ICD 10 code for dysphagia - R13

Diseases of the blood and blood-forming organs and certain disorders involving the forming organs and certain disorders involving the forming organs and certain disorders involving the immune mechanism (D50- immune mechanism (D50-D89)

Iron deficiency anemia (D50)

Iron deficiency anemia secondary to blood loss (chronic) (D50.0)

Sideropenic dysphagia (D50.1)

Other iron deficiency anemias (D50.8)

Iron deficiency anemia, unspecified (D50.9)

Vitamin B12 deficiency anemia (D51)

Vitamin B12 deficiency anemia due to intrinsic factor deficiency (D51.0)

Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria (D51.1)

Transcobalamin II deficiency (D51.2)

Other dietary vitamin B12 deficiency anemia (D51.3)

Other vitamin B12 deficiency anemias (D51.8)

Vitamin B12 deficiency anemia, unspecified (D51.9)

Folate deficiency anemia (D52)

Dietary folate deficiency anemia (D52.0)

Nausea and vomiting (R11)

Heartburn (R12)

Dysphagia (R13)

Flatulence and related conditions (R14)

Fecal incontinence (R15)

Drug-induced folate deficiency anemia (D52.1)

Other folate deficiency anemias (D52.8)

Folate deficiency anemia, unspecified (D52.9)

Other nutritional anemias (D53)

Protein deficiency anemia (D53.0)

Other megaloblastic anemias, not elsewhere classified (D53.1)

Scorbutic anemia (D53.2)

Other specified nutritional anemias (D53.8)

Nutritional anemia, unspecified (D53.9)



Iron deficiency

Originally described in the context of sideropenic dysphagia, it is an important cause of epithelial atrophy. The association of iron deficiency with oropharyngeal squamous cell carcinomas has been observed since the mid-thirties of the 20th century {21}. However, a significant decrease of cases with hypopharyngeal cancers and iron deficiency was noted in Sweden in the seventies {1433}. Few cases of oral cancer and iron deficiency have been published in the last 20 years.

Mucoepidermoid carcinoma

This most common malignant salivary gland tumour involves minor glands, and accounts for 9.5-23% of all minor gland tumours {669,704,2711}. About half of the cases arise in the palate and other common sites include the buccal mucosa, lips, floor of oral cavity and retromolar pad. They appear to be much more frequent in the lower lip than the upper lip {1871}. The tumour is often asymptomatic and detected during a routine dental examination.Many appear as bluish, domed swellings that resemble mucoceles or haemangiomas. Less commonly, the surface appears granular or papillary. Tumours of the base of tongue or oropharynx may cause dysphagia and sublingual tumours can lead to ankyloglossia and dysphonia. High-grade tumours are uncommon but can result in ulceration, loosening of teeth, paraesthesia or anaesthesia. Mucoepidermoid carcinoma is the most common salivary gland tumour to develop in a central location within the bone of the mandible or, less frequently, the maxilla {280}. The microscopical features of minor gland mucoepidermoid carcinomas are the same as those seen in the major glands.

Clinical features

Patients with NHL of the lip, buccal mucosa, gingiva, floor of mouth, tongue or palate usually present with ulcer, swelling, discoloration, pain, paraesthesia, anaesthesia, or loose teeth. Those with NHL of the Waldeyer ring (tonsils) or oropharynx usually present with a sensation of fullness of the throat, sore throat, dysphagia, or snoring. The high-grade tumours often show rapid growth. Systemic symptoms such as fever and night sweat are uncommon {201}.

Clinical examination reveals solitary or multiple lesions, in the form of an exophytic mass, ulcer or localized swelling. Some cases may mimic inflammatoryconditions, such as periodontitis.

Tonsillar lymphoma usually manifests as asymmetric tonsil enlargement, although the disease can be bilateral in up to 9% of cases {2250}. The regional lymph nodes can be enlarged as a result of lymphoma involvement or reactive changes secondary to ulceration.

REVIEW OF CLAIM DETERMINATIONS

Claim Determinations

When BCBSTX receives a properly submitted claim, it has authority and discretion under the Plan to interpret and determine benefits in accordance with the Plan provisions. BCBSTX will render an initial decision to pay or deny a claim within 30 days of receipt of the claim. If BCBSTX requires further information in order to process the claim, we will request it within that 30-day period.

You have the right to seek and obtain a full and fair review by BCBSTX of any determination of a claim, any determination of a request for preauthorization, or any other determination made by BCBSTX of your benefits under the Plan.

If a Claim Is Denied or Not Paid in Full

On occasion, BCBSTX may deny all or part of your claim. There are a number of reasons why this may happen. We suggest that you first read the Explanation of Benefits summary prepared by BCBSTX; then review this Benefit Booklet to see whether you understand the reason for the determination. If you have additional information that you believe could change the decision, send it to BCBSTX and request a review of the decision. Include your full name, group and subscriber numbers with the request.

If the claim is denied in whole or in part, you will receive a written notice from BCBSTX with the following information, if applicable:



The reasons for denial;

A reference to the health care plan provisions on which the denial is based;

A description of additional information which may be necessary to complete the claim and an explanation of why such information is necessary; and

An explanation of how you may have the claim reviewed by BCBSTX if you do not agree with the denial.

Right to Review Claim Determinations

If you believe BCBSTX incorrectly denied all or part of your benefits, you may have your claim reviewed.
BCBSTX will review its decision in accordance with the following procedure:

Within 180 days after you receive notice of a denial or partial denial, write to BCBSTX's Administrative Office. BCBSTX will need to know the reasons why you do not agree with the denial or partial denial. Send your request to:

Claim Review Section

Blue Cross and Blue Shield of Texas
P. O. Box 660044
Dallas, Texas 75266-0044

You may also designate a representative to act for you in the review procedure. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative.

BCBSTX will honor telephone requests for information, however, such inquiries will not constitute a request for review.

You and your authorized representative may ask to see relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of a denial or partial denial. BCBSTX will give you a written decision within 60 days after it receives your request for review.

If you have any questions about the claims procedures or the review procedure, write to BCBSTX's Administrative Office or call the toll-free Customer Service Helpline number shown in this Benefit Booklet or on your Identification Card.

If you have a claim for benefits which is denied or ignored, in whole or in part, and your Plan is governed by the Employee Retirement Income Security Act (ERISA), you may file suit under 502 (a) of ERISA.

CPT 88305, 88307 - Surgical pathology billing procedure codes

Procedure Code Description


88305 Level IV surgical pathology, gross and microscopic examination…prostate needle biopsy…

88307 (Level V -surgical pathology, gross and microscopic examination)

G0416 Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens

G0417 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 21-40 specimens

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens


Surgical Pathology and Related Prostate Needle Biopsy

DESCRIPTION

Surgical pathology involves the gross and microscopic examination by surgical (e.g., dermatologists) and non-surgical providers (e.g., pathologists) of surgical or biopsy specimens. The practice of surgical pathology allows for definitive diagnosis of disease (or lack thereof) in cases where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests. This policy applies to all professional providers billing Current Procedural Terminology (CPT®′) or Healthcare Common Procedure Coding System (HCPCS Level II) codes on a Form CMS-1500 for multiple surgical pathology services for prostate needle biopsy


POLICY

A prostate needle biopsy commonly occurs based on the detection of elevated prostate-specific antigen (PSA) performed as part of prostate cancer screening. Typically, the initial biopsy consists of a small number of core specimens taken of the prostate. Individuals with an elevated PSA level but with a normal initial biopsy often undergo repeat biopsy evaluation. Prostate saturation biopsy, also referred to as prostate saturation needle biopsy, involves taking numerous samples of prostate tissue, typically 20 to 40 cores, in order to increase the likelihood of detecting prostate cancer in a subgroup of high-risk individuals in whom previous conventional
prostate biopsies have been negative.

CPT code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for CPT code 88305 when reported with a prostate diagnosis. When CPT code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.


Billing and Reimbursement of Prostate Biopsy Services

Effective September 1, 2012, the global reimbursement for professional pathology services for prostate biopsy codes 88305 and 88307 will be capped at nine units.


Professional pathology services must be billed as a global charge when billing for both the technical and professional components. Healthcare Common Procedure Coding System (HCPCS) code G0416 should also be considered when billing for examination of prostate biopsy samples.


Payment Edit rules

88300 (Level I -surgical pathology, gross examination only) bundles with 88302 (Level II -Surgical pathology, gross and microscopic examination), 88304 (Level III -surgical pathology, gross and microscopic examination), 88305 (Level IV -surgical pathology, gross and microscopic examination),

88307 (Level V -surgical pathology, gross and microscopic examination) and 88309 (Level VI - surgical pathology, gross and microscopic examination).


CODE RULE CODE 88300 

Redundant/Mutually Exclusive 88302
88304
88305
88307
88309

Surgical Pathology Services payment Guide from Medicare

Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare. Surgical pathology services paid under the physician fee schedule are reported under the following CPT codes:

88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88318, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88342, 88346, 88347, 88348, 88349, 88355, 88356, 88358, 88361, 88362, 88365, 88380.

Depending upon circumstances and the billing entity, the carriers may pay professional component, technical component or both.

CPT code 15734, 15732, 15740 - Muscle, mycoutaneos procedure

15570* Formation of direct or tubed pedicle, with or without transfer; trunk

15731* Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap)

15732* Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)

15734* Muscle, myocutaneous, or fasciocutaneous flap; trunk

15736* Muscle, myocutaneous, or fasciocutaneous flap; upper extremity

15738* Muscle, myocutaneous, or fasciocutaneous flap; lower extremity

15740* Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

15756* Free muscle or myocutaneous flap with microvascular anastomosis


DEFINITIONS

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Cosmetic Surgery: Defined by the American Society of Plastic Surgeons, "is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem." Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas:

physical and motor tasks; independent movement; performing basic life functions.


Injury: Bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Microtia: The most complex congenital ear deformity when the outer ear appears as either a sausage-shaped structure resembling little more than the earlobe. It may or may not be missing the external auditory or hearing canal. Hearing is impaired to varying degrees.

Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, "is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”

Sickness: Physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse.


Coding Clarification

** Flaps (Skin and/or Deep Tissues) Procedures: 15570-15738

o The regions listed refer to a donor site when a tube is formed for later transfer or when a "delay" of flap occurs prior to the transfer. Codes 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap.

o A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure.

o (For microvascular flaps, see 15756-15758)

o (For flaps without inclusion of a vascular pedicle, see 15570-15576)

o (For adjacent tissue transfer flaps, see 14000-14302)

o The regions listed refer to the recipient area (not the donor site) when a flap is being attached in a transfer or to a final site.

o Codes 15570-15738 do not include extensive immobilization (e.g., large plaster casts and other immobilizing devices are considered additional separate procedures).

** Other Flaps and Grafts Procedures: 15740-15777

o Neurovascular pedicle procedures are reported with 15750. This code includes not only skin but also a functional motor or sensory nerve(s). The flap serves to reinnervate a damaged portion of the body dependent on touch or movement (e.g., thumb). Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure.

o Code 15740 describes a cutaneous flap, transposed into a nearby but not immediately adjacent defect, with a pedicle that incorporates an anatomically named axial vessel into its design. The flap is typically transferred through a tunnel underneath the skin and sutured into its new position. The donor site is closed directly.

o For random island flaps, V-Y subcutaneous flaps, advancement flaps, and other flaps from adjacent areas without clearly defined anatomically named axial vessels, see 14000-14302.



CPT 23472, 23470, 23474 - Arthroplasty procedure codes

CPT Code Description

23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total shoulder])

23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

23616 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement

SHOULDER REPLACEMENT SURGERY (ARTHROPLASTY)

CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.

Benefit Type General benefits package Referral Required

(Does not apply to non-gatekeeper products) No Authorization Required (Precertification always required for inpatient admission) Yes Precertification with Medical Director Review Required No Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required) Inpatient, Outpatient

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable.

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

Covered ICD 10


ICD-10-PCS Code ICD-10-PCS Description

ØRRJØJZ Replacement of right shoulder joint with synthetic substitute, open approach
ØRRKØJZ Replacement of left shoulder joint with synthetic substitute, open approach
ØRREØJZ Replacement of right sternoclavicular joint with synthetic substitute, open approach
ØRRFØJZ Replacement of left sternoclavicular joint with synthetic substitute, open approach
ØRRGØJZ Replacement of right acromioclavicular joint with synthetic substitute, open approach
ØRRHØJZ Replacement of left acromioclavicular joint with synthetic substitute, open approach
ØRRJØJ6 Replacement of right shoulder joint with synthetic substitute, humeral surface, open approach
ØRRKØJ6 Replacement of left shoulder joint with synthetic substitute, humeral surface, open approach
ØRRJØJ7 Replacement of right shoulder joint with synthetic substitute, glenoid surface, open approach
ØRRKØJ7 Replacement of left shoulder joint with synthetic substitute, glenoid surface, open approach
ØRRJØØZ Replacement of right shoulder joint with reverse ball and socket synthetic substitute, open approach
ØRRKØØZ Replacement of left shoulder joint with reverse ball and socket synthetic substitute, open approach
ØRWGØJZ Revision of synthetic substitute in right acromioclavicular joint, open approach
ØRWG4JZ Revision of synthetic substitute in right acromioclavicular joint, percutaneous endoscopic approach
Shoulder Coding Reference Guide
ØRWHØJZ Revision of synthetic substitute in left acromioclavicular joint, open approach
ØRWH4JZ Revision of synthetic substitute in left acromioclavicular joint, percutaneous endoscopic approach
ØRWJØJZ Revision of synthetic substitute in right shoulder joint, open approach
ØRWJ4JZ Revision of synthetic substitute in right shoulder joint, percutaneous endoscopic approach
ØRWKØJZ Revision of synthetic substitute in left shoulder joint, open approach
ØRWK4JZ Revision of synthetic substitute in left shoulder joint, percutaneous endoscopic approach

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