
| J0285 | Injection, amphotericin b, 50 mg |
| J0287 | Injection, amphotericin b lipid complex, 10 mg |
| J0288 | Injection, amphotericin b cholesteryl sulfate complex, 10 mg |
| J0289 | Injection, amphotericin b liposome, 10 mg |
| J0895 | Injection, deferoxamine mesylate, 500 mg |
| J1170 | Injection, hydromorphone, up to 4 mg |
| J1250 | Injection, dobutamine hydrochloride, per 250 mg |
| J1265 | Injection, dopamine hcl, 40 mg |
| J1325 | Injection, epoprostenol, 0.5 mg |
| J1455 | Injection, foscarnet sodium, per 1000 mg |
|---|---|
| J1457 | Injection, gallium nitrate, 1 mg |
| J1570 | Injection, ganciclovir sodium, 500 mg |
| J2175 | Injection, meperidine hydrochloride, per 100 mg |
|---|---|
| J2260 | Injection, milrinone lactate, 5 mg |
| J2270 | Injection, morphine sulfate, up to 10 mg |
| J3010 | Injection, fentanyl citrate, 0.1 mg |
| J3285 | Injection, treprostinil, 1 mg |
| J-Code | Description |
|---|---|
| J1551 JB | Injection, immune globulin (cutaquig), 100mg |
| J1555 JB | Injection, immune globulin (cuvitru), 100 mg |
| J1558 JB | Injection, immune globulin (xembify), 100mg |
| J1559 JB | Injection, immune globulin (hizentra), 100mg |
| J1561 JB | Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
| J1562 JB | Injection, immune globulin (vivaglobin), 100 mg |
| J1569 JB | Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg |
| J1575 JB | Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immune globulin |
| J7799 JB | This NOC code may be used to identify the subcutaneous immune globulin (cutaquig) |
| J-Code | Description |
|---|---|
| J9000 | Injection, doxorubicin hydrochloride, 10 mg |
| J9039 | Injection, blinatumomab, 1 microgram |
| J9040 | Injection, bleomycin sulfate, 15 units |
| J9065 | Injection, cladribine, per 1 mg |
| J9100 | Injection, cytarabine, 100 mg |
| J9190 | Injection, fluorouracil, 500 mg |
| J9360 | Injection, vinblastine sulfate, 1 mg |
| J9370 | Injection, vincristine sulfate, 1 mg |
The payment category may be determined by the contractor for any new home infusion drug additionsto the Local Coverage Determination (LCD) for External Infusion Pumps as identified by the following not- otherwise-classified (NOC) codes:
(Rev. 10269, Issued: 08-07-2020, Effective: 01-01-2021, Implementation: 01-04-2021)
Contractors shall accept and pay for home infusion therapy services to eligible home infusion therapy suppliers (new specialty D6) effective for claim lines with dates of service on or after January 1, 2021 using the one of the following 'G' codes and applicable 'J' codes listed in section 411.3 of this chapter. Claims for the home infusion therapy service G-codes are billed to the A/B MACs and are payable to home infusion therapy suppliers; this service is no longer payable to DME suppliers. The applicable 'J' codes are billed to the DME MACs by the DME supplier.
Contractors shall use Type of Service (TOS) Code 1 for all six G-codes. Contractors shall pay only one of the G-codes per line item date of service when one of the drugs from the applicable category is billed with the same line item date of service or a date of service within 30 days prior to the G-code visit.
Home infusion therapy suppliers will report the following HCPCS G-codes associated with the payment categories for the professional services furnished in the individual’s home and on an infusion drug administration calendar day.
Because the home infusion therapy services are contingent upon a home infusion drug J-code, home infusion therapy suppliers must ensure that the appropriate drug associated with the visit is billed no more than 30 days prior to the visit. In the event that multiple visits occur on the same date of service, or multiple drugs, which are not all assigned to the same payment category, are administered on the same infusion drug administration calendar day, a single payment would be made that is equal to the highest payment category. Suppliers must only bill for one visit and should report the highest paying visit with the applicable drug.
To differentiate the first visit from all subsequent visits, home infusion therapy suppliers may only bill one of the “initial visit” G-codes to indicate an visit for a new patient who had previously received their last home infusion therapy service visit more than 60 days prior to the new initial home infusion therapy service visit.
Home infusion therapy suppliers should report visit length in 15-minute increments (15 minutes=1 unit). See the Table 1 below for the rounding of units.
Table 1: Time Increments
| Unit | Time |
|---|---|
| 1 | <23 minutes |
| 2 | = 23 minutes to <38 minutes |
| 3 | = 38 minutes to <53 minutes |
| 4 | = 53 minutes to <68 minutes |
| 5 | = 68 minutes to <83 minutes |
| 6 | = 83 minutes to <98 minutes |
| 7 | = 98 minutes to <113 minutes |
| 8 | = 113 minutes to <128 minutes |
| 9 | = 128 minutes to <143 minutes |
| 10 | = 143 minutes to <158 minutes |
Table 2 shows the use of the G-codes established for the home infusion therapy benefit, and reflects the therapy type and complexity of the drug administration.
Table 2: Payment Categories for Home Infusion Therapy Professional Services (G-Codes)
| Category 1 | Category 2 | Category 3 | |
|---|---|---|---|
| Description | Intravenous anti-infective, pain management, chelation, pulmonary hypertension, inotropic, and other certain intravenous infusion drugs | Subcutaneous immunotherapy and other certain Subcutaneous infusion drugs | Chemotherapy and other certain highly complex intravenous drugs |
| G-Code | |||
| Initial Visit | G0088 | G0089 | G0090 |
| Subsequent Visit | G0068 | G0069 | G0070 |
Short Descriptor: Adm IV infusion drug in home
Short Descriptor: Adm SQ infusion drug in home
Short Descriptor: Adm of IV chemo drug in home
Short Descriptor: Adm IV drug 1st home visit
Short Descriptor: Adm SubQ drug 1st home visit
Short Descriptor: Adm IV chemo 1st home visit
(Rev. 10269, Issued: 08-07-2020, Effective: 01-01-2021, Implementation: 01-04-2021)
Contractors shall deny the CWF rejected claim if a new G-code is received for the same date of service as a previous claim was paid for the same line item date of service.
NOTE: The provider should submit an adjustment to the original claim to receive the higher payment.
Contractors shall use the following CARC/RARC codes when denying claims:
CARC 97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N111 - No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
Claim Adjustment Group Code - CO (Contractual Obligation)
MSN message: 41.14: This service/item was billed incorrectly. 41.14- Este servicio o artículo fue facturado incorrectamente.
Contractors shall deny the CWF rejected G-code line when the claim has recycled three times without finding the associated drug J-code claim and use the following messages:
CARC 16 - Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be
comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N657 - This should be billed with the appropriate code for these services. Claim Adjustment Group Code - CO (Contractual Obligation)
MSN message: 41.14: This service/item was billed incorrectly. 41.14- Este servicio o artículo fue facturado incorrectamente.
Contractors shall deny CWF rejected claims for more than one claim line service of G0088, G0089, or G0090 within a 60 day period and use the following messages:
CARC 96 - Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N640 - Exceeds number/frequency approved/allowed within time period.
Group Code - CO (Contractual Obligation)
(Rev. 10269, Issued: 08-07-2020, Effective: 01-01-2021, Implementation: 01-04-2021)
MCS shall create a new edit to identify when there is more than one of the following six HCPCS 'G0068', 'G0069', 'G0070', 'G0088', 'G0089', or 'G0090' with Date of Service on or after 1/1/2021 for the same Date of Service on the same Part B Professional claim.
CWF shall create a new reject for a Part B Professional claim with one of the following six HCPCS codes 'G0068', 'G0069', 'G0070', 'G0088', 'G0089', or 'G0090' with Date of Service on or after 1/1/2021 and there is no DME claim in history with one of the identified J-codes within 30 days prior to the incoming Date of Service.
NOTE: This edit shall have override capability at the claim detail line
CWF and contractors shall recycle 'G0068', 'G0069', 'G0070', 'G0088', 'G0089', or 'G0090' claim up to three times for a total of 15 days until a claim containing an allowable drug J-code from above is received with the same line item date of service or within 30 days prior to the line item date of service of the G-code.
CWF shall create a new reject for a Part B Professional claim with one of the following six 'G0068', 'G0069', 'G0070', 'G0088', 'G0089', or 'G0090' codes with a Date of Service on or after 1/1/2021 when there is a Part B claim in history with one of the identified six 'G0068', 'G0069', 'G0070', 'G0088', 'G0089', or 'G0090' codes for the same Date of Service.
NOTE: This edit shall have override capability at the claim detail line
CWF shall create a new reject for a Part B Professional claim with one of the new 'G0088', 'G0089', or 'G0090' codes and in history is an allowed DME or Part B Professional claim with any of the six 'G0068',
‘G0069’ ‘G0070’, ‘G0088’, ‘G0089’, or ‘G0090’ codes and the Dates of Service is within 60 days prior to the incoming claim’s Dates of Service. The incoming claim has Dates of Service on or after 1/1/2021.
CWF should still subject an incoming Part B Professional claim to the edit if it is within 60 days of posted DME claim, and if the claim in history is DME and has one of the three existing ‘G0068’, ‘G0069’ ‘G0070’ codes and has Dates of Service prior to 1/1/2021.
CWF shall create a new Informational Unsolicited Response (IUR) when a Part B Professional claim or a DME claim with one of the six ‘G0068’, ‘G0069’ ‘G0070’, ‘G0088’, ‘G0089’, or ‘G0090’ codes is received and in history is a Part B Professional claim with one of the three new ‘G0088’, ‘G0089’, or ‘G0090’ codes with Dates of Service within 60 days after the incoming claim’s Dates of Service.
CWF shall ensure that all new edits and the IUR appear on the ORPN Report.
(Rev. 12649; Issued: 05-23-2024; Effective: 04-07-22) Implementation: 06-24-24)
Effective April 7, 2022, CMS covers Food and Drug Administration (FDA)-approved monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s Disease (AD) when furnished in accordance with the coverage criteria below, under coverage with evidence development (CED) for patients who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed presence of amyloid beta pathology consistent with AD. For further information related to coverage, refer to Publication 100-03, National Coverage Determination (NCD) Section 200.3
(Rev. 12649; Issued: 05-23-2024; Effective: 04-07-22) Implementation: 06-24-24)
(Rev. 12649; Issued: 05-23-2024; Effective: 04-07-22) Implementation: 06-24-24)
Effective for claims with dates of service on or after April 7, 2022, contractors shall accept and pay for claims for monoclonal antibodies for the treatment of AD with an appropriate HCPCS, along with one of the diagnosis codes listed in Section 412.1 and condition code 30 (institutional claims only).
The following bill types are applicable for claims for monoclonal antibodies for the treatment of AD:
(Rev. 12649; Issued: 05-23-2024; Effective: 04-07-22) Implementation: 06-24-24)
--Contractors shall return to provider/return as unprocessable any monoclonal antibody claims that do not include an NCT number as indicated in 412.1 and use the following messages:
CARC 16 - Claim/service lacks information or has submission/billing error(s).
RARC MA50 – Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number
Group Code: CO
---Contractors shall deny any monoclonal antibody claims that do not have the specified diagnosis codes listed in 412.1 and use the following messages:
MSN 15.20 - “The following polices were used when we made this decision: NCD 200.3.”
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 200.3.”
NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.
CARC 96 – Non-covered charge(s). At least one Remark Code must be provided (May be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
RARC N386 – This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.
Group Code - CO or PR
---Contractors shall return to provider/return as unprocessable any monoclonal antibody claims that do not have the specified modifiers listed in Section 412.1 and use the following messages:
CARC 16 - Claim/service lacks information or has submission/billing error(s).
RARC N823 – Incomplete/invalid Procedure Modifier(s).
Group Code: CO
--Contractors shall deny claims from any bill type other than those listed 412.1 and use the following messages:
MSN 9.4 - This item or service was denied because information required to make payment was incorrect.
Spanish Version: Este servicio fue denegado debido a que la información requerida para hacer el pago fue incorrecta.
CARC 16 - Claim/service lacks information or has submission/billing error(s).
RARC MA30 - Missing/incomplete/invalid type of bill.
Group Code: CO
(Rev. 13611; Issued: 01-30-26; Effective: 06-09-25; Implementation: 10-22-25)
Respiratory Assist Devices (RADs) with bi-level capability, with or without a backup rate feature, are devices that use a non-invasive interface (mask) to deliver a higher level of airway pressure when the patient inhales than when the patient exhales. A backup rate feature enables the device to provide a prespecified respiratory rate if the patient’s spontaneous respiratory rate decreases below a set number.
A home mechanical ventilator (HMV) delivers a predetermined amount of air with each breath and typically has more monitoring, safety, alarm and backup power features (batteries) than a RAD.
(Rev. 13611; Issued: 01-30-26; Effective: 06-09-25; Implementation: 10-22-25)
Effective for services performed on or after June 9, 2025, the Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover RADs, with or without a backup rate feature and HMVs, in the home, to deliver high intensity noninvasive ventilation (NIV) as treatment for patients with chronic respiratory failure (CRF) consequent to chronic obstructive pulmonary disease (COPD) as long as certain patient criteria is met.
Note: This CR does not contain coding and billing instructions for masks.
Please refer to the National Coverage Determinations Manual (Publication, 100-03, Section 240.9 for coverage criteria, frequency, and more information.
(Rev. 13611; Issued: 01-30-26; Effective: 06-09-25; Implementation: 10-22-25)
Effective for claims with dates of service on and after June 9, 2025, contractors shall pay claims for RADs with or without a backup rate feature and HMVs, in the home, as treatment for patients with CRF consequent to COPD under the conditions and coverage criteria outlined in Pub. 100-03, Medicare NCD Manual, Chapter 1, Section 240.9.
Contractors shall allow NIPPV claims submitted with HCPCS code E0470 or E0471 with KX modifier.
NOTE: All national ICD-10 diagnosis codes shall be managed locally by the MACs.
Contractors shall allow NIPPV claims submitted with HCPCS code E0466, E0467, or E0468.
For the multifunction ventilators (E0467 and E0468), a beneficiary would need to meet the ventilator criteria plus the criteria for one of the other functions for coverage.
NOTE: All national ICD-10 diagnosis codes shall be managed locally by the MACs.
Patients must be evaluated at least twice within the first year after initially receiving a RAD or HMV. Evaluations must occur by the end of the six-month initial coverage period and again during months 7-12.
(Rev. 13800; Issued:05-28-26; Effective: 03-19-25; Implementation: 01-05-26)
The Centers for Medicare & Medicaid Services (CMS) covers transcatheter tricuspid valve replacement (TTVR) for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) according to the criteria outlined in IOM, Pub. 100-03, National Coverage Determination Manual, Ch 1, section 20.37.
(Rev. 13800; Issued:05-28-26; Effective: 03-19-25; Implementation: 01-05-26)
The following codes are applicable for TTVR:
ICD-10-PCS codes X2RJ3RA - Replacement of Tricuspid Valve with Multi-plane Flex Technology Bioprosthetic Valve, Percutaneous Approach, New Technology Group 10 and 02RJ38Z – Replace tricuspid valve with zooplastic tissue, percutaneous approach CPT code 0646T - Transcatheter tricuspid valve implantation (TTVI)/replacement with a prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed ICD-10 diagnosis codes:
I07.2 I08.1 I08.2 I08.3 136.1 136.2 Q22.8 Z00.6
(Rev. 13800; Issued:05-28-26; Effective: 03-19-25; Implementation: 01-05-26)
Professional claims for TTVR in a clinical research study shall be covered when billed with:
HCPCS code 0646T, - ICD-10 Z00.6 (as other diagnosis code), the 8-digit clinical trial identifier number, One of the ICD-10 diagnosis codes listed in section 414.1 as principal diagnosis code - Modifier Q0,
(Rev. 13800; Issued:05-28-26; Effective: 03-19-25; Implementation: 01-05-26)
Inpatient hospitals shall bill for TTVR on an 11X Type of Bill (TOB).
Inpatient hospital claims for TTVR shall be covered when billed with:
NOTE: When submitting claims for TTVR provided to Medicare Advantage enrollees, hospitals also report condition code 04. Medicare Advantage Organizations are responsible for payment of the service, consistent with Pub. 100-16, chapter 4, section 10.7.3.
(Rev. 13800; Issued:05-28-26; Effective: 03-19-25; Implementation: 01-05-26)
Claim Adjustment Reason Code (CARC) 167: This (these) diagnosis(es) is (are) not covered.
Remittance Advice Remark Code (RARC) N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code (GC) – CO (Contractual Obligation) or PR (Patient Responsibility) dependent upon liability. Use PR when:
Medicare Summary Notice (MSN) 15.20: The following policies were used when we made this decision: NCD 20.37.
Spanish Version – Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 20.37.
Contractors shall Return to Provider (RTP) claims for TTVR submitted on TOB other than 11X, or when submitted without condition code 30, or submitted without value code D4 and the 8-digit National Clinical Trial (NCT).
Contractors shall return as unprocessable line-items on claims containing HCPCS code 0646T in a clinical research study when billed without modifier Q0 using the following messages:
CARC 4: The procedure code is inconsistent with the modifier used.
RARC N519: Invalid combination of HCPCS modifiers.
Group Code: CO
Contractors shall return as unprocessable line-items of claims containing HCPCS code 0646T in a clinical research study when billed without the clinical trial number using the following messages:
CARC 16: Claim/service lacks information or has submission/billing error(s).
RARC MA50: Missing/incomplete Investigational Device Exemption number or clinical trial number.
Group Code: CO
(Rev. 13801; Issued: 05-28-26; Effective: 07-02-25; Implementation: 01-05-26)
The Centers for Medicare & Medicaid Services (CMS) covers T-TEER for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) according to the criteria outlined in IOM, Pub. 100-03, National Coverage Determination Manual, Ch 1, section 20.38.
(Rev. 13801; Issued: 05-28-26; Effective: 07-02-25; Implementation: 01-05-26)
The following codes are applicable for T-TEER:
ICD-10-PCS codes 02UJ3JZ (Supplement tricuspid valve with Synthetic Substitute, Percutaneous approach)
Healthcare Common Procedure Coding System (HCPCS) code 0569T (Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis) or 0570T (Each additional prosthesis during same session (List separately in addition to code for primary procedure)) ICD-10 diagnosis codes:
Z00.6 (reported as other diagnosis)
(Rev. 13801; Issued: 05-28-26; Effective: 07-02-25; Implementation: 01-05-26)
Professional claims for T-TEER in a clinical research study shall be covered when billed with:
(Rev. 13801; Issued: 05-28-26; Effective: 07-02-25; Implementation: 01-05-26)
Inpatient hospitals shall bill for T-TEER on an 11X Type of Bill (TOB).
Inpatient hospital claims for T-TEER shall be covered when billed with:
NOTE: When submitting claims for T-TEER provided to Medicare Advantage enrollees, hospitals also report condition code 04. Medicare Advantage Organizations are responsible for payment of the service, consistent with Pub. 100-16, chapter 4, section 10.7.3.
(Rev. 13801; Issued: 05-28-26; Effective: 07-02-25; Implementation: 01-05-26)
Contractors shall use the following messages when denying claims for T-TEER submitted with missing/incorrect ICD-10 diagnosis code (I07.1, I07.2, I08.1, I08.2, I08.3, I36.1 I36.2, Q22.8 and Z00.6): CARC 167 – This (these) diagnosis(es) is (are) not covered.
RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at: www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code – CO (Contractual Obligation) or PR (Patient Responsibility) dependent upon liability. Use PR when:
MSN 15.20: “The following policies were used when we made this decision: NCD 20.38”.
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 20.37”.
Contractors shall Return to Provider (RTP) claims for T-TEER submitted on TOB other than 11X, or when submitted without condition code 30, or submitted without value code D4 and the 8-digit National Clinical Trial (NCT).
Contractors shall return as unprocessable line-items on claims containing HCPCS 0569T or 0570T code in a clinical research study when billed without modifier Q0 using the following messages:
CARC 4: The procedure code is inconsistent with the modifier used.
RARC N519: Invalid combination of HCPCS modifiers.
Group Code: CO (Contractual Obligation)
Contractors shall return as unprocessable line-items of claims containing HCPCS code 0569T or 0570T in a clinical research study when billed without the clinical trial number using the following messages:
CARC 16: Claim/service lacks information or has submission/billing error(s).
RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or clinical trial number.
Group Code: CO (Contractual Obligation)
(Rev. 13808; Issued:05-29-26; Effective: 06-09-25; Implementation: 10-22-25)
Respiratory Assist Devices (RADs) with bi-level capability, with or without a backup rate feature, are devices that use a non-invasive interface (mask) to deliver a higher level of airway pressure when the patient inhales than when the patient exhales. A backup rate feature enables the device to provide a prespecified respiratory rate if the patient’s spontaneous respiratory rate decreases below a set number.
A home mechanical ventilator (HMV) delivers a predetermined amount of air with each breath and typically has more monitoring, safety, alarm and backup power features (batteries) than a RAD.
(Rev. 13808; Issued:05-29-26; Effective: 06-09-25; Implementation: 10-22-25)
Effective for services performed on or after June 9, 2025, the Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover RADs, with or without a backup rate feature and HMVs, in the home, to deliver noninvasive ventilation (NIV) as treatment for patients with chronic respiratory failure (CRF) consequent to chronic obstructive pulmonary disease (COPD) as long as certain patient criteria is met.
Note: This CR does not contain coding and billing instructions for masks.
Please refer to the National Coverage Determinations Manual (Publication, 100-03, Section 240.9 for coverage criteria, frequency, and more information.
(Rev. 13808; Issued:05-29-26; Effective: 06-09-25; Implementation: 10-22-25)
Effective for claims with dates of service on and after June 9, 2025, contractors shall pay claims for RADs with or without a backup rate feature and HMVs, in the home, as treatment for patients with CRF consequent to COPD under the conditions and coverage criteria outlined in Pub. 100-03, Medicare NCD Manual, Chapter 1, Section 240.9.
Contractors shall allow NIPPV claims submitted with HCPCS code E0470 or E0471 with KX modifier.
NOTE: All national ICD-10 diagnosis codes shall be managed locally by the MACs.
Contractors shall allow NIPPV claims submitted with HCPCS code E0466, E0467, or E0468.
For the multifunction ventilators (E0467 and E0468), a beneficiary would need to meet the ventilator criteria plus the criteria for one of the other functions for coverage.
NOTE: All national ICD-10 diagnosis codes shall be managed locally by the MACs.
Patients must be evaluated at least twice within the first year after initially receiving a RAD or HMV. Evaluations must occur by the end of the six-month initial coverage period and again during months 7-12.
(Rev. 13802; Issued: 05-28-26; Effective: 10-28-25; Implementation: 04-06-26)
Effective for claims with dates of service on or after October 28, 2025, the Centers for Medicare & Medicaid Services (CMS) covers radiofrequency renal denervation (rfRDN) and ultrasound renal denervation (uRDN) (collectively, RDN) for uncontrolled hypertension under Coverage with Evidence Development (CED). Refer to the criteria outlined in Publication 100-03, Chapter 1, section 20.40.
(Rev. 13802; Issued: 05-28-26; Effective: 10-28-25; Implementation: 04-06-26)
International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) codes:
Note: Recor Medical’s Paradise® Ultrasound Renal Denervation
Note: Medtronic's Symplicity Spyral™ Renal Denervation System, and
ICD-10-CM diagnosis is one of the following:
ICD-10-CM classifies hypertension by type as essential or primary (categories I10-I13), secondary (category I15), hypertensive crisis (category I16), and resistant (category I1A).
ICD-10-CM does not distinguish between controlled vs. uncontrolled hypertension.
0338T :Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral
0339T :Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral
0935T :Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral
C1735:Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components
Note: Device code for Medtronic's Symplicity Spyral™ Renal Denervation System
C1736:Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components
Note: Device code for Recor Medical's Paradise® Ultrasound Renal Denervation
Contractors shall Return to Provider (RTP) RDN claims when TOB is not equal to 11X or 13X.
Contractors shall allow claims with place of service (POS) = 19, 21, 22, or 24. Claims with any other POS shall be returned as unprocessable.
Contractors shall return as unprocessable claims for RDN services when services were billed in other than Place of Service (POS) 19, 21, 22 or 24 and use the following messages:
CARC 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Remittance Advice Remark Code (RARC) N386: 'This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service
is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code: CO
Contractors shall deny RDN claims not submitted with the following ICD-10-CM DX as a diagnosis listed in Section 415.1 and use the following messages:
Claim Adjustment Reason Code (CARC) 167: “This (these) diagnosis(es) is (are) not covered”.
Remittance Advice Remark Code (RARC) N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code – CO (Contractual Obligation) or PR (Patient Responsibility) dependent upon liability.
Use PR when:
Medicare Summary Notice (MSN) 15.20: “The following policies were used when we made this decision: NCD 20.40”.
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 20.40
Contractors shall return as unprocessable line-items on claims in a clinical research study when billed without the clinical trial number using the following messages:
CARC 16: Claim/service lacks information or has submission/billing error(s).
RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or clinical trial number.
Group Code: CO
Contractors shall return as unprocessable line-items on claims containing one of the CPT or HCPCS codes mentioned in Section 415.1 when billed without modifier Q0 using the following messages:
CARC 4: The procedure code is inconsistent with the modifier used.
RARC N519: Invalid combination of HCPCS modifiers.
Group Code:CO
Contractors shall deny RDN claims not submitted with the following ICD-10-CM DX as diagnosis
I15.2
I15.8
Z00.6 (reported as other diagnosis)
Contractors shall use the following messages when denying claims:
Claim Adjustment Reason Code (CARC) 167: “This (these) diagnosis(es) is (are) not covered”.
Remittance Advice Remark Code (RARC) N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code – CO (Contractual Obligation) or PR (Patient Responsibility) dependent upon liability.
Use PR when:
Medicare Summary Notice (MSN) 15.20: “The following policies were used when we made this decision: NCD 20.40”.
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 20.40
(Rev. 13806, Issued: 05-28-26, Effective: 10-28- 25, Implementation: 04- 06-26)
Effective October 28, 2025, the Centers for Medicare & Medicaid Services (CMS) covers CCM used for the treatment of HF under Coverage with Evidence Development (CED) according to the criteria outlined in NCD manual, chapter 1, section 20.39. Consistent with section 1142 of the Act, AHRQ supports clinical research studies that CMS determines meet all the criteria and standards identified above.
CCM used for the treatment of HF is not covered for patients outside of a CMS-approved study.
(Rev. 13806, Issued: 05-28-26, Effective: 10-28- 25, Implementation: 04- 06-26)
The following CPT codes are applicable for CCM:
0408T - Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes
0409T- Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only
0410T- Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only
0411T- Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only
0412T-Removal of permanent cardiac contractility modulation system; pulse generator only
0413T- Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)
0414T- Removal and replacement of permanent cardiac contractility modulation system pulse generator only
0415T- Repositioning of previously implanted cardiac contractility modulation transvenous electrode (atrial or ventricular lead)
0416T- Relocation of skin pocket for implanted cardiac contractility modulation pulse generator
0417T- Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system
0418T- Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system
0JH60AZ- Insertion of Contractility Modulation Device into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH63AZ- Insertion of Contractility Modulation Device into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH80AZ- Insertion of Contractility Modulation Device into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH83AZ- Insertion of Contractility Modulation Device into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
02H63MZ- Insertion of cardiac lead into right atrium, percutaneous approach (when specified as a lead for a contractility modulation device)
02HK3MZ- Insertion of cardiac lead into right ventricle, percutaneous approach (when specified as a lead for a contractility modulation device)
C1824- Generator, cardiac contractility modulation (implantable)
C1898- Lead, pacemaker, other than transvenous VDD single pass
NOTE: HCPCS codes C 1824 and C1898 are not separately paid, as the payment is packaged and considered part of the eligible comprehensive procedure.
K1030- External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only. Contractors shall establish local fee schedule amounts to pay claims for HCPCS K1030, when applicable.
I50.1- Left ventricular failure, unspecified
I50.20- Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.21- Acute systolic (congestive) heart failure
I50.22- Chronic systolic (congestive) heart failure
I50.23- Acute on chronic systolic (congestive) heart failure
I50.30- Unspecified diastolic (congestive) heart failure
I50.31- Acute diastolic (congestive) heart failure
I50.32- Chronic diastolic (congestive) heart failure
I50.33- Acute on chronic diastolic (congestive) heart failure
I50.40- Unspecified combined systolic (congestive and diastolic (congestive) heart failure
I50.41- Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42- Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43- Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810- Right heart failure, unspecified
I50.811- Acute right heart failure
I50.812- Chronic right heart failure
I50.813- Acute on chronic right heart failure
I50.814- Right heart failure due to left heart failure
I50.82- Biventricular heart failure
I50.83- High output heart failure
I50.84- End stage heart failure
I50.89- Other heart failure
I50.9- Heart failure, unspecified
Z00.6- encounter for examination for normal comparison and control in a clinical research program (reported as other diagnosis)
(Rev. 13806, Issued: 05-28-26, Effective: 10-28- 25, Implementation: 04- 06-26)
Professional claims for CCM in a clinical research study shall be covered when billed with:
(Rev. 13806, Issued: 05-28-26, Effective: 10-28- 25, Implementation: 04- 06-26)
Institutional claims for CCM in a clinical research study shall be covered when billed with:
OR
(Rev. 13806, Issued: 05-28-26, Effective: 10-28- 25, Implementation: 04- 06-26)
Contractors shall use the following messages when denying CCM claims submitted with missing/incorrect ICD-10 diagnosis code:
Claim Adjustment Reason Code (CARC) 167: “This (these) diagnosis(es) is (are) not covered”.
Remittance Advice Remark Code (RARC) N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code – CO (Contractual Obligation) or PR (Patient Responsibility) dependent upon liability.
Use PR when:
Medicare Summary Notice (MSN) 15.20: “The following policies were used when we made this decision: NCD 20.39”.
Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 20.39.
Contractors shall return as unprocessable line-items on CCM claims in a clinical research study when billed without the clinical trial number using the following messages:
CARC 16: Claim/service lacks information or has submission/billing error(s).
RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or clinical trial number.
Group Code: CO
Contractors shall return as unprocessable line-items on CCM claims containing one of the CPT or HCPCS codes mentioned in Section 415.1 when billed without modifier Q0 using the following messages:
CARC 4: The procedure code is inconsistent with the modifier used.
RARC N519: Invalid combination of HCPCS modifiers.
Group Code: CO
Contractors shall return as unprocessable claims for CCM services when services were billed in other than Place of Service (POS) 11, 19, 21, 22, 24, 26, 71, or 72 and use the following messages:
CARC 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Remittance Advice Remark Code (RARC) N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Group Code: CO
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R13808CP | 05/29/2026 | Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD) | 10/22/2025 | 14177 |
| R13806CP | 05/28/2026 | Cardiac Contractility Modulation (CCM) for Heart Failure (HF) | 04/06/2026 | 14311 |
| R13802CP | 05/28/2026 | NCD 20.40- Renal Denervation (RDN) for Uncontrolled Hypertension | 04/06/2026 | 14302 |
| R13801CP | 05/28/2026 | NCD 20.38 - Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER) | 01/05/2026 | 14200 |
| R13800CP | 05/28/2026 | NCD 20.37 - Transcatheter Tricuspid Valve Replacement (TTVR) | 01/05/2026 | 14149 |
| R13756CP | 05/29/2026 | Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD)- Rescinded and replaced by transmittal 13808 | 10/22/2025 | 14177 |
| R13716CP | 04/03/2026 | Cardiac Contractility Modulation (CCM) for Heart Failure (HF)- Rescinded and replaced by transmittal 13806 | 04/06/2026 | 14311 |
| R13709CP | 04/02/2026 | Update to the Internet Only Manual (IOM) Publication 100-04, Chapter 18, Section 170.1 and Chapter 32, sections 330.1 and 330.2 for Updates in Change Request (CR) 14356 - International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)- July 2026 | 06/02/2026 | 14430 |
| R13695CP | 03/09/2026 | NCD 20.40- Renal Denervation (RDN) for Uncontrolled Hypertension- Rescinded and replaced by transmittal 13802 | 04/06/2026 | 14302 |
| R13672CP | 03/09/2026 | Cardiac Contractility Modulation (CCM) for Heart Failure (HF) Rescinded and replaced by transmittal 13716 | 04/06/2026 | 14311 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R13640CP | 02/13/2026 | NCD 20.40- Renal Denervation (RDN) for Uncontrolled Hypertension- Rescinded and replaced by transmittal 13695 | 04/06/2026 | 14302 |
| R13612CP | 01/30/2026 | NCD 20.40- Renal Denervation (RDN) for Uncontrolled Hypertension- Rescinded and replaced by transmittal 13640 | 04/06/2026 | 14302 |
| R13611CP | 1/30/2026 | Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD) | 10/22/2025 | 14177 |
| R13608CP | 01/26/2026 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Sections 150.4, 150.6, 200.2, 300.2, 400.2, 400.2.2, 400.2.3, 400.2.3.1, 400.2.4, and 400.3 for Coding Revisions to National Coverage Determinations (NCDs) - July 2025 Change Request (CR) 13939 | 08/25/2025 | 14108 |
| R13538CP | 12/19/2025 | Cardiac Contractility Modulation (CCM) for Heart Failure (HF) Rescinded and replaced by transmittal 13672 | 04/06/2026 | 14311 |
| R13551CP | 12/19/2025 | Updates to the Internet Only Manual (IOM) Publication 100-04, Chapter 32, Sections 69.1, 69.6 and 69.9 to Clarify Requirements for Clinical Trial Services | 01/21/2026 | 14268 |
| R13549CP | 12/18/2025 | Update to the Internet Only Manual (IOM) Publication 100-04, Chapter 18, Sections 150.1, 150.2.1, 150.3 and Chapter 32, Sections 12.1, 12.3, 320.3.3, 400.2.2, 400.2.3 and 400.2.3.1 for Coding Revisions to National Coverage Determinations (NCDs) - October 2025 Change Request (CR) 14041 | 01/20/2026 | 14267 |
| R13427CP | 09/22/2025 | NCD 20.37 - Transcatheter Tricuspid Valve Replacement (TTVR)- Rescinded and replaced by transmittal 13800 | 01/05/2026 | 14149 |
| R13374CP | 08/21/2025 | Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD)- Rescinded and replaced by transmittal 13611 | 10/22/2025 | 14177 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R13366CP | 08/14/2025 | NCD 20.38 - Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)- Rescinded and replaced by transmittal 13801 | 01/05/2026 | 14200 |
| R13343CP | 07/30/2025 | NCD 20.37 - Transcatheter Tricuspid Valve Replacement (TTVR)- Rescinded and replaced by transmittal 13427 | 01/05/2026 | 14149 |
| R13317CP | 07/24/2025 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Sections 150.4, 150.6, 200.2, 300.2, 400.2, 400.2.2, 400.2.3, 400.2.3.1, 400.2.4, and 400.3 for Coding Revisions to National Coverage Determinations (NCDs) - July 2025 Change Request (CR) 13939-- Rescinded and replaced by transmittal 13608 | 08/25/2025 | 14108 |
| R13304CP | 07/15/2025 | Technical Revisions Only to the Claims Processing Manual (CPM), Publication (Pub) 100-04, Chapter 18 and Chapter 32 | 06/23/2025 | 14070 |
| R13282CP | 06/20/2025 | National Coverage Determination (NCD) 20.36 Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management | 10/06/2025 | 14000 |
| R13246CP | 05/22/2025 | National Coverage Determination (NCD) 20.36 Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management- Rescinded and replaced by transmittal 13282 | 10/06/2025 | 14000 |
| R13243CP | 05/22/2025 | Technical Revisions Only to the Claims Processing Manual (CPM), Publication (Pub) 100-04, Chapter 18 and Chapter 32- | 06/23/2025 | 14070 |
| R12883CP | 10/11/2024 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 18 Section 170.1 and Chapter 32 Section 340.2 for Coding Revisions to the National Coverage Determinations (NCDs) - January 2025 Change Request (CR) 13706 | 01/16/2025 | 13804 |
| R12822CP | 09/05/2024 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 18 Section 170.1 and Chapter 32 Section 190.2 for Coding Revisions to the National Coverage Determinations (NCDs)--April | 11/07/2024 | 13738 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| 2024 Change Request (CR) 13390 | ||||
| R12683CP | 06/13/2024 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 150.3 for Coding Revisions to the National Coverage Determinations (NCDs)--October 2024 Change Request (CR)13596 | 07/15/2024 | 13622 |
| R12649CP | 05/23/2024 | National Coverage Determination (NCD) 200.3 - Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) | 06/24/2024 | 13598 |
| R12571CP | 04/11/2024 | National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting | 05/13/2024 | 13512 |
| R12533CP | 03/07/2024 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 90 for Coding Revisions to the National Coverage Determinations (NCDs)--July 2024 Change Request (CR) 13507. | 04/08/2024 | 13545 |
| R12497CP | 02/08/2024 | Pulmonary Rehabilitation, Cardiac Rehabilitation and Intensive Cardiac Rehabilitation (PR/CR/ICR) Expansion of Supervising Practitioners | 03/12/2024 | 13513 |
| R12435CP | 12/28/2023 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 18, Sections 20.2, 60.3 and Chapter 32, Sections 50.4.1, 200.2 for Coding Revisions to the National Coverage Determinations (NCDs)--April 2024 Change Request (CR) 13391 | 01/29/2024 | 12435 |
| R12396CP | 12/07/2023 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32 Sections 320.3.3 and 370.1 for Coding Revisions to the National Coverage Determinations (NCDs)--April 2024 Change Request (CR) 13390 | 01/09/2024 | 13438 |
| R12109CP | 06/29/2023 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32 Sections 130.1, for International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)- | 10/02/2023 | 13227 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| -October 2023 Update Change Request (CR) 13166 | ||||
| R11902CP | 03/16/2023 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 18 Sections 50.3-50.4, and Chapter 32 Sections 130.1, 170.2 for Coding Revisions to National Coverage Determinations (NCDs)--July 2023 Change Request (CR) 13070 | 04/17/2023 | 13104 |
| R11875CP | 02/23/2023 | National Coverage Determination (NCD) 50.3 - Cochlear Implantation Manual Update | 03/24/2023 | 13073 |
| R11789CP | 01/19/2023 | Update to the Internet Only Manual (IOM) For Alpha-Numerical Order in Publication (Pub.) 100-04, Chapter 32, Index, Sections 40.2.1 and 40.2.4 | 02/21/2023 | 13025 |
| R11759CP | 12/21/2022 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 18 Section 170.1 and Chapter 32 Section 270.2 due to the National Coverage Determinations (NCDs) April 2023 Change Request (CR) 12960 | 01/23/2023 | 12993 |
| R11721CP | 11/28/2022 | National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy | 01/03/2023 | 12928 |
| R11430CP | 05/24/2022 | Update to 'J' Drug Code List for Billing Home Infusion Therapy (HIT) Services | 07/05/2022 | 12667 |
| R11426CP | 05/20/2022 | An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage- Rescinded and replaced by transmittal 11426 | 07/05/2022 | 12613 |
| R11272CP | 02/18/2022 | An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) | 07/05/2022 | 12613 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage | ||||
| R11214CP | 01/20/2022 | National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds | 01/03/2022 | 12403 |
| R11171CP | 01/12/2022 | National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds Rescinded and replaced by transmittal 11214 | 01/03/2022 | 12403 |
| R11119CP | 11/13/2021 | National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds Rescinded and replaced by transmittal 11171 | 01/03/2022 | 12403 |
| R11035CP | 10/13/2021 | Revisions to Chapters 3, 18, and 32 to Update Coding | 10/13/2021 | 12377 |
| R11021CP | 10/01/2021 | Revisions To Chapters 13, 18 And 32 To Update Coding | 10/29/2021 | 12376 |
| R10981CP | 09/10/2021 | National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds - Rescinded and replaced by transmittal 11119 | 01/03/2022 | 12403 |
| R10985CP | 09/08/2021 | Claims Processing Instructions for National Coverage Determination 20.33 - Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation | 10/08/2021 | 12361 |
| R10881CP | 08/06/2021 | REVISIONS TO CHAPTERS 13 AND 32 TO UPDATE CODING | 09/07/2021 | 12069 |
| R10891CP | 07/20/2021 | National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy - This CR Rescinds and Fully Replaces CR 11783. 230.2222 | 09/20/2021 | 12177 |
| R10796CP | National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy - This CR Rescinds and Fully Replaces CR 11783- Rescinded and | 07/23/2021 | 12177 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| replaced by transmittal 10891 | ||||
| R10837CP | 06/11/2021 | National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs) | 07/27/2021 | 12290 |
| R10796CP | 05/20/2021 | National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy - This CR Rescinds and Fully Replaces CR 11783. - Rescinded and replaced by transmittal 10891 | 07/23/2021 | 12177 |
| R10573CP | 03/24/2021 | Update to Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Program Manual Sections | 04/26/2021 | 12115 |
| R10547CP | 12/31/2020 | Billing for Home Infusion Therapy Services On or After January 1, 2021 | 01/04/2021 | 11880 |
| R10463CP | 11/13/2020 | Billing for Home Infusion Therapy Services On or After January 1, 2021 | 01/04/2021 | 11880 |
| R10343CP | 09/04/2020 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 40.2.1 and 40.2.4 | 10/06/2020 | 11950 |
| R10337CP | 08/27/2020 | National Coverage Determination (NCD30.3.3): Acupuncture for Chronic Low Back Pain (cLBP) | 01/04/2021 | 11755 |
| R10269CP | 08/07/2020 | Billing for Home Infusion Therapy Services On or After January 1, 2021- Rescinded and replaced by transmittal 10463 | 01/04/2021 | 11880 |
| R10229CP | 07/21/2020 | Modify Edits in the Fee for Service (FFS) System When a Beneficiary has a Medicare Advantage (MA) Plan | 10/05/2020 | 11580 |
| R10179CP | 06/10/2020 | NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR) | 06/12/2020 | 11660 |
| R10128CP | 05/08/2020 | National Coverage Determination (NCD30.3.3): Acupuncture for Chronic Low Back Pain (cLBP) Rescinded and replaced by transmittal 10337 | 01/04/2021 | 11755 |
| R10071CP | 05/01/2020 | Modify Edits in the Fee for Service (FFS) System When a Beneficiary has a Medicare Advantage (MA) Plan Rescinded and replaced by transmittal 10229 | 10/05/2020 | 11580 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R4546CP | 03/13/2020 | NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR) Rescinded and replaced by transmittal 10179 | 06/12/2020 | 11660 |
| R4237CP | 02/08/2019 | Update to the Internet-Only-Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 12.1 | 03/12/2019 | 11127 |
| R4222CP | 02/01/2019 | Update to Intensive Cardiac Rehabilitation (ICR) Programs | 03/19/2019 | 11117 |
| R4203CP | 01/18/2019 | Update to Pub. 100-04 Chapter 32 to Provide Language-Only Changes for the New Medicare Card Project | 02/19/2019 | 11118 |
| R4111CP | 08/10/2018 | Revisions to Medicare Claims Processing Manual for Foreign, Emergency and Shipboard Claims | 09/11/2018 | 10856 |
| R4049CP | 05/11/2018 | Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) | 07/02/2018 | 10295 |
| R4016CP | 04/03/2018 | Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) | 07/02/2018 | 10295 |
| R4013CP | 03/30/2018 | Institutional Billing for No Cost Items | 06/29/2018 | 10521 |
| R3969CP | 02/02/2018 | Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) | 04/03/2018 | 10295 |
| R203NCD | 11/17/2017 | Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen) | 12/18/2017 | 10220 |
| R3898CP | 10/27/2017 | Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans | 04/02/2018 | 10238 |
| R3871CP | 09/29/2017 | Revisions to Medicare Claims Processing Manual for Foreign, Emergency and Shipboard Claims | 10/30/2017 | 10287 |
| R3848CP | 08/25/2017 | Updates to Pub. 100-04, Chapter 18 Preventive and Screening Services and Chapter 32 Billing Requirements for Special Services and Publication 100-03, Chapter 1 Coverage Determinations Part 4 | 09/26/2017 | 10199 |
| R3815CP | 07/28/2017 | National Coverage Determination | 08/29/2017 | 10117 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| (NCD20.8.4): Leadless Pacemakers | ||||
| R3811CP | 07/25/2017 | Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) | 06/27/2017 | 10089 |
| R3805CP | 07/11/2017 | Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) – Rescinded and replaced by transmittal 3811 | 08/11/2017 | 10089 |
| R3787CP | 05/26/2017 | Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) – Rescinded and replaced by transmittal 3805 | 06/27/2017 | 10089 |
| R3556CP | 07/01/2016 | Stem Cell Transplantation for Multiple Myeloma, Myelofibrosis, Sickle Cell Disease, and Myelodysplastic Syndromes | 10/03/2016 | 9620 |
| R3509CP | 04/29/2016 | Stem Cell Transplantation for Multiple Myeloma, Myelofibrosis, Sickle Cell Disease, and Myelodysplastic Syndromes - Rescinded and replaced by Transmittal 3556 | 10/03/2016 | 9620 |
| R3384CP | 10/26/2015 | National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers - This CR rescinds and fully replaces CR 8525 | 07/06/2015 | 9078 |
| R3287CP | 06/30/2015 | Revisions to Medicare Claims Processing Manual for Foreign, Emergency and Shipboard Claims | 04/21/2015 | 8940 |
| R3265CP | 05/22/2015 | NCD20.30 Microvolt T-wave Alternans (MTWA) | 06/23/2015 | 9162 |
| R3241CP | 04/24/2015 | Transcatheter Mitral Valve Repair (TMVR)-National Coverage Determination (NCD) | 04/06/2014 | 9002 |
| R3199CP | 02/20/2015 | Revisions to Medicare Claims Processing Manual for Foreign, Emergency and Shipboard Claims – Rescinded and replaced by Transmittal 3287 | 04/21/2015 | 8940 |
| R3204CP | 02/20/2015 | National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers - This CR rescinds and fully replaces CR 8525 - | 07/06/2015 | 9078 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| Rescinded and replaced by Transmittal 3384 | ||||
| R3181CP | 01/30/2015 | Implementation of New NUBC Condition Code “53” “Initial placement of a medical device provided as part of a clinical trial or a free sample” | 07/06/2015 | 8961 |
| R3175CP | 01/30/2015 | Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)-Blinded Clinical Trial – Follow-Up CR to Implement a Second Claims Processing Procedure Code | 03/02/2015 | 8954 |
| R3142CP | 12/05/2014 | Transcatheter Mitral Valve Repair (TMVR)-National Coverage Determination (NCD) – Rescinded and replaced by Transmittal 3241 | 04/06/2014 | 9002 |
| R3105CP | 11/06/2014 | Medicare Coverage of Items and Services in Category A and B Investigational Device Exemption (IDE) Studies | 01/05/2015 | 8921 |
| R3084CP | 10/03/2014 | Intensive Cardiac Rehabilitation Program - Benson-Henry Institute Cardiac Wellness Program | 11/04/2014 | 8894 |
| R3058CP | 08/29/2014 | Cardiac Rehabilitation Programs for Chronic Heart Failure | 08/18/2014 | 8758 |
| R3054CP | 08/29/2014 | Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy | 09/30/2014 | 8803 |
| R3050CP | 08/22/2014 | Extracorporeal Photopheresis | 09/23/2014 | 8808 |
| R2998CP | 07/25/2014 | Update to Pub. 100-04, Chapter 32 to Provide Language-Only Changes for Updating ICD-10 and ASC X12 | 08/25/2014 | 8693 |
| R2989CP | 07/18/2014 | Cardiac Rehabilitation Programs for Chronic Heart Failure Failure – Rescinded and replaced by Transmittal 3058 | 08/18/2014 | 8758 |
| R2959CP | 05/16/2014 | Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) | 10/06/2014 | 8757 |
| R2955CP | 05/14/2014 | Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims | 01/06/2014 | 8401 |
| R2872CP | 02/06/2014 | National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – | 07/07/2014 | 8525 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| Rescinded and replaced by Transmittal 2986 | ||||
| R2841CP | 12/23/2013 | Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity | 12/17/2013 | 8484 |
| R2827CP | 11/29/2013 | Transcatheter aortic valve replacement (TAVR) - Implementation of Permanent CPT Code | 01/06/2013 | 8537 |
| R2816CP | 11/15/2013 | Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity – Rescinded and replaced by Transmittal 2841 | 12/17/2013 | 8484 |
| R2805CP | 10/30/2013 | Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims – Rescinded and replaced by Transmittal 2955 | 01/06/2014 | 8401 |
| R2783CP | 09/10/2013 | Corrections to the Medicare Claims Processing Manual | 09/17/2013 | 8343 |
| R2758CP | 08/09/2013 | Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims – Rescinded and replaced by Transmittal 2805 | 01/06/2014 | 8401 |
| R2743CP | 07/25/2013 | Coding Changes to Ultrasound Diagnostic Procedures for Transesophageal Doppler Monitoring | 08/26/2013 | 8330 |
| R2737CP | 07/11/2013 | National Coverage Determination (NCD) for Transcatheter Aortic Valve Replacement (TAVR) – Implementation of Mandatory Reporting of Clinical Trial Number | 10/07/2013 | 8255 |
| R2728CP | 06/14/2013 | Ocular Photodynamic Therapy (OPT) with Verteporfin for Macular Degeneration | 07/16/2013 | 8292 |
| R2725CP | 06/14/2013 | Corrections to the Medicare Claims Processing Manual – Rescinded and replaced by Transmittal 2783 | 09/17/2013 | 8343 |
| R2720CP | 06/10/2013 | Autologous Platelet-Rich Plasma (PRP) for Chronic Non-Healing Wounds | 07/01/2013 | 8213 |
| R2710CP | 05/21/2013 | Autologous Platelet-Rich Plasma (PRP) for Chronic Non-Healing Wounds – Rescinded and replaced by Transmittal 2720 | 07/01/2013 | 8213 |
| R2689CP | 05/03/2013 | National Coverage Determination (NCD) for Transcatheter Aortic Valve | 10/07/2013 | 8255 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| Replacement (TAVR) – Implementation of Mandatory Reporting of Clinical Trial Number – Rescinded and replaced by Transmittal 2737 | ||||
| R2666CP | 03/08/2013 | Autologous Platelet-Rich Plasma (PRP) for Chronic Non-Healing Wounds – Rescinded and replaced by Transmittal 2710 | 07/01/2013 | 8213 |
| R2641CP | 01/29/2013 | Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination, Addition of Laparoscopic Sleeve Gastrectomy (LSG) | 02/28/2013 | 8028 |
| R2628CP | 01/07/2013 | NCD: Transcatheter Aortic Valve Replacement (TAVR) Coding Update/Policy Clarification | 04/01/2013 | 8168 |
| R2590CP | 11/09/2012 | Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination, Addition of Laparoscopic Sleeve Gastrectomy (LSG) – Rescinded and replaced by Transmittal 2641 | 12/10/2012 | 8028 |
| R2252CP | 09/24/2012 | National Coverage Determination (NCD) FOR Transcatheter Aortic Valve Replacement | 01/07/2013 | 7897 |
| R2551CP | 09/24/2012 | Extracorporeal Photopheresis (ICD-10) – Rescinded and replaced by Transmittal 2551 | 10/01/2012 | 7806 |
| R2544CP | 09/13/2012 | Contractor and Common Working File (CWF) Additional Instructions Related to Change Request (CR) 7633-Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse | 10/01/2012 | 7791 |
| R2543CP | 09/07/2012 | Extracorporeal Photopheresis (ICD-10) – Rescinded and replaced by Transmittal 2551 | 10/01/2012 | 7806 |
| R2512CP | 08/03/2012 | National Coverage Determination (NCD) FOR Transcatheter Aortic Valve Replacement – rescinded and Replaced by Transmittal 2552 | 01/07/2013 | 7897 |
| R2506CP | 08/03/2012 | Extracorporeal Photopheresis (ICD-10) – Rescinded and replaced by Transmittal 2543 | 10/01/2012 | 7806 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R2494CP | 07/10/2012 | Extracorporeal Photopheresis (ICD-10) – Rescinded and replaced by Transmittal 2506 | 10/01/2012 | 7806 |
| R2488CP | 06/21/2012 | Contractor and Common Working File (CWF) Additional Instructions Related to Change Request (CR) 7633-Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse – Rescinded and replaced by Transmittal 2544 | 10/01/2012 | 7791 |
| R2473CP | 05/18/2012 | Extracorporeal Photopheresis (ICD-10) | 10/01/2012 | 7806 |
| R2454CP | 04/26/2012 | Contractor and Common Working File (CWF) Additional Instructions Related to Change Request (CR) 7633-Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse – Rescinded and replaced by Transmittal 2488 | 10/01/2012 | 7791 |
| R2394CP | 01/25/2012 | CWF Editing for Autologous Cellular Immunotherapy Treatment of Metastatic Prostate Cancer (PROVENGE®) | 07/02/2012 | 7659 |
| R2380CP | 01/06/2012 | Autologous Cellular Immunotherapy Treatment of Metastatic Prostate Cancer | 08/08/2011 | 7431 |
| R2339CP | 11/02/2011 | Autologous Cellular Immunotherapy Treatment of Metastatic Prostate Cancer - Rescinded and replaced by Transmittal 2380 | 08/08/2011 | 7431 |
| R2254CP | 07/08/2011 | Autologous Cellular Immunotherapy Treatment of Metastatic Prostate Cancer – Rescinded and replaced by Transmittal 2339 | 08/08/2011 | 7431 |
| R2113CP | 12/10/2010 | Payment for 510k Post-Approval Extension Studies Using 501k-Cleared Embolic Protection Devices During Carotid Artery Stenting (CAS) Procedures | 01/12/2011 | 7249 |
| R2105CP | 11/24/2010 | Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS) | 07/06/2010 | 6953 |
| R2062CP | 10/08/2010 | Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS) | 11/10/2010 | 7137 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R2052CP | 09/17/2010 | Billing and Processing for Healthy Control Group Volunteers in a Qualified Clinical Trial | 07/06/2010 | 6776 |
| R2005CP | 07/23/2010 | Billing and Claims Processing for Automatic Implantable Cardiac Defibrillator (ICD) Services | 08/31/2010 | 7015 |
| R1994CP | 07/02/2010 | Billing and Claims Processing for Automatic Implantable Cardiac Defibrillator (ICD) Services - Rescinded and replaced by Transmittal 2005 | 08/31/2010 | 7015 |
| R1978CP | 06/04/2010 | Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS) – Rescinded and replaced by Transmittal 2105 | 07/06/2010 | 6953 |
| R1974CP | 05/21/2010 | Cardiac Rehabilitation and Intensive Cardiac Rehabilitation | 10/04/2010 | 6850 |
| R1966CP | 05/07/2010 | Pulmonary Rehabilitation (PR) Services | 10/04/2010 | 6823 |
| R1925CP | 03/05/2010 | Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting | 04/05/2010 | 6839 |
| R1924CP | 02/26/2010 | April 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS) | 04/05/2010 | 6857 |
| R1901CP | 01/29/2010 | Billing and Processing for Healthy Control Group Volunteers in a Qualified Clinical Trial – Rescinded and replaced by Transmittal 2052 | 07/06/2010 | 6776 |
| R1889CP | 01/08/2010 | Pharmacogenomic Testing for Warfarin Response | 04/05/2010 | 6715 |
| R1882CP | 12/21/2009 | January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS) | 01/04/2010 | 6751 |
| R1871CP | 12/11/2009 | January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS) - Rescinded and replaced by Transmittal 1882 | 01/04/2010 | 6751 |
| R1877CP | 12/18/2009 | Instructions Regarding Processing Claims Rejecting for Gender/Procedure Conflict | 04/05/2010 | 6638 |
| R1876CP | 12/18/2009 | Coverage of Kidney Disease Patient Education Services | 04/05/2010 | 6557 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R1839CP | 10/28/2009 | Instructions Regarding Processing Claims Rejecting for Gender/Procedure Conflict - Rescinded and replaced by Transmittal 1877 | 04/05/2010 | 6638 |
| R1816CP | 09/17/2009 | Fiscal Year (FY) 2010 Inpatient Prospective Payment System (IPPS), Long Term Care Hospital (LTCH) PPS, and Inpatient Psychiatric Facility (IPF) PPS Changes | 10/05/2009 | 6634 |
| R1815CP | 09/09/2009 | Fiscal Year (FY) 2010 Inpatient Prospective Payment System (IPPS), Long Term Care Hospital (LTCH) PPS, and Inpatient Psychiatric Facility (IPF) PPS Changes - Rescinded and replaced by Transmittal 1816 | 10/05/2009 | 6634 |
| R1778CP | 07/24/2009 | Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure Performed on the Wrong Patient | 07/06/2009 | 6405 |
| R1764CP | 07/02/2009 | Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure Performed on the Wrong Patient – Rescinded and replaced by Transmittal 1778 | 07/06/2009 | 6405 |
| R1761CP | 06/26/2009 | Billing Routine Cost of Clinical Trials | 09/28/2009 | 6431 |
| R1755CP | 06/12/2009 | Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure Performed on the Wrong Patient – Rescinded and replaced by Transmittal 1764 | 07/06/2009 | 6405 |
| R1743CP | 05/22/2009 | Billing Routine Cost of Clinical Trials - Rescinded and replaced by Transmittal 1761 | 07/10/2009 | 6431 |
| R1742CP | 05/22/2009 | Clarification of CMS Publication 100-04, Chapter 32, Section 80.8 Billing of Routine Foot Care When Payment Ceases for Loss | 06/08/2009 | 6456 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| of Protective Sensation Evaluation and Management | ||||
| R1731CP | 05/08/2009 | Clarification of CMS Publication 100-04, Chapter 32, Section 80.8 Billing of Routine Foot Care When Payment Ceases for Loss of Protective Sensation Evaluation and Management - Rescinded and replaced by Transmittal 1742 | 06/08/2009 | 6456 |
| R1728CP | 05/01/2009 | Surgery for Diabetes | 05/18/2009 | 6419 |
| R1723CP | 05/01/2009 | Ensuring Only Clinical Trial Services Receive Fee-For-Service Payment on Claims Billed for Managed Care Beneficiaries | 10/05/2009 | 6455 |
| R1721CP | 04/29/2009 | Billing Routine Cost of Clinical Trials - Rescinded and replaced by Transmittal 1743 | 07/10/2009 | 6431 |
| R1711CP | 04/17/2009 | Surgery for Diabetes – Rescinded and replaced by Transmittal 1728 | 05/18/2009 | 6419 |
| R1710CP | 04/10/2009 | Billing Routine Cost of Clinical Trials - Rescinded and replaced by Transmittal 1721 | 07/10/2009 | 6431 |
| R1663CP | 01/08/2009 | Correction to Prothrombin Time (PT/INR) Monitoring for Home Anticoagulation Management | 02/09/2009 | 6313 |
| R1657CP | 12/31/2008 | January 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) | 01/05/2009 | 6320 |
| R1646CP | 12/09/2008 | Thermal Intradiscal Procedures (TIPs) | 01/05/2009 | 6291 |
| R1593CP | 09/12/2008 | Smoking and Tobacco Use Cessation Counseling Billing Update for Comprehensive Outpatient Rehabilitation Facilities (CORFs) and Outpatient Physical Therapy Providers (OPTs) | 12/12/2008 | 6163 |
| R1592CP | 09/10/2008 | Artificial Hearts | 12/01/2008 | 6185 |
| R1583CP | 08/29/2008 | Artificial Hearts - Replaced by Transmittal 1592 | 10/06/2008 | 6185 |
| R1562CP | 07/25/2008 | Prothrombin Time (PT/INR) Monitoring for Home Anticoagulation Management - Rescinded and replaced by CR 6313 | 08/25/2008 | 6138 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R1509CP | 05/16/2008 | Adjusting Inpatient Prospective Payment System (IPPS) Reimbursement for Replaced Devices Offered Without Cost or With a Credit | 10/06/2008 | 5860 |
| R1498CP | 05/02/2008 | Adjusting Inpatient Prospective Payment System (IPPS) Reimbursement for Replaced Devices Offered Without Cost or With a Credit – Replaced by Transmittal 1509 | 10/06/2008 | 5860 |
| R1472CP | 03/06/2008 | Update of Institutional Claims References | 04/07/2008 | 5893 |
| R1433CP | 02/01/2008 | Smoking and Tobacco Use Cessation Counseling Billing Code Update | 07/07/2008 | 5878 |
| R1430CP | 02/01/2008 | Use of HCPCS V2787 When Billing Approved Astigmatism-Correcting Intraocular Lens (A-CIOLs) in Ambulatory Surgery Centers (ASCs), Physician Offices, and Hospital Outpatient Departments (HOPDs) | 03/03/2008 | 5853 |
| R1421CP | 01/25/2008 | Update of Institutional Claims References - Rescinded and Replaced by Transmittal 1472 | 04/07/2008 | 5893 |
| R1418CP | 01/18/2008 | New HCPCS Modifiers When Billing for Patient Care in Clinical Research Studies | 04/07/2008 | 5805 |
| R1340CP | 09/21/2007 | Lumbar Artificial Disc Replacement (LADR) | 10/01/2007 | 5727 |
| R1315CP | 08/10/2007 | Clarification of Percutaneous Transluminal Angioplasty (PTA) Billing Requirements Issued in CR 3811 | 10/01/2007 | 5667 |
| R1271CP | 06/22/2007 | Vagus Nerve Stimulation (VNS) for Resistant Depression | 07/23/2007 | 5612 |
| R1233CP | 04/27/2007 | Clarification of Bariatric Surgery Billing Requirements Issued in CR 5013 | 05/29/2007 | 5477 |
| R1228CP | 04/27/2007 | Instructions for Implementation of CMS 1536-R; Astigmatism-Correcting Intraocular Lens (A-C IOLs) | 05/29/2007 | 5527 |
| R1206CP | 03/16/2007 | Extracorporeal Photopheresis | 04/02/2007 | 5464 |
| R1192CP | 03/02/2007 | Payment and Billing for Islet Isolation Add-On in National Institutes of Health (NIH) Clinical Trial | 04/02/2007 | 5505 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R1164CP | 01/26/2007 | Coding Change for Lumbar Artificial Disc Replacement (LADR) | 03/13/2007 | 5462 |
| R1147CP | 01/05/2007 | Intracranial Percutaneous Transluminal Angioplasty (PTA) with Stenting | 02/05/2007 | 5432 |
| R1111CP | 11/09/2006 | Clarification on Billing for Cryosurgery of the Prostate Gland | 04/02/2007 | 5376 |
| R1042CP | 08/25/2006 | Clarification on Billing Requirements for Percutaneous Transluminal Angioplasty (PTA) Concurrent With the Placement of an Investigational or FDA-Approved Carotid Stent | 10/02/2006 | 5022 |
| R1000CP | 07/19/2006 | Common Working File (CWF) to the Medicare Beneficiary Database (MDB) Data Exchange Changes | 10/02/2006 | 4300 |
| R992CP | 06/23/2006 | Lumbar Artificial Disc Replacement (LADR) | 07/17/2006 | 5057 |
| R986CP | 06/16/2006 | Payment for Islet Cell Transplantation in NIH-Sponsored Clinical Trials | 07/31/2006 | 5140 |
| R951CP | 05/12/2006 | Payment for Carotid Artery Stenting (CAS) Post-Approval Extension Studies | 06/12/2006 | 5088 |
| R931CP | 04/28/2006 | Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity | 05/30/2006 | 5013 |
| R911CP | 04/21/2006 | Clarification on Billing Requirements for Percutaneous Transluminal Angioplasty (PTA) Concurrent With the Placement of an Investigational or FDA-Approved Carotid Stent | 10/02/2006 | 5022 |
| R909CP | 04/21/2006 | Cardiac Rehabilitation Programs | 06/21/2006 | 4401 |
| R908CP | 04/21/2006 | Common Working File (CWF) to the Medicare Beneficiary Database (MBD) Data Exchange Changes | 10/02/2006 | 4300 |
| R898CP | 03/31/2006 | External Counterpulsation (ECP) Therapy | N/A | 4350 |
| R816CP | 01/20/2006 | Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing | 04/03/2006 | 4085 |
| R801CP | 12/30/2005 | Instructions for Reporting New HCPCS Code V2788 for Presbyopia-Correcting Intraocular Lenses (P-C IOLs) | 01/03/2006 | 4184 |
| R795CP | 12/30/2005 | Redefined Type of Bill (TOB) 14X for Non-Patient Laboratory Specimens-CR 3835 Manualization | 04/03/2006 | 4208 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R766CP | 12/02/2005 | Stem Cell Transportation | 01/03/2006 | 4173 |
| R726CP | 10/21/2005 | Smoking and Tobacco-Use Cessation Counseling Services: Common Working File (CWF) Inquiry for Providers | 01/24/2006 | 4104 |
| R671CP | 09/09/2005 | Updated Manual Instructions for the Medicare Claims Processing Manual, Regarding Smoking and Tobacco-Use Cessation Counseling Services | 10/03/2005 | 4045 |
| R605CP | 07/15/2005 | Frequency Instructions for Smoking and Tobacco-Use Cessation Counseling Services | 10/03/2005 | 3929 |
| R601CP | 07/01/2005 | Cochlear Implantation | 07/25/2005 | 3796 |
| R597CP | 06/24/2005 | Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing | 08/01/2005 | 3836 |
| R589CP | 06/24/2005 | Cochlear Implantation | 07/05/2005 | 3796 |
| R562CP | 05/20/2005 | Smoking and Tobacco-Use Cessation Counseling Services | 07/05/2005 | 3834 |
| R526CP | 04/15/2005 | Updated Requirements for Autologous Stem Cell Transplantation (AuSCT) | 05/16/2005 | 3797 |
| R498CP | 03/11/2005 | Billing of the Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes | N/A | 3580 |
| R487CP | 03/04/2005 | Manualization of Claims Processing Instructions for Medicare Qualifying Clinical Trials | N/A | 3625 |
| R486CP | 03/04/2005 | Manualization of Carrier Claims Processing Instructions for Stem Cell Transplantation | N/A | 3684 |
| R371CP | 11/19/2004 | Updated Billing Instructions for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) | 04/04/2005 | 3487 |
| R261CP | 07/30/2004 | Billing Requirements for Islet Cell Transplantation for Beneficiaries in a National Institutes of Health Sponsored Clinical Trial | 10/04/2004 | 3385 |
| R216CP | 06/25/2004 | Manualization of Instructions for of INR Monitoring | N/A | 2323 |
| R187CP | 05/28/2004 | Manualization of Instructions for Billing for Hyberbaric Oxygen Therapy for the | 06/28/2004 | 3172 |
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| Treatment of Wounds of the Lower Extremities | ||||
| R130aCP | 03/26/2004 | Manualization of Instructions for INR Monitoring | N/A | 2323 |
| R128CP | 03/26/2004 | Manualization of Instructions for Deep Brain Stimulation | N/A | 2553 |
| R125CP | 03/26/2004 | Manualization of Instructions for Sacral Nerve Stimulation | N/A | 2532 |
| R124CP | 03/19/2004 | Policy and Claims Processing Instructions for Electrical Stimulation And Electromagnetic Therapy | 07/06/2004 | 3149 |
| R109CP | 02/27/2004 | Updated Policy and Claims Processing Instructions for Ambulatory Blood Pressure Monitoring (AMPM) | 04/05/2004 | 2726 |
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