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Did You Know? – Medical Policies and Coverage

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  1. CGS promised to develop PET Scan articles to address CGS' proof of medical necessity and coverage of ICD-9 CM diagnosis code 793.1 Were articles developed and published?
  2. Where do we find Local Coverage Determinations (LCDs) for CGS?

    • CGS J15 LCDs are not housed on the CGS website, although CGS maintains an LCD web page. Follow the links on the CGS LCD web page to go directly to the CMS LCD database. Follow these step-by-step instructions for viewing CGS LCDs from the CMS website in the Medicare Coverage DatabaseExternal Website.

      1. Under Quick Search, click on the Local Coverage Documents radio button.
      2. In the Select Geographic Area/Regionchoose a state/jurisdiction.
      3. Type a keyword (the topic you wish to view) – example: PET.
      4. Click on Search By Type.

      Note: Pay close attention to whether the LCD is specific to Part A or Part B. Also, note that there may not be an LCD for every service. Some services are subject to National Coverage Determinations (NCDs). The Social Security Act (section 1862(a)(1)(A)) defines "medical necessity" as a criterion for payment (there are some exceptions for certain preventive and screening services.

      Reviewed 09/22/2021
  3. If a CT scan is done on the same day as a PET scan, since they are different machines, are they allowed separately with a modifier and same diagnosis?

    • Check the National Correct Coding Initiative (NCCI) editsExternal Websiteon the CMS website to determine if certain code pairs are billable and payable separately. According to NCCI rules and edits, a diagnostic test code may be considered to be a comprehensive code and includes the component code, resulting in no separate payment for the component service. The edit tables indicate if a component code is billable and considered for payment with a modifier. Reminder: documentation must support the need for two separate tests on the same day, any/all modifiers submitted with the services, and the medical necessity for the two tests. If you are not familiar with NCCI edits, please review the CMS MLN® booklet How to Use the National Correct Coding Initiative (NCCI) ToolsExternal PDF.

      Reviewed 09/22/2021
  4. We recently found out that these procedure codes are no longer valid in place of service #11 (office). Whys is this if the physician is interpreting the home sleep studies in the office; he does not do this in the patient's home.

    G0398 Home sleep test/type II portable monitor
    G0399 Home sleep test with type III portable monitor
    G0400 Home sleep test with type IV portable monitor
    95800 Sleep study, unattended, simultaneous recording w/sleep time
    95801 Sleep study, unattended, simultaneous recording

    • According to CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 13, section 150External PDF

      "The appropriate POS code for the interpretation or professional component (PC) of a procedure is the setting where the beneficiary receives the technical component (TC) of the service. "

      The code descriptions of Home or Unattended monitoring provide that the patient cannot be in a supervised clinical setting while receiving the test.

      Reviewed 09/22/2021
  5. Is it required for "Direct Supervision" of care to be provided by the same specialty as the person performing the procedure?
  6. We have a patient who already has a Cochlear Implant, but would greatly benefit from one on her other ear. How many will Medicare pay for on one patient?

    • Medicare coverage for cochlear implants is provided only for those patients who have bilateral moderate-to-profound hearing impairment. Assuming the initial cochlear implant was effective in amplifying hearing above 40%, the patient would no longer meet the coverage requirement of "bilateral hearing loss."

      Reference:

      Reviewed 09/22/2021
  7. Does CMS allow for physicians to bill an E/M encounter at the same time as the Face to Face for Transitional Care Management (TCM) if the patient presents with additional problems not treated in the hospital?

    • CMS does not allow providers to bill an Evaluation and Management (E/M) visit on the same day as the TCM Face-to-Face visit regardless of the issues identified during the visit. The required encounter encompasses all problems or potential problems even if they are not related to why the beneficiary was hospitalized. The rationale is that following an inpatient admission, one would expect findings to be more comprehensive than a routine visit. The complexity of the evaluation is already incorporated into the TCM codes. If additional visits are required during the 30 day period, those encounters may be billed with the appropriate Established Patient E/M code without Modifier 25. It is important to note this should be a relatively rare occurrence and if billed in excess, claims may be subject to Medical Review.

      Reference:

      Reviewed 09/22/2021
  8. Is there a mechanism in place that allows for reimbursement of prolonged Drug and Biological Infusions started Incident-to Physician's services using external pumps?
  9. Regarding Transitional Care Management (TCM), is it required for an advanced trained clinician (MD or NPP) required to conduct an Interactive Contact with the patient?

    • Per the attached CMS Publication, an Interactive Contact may be made by you OR clinical staff who "have the capacity for prompt interactive communication addressing the patient's status and needs beyond scheduling follow-up care."

      CMS does not require this service to be performed by an advanced care practitioner, assuming all other coverage criteria are met.

      Reference:

      Reviewed 09/22/2021

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