cpt code 76942,97032, 76881, 76882, g0283 - Nerve conduction study - eletromyography

Coverage Indications, Limitations, and/or Medical Necessity

For the purposes of this LCD and consistent with standard community understanding and the recommendations of specialty societies, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for three months or more.

Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local anesthetic solutions. Their utility in the diagnosis and treatment of non-neuropathic pain and specific syndromes mediated by sympathetic nervous system overactivity has been established.

• Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is central (within the brain and spinal cord) or peripheral (outside the brain and spinal cord) in origin; or to determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate the patient's response, as an initial diagnostic step so that other pain relief options may be considered.

• Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) and /or “inappropriate” sympathetic nervous system activity. An appropriate injection of local anesthetic induces a temporary interruption in the conduction of impulses by peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. When blockade has been of value in the relief of acute or chronic cancer related pain, somatic or epidural blockade may be maintained through the infusion of local anesthetics via indwelling catheter.

Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other collaborative comprehensive evaluation.

Imaging guidance with fluoroscopy, CT or ultrasound may be necessary to perform somatic nerve blockade. Only fluoroscopic or CT guidance will be covered for epidural injections.

Provider Qualifications

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

Patient safety and quality of care mandate that healthcare professionals who perform Nerve Blocks are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities.

PERIPHERAL NEUROPATHY

• Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain.

• The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-covered injections is also considered not medically necessary.

• The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Medical management using systemic medications is clinically indicated for the treatment of these conditions.


SOMATIC NERVE BLOCK

• Radiculopathy and other neurological deficits require further evaluation and management prior to performing the blocks.

EPIDURAL BLOCK (Cervical and Thoracic)

This policy does not cover lumbar epidural blocks, which are covered in another Noridian policy.

• Injections should not be repeated in less than five days.

• Injections are limited to a total of three in a three to six month period of time and should only be repeated if the injections produced significant and sustained relief documented by objective evidence, including improvements in the ability to perform activities of daily living (ADLs).

• Steroids should be used only in the presence of radiculopathy. Particulate steroids in the cervical region have been shown to be hazardous.



Bill Type Codes:

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

Revenue Codes:

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

CPT/HCPCS Codes

Group 1 Paragraph: CPT codes 64450 or 64640 may not be billed with diagnosis G57.61 and G57.62. The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma.



Group 1 Codes:

62281 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC
62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62321 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62324 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62325 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
64402 INJECTION, ANESTHETIC AGENT; FACIAL NERVE
64405 INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE
64408 INJECTION, ANESTHETIC AGENT; VAGUS NERVE
64410 INJECTION, ANESTHETIC AGENT; PHRENIC NERVE
64413 INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS
64415 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE
64417 INJECTION, ANESTHETIC AGENT; AXILLARY NERVE
64418 INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR NERVE
64420 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE
64421 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, REGIONAL BLOCK
64425 INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES
64430 INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE
64435 INJECTION, ANESTHETIC AGENT; PARACERVICAL (UTERINE) NERVE
64445 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE
64446 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE
64448 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64449 INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
64455 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)
64461 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64462 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SECOND AND ANY ADDITIONAL INJECTION SITE(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64463 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; CONTINUOUS INFUSION BY CATHETER (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64479 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL
64480 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64505 INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION
64508 INJECTION, ANESTHETIC AGENT; CAROTID SINUS (SEPARATE PROCEDURE)
64510 INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)
64517 INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS
64520 INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)
64530 INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MONITORING
64620 DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE
64632 DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE
64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH

Group 2 Paragraph: CPT code 64450 is NOT medically necessary when billed with any other CPT code in the GROUP 2 Codes listed PLUS any one of the GROUP 1 diagnosis listed in the ICD-10 Codes the DO NOT Support Medical Necessity section below.

Group 2 Codes:

64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
76881 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE
76882 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC
76942 ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION
76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)
97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES
97139 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY)
G0282 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0281
G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE





ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

B02.0 Zoster encephalitis
B02.1 Zoster meningitis
B02.21 Postherpetic geniculate ganglionitis
B02.22 Postherpetic trigeminal neuralgia
B02.23 Postherpetic polyneuropathy
B02.24 Postherpetic myelitis
B02.29 Other postherpetic nervous system involvement
B02.7 Disseminated zoster
B02.8 Zoster with other complications
B02.9 Zoster without complications
G50.0 Trigeminal neuralgia
G54.0 Brachial plexus disorders
G54.1 Lumbosacral plexus disorders
G54.2 Cervical root disorders, not elsewhere classified
G54.3 Thoracic root disorders, not elsewhere classified
G54.4 Lumbosacral root disorders, not elsewhere classified
G54.5 Neuralgic amyotrophy
G54.6 Phantom limb syndrome with pain
G54.8 Other nerve root and plexus disorders
G55 Nerve root and plexus compressions in diseases classified elsewhere
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
G56.03 Carpal tunnel syndrome, bilateral upper limbs
G56.11 Other lesions of median nerve, right upper limb
G56.12 Other lesions of median nerve, left upper limb
G56.13 Other lesions of median nerve, bilateral upper limbs
G56.21 Lesion of ulnar nerve, right upper limb
G56.22 Lesion of ulnar nerve, left upper limb
G56.23 Lesion of ulnar nerve, bilateral upper limbs
G56.31 Lesion of radial nerve, right upper limb
G56.32 Lesion of radial nerve, left upper limb
G56.33 Lesion of radial nerve, bilateral upper limbs
G56.41 Causalgia of right upper limb
G56.42 Causalgia of left upper limb
G56.43 Causalgia of bilateral upper limbs
G56.81 Other specified mononeuropathies of right upper limb
G56.82 Other specified mononeuropathies of left upper limb
G56.91 Unspecified mononeuropathy of right upper limb
G56.92 Unspecified mononeuropathy of left upper limb
G57.01 Lesion of sciatic nerve, right lower limb
G57.02 Lesion of sciatic nerve, left lower limb
G57.03 Lesion of sciatic nerve, bilateral lower limbs
G57.11 Meralgia paresthetica, right lower limb
G57.12 Meralgia paresthetica, left lower limb
G57.13 Meralgia paresthetica, bilateral lower limbs
G57.21 Lesion of femoral nerve, right lower limb
G57.22 Lesion of femoral nerve, left lower limb
G57.23 Lesion of femoral nerve, bilateral lower limbs
G57.31 Lesion of lateral popliteal nerve, right lower limb
G57.32 Lesion of lateral popliteal nerve, left lower limb
G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs
G57.41 Lesion of medial popliteal nerve, right lower limb
G57.42 Lesion of medial popliteal nerve, left lower limb
G57.43 Lesion of medial popliteal nerve, bilateral lower limbs
G57.51 Tarsal tunnel syndrome, right lower limb
G57.52 Tarsal tunnel syndrome, left lower limb
G57.53 Tarsal tunnel syndrome, bilateral lower limbs
G57.61* Lesion of plantar nerve, right lower limb
G57.62* Lesion of plantar nerve, left lower limb
G57.63* Lesion of plantar nerve, bilateral lower limbs
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.73 Causalgia of bilateral lower limbs
G57.81 Other specified mononeuropathies of right lower limb
G57.82 Other specified mononeuropathies of left lower limb
G57.91* Unspecified mononeuropathy of right lower limb
G57.92* Unspecified mononeuropathy of left lower limb
G58.0 Intercostal neuropathy
G58.7* Mononeuritis multiplex
G58.8* Other specified mononeuropathies
G58.9* Mononeuropathy, unspecified
G59* Mononeuropathy in diseases classified elsewhere
G89.11 Acute pain due to trauma
G89.12 Acute post-thoracotomy pain
G89.18 Other acute postprocedural pain
G89.21 Chronic pain due to trauma
G89.22 Chronic post-thoracotomy pain
G89.28 Other chronic postprocedural pain
G89.3 Neoplasm related pain (acute) (chronic)
G90.50 Complex regional pain syndrome I, unspecified
G90.511 Complex regional pain syndrome I of right upper limb
G90.512 Complex regional pain syndrome I of left upper limb
G90.513 Complex regional pain syndrome I of upper limb, bilateral
G90.521 Complex regional pain syndrome I of right lower limb
G90.522 Complex regional pain syndrome I of left lower limb
G90.523 Complex regional pain syndrome I of lower limb, bilateral
G90.59 Complex regional pain syndrome I of other specified site
I73.00 Raynaud's syndrome without gangrene
I73.01 Raynaud's syndrome with gangrene
L74.510 Primary focal hyperhidrosis, axilla
L74.511 Primary focal hyperhidrosis, face
L74.512 Primary focal hyperhidrosis, palms
L74.513 Primary focal hyperhidrosis, soles
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.561 Pain in right knee
M25.562 Pain in left knee
M43.27 Fusion of spine, lumbosacral region
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *R07.9 is used to describe rib pain
*G57.61, G57.62, G57.63 - The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma. CPT codes 64450 or 64640 may not be billed with diagnosis G57.61, G57.62 or G57.63.
*G57.91, G57.92, G58.7, G58.8, G58.9, G59, M54.10 and M79.2 - Is allowed when 64450 is billed WITHOUT CPT codes 76881, 76882, 76942, 76999, 97032, 97139, G0282 and/or G0283 on the same date of service (DOS). (Please see information in the ICD-10 Codes that DO NOT Support Medical Necessity section below).

G57.91 Unspecified mononeuropathy of right lower limb
G57.92 Unspecified mononeuropathy of left lower limb
G58.7 Mononeuritis multiplex
G58.8 Other specified mononeuropathies
G58.9 Mononeuropathy, unspecified
G60.0 Hereditary motor and sensory neuropathy
G60.1 Refsum's disease
G60.2 Neuropathy in association with hereditary ataxia
G60.3 Idiopathic progressive neuropathy
G60.8 Other hereditary and idiopathic neuropathies
G60.9 Hereditary and idiopathic neuropathy, unspecified
G61.0 Guillain-Barre syndrome
G61.1 Serum neuropathy
G61.81 Chronic inflammatory demyelinating polyneuritis
G61.89 Other inflammatory polyneuropathies
G61.9 Inflammatory polyneuropathy, unspecified
G62.0 Drug-induced polyneuropathy
G62.2 Polyneuropathy due to other toxic agents
G62.81 Critical illness polyneuropathy
G62.82 Radiation-induced polyneuropathy
G62.89 Other specified polyneuropathies
G63 Polyneuropathy in diseases classified elsewhere
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M54.10 Radiculopathy, site unspecified
M79.2 Neuralgia and neuritis, unspecified
R20.0 Anesthesia of skin
R20.1 Hypoesthesia of skin
R20.2 Paresthesia of skin
R20.3 Hyperesthesia
R20.8 Other disturbances of skin sensation
R20.9 Unspecified disturbances of skin sensation

CPT CODE 72141, 70486, 72125, 70491, 70543


Coverage Indications, Limitations, and/or Medical Necessity

Note: Providers should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor's discretionary coverage related to this service.

This policy addresses standard CT and MR imaging. Magnetic Resonance Angiography (MRA) is not addressed in this policy.

Computerized Tomography (CT)

Computerized tomography (CT scanning) uses the attenuation of an x-ray beam by an object in its path to create cross-sectional images. As x-rays pass through planes of the body, the photons are detected and recorded as they exit from different angles. Computers process the signals to produce a cross-sectional view of the body. The signal data may be subjected to a variety of post-acquisitional processing algorithms to obtain a multiplanar view of the anatomy.

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic scanning technique that employs a powerful and highly uniform static magnetic field, rather than ionizing radiation, to produce images. Fluctuations in the strength of the magnetic field alter the motion and relaxation times of hydrogen molecules, which are related to the density of molecules and reflect the physicochemical properties of the tissues. Reconstructed images can be displayed in multiple planes to facilitate analysis. See national non-coverage in CMS section above.

Coverage is limited to those CT and MRI machines that have received pre-market approval by the FDA. Such units must be operated within the parameters specified by the approval.

Medicare coverage for CT scans is allowed provided the service is medically reasonable and necessary.

Inconclusive findings on a CT scan may warrant a MRI study and, conversely, findings of a MRI study may be further clarified (under certain circumstances) with a subsequent CT scan. The information provided by the two modalities may be complementary.

Cancer Staging. Clinicians commonly use CT and MRI of the brain when metastatic involvement is suspected.

Non-covered indications: esophagus, oropharynx, and prostate, and non-melanoma skin cancer in the absence of symptoms of brain involvement. “Certain tumors almost never metastasize to the brain parenchyma. These include carcinomas of the esophagus, oropharynx, and prostate, and non-melanoma skin cancers.” (DeVita, Chapter 52.1) Accordingly, the related diagnoses found in the following diagnosis code list do not justify brain scans for “staging” purposes unless a patient has signs or symptoms suggesting brain involvement. Covered: In contrast, for those malignancies that commonly metastasize to the brain, staging in the absence of neurological findings may be appropriate.

Payment will be allowed for reasonable and necessary scans of different areas of the body that are performed on the same day.



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.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
085x 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.

032X Radiology - Diagnostic - General Classification
035X CT Scan - General Classification
040X Other Imaging Services - General Classification
061X Magnetic Resonance Technology (MRT) - General Classification

Procedure Codes and Description

Group 1 Paragraph: CT Scans

Group 1 Codes:
70450 Ct head/brain w/o dye
70460 Ct head/brain w/dye
70470 Ct head/brain w/o & w/dye
70480 Ct orbit/ear/fossa w/o dye
70481 Ct orbit/ear/fossa w/dye
70482 Ct orbit/ear/fossa w/o&w/dye
70486 Ct maxillofacial w/o dye
70487 Ct maxillofacial w/dye
70488 Ct maxillofacial w/o & w/dye
70490 Ct soft tissue neck w/o dye
70491 Ct soft tissue neck w/dye
70492 Ct sft tsue nck w/o & w/dye
72125 Ct neck spine w/o dye
72126 Ct neck spine w/dye
72127 Ct neck spine w/o & w/dye

Group 2 Paragraph: MRI Scans

Group 2 Codes:
70336 Magnetic image jaw joint
70540 Mri orbit/face/neck w/o dye
70542 Mri orbit/face/neck w/dye
70543 Mri orbt/fac/nck w/o &w/dye
70551 Mri brain stem w/o dye
70552 Mri brain stem w/dye
70553 Mri brain stem w/o & w/dye
70557 Mri brain w/o dye
70558 Mri brain w/dye
70559 Mri brain w/o & w/dye
72141 Mri neck spine w/o dye
72142 Mri neck spine w/dye
72156 Mri neck spine w/o & w/dye



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: The following list of ICD-10-CM codes represents diagnoses that, alone or together, support the medical necessity of either MRIs or CTs. These diagnoses must be supported by appropriate documentation of medical necessity in the medical record. These are the only covered diagnoses:


ICD-10 CODE DESCRIPTION

A02.21 Salmonella meningitis
A06.6 Amebic brain abscess
A17.0 Tuberculous meningitis
A17.1 Meningeal tuberculoma
A17.81 Tuberculoma of brain and spinal cord
A17.82 Tuberculous meningoencephalitis
A17.83 Tuberculous neuritis
A17.89 Other tuberculosis of nervous system
A17.9 Tuberculosis of nervous system, unspecified
A18.01 Tuberculosis of spine
A18.03 Tuberculosis of other bones
A18.2 Tuberculous peripheral lymphadenopathy
A18.50 Tuberculosis of eye, unspecified
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A27.81 Aseptic meningitis in leptospirosis
A32.0 Cutaneous listeriosis
A32.11 Listerial meningitis
A32.12 Listerial meningoencephalitis
A32.7 Listerial sepsis
A32.81 Oculoglandular listeriosis
A32.82 Listerial endocarditis
A32.89 Other forms of listeriosis
A32.9 Listeriosis, unspecified
A39.0 Meningococcal meningitis
A39.1 Waterhouse-Friderichsen syndrome
A39.2 Acute meningococcemia
A39.3 Chronic meningococcemia
A39.4 Meningococcemia, unspecified
A39.50 Meningococcal carditis, unspecified
A39.51 Meningococcal endocarditis
A39.52 Meningococcal myocarditis
A39.53 Meningococcal pericarditis
A39.81 Meningococcal encephalitis
A39.82 Meningococcal retrobulbar neuritis
A39.83 Meningococcal arthritis
A39.84 Postmeningococcal arthritis
A39.89 Other meningococcal infections
A39.9 Meningococcal infection, unspecified
A41.9 Sepsis, unspecified organism
A50.30 Late congenital syphilitic oculopathy, unspecified
A50.32 Late congenital syphilitic chorioretinitis
A50.39 Other late congenital syphilitic oculopathy
A50.40 Late congenital neurosyphilis, unspecified
A50.41 Late congenital syphilitic meningitis
A50.42 Late congenital syphilitic encephalitis
A50.43 Late congenital syphilitic polyneuropathy
A50.44 Late congenital syphilitic optic nerve atrophy
A50.45 Juvenile general paresis
A50.49 Other late congenital neurosyphilis
A50.51 Clutton's joints
A50.52 Hutchinson's teeth
A50.53 Hutchinson's triad
A50.54 Late congenital cardiovascular syphilis
A50.55 Late congenital syphilitic arthropathy
A50.56 Late congenital syphilitic osteochondropathy
A50.57 Syphilitic saddle nose
A50.59 Other late congenital syphilis, symptomatic
A51.41 Secondary syphilitic meningitis
A51.49 Other secondary syphilitic conditions
A52.00 Cardiovascular syphilis, unspecified
A52.10 Symptomatic neurosyphilis, unspecified
A52.11 Tabes dorsalis
A52.12 Other cerebrospinal syphilis
A52.13 Late syphilitic meningitis
A52.14 Late syphilitic encephalitis
A52.15 Late syphilitic neuropathy
A52.16 Charcot's arthropathy (tabetic)
A52.17 General paresis
A52.19 Other symptomatic neurosyphilis
A52.2 Asymptomatic neurosyphilis
A52.3 Neurosyphilis, unspecified
A54.81 Gonococcal meningitis
A80.0 Acute paralytic poliomyelitis, vaccine-associated
A80.1 Acute paralytic poliomyelitis, wild virus, imported
A80.2 Acute paralytic poliomyelitis, wild virus, indigenous
A80.30 Acute paralytic poliomyelitis, unspecified
A80.39 Other acute paralytic poliomyelitis
A80.4 Acute nonparalytic poliomyelitis
A80.9 Acute poliomyelitis, unspecified
A81.00 Creutzfeldt-Jakob disease, unspecified
A81.01 Variant Creutzfeldt-Jakob disease
A81.09 Other Creutzfeldt-Jakob disease
A81.1 Subacute sclerosing panencephalitis
A81.2 Progressive multifocal leukoencephalopathy
A81.81 Kuru
A81.82 Gerstmann-Straussler-Scheinker syndrome
A81.83 Fatal familial insomnia
A81.89 Other atypical virus infections of central nervous system
A81.9 Atypical virus infection of central nervous system, unspecified
A82.0 Sylvatic rabies
A82.1 Urban rabies
A82.9 Rabies, unspecified
A83.0 Japanese encephalitis
A83.1 Western equine encephalitis
A83.2 Eastern equine encephalitis
Showing 1 to 100 of 6797 entries in Group 1
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Group 2 Codes:


ICD-10 CODE DESCRIPTION
F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.222 Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231 Other psychoactive substance dependence with withdrawal delirium
F19.232 Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.288 Other psychoactive substance dependence with other psychoactive substance-induced disorder
F32.81 Premenstrual dysphoric disorder
F32.89 Other specified depressive episodes
F53 Puerperal psychosis
G83.5 Locked-in state
G92 Toxic encephalopathy
Showing 1 to 18 of 18 entries in Group 2
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Group 3 Paragraph: AND

ICD-10 CODE DESCRIPTION

S09.11XA Strain of muscle and tendon of head, initial encounter
S09.19XA Other specified injury of muscle and tendon of head, initial encounter
S09.8XXA Other specified injuries of head, initial encounter
S14.5XXA Injury of cervical sympathetic nerves, initial encounter
S16.8XXA Other specified injury of muscle, fascia and tendon at neck level, initial encounter
S19.81XA Other specified injuries of larynx, initial encounter
S19.82XA Other specified injuries of cervical trachea, initial encounter
S19.83XA Other specified injuries of vocal cord, initial encounter
S19.84XA Other specified injuries of thyroid gland, initial encounter
S19.85XA Other specified injuries of pharynx and cervical esophagus, initial encounter
S19.89XA Other specified injuries of other specified part of neck, initial encounter
Z91.410 Personal history of adult physical and sexual abuse

cpt code 36471, 36475, 36478, 37799 - Vericose veins

Procedure Codes and Description

Group 1 Paragraph: 36299* is used for sclerotherapy with mechanical agitation (e.g. Clarivein® device).

37799* should be used to report "Trivex Procedure"

36299 UNLISTED PROCEDURE, VASCULAR INJECTION

36470 INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN

36471 INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG

36473 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED

36474 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

36475 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED

36476 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

36478 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED

36479 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS

37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN

37722 LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW

37735 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA

37760 LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), INCLUDING SKIN GRAFT, WHEN PERFORMED, OPEN,1 LEG

37761 LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN, INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG

37765 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS

37766 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS

37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)

37785 LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG

37799 UNLISTED PROCEDURE, VASCULAR SURGERY

93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY

93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY


Coverage Indications, Limitations, and/or Medical Necessity

Varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes. Treatment of telangiectases (36468) is not covered by Medicare.

Historically, varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and avoidance of prolonged immobility. When conservative measures are unsuccessful, and symptoms persist, the next step has been sclerotherapy or surgical ligation with or without stripping. Sclerotherapy involves the injection of a sclerosing solution into the varicose vein(s).

Compressive sclerotherapy is the injection of the sclerosant into an empty vein (elevated limb) followed by application of a compressive bandage or dressing. This is the most commonly performed sclerotherapy procedure for varicose veins of the lower extremity. Compressive sclerotherapy is indicated for local small to medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after adequate surgical removal of varices. It is not considered an appropriate option for large, extensive or truncal varicosities. Foam sclerotherapy is FDA indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein (GSV) system above and below the knee. It is usually given with ultrasound guidance. Non-Compressive sclerotherapy is not covered by Medicare.

More recently, endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been developed as alternatives to sclerotherapy and surgical intervention. These procedures are designed to damage the intimal wall of the vein resulting in fibrosis and subsequent ablation of the lumen of a segment of the vessel. Both procedures utilize specially designed catheters inserted through a small incision in the distal thigh and advanced, often under ultrasound guidance, nearly to the saphenofemoral junction. The catheter is then slowly withdrawn while controlled radiofrequency or laser energy is applied. This is followed by external compression of the treated segment.

Doppler ultrasound or duplex studies are often used to map the anatomy of the venous system prior to the procedure. There is adequate evidence that pre-procedural ultrasound is helpful, and Medicare will cover one ultrasound or duplex scan prior to the procedure to determine the extent and configuration of the varicosities.

Evidence and clinical experience supports the use of ultrasound guidance during the procedure (ERFA and laser ablation only) and shows that the outcomes may be improved and complication rates may be minimized when ultrasound guidance is used. The CPT codes for radiofrequency and laser include the intraoperative ultrasound service in the valuation and ultrasound may not be billed separately with these procedures.

In contrast to ERFA and laser procedures, intra-operative ultrasound guidance techniques have not been shown to increase the effectiveness or safety of sclerotherapy for varicose veins, therefore, intra-operative ultrasound guidance will not be separately covered for sclerotherapy.

A. Indications for surgical treatment (CPT codes: 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785) and sclerotherapy (CPT codes: 36470, 36471):

1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND

2. The patient is symptomatic and has one, or more, of the following:
a. Pain or burning in the extremity severe enough to impair mobility
b. Recurrent episodes of superficial phlebitis
c. Non-healing skin ulceration
d. Bleeding from a varicosity
e. Stasis dermatitis
f. Refractory dependent edema

B. Indications for ERFA or laser ablation (CPT codes 36475, 36476, 36478, 36479):

In addition to the above (see A), the patient's anatomy and clinical condition are amenable to the proposed treatment including ALL of the following:

1. Absence of aneurysm in the target segment.
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. –4. The absence of significant peripheral arterial diseases.

C. Limitations for ERFA and laser ablation:
1. ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy.
2. Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation, and sclerotherapy.
3. The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3-month trial of conservative measures, by any technique will be considered cosmetic and therefore not covered.
4. The treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic, and therefore not covered.
5. Coverage is only for devices specifically FDA-approved for these procedures.
6. One pre-operative Doppler ultrasound study or duplex scan will be covered.

Noridian notes that stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this LCD are met.

Noridian notes that if sclerotherapy is used with endovenous radiofrequency ablation, it may be covered if the criteria for reasonable and necessary as described in this LCD are met.

Noridian will not consider the treatment of asymptomatic veins with endoluminal ablation or sclerotherapy medically reasonable and necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.


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.
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to Part A.
0330 Radiology - Therapeutic and/or Chemotherapy Administration - General Classification
0360 Operating Room Services - General Classification
0490 Ambulatory Surgical Care - General Classification
0510 Clinic - General Classification
0520 Freestanding Clinic - General Classification







ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity
I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.11 Varicose veins of right lower extremity with inflammation
I83.12 Varicose veins of left lower extremity with inflammation
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.811 Varicose veins of right lower extremities with pain
I83.812 Varicose veins of left lower extremities with pain
I83.813 Varicose veins of bilateral lower extremities with pain
I83.891 Varicose veins of right lower extremities with other complications
I83.892 Varicose veins of left lower extremities with other complications
I83.893 Varicose veins of bilateral lower extremities with other complications
I87.001 Postthrombotic syndrome without complications of right lower extremity
I87.002 Postthrombotic syndrome without complications of left lower extremity
I87.003 Postthrombotic syndrome without complications of bilateral lower extremity
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.021 Postthrombotic syndrome with inflammation of right lower extremity
I87.022 Postthrombotic syndrome with inflammation of left lower extremity
I87.023 Postthrombotic syndrome with inflammation of bilateral lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.091 Postthrombotic syndrome with other complications of right lower extremity
I87.092 Postthrombotic syndrome with other complications of left lower extremity
I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity
I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity
I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity

how many diagnoses can be reported on the CMS 1500

• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12)

DIAGNOSIS – ICD Indicator Enter 9 for ICD-9 diagnosis codes and 0 for ICD-10 diagnosis codes. The correct code set is determined by date of service.


ICD - Dianosis code can be reported in CMS 1500


Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties(i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All  arrative diagnoses for nonphysician specialties shall be submitted on an attachment.

Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to implementation of ICD-10-CM, on either the old or revised version of the CMS-1500 claim form. For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes. For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).

• The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

Indicator Code Set

9 ICD-9-CM diagnosis

0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)

• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.

• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

• Do not insert a period in the ICD-9-CM or ICD-10-CM code.

Coding and Reporting Principles 

Claims-Based Reporting Principles Reporting DX for PQRS

• The 2014 Physician Quality Reporting System (PQRS) Measure Specifications contain ICD-9-CM coding and ICD-10-CM coding. Beginning 10/01/2015, the PQRS system will only accept ICD-10-CM codes for analysis.

• A new CMS-1500 claim form (02/12) is available for use to accommodate the new ICD-10-CM coding. CMS will continue to accept the old CMS-1500 claim form (08/05) through March 31, 2014. However, on April 1, 2014, CMS will receive claims on only the revised CMS-1500 claim form (02/12). Claims sent on the old CMS-1500 claim form (08/05) will not be accepted.

• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12) (see the 2014 PQRS Implementation Guide) and up to twelve diagnoses can be reported in the header on the electronic claim.

o Only one diagnosis can be linked to each line item.

o PQRS analyzes claims data using ALL diagnoses from the base claim (item 21 of the CMS-1500 or electronic equivalent) and service codes for each individual EP (identified by individual NPI).

o EPs should review ALL diagnosis and encounter codes listed on the claim to make sure they are capturing ALL measures chosen to report and that are applicable to patient’s care.

• All diagnoses reported on the base claim will be included in PQRS analysis, as some measures require reporting more than one diagnosis on a claim.

o For line items containing QDC, only one diagnosis from the base claim should be referenced in the diagnosis pointer field.

o To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, all diagnoses on the claim(s) are considered in PQRS analysis.

• If your billing software limits the number of line items available on a claim, you must add a $0.01 nominal amount to one of the line items on that second claim for a total charge of one penny.

o PQRS analysis will subsequently join claims based on the same beneficiary for the same dateof-service, for the same Taxpayer Identification Number/National Provider Identifier (TIN/NPI) and analyze as one claim.

o Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses, QDCs, or nominal charge amounts are not dropped.

o In an effort to streamline reporting of QDCs across multiple CMS quality reporting programs, CMS strongly encourages all EPs and practices to begin billing 2014 QDCs with a $0.01 charge. EPs should pursue updating their billing software to accept the $0.01 charge prior to implementing 2014 PQRS. EPs and practices will need to work with their billing software or EHR vendor to ensure this capability is activated.

What is Copay - Insurance copayment

what is copay?

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Definition of terms: Copayment (copay): A predetermined fee for physician office visits, prescriptions or hospital services that the member pays at the time of service.

Medicare Definition

• A copayment amount for each service you get in an outpatient visit. For each service, this amount generally can’t be more than the Part A inpatient hospital deductible. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.

• All charges for items or services that Medicare doesn’t cover.

Example: Mr. Davis needs to have his cast removed. He goes to his local hospital outpatient department. The hospital charges $150 for this procedure. His copayment amount for this procedure, under the outpatient prospective payment system, is $20. Mr. Davis has paid $85 of his $155 Part B deductible. To have his cast removed, Mr. Davis must pay $90 ($70 remaining deductible amount + $20 copayment amount). The amount you pay may change each year. The amount you pay may also be different for different hospitals. Note: If you have a Medigap (Medicare Supplement Insurance) policy, other supplemental coverage, or employer or union coverage, it may pay the Part B deductible and copayment amounts


Medicaid Co-pay Guide


Provider Responsibilities

• Check Medicaid eligibility and co-pay status each time they see participant

• Reimburse the participant if they charged a co-pay for exempt services or exempt participant

• Direct participants to Molina call center at (208) 373- 1432 or toll free at (866) 686-4752 if they feel they have met their max out- of-pocket for the month (CAP)


Which Providers can charge a Co-pay?

• Chiropractors

• Podiatrists

• Optometrists

• Physical, Occupational & Speech Therapists

• Hospitals (outpatient services except ER)

• Physicians & mid-levels (NP or PA)

• FQHCs & RHCs


How do I know to collect a Co-pay?

• First check eligibility on the participant to see if they are Medicaid eligible and co-pay exempt or not

– PORTAL
– EDI
– MACS

• Then determine whether or not the services you are about to render are subject to Co-pay by using this guide.


Who is exempt from Co-pay?

• A child with family income less than 133% FPG

• An adult with family income less than 100% FPG

• A pregnant or post-partum woman

• Children in foster care

• Those women who are eligible due to breast or cervical cancer

• Those on Hospice

• Those in Long Term care facilities

• Those on A&D or DD waiver

• Those who have primary insurance other than Medicaid

• Native Americans/Alaskan Natives

• Members who have reached a 5% CAP (a member who has paid out 5% or more of their monthly income is exempt for the remainder of the month)

• Workers with Disabilities Providers do not need to remember all these exemptions – the eligibility information provided by the system will reflect them.


What services can a provider charge a Co-pay for?

• Chiropractic services-services performed by a chiropractor.

• Podiatrist services-services performed by a podiatrist.

• Optometrist services- General Ophthalmological services billed by an Optometrist

• Physical, Occupational & Speech Therapy Services rendered in the therapist’s office or as an Outpatient hospital service


What services are subject to Co-pay? 

• Outpatient Hospital –any of the services on this list performed in an outpatient hospital setting, except the emergency department

• Physician office visit-services provided at a doctor’s office unless preventive, family planning, or pregnancy-related.

• FQHC & RHC medical encounters, unless preventive, family planning, pregnancy-related or mental health.


Which Services are Co-pay exempt?

• Services performed in an Emergency room

• Services performed by an Urgent care clinic billing as an Urgent Care Facility

• Preventive services

• Family Planning

• Pregnancy related services

• Mental Health Services

• Services rendered that are $36.49 or less for the total claim.


What can I do if a participant doesn’t make their Co-pay?

• You can refuse to render services

• You can waive the Co-pay but you must have a written policy documenting under what circumstances you will waive it

• You can bill the patient

• Whether or not you choose to charge a Co-pay, when both the participant and the visit is subject to Co-pay provisions, the Co-pay amount will be deducted from your reimbursement.


What about the 5% cost-sharing cap?

• The copay will be tracked against the CAP. It is possible the exempt status may not be triggered due to the timing of providers submitting claims. DHW will handle reimbursements to participants should this happen.

• How long will reimbursement to the participant take?

– The length of reimbursement time will vary depending on the situation. I.e. provider billing, number of visits.


How do I know if I have met my 5% 

CAP for Co-pay?

• You must calculate your CAP using the income information you provided Medicaid to determine your eligibility.

• EXAMPLE ONLY: If your family income is $1,635.00 a month you would need to go to 22 qualifying appointments in a month to reach your CAP. (Use this guide to determine “qualifying” appointments)

(Calculation for example: $1635 x 5% = $81.75 (Max out-of-pocket (CAP)) $81.75 divided by $3.65 = 22 visits)


Copayment for commercial insurance

Its differ patient to patient and plan to plan. For example see the different type of plan or treatment and the copayment.

Copayment for different plan

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