Sunday, February 7, 2016

Worker compensation claim - standard terms - Part 3

(s) “NCPDP” means the National Council for Prescription Drug Programs.

(t) Official Medical Fee Schedule (OMFS) means all of the fee schedules found in Article 5.3 of Subchapter 1 of Chapter 4.5 of Title 8, California Code of Regulations (Sections 9789.10 - 9789.111), adopted pursuant to Section 5307.1 of the Labor Code for all medical services, goods, and treatment provided pursuant to Labor Code Section 4600. These include the following schedules: Physician?s services; Inpatient Facility; Outpatient Facility; Clinical Laboratory; Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS); Ambulance; and Pharmaceutical.

(u) “Physician” has the same meaning specified in Labor Code Section 3209.3: physicians and surgeons holding an M.D. or D.O. degree, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners licensed by California state law and within the scope of their practice as defined by California state law.

(1) "Psychologist" means a licensed psychologist with a doctoral degree in psychology, or a doctoral degree deemed equivalent for licensure by the Board of Psychology pursuant to Section 2914 of the Business and Professions Code, and who either has at least two years of clinical experience in a recognized health setting or has met the standards of the National Register of the Health Service Providers in Psychology.

(2) "Acupuncturist" means a person who holds an acupuncturist's certificate issued pursuant to Chapter 12 (commencing with Section 4925) of Division 2 of the Business and Professions Code.

(v) "Required report" means a report which must be submitted pursuant to title 8, California Code of Regulations sections 9785 – 9785.4 or pursuant to the OMFS. These reports include the Doctor?s First Report of Injury, PR-2, PR-3, PR-4 and their narrative equivalents, as well as any report accompanying a “By Report” code billing.

(w) “Supporting Documentation” means those
documents, other than a required report, necessary to support a bill. These include, but are not limited to an invoice required for payment of the DME item being billed. For paper bills, supporting documentation includes any written authorization for services that may have been received by the physician.

(x) “Treating Physician” means the primary treating physician or secondary physician as defined by section 9785(a)(1), (2).

(y) “Uniform Billing Forms” are the CMS 1500, UB-04, NCPDP Universal Claim Form and the ADA 2006 set forth in Appendix A.

(z) “Uniform Billing Codes” are defined as:

(1) “California Codes” means those codes adopted by the Administrative Director for use in the Physician?s Services section of the Official Medical Fee Schedule (Title 8, California Code of Regulations §§ 9789.10-11).

(2) "CDT-4 Codes" means the current dental codes, nomenclature, and descriptors prescribed by the American Dental Association in “Current Dental Terminology, Fourth Edition.”

(3) "CPT-4 Codes" means the procedural terminology and codes contained in the “Current Procedural Terminology, Fourth Edition,” as published by the American Medical Association and as adopted in the appropriate fee schedule contained in sections 9789.10-9789.100.

(4) “Diagnosis Related Group (DRG)” or “Medicare Severity-Diagnosis Related Codes” (MS-DRG) means the inpatient classification schemes used by CMS for hospital inpatient reimbursement. The DRG/MS-DRG systems classify patients based on principal diagnosis, surgical procedure, age, presence of co-morbidities and complications and other pertinent data.

(5) "HCPCS" means CMS? Healthcare Common Procedure Coding System, a coding system which describes products, supplies, procedures and health professional services and includes, the American Medical Association?s (AMA's) Physician “Current Procedural Terminology, Fourth Edition,” (CPT-4) codes, alphanumeric codes, and related modifiers.

(6) "ICD-9-CM Codes" means the diagnosis and procedure codes in the International Classification of Diseases, Ninth Revision, Clinical Modification published by the U.S. Department of Health and Human Services.

(7) "NDC" means the National Drug Codes of the Food and Drug Administration.

(8) “Revenue Codes” means the 4-digit coding system developed and maintained by the National Uniform Billing Committee for billing inpatient and outpatient hospital services, home health services and hospice services.

(9) "UB-04 Codes" means the code structure and instructions established for use by the National Uniform Billing Committee (NUBC).

(aa) “Working days” means Mondays through Fridays but shall not include Saturdays, Sundays or the following State Holidays. (1) January 1st (“New Year?s Day”.)
(2) The third Monday in January ("Dr. Martin Luther King, Jr. Day.")
(3) The third Monday in February (“Washington Day” or “President?s Day.”)
(4) March 31st ("Cesar Chavez Day.")
(5) The last Monday in May (“Memorial Day.”)
(6) July 4th (“Independence Day.”)
(7) The first Monday in September (“Labor Day.”)
(8) November 11th ("Veterans Day.")
(9) The third Thursday in November (“Thanksgiving Day.”)
(10) The Friday After Thanksgiving Day
(11) December 25th (“Christmas Day.”)
(12) If January 1st, March 31st, July 4th, November 11th, or December 25th falls upon a Sunday, the Monday following is a holiday. If November 11th falls upon a Saturday, the preceding Friday is a holiday.

Sunday, January 31, 2016

Worker compensation - Some standard definition - Part 2

k) “Duplicate bill” means a bill that is exactly the same as a bill that has been previously submitted with no new services added, except that the duplicate bill may have a different “billing date.”

(l) "Electronic Standard Formats" means the ASC X12N standard formats developed by the Accredited Standards Committee X12N Insurance Subcommittee of the American National Standards Institute and the retail pharmacy specifications developed by the National Council for Prescription Drug Programs (“NCPDP”) identified in Section Two - Transmission Standards, which have been and adopted by the Secretary of Health and Human Services under HIPAA.. See the Companion Guide for specific format information.

(m) “Explanation of Review” (EOR) means the explanation of payment or the denial of the payment using the standard code set found in Appendix B – 1.0. EORs use the following standard codes:

(1) DWC Bill Adjustment Reason Codes provide California specific workers? compensation explanations of a payment, reduction or denial for paper bills. They are found in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(2) Claims Adjustment Group Codes represent the general category of payment, reduction, or denial for electronic bills. The most current, valid codes should be used as appropriate for workers? compensation. These codes are obtained from the Washington Publishing Company

(3) Claims Adjustment Reason Codes (CARC) represent the national standard explanation of payment, reduction or denial information. These codes are obtained from the Washington Publishing Company A subset of the CARCs is adopted for use in responding to electronic bills in workers? compensation in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(4) Remittance Advice Remark Codes (RARC) represent supplemental explanation for a payment, reduction or denial. These are always used in conjunction with a Claims Adjustment Reason Code. These codes are obtained from the Washington Publishing Company A subset of the RARCs is adopted for use in responding to electronic bills in workers? compensation in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(n) "Health Care Provider" means a provider of medical treatment, goods and services, including but not limited to a physician, a non-physician or any other person or entity who furnishes medical treatment, goods or services in the normal course of business.

(o) “Health Care Facility” means any facility as defined in Section 1250 of the Health and Safety Code, any surgical facility which is licensed under subdivision (b) of Section 1204 of the Health and Safety Code, any outpatient setting as defined in Section 1248 of the Health and Safety Code, any surgical facility accredited by an accrediting agency approved by the Licensing Division of the Medical Board of California pursuant to Health and Safety Code Sections 1248.15 and 1248.4, or any ambulatory surgical center or hospital outpatient department that is certified to participate in the Medicare program under Title XVIII (42 U.S.C. Sec. 1395 et seq.) of the federal Social Security Act.

(p) “Itemization” means the list of medical treatment, goods or services provided using the codes required by Section One – 3.0 to be included on the uniform billing form.

(q) “Medical Treatment” means the treatment, goods and services as defined by Labor Code Section 4600.

(r) “National Provider Identification Number” or “NPI” means the unique identifier assigned to a health care provider or health care facility by the Secretary of the United States Department of Health and Human Services.

Time limit for West Virginia Medicaid and MCO

Timely Filing Policy

To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service.
The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit.

(See exceptions below for Medicare primary claims and backdated medical card.) The original claim must have had the following valid information:

• Valid provider number
• Valid member number
• Valid date of service
• Valid type of bill

Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.

This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim.

If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing

Medicare Primary Claims/Secondary Claims
Timely filing requirement for Medicare primary claims is one year from the EOMB date.
Did you know that secondary claims can be submitted electronically? For more infortion, please call our EDI help desk at 888-483-0793, option 6.

TPL Primary Claims
Timely filing requirement for TPL insurance primary claims is one year from the date of service.

Backdated Medicaid Cards
If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card. Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.

MCO’s and Timely Filing

Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible. In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service.
Please Note: The MCO must be one of the MCO’s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.

Saturday, January 23, 2016

Worker compensation - Some terms and definition - Part 1

1.0 Standardized Billing / Electronic Billing Definitions;

(a) “Assignee” means a person or entity that has purchased the right to payments for medical goods or services from the health care provider or health care facility and is authorized by law to collect payment from the responsible payer.

(b) “Authorized medical treatment” means medical treatment in accordance with Labor Code section 4600 that was authorized pursuant to Labor Code section 4610 and which has been provided or authorized by the treating physician.

(c) “Balance forward bill” is a bill that includes a balance carried over from a previous bill along with additional services or a summary of accumulated unpaid balances.

(d) “Bill” means:

(1) the uniform billing form found in Appendix A setting forth the itemization of services provided along with the required reports and/or supporting documentation as described in Section One – 3.0 Complete Bills; or

(2) the electronic billing transmission utilizing the standard formats found in Section Two – Transmission Standards 2.0 Electronic Standard Formats, 2.1 Billing, along with the required reports and/or supporting documentation as described in Section One – 3.0 Complete Bills.

(e) “Billing Agent” means a person or entity that has contracted with a health care provider or health care facility to process bills for services provided by the health care provider or health care facility.

(f) “California Electronic Medical Billing and Payment Companion Guide” is a separate document which gives detailed information for electronic billing and payment. The guide outlines the workers? compensation industry national standards and California jurisdictional procedures necessary for engaging in Electronic Data Interchange (EDI) and specifies clarifications where applicable. It will be referred to throughout this document as the “Companion Guide”.

(g) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.

(h) “Clearinghouse” means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value-added" networks and switches that provides either of the following functions:

(1) Processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.

(2) Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity.

(i) “Complete Bill” means a bill submitted on the correct uniform billing form/format, with the correct uniform billing code sets, filled out in compliance with the form/format requirements of Appendix A and/or the Companion Guide with the required reports and/or supporting documentation as set forth in Section One – 3 0.

(j) “CMS” means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.w

Friday, January 22, 2016

Common Error that results Denial - Molina Healthcare

Errors That Result In Denied Claims;

This information is presented for you to review your internal procedures and identify areas where the number of denied claims could be reduced. Denied claims result in delay of payment. Please note HIPAA claim adjustment reason and remit remark codes as provided on the remittance advice.

Claim Errors (Remittance Advice Remarks)

• The rendering provider is not eligible to perform the service billed (185) or claim/service lacks information which is needed for adjudication. (16/MA30)
o Service code not covered to the provider type or specialty

Note: If a procedure code is not covered, the provider will need to submit documentation for review to Molina per the following:
• The request must submitted in writing
• The request must be supported with documentation
o documentation should include any claim examples or indicate why the code should be payable
• If there is no supporting documentation, the request will not be considered.

• Missing/incomplete/invalid HCPCS Code (A1/M20)
o Validate code keyed correctly
o Validate code is current for Date of Service (DOS)

• Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC) (16/M119)
o For resolution to these denials, please refer to
----Select Drug Code/NDC Drug Information.
o NDC, unit of measure and units should be submitted on Medicare primary claims (even though not required by Medicare) so the information will cross over to Medicaid, eliminating the need to submit Medicaid secondary -claims on paper.

• Incomplete/invalid plan information for other insurance (Invalid Medicare Action Code) (16/N245)
o Claims denied by Medicare and submitted electronically must include a Medicare Action Code (MAC)

• This service/equipment/drug is not covered under the patient’s current benefit plan (204)
o Non-covered WV Medicaid Service

• This case may be covered by another payer per coordination of benefits/secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible. (22/MA04)

o Payer information is not submitted on electronic claim
o Explanation of Benefit (EOB) is not submitted with paper claim

• Charges are covered under a capitation agreement/managed care plan (24)

o For members enrolled in Medicaid MCO - MCO is responsible for the service
o For Members who have a PAAS provider, PAAS approval is required
–View member’s Medicaid Card to verify MCO or PAAS information
–Utilize AVRS to verify MCO or PAAS information

Tuesday, January 12, 2016

POS 19 - When should we use

New and revised place of service codes for outpatient hospitals

Note: This article was revised December 9, 2015, to clarify the effective date of place of service (POS) 19. POS 19 will be accepted for any claims processed on or after January 1, 2016. That is, POS code 19 is valid for any claim, regardless of the date of service, when it is processed on or after January 1, 2016. The title of the table was also changed for clarification. All other information is unchanged.

** Revising the current place of service (POS) code set by adding new POS code 19 for “off campus-outpatient hospital” and revising POS code 22 from “outpatient
hospital” to “on campus-outpatient hospital;” and

** Making minor corrections to POS codes 17 (walk-in retail health clinic) and 26 (military treatment facility).

You should ensure that your billing staffs are aware of these POS code change

Therefore, in response to the discussion in the 2015 physician fee schedule (PFS) final rule with comment period published November 13, 2014 (79 FR 67572); in order to differentiate between on-campus and off-campus provider-based hospital departments, CMS is creating a new POS code (POS 19) and revising the current POS code description for outpatient hospital (POS 22).

CR 9231, from which this article is taken, provides this POS code update, effective January 1, 2016. Specifically, CR 9231 updates the current POS code set by adding
new POS code 19 for “off campus-outpatient hospital” and revising POS code 22 from “outpatient hospital” to “on campus-outpatient hospital” as described in the   following table.

Code Descriptor

POS 19 Off campusoutpatient hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22 On campusoutpatient  hospital

A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons
who do not require hospitalization or institutionalization.

Additional information related to POS codes 19 and 22

** Payments for services provided to outpatients who are later admitted as inpatients within three days (or, in the case of non-IPPS hospitals, one day) are bundled when the patient is seen in a wholly-owned or whollyoperated physician practice. The three-day payment window applies to diagnostic and nondiagnostic
services that are clinically related to the reason for the patient’s inpatient admission, regardless of whether the inpatient and outpatient diagnoses are the same.
The three-day payment rule will also apply to services billed with POS code 19.

** Claims for covered services rendered in an off campus-outpatient hospital setting (or in an on campus-outpatient hospital setting, if payable by Medicare) will be paid at the facility rate. The payment  policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19
unless otherwise stated.

** Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the PFS when services are provided
to a registered outpatient. Therefore, you should use POS code 19 or POS code 22 when you furnish services to a hospital outpatient regardless of where the face-to-face encounter occurs.

** Your MACs will allow POS 19 to be billed for G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) and G0473 (Face-to-face behavioral counseling
for obesity, group (2-10), 30 minutes) in the same way as those services are billed with POS code 22

Friday, January 8, 2016

Can we appeal while using GA modifier -Medicare

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

GA modifier and appeals

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting the modifier GA (wavier of liability statement on file).

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Nonassigned claims containing the modifier GA in which the patient has been found liable must have the patient’s written consent for an appeal. Refer to the applicable contact section located at the end of this publication for the address in which to send written appeals requests.

Wednesday, December 23, 2015

Sacral Nerve Stimulation Coding Information CPT code 64561, 64581, A4290

Bill Type Codes

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

12x    Hospital Inpatient (Medicare Part B only)
13x    Hospital Outpatient
83x    Ambulatory Surgery Center
85x    Critical Access Hospital

Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Claims Processing Manual, for further guidance.

0360    Operating Room Services - General Classification
0361    Operating Room Services - Minor Surgery
0362    Operating Room Services - Organ Transplant - Other than Kidney
0367    Operating Room Services - Kidney Transplant
0369    Operating Room Services - Other OR Services


Group 1 Paragraph

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

NOTE: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
64561    Implant neuroelectrodes
64581    Implant neuroelectrodes
64585    Revise/remove neuroelectrode
A4290    Sacral nerve stim test lead
ICD-9 Codes that Support Medical Necessity

Group 1 Paragraph : It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Note: CPT/HCPCS Code 64585 is used for various other services. Medicare is not establishing limited coverage for this code at this time.

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 64561, 64581 and A4290:

Group 1 Codes
ICD-9 Codes that DO NOT Support Medical Necessity

Associated Information
Documentation Requirements
1.    All documentation must be maintained in the patient's medical record and available to the contractor upon request.
2.    Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3.    The submitted medical record must support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4.    The medical record documentation must support the medical necessity of the services as directed in this policy.
5.    Documentation must include objective evidence supporting a covered indication and objective evidence that the nationally prescribed indications and limitations are met. Such documentation should include the conservative measure used, the length of time it was tried, and any other information to support coverage.

Sunday, December 13, 2015

What we can do in IVR - What are information need to use IVR

Interactive voice response (IVR) system capabilities
The IVR system provides automated information on claims, benefits and more, 24 hours a day, seven days a week.

Call the number on the back of the member’s Humana identification card to reach the IVR system.

Information available through IVR system
You can obtain a variety of information by using the IVR system.

The system can:
Confirm member coverage and the date the coverage began.
Notify you if referrals are required by the member’s plan.
Give you the status of a referral request.
Provide the member’s deductible, copayment and coinsurance information.
Provide the member’s out-of-pocket and lifetime maximum information.
Retrieve claim status for specific members.
Retrieve claim status for all your claims on one or more days.
Initiate inpatient admission and non-HMO (health maintenance organization) outpatient preauthorization requests.
Provide preauthorization request status*, directing your call to a Humana customer care representative, if needed.
In addition, you can use the system to request that the following information be sent to you by fax:
Member eligibility information.
Claims status: 40 claims per page, organized in a remit format.
Referral documentation.
Preauthorization documentation.
*Available in most areas

The IVR system gives you the option of requesting help from a Humana customer care representative. Assistance is available Monday through Friday on the following topics:

Medical eligibility, benefits and claims status: 8 a.m. to 8 p.m. EST.
Dental eligibility, benefits and claims status: 8 a.m. to 8 p.m. EST.
Preauthorizations: 8 a.m. to 6 p.m. EST.
Financial recovery: 8 a.m. to 5 p.m. EST.

Information you will need to use IVR
Before calling the IVR system, make sure you have the following information handy:
Nine-digit tax ID number.
Nine-digit member ID number (listed on member's ID card).
Member's date of birth (mm/dd/yy).
Date of service in mm/dd/yyyy format (for specific options, such as claims or precertifications).
Your fax number (if a fax-back option is requested).
Specific information to initiate a preauthorization, including the following: CPT-4 (five-digit) codes for procedures and surgeries; ICD-9 (three-, four- or five-digit) codes for diagnoses; CPT or HCPCS codes for outpatient procedures.

Thursday, December 10, 2015

Sacral Nerve Stimulation Coverage Guidance

Sacral nerve stimulation is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder function. This treatment is one of several alternative modalities for patients with urge urinary incontinence whose incontinence has been refractory to behavioral and pharmacologic treatment.

This treatment involves electrical stimulation of the sacral nerves in the lower region of the spine via a totally implantable system. System components include a lead, an implantable pulse generator and an extension that connects the lead to the pulse generator. It is expected that the physician performing this service has completed a training course in the use and implantation of the device.

Sacral nerve stimulation is covered for the following indications and limitations under CMS National Coverage Determination 230.18:

•    Urinary urge incontinence.
•    Urgency-frequency syndrome.
•    Urinary retention.
Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and if a permanent implantation is appropriate for candidates. Both the test and the permanent implantation are covered.

•    Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.
•    Patients with stress incontinence, urinary obstruction or specific neurologic disease (e.g., diabetes with peripheral nerve involvement) with associated secondary manifestations of the above indications are excluded from coverage for test stimulation and permanent implantation of sacral nerve stimulation.
•    Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries.
•    Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.

Fecal Incontinence:

Sacral nerve neuromodulation may be considered medically necessary for the treatment of fecal incontinence when ALL of the following criteria are met:
•    chronic fecal incontinence of greater than two incontinent episodes on average per week with duration greater than six months; AND
•    documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND
•    a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms, was performed; AND
•    condition is not related to an anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease; AND
•    incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.
Sacral nerve neuromodulation is considered experimental, investigational and unproven in the treatment of chronic constipation or chronic pelvic pain.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Chapter 13, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
•    Safe and effective.
•    Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the CLinical Trials NCD are considered reasonable and necessary).
•    Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
o    Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
o    Furnished in a setting appropriate to the patient's medical needs and condition.
o    Ordered and furnished by qualified personnel.
o    One that meets, but does not exceed, the patient's medical needs.
o    At least as beneficial as an existing and available medically appropriate alternative.