Amniotic Membrane Billing Guidelines for HCPCS Code V2790

Amniotic Membrane Billing Guidelines for HCPCS Code V2790
HCPCS code V2790 (amniotic membrane for surgical reconstruction, per procedure) is included in the allowance for CPT Codes 65778 and 65779. In an inpatient facility reimbursement for HCPCS code V2790 is included in the Outpatient Prospective Payment System (OPPS) allowance. In an Ambulatory Surgical Center (ASC) reimbursement for V2790 is included in the facility allowance.

HCPCS code V2790 (amniotic membrane for surgical reconstruction, per procedure) should not be billed to Part B separately except as noted below:

•HCPCS code V2790 can be reimbursed separately in an office setting when billed with CPT Code 65780. A copy of the invoice must be submitted when billing for V2790 and 65780 on the same claim.
•HCPCS code V2790 should not be billed with CPT Code 65775. However, if amniotic membrane application is required in the course of that procedure, then either CPT Codes 65778 or 65779, depending on the method of application of the membrane must be billed with 65775 when a membrane is applied. As indicated above, CPT Codes 65778 and 65779 both include payment for the membrane itself (V2790) and therefore V2790 should not be billed separately when those codes are billed.

Documentation That Must Be Submitted with Claim

•For electronic claims, submit an invoice via fax.
•For paper claims, please submit the actual invoice with the claim.



Coding Information

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
CPT/HCPCS Codes Information Table

CODE DESCRIPTION

65775 CORNEAL WEDGE RESECTION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM
65778 PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; WITHOUT SUTURES
65779 PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED
65780 OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS
V2790 AMNIOTIC MEMBRANE FOR SURGICAL RECONSTRUCTION, PER PROCEDURE

ICD-10 Codes that are Covered
N/A

ICD-10 Codes that are Not Covered
N/A

References:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53441&ver=8&DocType=All&bc=AACAAAAAAAAA&

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy Coding Guide

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy Coding Guide

Coverage Indications, Limitations, and/or Medical Necessity

Introduction:

This policy does not address sacral conditions, injections or neurotomies. Sacral injections, identified on the claim by the ICD-10 code M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.87 or M53.88 are not subject to the requirements of this local coverage determination (LCD).

Facet joints are paired diarthrodial articulations of the superior and inferior articular processes of adjacent vertebrae. The medial branches (MB) of the dorsal rami of the segmental nerves innervate facet joints and the MB nerves from the two adjacent dorsal rami innervate each joint. [Exceptions to this rule are the C2-3 facet joint, which is innervated by the third occipital nerve and the L5-S1 facet joint, which is innervated by the L4 MB and the L5 dorsal ramus.]

Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.

Definitions

A zygapophyseal (aka facet) joint “level” refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint.
A “session” is defined as all injections/blocks/radiofrequency (RF) procedures performed on one day and includes medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures and RF ablations.

A “region” is all injections performed in the cervical/thoracic area or all injections performed in lumbar (not sacral) spinal areas.
"Diagnosis” of facet-mediated pain requires the establishment of pain relief following dual medial branch blocks (MBBs) performed at different sessions. Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source.

Indications

Patient must have a history of at least 3 months of moderate to severe pain with functional impairment and the pain is inadequately responsive to conservative care such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and/or physical therapy (as tolerated).

The pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication.

There is no non-facet pathology that could explain the source of the patient’s pain, such as fracture, tumor, infection or significant deformity.

Clinical assessment implicates the facet joint as the putative source of pain.

General Procedure Requirements:

Pre-procedural documentation must include a complete initial evaluation including history and an appropriately focused musculoskeletal and neurological physical examination. There should be a summary of pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain.

A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations, as well as pre and post-procedural pain assessments. With RF neurotomy, electrode position, cannula size, lesion parameters and electrical stimulation parameters and findings must be specified and documented.

Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be reimbursed.

A hard (plain radiograph with conventional film or specialized paper) digital copy image or images which adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in which using contrast is contra-indicated, such as patients with documented contrast allergies) must be retained and submitted if requested.

In order to maintain target specificity, total intra-articular (IA) injection volume must not exceed 1.0 ml per cervical joint or 2 ml per lumbar joint, including contrast. Larger volumes may be used only when performing a purposeful facet cyst rupture in the lumbar spine.

Total MBB anesthetic volume shall be limited to a maximum of 0.5 ml per MB nerve for diagnostic purposes and 2 ml for therapeutic. For a third occipital nerve block, up to 1.0 mL is allowed for diagnostic and 2 ml for therapeutic purposes.

In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or dexamethasone or equivalents shall be injected during any single session.

Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) may be acceptably performed without steroids.

Provider Qualifications
Provider Qualification requirements must be met. Patient safety and quality of care mandate that healthcare professionals who perform facet joint injections, medial branch blocks and facet joint radiofrequency neurotomy are appropriately experienced and/or trained to provide and manage the services. The CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1 underscores this point and states that "reasonable and necessary" services must be "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately experienced and/or formally trained providers.

The following training requirement applies only to those providers who have not provided these specific interventional pain management services on a regular basis (at least two times per month) during the ten years prior to the effective date of this LCD as may be established by claims billings. A basic requirement of payment is training and/or credentialing by a formal residency/fellowship program and/or other training program that is accredited by a nationally-recognized body and whose core curriculum includes the performance and management of the procedures addressed in this policy. Recognized accrediting bodies include only those whose program accreditation gains the trainee eligibility to sit for a healthcare-related licensing exam or licensing itself, which in turn allows the licensee to perform these procedures. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics, the technical performance of the procedure(s) and utilization of the required associated imaging modalities and the diagnosis and management of potential complications from the intervention.

The following credentialing requirement applies to all providers of the services addressed in this policy. 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.

Diagnostic Facet Joint Injections

Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections.
A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant relief of primary (index) pain ≥ 50% as evidenced by documented functional improvement, increased range of motion, a decreased requirement for pain medications and duration of relief is consistent with the agent employed.

Intra-articular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to specific documented anatomic restrictions.

Therapeutic Injections

Either intra-articular or medial branch blocks may provide temporary or long-lasting or permanent relief of facet-mediated pain. Injections may be repeated if the first injection results in significant pain relief (≥ 50%) for at least 3 months. (See the Limitations of Coverage section for the total number of injections that may be performed in one year).
Recurrent pain at the site of a previously treated facet joint may be treated without additional diagnostic blocks if documentation supports ≥ 50% pain relief from the previous block(s) as evidenced by functional improvement, increased range of motion and decreased requirement for pain medications, that has lasted at least 3 months.

Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):

Facet joint denervation with RF medial branch neurotomy may be considered only when dual MBBs provide significant relief of the primary or index pain and duration of relief is consistent with the agent employed (see notation above regarding therapeutic blocks).
Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced ≥ 50% improvement of pain and improvement in patient specific activities of daily living (ADLs) that are documented for at least 6 months.

Limitations of Coverage:

A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the cervical/thoracic spine and five (5) in the lumbar spine.

For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.

Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented.

Non-thermal RF modalities for facet joint denervation including chemical denervation (alcohol, phenol, etc.), laser therapy, cryotherapy, as well as pulsed RF are not covered.

Intraarticular and/or extraarticular facet joint prolotherapy is not covered.


CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
CODE DESCRIPTION

64490 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

64491 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64493 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

64494 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT

64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)


ICD-10 Codes that Support Medical Necessity
Group 1 Codes:
ICD-10 CODE DESCRIPTION
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M62.830* Muscle spasm of back
M71.30 Other bursal cyst, unspecified site


References:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36471&ContrId=391&ver=18&ContrVer=1&CntrctrSelected=391*1&Cntrctr=391&s=All&DocType=2%7c4&bc=AAgAAAQAAAAA&

Ankle-Foot/Knee-Ankle-Foot Orthoses Coding Guidelines

Ankle-Foot/Knee-Ankle-Foot Orthoses Coding Guidelines


NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

For a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Ankle-foot orthoses (AFO) and knee-ankle foot orthoses (KAFO) are covered under the Medicare Braces Benefit (Social Security Act §1861(s)(9)). For coverage under this benefit, the orthosis must be a rigid or semi-rigid device, which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Items that are not sufficiently rigid to be capable of providing the necessary immobilization or support to the body part for which it is designed do not meet the statutory definition of the Braces Benefit. Items that do not meet the definition of a brace are statutorily noncovered, no benefit.

Both “off-the-shelf” (OTS) and custom-fit items are considered prefabricated braces for Medicare coding purposes. 42 CFR §414.402 establishes that correct coding of AFO and KAFO items is dependent upon whether there is a need for “minimal self-adjustment” during the final fitting at the time of delivery. (See definitions below in Coding Guidelines). If a custom fit code is billed when minimal self-adjustment was provided at final delivery, or if an OTS code is billed when more than minimal self-adjustments were made at final delivery, the claims will be denied as incorrect coding with a statutory denial.

A static/dynamic Ankle-Foot Orthosis (AFO) (L4396, L4397) and replacement interface (L4392) are denied as noncovered (no Medicare benefit) when they are used solely for the prevention or treatment of a heel pressure ulcer because for these indications they are not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).

A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) are denied as noncovered (no Medicare benefit) when they are used solely for the prevention or treatment of a pressure ulcer because for these indications they are not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).

Elastic or other fabric support garments (A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE)) with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Code A4467 is denied as noncovered (no Medicare benefit). Refer to the coding guideline below for additional information.

A foot pressure off-loading/supportive device (A9283) is denied as noncovered (no Medicare benefit), because it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body.

An inversion/eversion correction device (A9285) is denied as noncovered (no Medicare benefit), because it does not act as a brace; that is, it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body.

Socks (L2840, L2850) used in conjunction with orthoses are denied as noncovered (no Medicare benefit).

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

There is no separate payment if CAD-CAM technology is used to fabricate an orthosis. Reimbursement is included in the allowance of the codes for custom fabricated orthoses.

Evaluation of the beneficiary, measurement and/or casting, and fitting/adjustments of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.

Payment for ankle-foot orthoses or knee-ankle foot orthoses are included in the payment to a hospital or skilled nursing facility (SNF) if:

The orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; and,

The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., after ankle, foot, or knee surgery).
A claim should not be submitted to the DME MAC in this situation.

Payment for ankle-foot orthoses or knee-ankle foot orthoses are also included in the payment to a hospital or a Part A covered SNF stay if:

The orthosis is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to the day of discharge; and,

The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.
A claim must not be submitted to the DME MAC in this situation.

Payment for ankle-foot orthoses or knee-ankle foot orthoses delivered to a beneficiary in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if:

The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and,

The orthosis is provided to the beneficiary within two days prior to discharge to home; and,

The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

General Requirements

The supplier must include on the claim line the diagnosis code(s) for HCPCS codes L4396, L4397, L4392 and L4631.

For a custom-fabricated orthosis, there must be documentation in the supplier's records to support the medical necessity of that type device rather than a prefabricated orthosis. This information must be available upon request.

When providing these items suppliers must:

Provide the product that is specified by the ordering physician
Be sure that the ordering physician's medical record justifies the need for the type of product (i.e., Prefabricated versus Custom Fabricated)
Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
Have detailed documentation in the supplier's record that justifies the code selected
For prefabricated orthoses (L1902, L1906, L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4350, L4360, L4361, L4370, L4386, L4387 and L4396-L4398), there is no physical difference between orthoses coded as custom fitted versus those coded as off-the-shelf. The differentiating factor for proper coding (see definitions in Coding Guidelines below) is the need for “minimal self-adjustment” at the time of fitting by the beneficiary, caretaker for the beneficiary, or supplier. This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training. Items requiring minimal self-adjustment are coded as off-the-shelf orthoses. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category.

Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS.

Items requiring more than minimal self-adjustment by a qualified practitioner (as defined in the Coding Guidelines below) are coded as custom fitted (L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4360, L4386, L4396). Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.

For custom fabricated orthoses (L1904, L1907, L1920, L1940-L1950, L1960, L1970, L1980-L2034, L2036-L2038, L2106-L2108, L2126-L2128, L4631), there must be detailed documentation in the treating physician’s records to support the medical necessity of custom fabricated rather than a prefabricated orthosis as described in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD. This information will be corroborated by the functional evaluation in the orthotist or prosthetist’s records. This information must be available upon request.

MODIFIERS

KX, GA, and GZ MODIFIERS:

Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the “Coverage Indications, Limitations and or Medical Necessity” section in the related LCD have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.

MISCELLANEOUS

In addition, if the item is custom fabricated, a complete and clear description of the item, including what makes this item unique, and a breakdown of charges (material and labor used in fabrication). This information should be entered in the narrative field of an electronic claim.

A claim for code L4205 must include an explanation of what is being repaired. A claim for code L4210 must include a description of each item that is billed. This information should be entered in the narrative field of an electronic claim.

All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.

Refer to the Orthopedic Footwear policy for information on documentation requirements for shoes and related items which are an integral part of a brace.

CODING GUIDELINES

Off-the-shelf (OTS) orthotics are:

Items that are prefabricated.
They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, and molding, assembling, or customizing to fit an individual.
This fitting does not require expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary.
The term “minimal self-adjustment” is defined at 42 CFR §414.402 as an adjustment the beneficiary, caregiver for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. See “more than minimal self-adjustment” definition below for additional information.

Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient may be considered as OTS if the final fitting upon delivery to the patient requires minimal self-adjustment not requiring expertise as described in this section.

Custom fitted orthotics are:

Devices that are prefabricated.
They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
Classification as custom fitted requires more than minimal self-adjustment for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.
This fitting at delivery does require expertise of a certified orthotist or an individual who has specialized training in the provision of orthosis to fit the item to the individual beneficiary.
In contrast to “minimal self-adjustment,” “more than minimal self-adjustment” is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.

In most cases for prefabricated orthoses, the correct coding of the orthosis is dictated by actions that take place at the time of fitting to the beneficiary, either custom-fit (requiring expertise) or OTS (requiring minimal self-adjustment). However, for certain types of orthoses, the HCPCS code narrative that best describes the product does not make a distinction between prefabricated orthoses that are provided as custom-fit or OTS. These code narratives are correct and must be used for Medicare billing, without regard to how the product is provided to the beneficiary at the final delivery.

There are products that may be either fit by the beneficiary or require custom fitting at the time of final delivery. There are parallel sets of HCPCS codes (L4360, L4361, L4386, L4387, L4396 and L4397) that describe identical types of items. The codes are only differentiated based upon the nature of the final fitting performed at the time of delivery. The alternative HCPCS code types are:

HCPCS codes which describe “PREFABRICATED, OFF-THE-SHELF” must be used when minimal self-adjustment is the extent of the fitting performed at delivery.
HCPCS codes which describe “PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE” must be used when more than minimal self-adjustment is necessary at delivery.
Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient may be considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.

Kits are:

A collection of components, materials, and parts that require further assembly before delivery of the final product.
The elements of a kit may be packaged and complete from a single source or may be an assemblage of separate components from multiple sources by the supplier.

Elastic and Similar Stretchable Materials

For items where the HCPCS code specifies “elastic” or other similar terminology for stretchable material, use the code that is most applicable to the item. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.

For items where the HCPCS code does not specify elastic or other similar terminology for stretchable material, the following guidelines apply:

Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra®) (not all-inclusive)) must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).
Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra®]) (not all-inclusive)) that contain stays and/or panels must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).
Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).
Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).
Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed must be coded using the applicable specific HCPCS code for the type of product. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.
Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using the applicable specific HCPCS code for the type of product. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and relevant coding guideline for the criteria applicable for each HCPCS code.
Items that are not capable of providing the necessary immobilization or support to the body part for which it is designed (regardless of materials) must be coded using A9270 (NONCOVERED ITEM OR SERVICE).
Ankle-foot orthoses described by codes L1900, L1910 - L1990, extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthotics which are shoe inserts that do not extend above the ankle and ankle gauntlets described by codes L1902 – L1907.

Code L1906 describes a multiligamentous ankle support that provides control of the ankle joint between the medial and lateral malleoli while allowing for dorsiflexion and plantar flexion by way of a hinge or joint mechanism. This off-the-shelf ankle support includes a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation. This, in conjunction with wrap-around straps and the inherent gauntlet design, offers areas of multiligamentous support as described by the code. There are no additional HCPCS codes for this type of prefabricated ankle orthosis. Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification List.

L1960 describes an Ankle Foot Orthosis (AFO) which provides ankle control for beneficiaries with musculoskeletal or neuromuscular dysfunction. The AFO is designed to provide rigid immobilization of the ankle-foot complex in the sagittal, coronal, and transverse planes. The custom fabricated solid ankle AFO can be constructed from thermosetting materials, thermoplastics, or composite type materials.

L2340 is a pre-tibial shell, custom fabricated, that provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.

Code L2755 describes an addition to a lower extremity orthosis composed of high strength and/or lightweight material such as Kevlar®, carbon fiber or other laminated or impregnated composite material.

A nonambulatory ankle-foot orthosis may be either an ankle contracture splint, night splint or a foot drop splint.

A static or dynamic positioning ankle-foot orthosis (L4396, L4397) is a prefabricated ankle-foot orthosis which has all of the following characteristics:

Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45°; and,

Applies a dorsiflexion force to the ankle; and,

Used by a beneficiary who is minimally ambulatory, or nonambulatory; and,

Has a soft interface.
A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of the following characteristics:

Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and,

Not designed to accommodate an ankle with a plantar flexion contracture; and,

Used by a beneficiary who is nonambulatory; and,

Has a soft interface.
Code L4631 describes a Charcot’s restraint orthotic walker (CROW) orthosis. Code L4631 is a custom fabricated ankle-foot orthosis which has all of the following characteristics:

Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and,

Allows for varus or valgus deformity correction; and,

Contains a rocker bottom sole with a custom arch support; and,

Incorporates a rigid anterior tibial shell; and,

Used by a beneficiary who is ambulatory; and,

Has a soft interface

Totally encapsulated.

Code L4631 includes all additions including straps and closures. No additional codes may be billed with code L4631.

Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2034, L2036-L2108, L2126-L2128 and L4631 describe custom-fabricated orthoses. These codes must not be used for prefabricated orthoses.

Codes L1902, L1906, L1910, L1930-L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, and L4350-L4398 describe prefabricated orthoses. These codes must not be used for custom-fabricated orthoses.

Codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are used for an ankle-foot orthosis which is worn when a beneficiary is ambulatory.

Codes L4396 and L4397 are used for an ankle-foot orthosis which is worn when a beneficiary is nonambulatory, or minimally ambulatory.

Code L4398 is used for an ankle-foot orthosis which is worn when a beneficiary is nonambulatory.

Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.

HCPCS codes L4050 and L4055 do not describe replacement soft interfaces used with contracture orthoses.

Foot orthotics are shoe inserts that do not extend above the ankle. The correct codes for foot orthotics provided for beneficiaries without diabetes are L3000-L3090 (Refer to the Orthopedic Footwear policy for more information). Multiple density foot orthotics used in the management of diabetic foot problems are coded A5512, A5513, and K0903 (code K0903 effective for DOS on or after 04/01/2018) (Refer to the Therapeutic Shoes for Persons with Diabetes policy for more information).

All claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint for any condition other than an assistive function to joint extension motion must be coded as Durable Medical Equipment using code E1810 (DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). If a concentric adjustable torsion style mechanism in the knee joint is used solely to provide an assistive function for joint extension, it must be coded as L2999 (See Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).

All claims for devices that contain a concentric adjustable torsion style mechanism in the ankle joint for any condition other than an assistive function to joint plantar- or dorsiflexion motion must be coded as Durable Medical Equipment using code E1815 (DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). If a concentric adjustable torsion style mechanism in the ankle joint is used solely to provide an assistive function for joint plantar or dorsiflexion, it must be coded as L2999 (See Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).

Claims for devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint and that are being used to treat any condition other than an assistive function to joint extension motion are not covered under the Braces benefit and will be denied as incorrect coding when billed using code L2999 (See Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).

Code A9283 (FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH) is used for an item that is designed primarily to reduce pressure on the sole or heel of the foot. It may be a shoe-like item, an item that is used inside a shoe and may or may not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated. Code A9283 does not include items that meet the definition of a therapeutic shoe for diabetes (A5500, A5501).

Prefabricated walking boots are coded using codes L4360, L4361, L4386 or L4387. These codes describe complete products. Claims for add-on codes used with walking boots coded L4360, L4361, L4386 or L4387 will be denied as unbundling.

Certain products may have both covered and non-covered uses, as defined by the Braces benefit category, and must be coded based on the beneficiary’s condition. For example, when used as a brace for the treatment of an orthopedic condition, walking boots are coded L4360, L4361, L4386, L4387 and L4631. However, walking boots must be coded A9283 when used solely for the prevention or treatment of a lower extremity ulcer or pressure reduction.

When using code A9283, there is no separate billing using addition codes. Replacement liners for devices billed with A9283 must be billed with code A9270 (noncovered item or service).

Code A9285 (INVERSION/EVERSION CORRECTION DEVICE) is designed to provide off-loading pressure to the knee for the treatment of knee osteoarthritis. The device is applied at the foot and extends across the ankle to apply pressure to the side of the leg below the knee. It does not provide any support at the ankle.

The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions, and replacement parts. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

Code L4205 (Repair of orthotic device, labor component, per 15 minutes) may only be billed for time involved with the actual repair of an orthosis or for medically necessary adjustments made more than 90 days after delivery. Code L4205 must not be used to bill for time involved with other professional services including, but not limited to:
Evaluating the beneficiary
Taking measurements, making a cast, making a model, use of CAD/CAM
Making modifications to a prefabricated item to fit it to the individual beneficiary
Follow-up visits
Making adjustments at the time of or within 90 days after delivery
Suppliers must distinguish between repair and replacement of an orthosis. When an orthotic is replaced, there is no separate billing for the above services because reimbursement for these services is included in the allowance for the replacement item.

Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier's record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.

The allowance for the labor involved in replacing an orthotic component that is coded with a specific L code is included in the allowance for that component. The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous code L4210 is separately payable in addition to the allowance for that component.

Addition codes L4002 – L4130, and L4392 are for billing of replacement components and are not payable at initial issue of a base orthosis. When claims for code(s) L4002 – L4130, and L4392 are billed at the time of initial issue of a base orthosis, the addition code(s) will be rejected as incorrect coding.

Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.

Coding Information
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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes
N/A

ICD-10 Codes that are Covered

Group 1 Paragraph:
The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on “Coverage Indications, Limitations, and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS codes L4392, L4396 and L4397:


ICD-10 CODE DESCRIPTION
M24.571 Contracture, right ankle
M24.572 Contracture, left ankle
M24.573 Contracture, unspecified ankle
M24.574 Contracture, right foot
M24.575 Contracture, left foot
M24.576 Contracture, unspecified foot
M72.2 Plantar fascial fibromatosis



Group 2 Paragraph:
For HCPCS code L4631:

ICD-10 CODE DESCRIPTION
A52.16 Charcot's arthropathy (tabetic)
M14.671 Charcot's joint, right ankle and foot
M14.672 Charcot's joint, left ankle and foot
M14.679 Charcot's joint, unspecified ankle and foot


Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Coding

Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Coding
Arthroscopy is a surgical procedure that allows the direct visualization of the interior joint space. In addition to providing visualization, arthroscopy enables the process of joint cleansing through the use of lavage or irrigation. Lavage alone may involve either large or small volume saline irrigation of the knee by arthroscopy. Although generally performed to reduce pain and improve function, current practice does not recognize the benefit of lavage alone for the reduction of mechanical symptoms. Arthroscopy also permits the removal of any loose bodies from the interior joint space, a procedure termed debridement. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 150.9).

In June, 2004 CMS issued a national coverage determination (NCD) for non-covered arthroscopic procedures for patients with osteoarthritis. This NCD specified that medical necessity decisions for coverage of debridement procedures in patients without severe osteoarthritis of the knee who presented with symptoms in addition to pain were at the discretion of the Medicare contractor (carrier or intermediary). This article reiterates non-coverage instructions in CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 150.9 and provides coding and billing guidelines for arthroscopic lavage and debridement procedures. All language quoted from Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout this article.

Indications:

Not applicable

Limitation:

CMS does not consider the following procedures to be reasonable or necessary in the treatment of the osteoarthritic knee and is considered non-covered by the Medicare program:

Arthroscopic lavage used alone for the osteoarthritic knee; or
Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,
Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis
Patients without severe osteoarthritis of the knee who present with symptoms other than pain alone; i.e., (1) mechanical symptoms that include, but are not limited to, locking, snapping, or popping (2) limb and knee joint alignment, and (3) less severe and/or early degenerative arthritis, remain at local contractor discretion. Medicare contractors may require submission of one or all of the following documents to define the patient’s knee condition:
Operative notes,
Reports of standing x-rays, or,
Arthroscopy results.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed.

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services):

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, revised 09/05/2008, for complete instructions.

Specific coding information for this policy

The physician/provider performing the procedure is responsible for identifying those patients for whom Medicare does not consider the procedure “reasonable or necessary.”

Report CPT code 29999 (Unlisted procedure, arthroscopy) for arthroscopic lavage of the knee for treatment of osteoarthritis and/or arthroscopic debridement and lavage for patients with severe osteoarthritis.

Report CPT code 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chrondroplasty]) for arthroscopic debridement with presentation of knee pain only, or arthroscopic debridement without lavage for patients with severe osteoarthritis.

Report HCPCS code G0289 for arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee.

For claims submitted to the Part B MAC:

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.



Coding Information
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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Bill Type Codes Information Table

CODE DESCRIPTION

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital 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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

The Revenue Codes Information Table

CODE DESCRIPTION

036X Operating Room Services - General Classification
049X Ambulatory Surgical Care - General Classification
076X Specialty Services - General Classification
096X Professional Fees - General Classification
0975 Professional Fees - Operating Room
0982 Professional Fees - Outpatient Services
CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
CPT/HCPCS Codes Information Table

CODE DESCRIPTION

29877 ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)

29999 UNLISTED PROCEDURE, ARTHROSCOPY

G0289 ARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, FOREIGN BODY, DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) AT THE TIME OF OTHER SURGICAL KNEE ARTHROSCOPY IN A DIFFERENT COMPARTMENT OF THE SAME KNEE

ICD-10 Codes that are Covered
N/A

ICD-10 Codes that are Not Covered

Group 1 Paragraph: For CPT codes 29999, 29877, G0289 that are performed for nationally non-covered indications please report the ICD-10-CM codes below for osteoarthritis or knee pain and append the –GA or –GZ modifier as applicable

ICD-10 CODE DESCRIPTION

Bilateral primary osteoarthritis of knee
M17.11 Unilateral primary osteoarthritis, right knee
M17.12 Unilateral primary osteoarthritis, left knee
M17.2 Bilateral post-traumatic osteoarthritis of knee
M17.31 Unilateral post-traumatic osteoarthritis, right knee
M17.32 Unilateral post-traumatic osteoarthritis, left knee
M17.4 Other bilateral secondary osteoarthritis of knee
M17.5 Other unilateral secondary osteoarthritis of knee
M17.9 Osteoarthritis of knee, unspecified
M25.561 Pain in right knee
M25.562 Pain in left knee

Referencess:

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52369&ver=7&DocType=All&bc=AACAAAAAAAAA&


Bariatric Surgery CPT Coding & Coverage

Bariatric Surgery CPT Coding & Coverage

The following coding guidance is published based on the requirements in effect as of the effective date of this article and no longer addresses past coverage. Prior coverage may be different depending upon the date of service and can be obtained from the National Coverage Determination 100.1.

As of the effective date of this article revision Medicare (CMS) has established by NCD 100.1 that the following bariatric surgery procedures are reasonable and necessary under specified conditions for the treatment of complications of morbid obesity.
1. Roux-en-Y Gastric Bypass (RYGBP)
2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS)
3. Laparoscopic Adjustable Gastric Banding (AGB)
4. Laparoscopic Sleeve Gastrectomy

To be eligible for bariatric surgery the patient must have a body-mass index (BMI) ≥ 35, and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant.

Noridian considers the following, based on national guidelines for bariatric care, to be the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD:

1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patient’s weight and BMI, current dietary regimen and physical activity (e.g. exercise program).
2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.
3. A thorough multidisciplinary evaluation is required within the previous six months which includes ALL of the following:
a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s)
b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiary’s primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgery
c. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirements
d. a nutritional evaluation by a physician or registered dietician.

Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZ

Nationally Covered Inpatient Facility ICD-10-CM Procedure Codes

For services on or after October 1, 2014, the following ICD-10 procedure codes are covered for bariatric surgery:

Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the following ICD-10-PCS codes:

0DB64Z3
0DV64CZ
0D16479
0D1647A
0D1647B
0D1647L
0D164J9
0D164JA
0D164JB
0D164JL
0D164K9
0D164KA
0D164KB
0D164KL
0D164Z9
0D164ZA
0D164ZB
0D164ZL

Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes:

0D16079
0D1607A
0D1607B
0D1607L
0D160J9
0D160JA
0D160JB
0D160JL
0D160K9
0D160KA
0D160KB
0D160KL
0D160Z9
0D160ZA
0D160ZB
0D160ZL
0D16879
0D1687A
0D1687B
0D1687L
0D168J9
0D168JA
0D168JB
0D168JL
0D168K9
0D168KA
0D168KB
0D168KL
0D168Z9
0D168ZA
0D168ZB
0D168ZL

To describe either laparoscopic or open BPD with DS or GRDS, one code from each of the following three groups must be on the claim:

Group 1:
0DB60Z3
0DB60ZZ
0DB63Z3
0DB63ZZ
0DB67Z3
0DB67ZZ
0DB68Z3

Group 2:
One code from Groups A-C below is required.

Group A:
0DB80ZZ
0DB90ZZ
0DBB0ZZ

Group B:
0D160ZB

Group C:
0F190Z3

Group 3:
0D19079
0D1907A
0D1907B
0D190J9
0D190JA
0D190JB
0D190K9
0D190KA
0D190KB
0D190Z9
0D190ZA
0D190ZB
0D19479
0D1947A
0D1947B
0D194J9
0D194JA
0D194JB
0D194K9
0D194KA
0D194KB
0D194Z9
0D194ZA
0D194ZB
0D19879
0D1987A
0D1987B
0D198J9
0D198JA
0D198JB
0D198K9
0D198KA
0D198KB
0D198Z9
0D198ZA
0D198ZB
0D1A07A
0D1A07B
0D1A0JA
0D1A0JB
0D1A0KA
0D1A0KB
0D1A0ZA
0D1A0ZB
0D1A47A
0D1A47B
0D1A4JA
0D1A4JB
0D1A4KA
0D1A4KB
0D1A4ZA
0D1A4ZB
0D1A87A
0D1A87B
0D1A8JA
0D1A8JB
0D1A8KA
0D1A8KB
0D1A8ZA
0D1A8ZB
0D1A8ZH
0D1B07B
0D1B0JB
0D1B0KB
0D1B0ZB
0D1B47B
0D1B4JB
0D1B4KB
0D1B4ZB
0D1B87B
0D1B8JB
0D1B8KB
0D1B8ZB
0D1B8ZH

NOTE: There is no distinction between open and laparoscopic BPD with DS or GRDS for the inpatient setting. For either approach, one code from each of the above three groups must appear on the claim to be covered.

Nationally Non-Covered Procedures

For services on or after February 21, 2006, Medicare (CMS) has determined that the following bariatric surgery procedures are not reasonable and necessary for the treatment of morbid obesity (primary ICD-10-CM diagnosis code E66.01):
• Open adjustable gastric banding (Billed with a Not Otherwise Classified (NOC) code)
• Open sleeve gastrectomy;
• Laparoscopic sleeve gastrectomy (prior to June 27, 2012);
• Open and laparoscopic vertical banded gastroplasty;
• Intestinal bypass surgery; and,
• Gastric balloon for treatment of obesity.


Coding Information

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Bill Type Codes Information Table

CODE DESCRIPTION
011x Hospital Inpatient (Including Medicare Part A)
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph:
Nationally Covered CPT Procedure Codes

For services on or after February 21, 2006, the following CPT procedure codes are covered for bariatric surgery:



Group 1 Codes:

CPT/HCPCS Codes Information Table

CODE DESCRIPTION

43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)

43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

43770 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)

43845 GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

43846 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY

43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

Group 2 Paragraph:
Noridian Local Coverage for Laparoscopic Sleeve Gastrectomy



Group 2 Codes:

CPT/HCPCS Codes Information Table

CODE DESCRIPTION

43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)

ICD-10 Codes that are Covered

Group 1 Paragraph:

To ensure proper claims processing, claims must contain the following information:
• CPT 43775 or ICD-10-PCS 0DV64CZ
• The ICD-10-CM code E66.01 (Morbid (severe) obesity due to excess calories),
• An ICD-10-CM code reflecting the co-morbid condition necessitating the procedure (e.g., diabetes, hypertension, cardiac or respiratory diseases) and
• An ICD-10-CM code describing the patient’s BMI.

Acceptable ICD-10-CM codes describing the co-morbid condition and supporting medical necessity for bariatric surgical procedures are:

ICD-10 CODE DESCRIPTION

E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma
E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye
E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye
E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye
E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye
E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye
E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye
E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye
E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye
E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral
E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E08.59 Diabetes mellitus due to underlying condition with other circulatory complications
E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy
E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis
E08.621 Diabetes mellitus due to underlying condition with foot ulcer
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer
E08.628 Diabetes mellitus due to underlying condition with other skin complications
E08.630 Diabetes mellitus due to underlying condition with periodontal disease
E08.638 Diabetes mellitus due to underlying condition with other oral complications
E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication
E08.8 Diabetes mellitus due to underlying condition with unspecified complications
E08.9 Diabetes mellitus due to underlying condition without complications
E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma
E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma
E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy
E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease
E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema
E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

ICD-10 CODE DESCRIPTION
Z68.35 Body mass index (BMI) 35.0-35.9, adult
Z68.36 Body mass index (BMI) 36.0-36.9, adult
Z68.37 Body mass index (BMI) 37.0-37.9, adult
Z68.38 Body mass index (BMI) 38.0-38.9, adult
Z68.39 Body mass index (BMI) 39.0-39.9, adult
Z68.41 Body mass index (BMI) 40.0-44.9, adult
Z68.42 Body mass index (BMI) 45.0-49.9, adult
Z68.43 Body mass index (BMI) 50-59.9, adult
Z68.44 Body mass index (BMI) 60.0-69.9, adult
Z68.45 Body mass index (BMI) 70 or greater, adult

References: