Local Coverage Article: Category III CPT® Code Coverage (A52375)

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Contractor Information

Contractor Name Contract Type Contract Number Jurisdiction State(s) CGS Administrators, LLC MAC - Part A 15101 - MAC A J - 15 Kentucky CGS Administrators, LLC MAC - Part B 15102 - MAC B J - 15 Kentucky CGS Administrators, LLC MAC - Part A 15201 - MAC A J - 15 Ohio CGS Administrators, LLC MAC - Part B 15202 - MAC B J - 15 Ohio Back to Top Article Information

General Information

Article ID Original Article Effective Date A52375 10/01/2015

Original ICD-9 Article ID Revision Effective Date A50740 01/01/2018

Revision Ending Date Article Title N/A Category III CPT® Code Coverage Retirement Date AMA CPT / ADA CDT / AHA NUBC Copyright N/A Statement CPT only copyright 2002-2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association.

Printed on 2/18/2018. Page 1 of 16 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

Article Guidance

Article Text:

The information in this article supplements the information provided in the local coverage determination (LCD) for CPT Category III Codes. The LCD and accompanying supplemental instructions article (SIA) can be accessed through our contractor Web site at www.cgsmedicare.com/J15. It can also be found through the Medicare Coverage Database at www.cms.gov/mcd.

Abstract:

The CGS "LCD for Category III CPT ® Codes (L34370)" states that CGS will not consider items, services, or procedures represented by these codes to be medically necessary unless there is a published local coverage determination or coverage article specifically extending coverage to a particular Category III code. The following lists services for which past claim or other reviews have been found to be "reasonable and medically necessary." Coverage will be allowed when the service is delivered in clinical situations meeting criteria for medical necessity.

Indications:

0024T Non-surgical septal reduction therapy (eg, alcohol ablation), for hypertrophic obstructive cardiomyopathy, with coronary arteriograms, with or without temporary pacemaker

Patients with resting or provocable outflow gradients have derived benefit from intentional infarction of a portion of the interventricular septum by the infusion of alcohol into a selectively catheterized septal artery. Reduction of outflow gradient and mitral regurgitation, improvement of ventricular relaxation, regression of hypertrophy, and reduction in symptoms have followed. It is anticipated the procedure would only be performed in individuals whose severity of symptoms and disease were appropriate for the procedure.

The CPT code 0024T was added because the existing Category I CPT codes did not describe all of the work required to perform the procedure. However, the code (0024T) will be deleted effective December 31, 2007. The CPT code 93799 (unlisted cardiovascular service or procedure) should be used effective January 1, 2008.

Diagnoses that support the medical necessity for 0024T must include the following in addition to the condition(s) necessitating the procedure:

I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy

0048T Implantation of a ventricular assist device, extracorporeal, percutaneous transeptal access, single or dual cannulation

0048T has been deleted effective 12/31/12 and replaced with CPT code 33991 effective 01/01/13.

+0049T Prolonged extracorporeal percutaneous transeptal ventricular assist device, greater than 24 hours, each subsequent 24 hour period (list separately in addition to code for primary procedure)

CPT code 0049T has been deleted effective 12/31/2008. Effective for dates of service on and after 01/01/2009, Category I CPT code 33999 (unlisted procedure, cardiac surgery) should be reported.

0050T Removal of a ventricular assist device, extracorporeal, percutaneous transspetal access, single or dual cannulation

Printed on 2/18/2018. Page 2 of 16 0050T has been deleted effective 12/31/12 and replaced with CPT codes 33990-33993 effective 01/01/2013.

Ventricular assist devices can be implanted to provide extracorporeal circulatory support for patients in cardiogenic shock. Open-heart surgery is not required. The implantation is usually performed in the cardiac catheterization laboratory. Removal, after weaning, can be performed at the patient’s bedside.

The ICD-10-CM diagnosis code that supports the medical necessity for 0048T – 0050T is R57.0, cardiogenic shock.

0051T, 0052T, and 0053T-Artificial Heart and Devices

Codes 0051T-0053T will be covered under the NCD for artificial hearts and their devices effective 04/01/13. Please follow the information outlined in NCD 20.9.

+0056T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, image-less (List separately in addition to code for primary procedure)

Computer-assisted musculoskeletal surgical navigational techniques have been applied to many different orthopedic surgical techniques to allow the surgeon to improve the accuracy and minimize the invasiveness of the surgical procedure. A computer uses an optical or electromagnetic sensor to track the surgical instruments and the predicted path of devices. Imageless procedures allow the surgeon to create an image which provides an intraoperative, real-time image of the patient’s anatomy.

Payment for 0056T has been allowed when used for patients undergoing knee or hip arthroplasty. The diagnoses supporting the medical necessity for 0056T are those supporting the knee or hip arthroplasty:

M16.0 Bilateral primary osteoarthritis of hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unliateral primary osteoarthritis, left hip M17.0 Bilateral primary osteoarthritsis of knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 unilateral primary osteoarthritis, left knee M16.9 Osteoarthrosis of hip, unspecified M17.9 Osteoarthritis of knee, unspecified

The CPT code +0056T will be deleted effective December 31, 2007. The replacement code will be CPT code 20985.

0073T Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session

Compensator-based beam modulation therapy uses intensity modulated radiotherapy (IMRT) dose delivery and beam modulation using a physical absorber to modulate the radiation beam with placement of the compensator between the accelerator target and the patient. The category III CPT code was developed because multileaf collimation is not used and current CPT codes did not accurately describe this method of radiation delivery.

The CMS has given CPT code 0073T an "A" = active status on the Medicare Physician Fee Schedule Database and also determined the fee for the service. The diagnosis supporting the medical necessity for 0073T is the ICD-10- CM code for the malignancy requiring IMRT treatment.

0073T was end dated 12/31/2015 and replaced with CPT code 77385.

0075T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel

+0076T each additional vessel (List separately in addition to code for primary procedure)

Services described by CPT codes 0075T and +0076T are allowed when provided in accordance with the "NCD for Percutaneous Transluminal Angioplasty (PTA) (20.7)." (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.7). Billing instructions are listed in the CMS Publication 100 -04, Medicare Claims Processing Manual, Chapter 32, Sections 160-160.3.

The Medicare Claims Processing Manual, as referenced immediately above, instructs contractors to allow claims Printed on 2/18/2018. Page 3 of 16 that contain any of the following ICD-10-CM diagnosis codes. All other criteria listed in the national coverage determination must also be met. The ICD-10-CM diagnosis codes that support medical necessity are:

I63.031 Cerebral infarction due to thrombosis of right carotid artery I63.032 Cerebral infarction due to thrombosis of left carotid artery I63.131 Cerebral infarction due to embolism of right carotid artery I63.132 Cerebral infarction due to embolism of left carotid artery I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries I65.21 Occlusion and stenosis of right carotid artery I65.22 Occlusion and stenosis of left carotid artery I65.23 Occlusion and stenosis of bilateral carotid arteries I65.8 Occlusion and stenosis of other precerebral arteries and one of the following: I65.21, I65.22, or I65.23

I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery and one of the following: I63.031, I63.032, I63.131, I63.132, I63.231, or I63.232

0088T Submucosal radiofrequency tissue volume reduction of tongue base, one or more sites, per session (i.e., for treatment of obstructive sleep apnea syndrome)

Submucosal radiofrequency tissue volume reduction of the tongue base is only allowed when performed with other medically necessary surgical procedures for the treatment of obstructive sleep apnea which has not responded to appropriate medical management.

The ICD-10-CM diagnosis code supporting the medical necessity for 0088T is:

G47.33 Obstructive sleep apnea, (adult) (pediatric)

The procedure is specifically not allowed for snoring [ICD-10-CM R06.00, R06.09,R06.83, or R06.89(Symptoms involving respiratory system and other chest symptoms; other)].

CPT code 0088T has been deleted effective 12/31/2008. Effective for dates of service 01/01/2009 and after, Category I CPT code 41530 (submucosal ablation of the tongue base, radiofrequency, one or more sites, per session) should be reported.

0135T Ablation, renal tumor(s) unilateral, percutaneous, cryotherapy

Patients with renal tumors < 4 cm. in size may be candidates for percutaneous cryotherapy ablation of the tumor. Patients for whom this procedure may be appropriate include those who are poor surgical candidates, who refuse radical nephrectomy or partial nephrectomy; have multiple comorbid illnesses, a solitary kidney, renal insufficiency, or those for whom renal preservation is desired. Imaging guidance using computed tomography, magnetic resonance imaging, or ultrasound is used and separately reported.

The CPT code 0135T will be deleted effective December 31, 2007. The replacement code is 50593 [Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy]. The ICD-10-CM diagnosis code supporting the medical necessity for 0135T is:

C64.1 Malignant neoplasm of the right kidney, except renal pelvis C64.2 Malignant neoplasm of the left kidney, except renal pelvis

0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level +0172T each additional level (List separately in addition to code for primary procedure)

The Food and Drug Administration (FDA) gave pre-market approval of a spinouts process distraction device for treatment of patients aged 50 or older suffering from neurogenic intermittent claudication secondary to a confirmed diagnosis of lumbar spinal stenosis (with X-Ray, MRI, and/or CT evidence of thickened ligamentum flavum, narrowed lateral recess and/or central canal narrowing). Additional patient indications included moderately impaired physical function, symptom relief of leg/buttock/groin pain with or without back pain with flexion, and persistence of symptoms after at least six months of nonoperative treatment.

The CMS determined the spinous process distraction device met criteria for substantial clinical improvement and approved new technology add-on payment beginning in fiscal year 2007. Coverage for the device will be allowed for the FDA-approved indications. Payment for 0171T (and 0172T) will be an inclusive payment. No additional codes for approach or hardware placement should be billed or paid.

Printed on 2/18/2018. Page 4 of 16 CPT codes 0171T and 0172T were deleted effective 12/31/2015. CPT codes 22867-22870 should be used effective 01/01/2017.

Effective for dates of service 10/01/2010 and after, the following ICD-10-CM code should be reported:

M48.06

For dates of service prior to 10/01/2010, the following ICD-10-CM codes that support medical necessity includes but is not limited to:

M48.06 M48.07 M99.23 M99.33 M99.43 M99.53 M99.63 M99.73

The ICD-10-CM code G96.9 (Disorder of central nervous system, unspecified) or G98.8 (Other disorders of the nervous system) may be used for neurogenic intermittent claudication.

0176T Transluminal dilation of aqueous outflow canal; without retention of device or stent 0177T with retention of device or stent

CPT codes 0176T and 0177T have been deleted effective 12/31/2010. Effective for dates of service 01/01/2011 and after, Category I codes 66174 - transluminal dilation of aqueous outflow canal; without retention of device or stent and 66175 - transluminal dilation of aqueous outflow canal; with retention of device or stent should be reported.

Transluminal dilation of the aqueous outflow canal or transluminal canaloplasty is a form of non-penetrating glaucoma surgery that serves as an alternative to trabeculectomy in patients requiring surgical treatment of primary open-angle glaucoma (POAG). Patients requiring surgery for POAG are those in whom medical management is no longer providing adequate results. Transluminal canaloplasty has been shown to lower the intra-ocular pressure and may be associated with fewer short- and long-term complications than trabeculectomy. The procedure involves placement of a catheter into Schlemm's canal and dilation of the canal by injection of sodium hyaluronate. The device or stent may or may not be retained in Schlemm’s canal.

The ICD-10-CM diagnosis code supporting the medical necessity of the procedure is one of the following: H40.1111 H40.1112 H40.1113 H40.1114 H40.1121 H40.1122 H40.1123 H40.1124 H40.1131 H40.1132 H40.1133 H40.1134

For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.

0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and 0376T insertion eye drainage device (Note: 0376T is performed in conjunction with 0191T and is a new code for 2015)

Effective July 1, 2012 the insertion of anterior segment aqueous drainage device is allowed for medical necessity and performed in one of the following place of service; 11(office), 21 (inpatient hospital), 22 (outpatient hospital), 24 (ambulatory surgical center), and 49 (independent clinic). The ICD-10-CM diagnosis codes supporting medical necessity for 0191T and 0376T are: H40.10X1 H40.10X2 H40.10X3

Printed on 2/18/2018. Page 5 of 16 H40.10X4 H40.1111 H40.1112 H40.1113 H40.1114 H40.1121 H40.1122 H40.1123 H40.1124 H40.1131 H40.1132 H40.1133 H40.1134 H40.1211 H40.1212 H40.1213 H40.1214 H40.1221 H40.1222 H40.1223 H40.1224 H40.1231 H40.1232 H40.1233 H40.1234 H40.1311 H40.1312 H40.1313 H40.1314 H40.1321 H40.1322 H40.1323 H40.1324 H40.1331 H40.1332 H40.1333 H40.1334 . H40.151 H40.152 H40.153 Q15.0

0226T and 0227T High-Resolution Anoscopy (HRA)

CGS considers the use of HRA guidance, 0226T and 0227T, medically necessary for biopsy and ablation of high grade anal intraepithelial neoplasia, effective 11/01/2014. At this time CGS considers HRA experimental and investigational for screening of persons for anal dysplasia and anal cancer.

Effective 01/01/2015 0226T and 0227T will be replaced with G6027 and G6028

Covered ICD-10: A63.0 B20 B97.7 C21.0 C21.1 C78.5 D01.3 D12.7 D12.8 D12.9 K62.0 K62.1 K62.5 K62.6 K62.7 K62.82

Printed on 2/18/2018. Page 6 of 16 K62.89 R85.610 R85.611 R85.612 R85.613. R85.614 R85.615 R85.616 R85.618 R85.81 R85.82 Z12.0 Z12.12 Z12.79 Z12.89

0245T open treatment of rib fracture requiring internal fixation, unilateral; 1-2 ribs 0246T 3-4 ribs 0247T 5-6 ribs 0248T 7 or more ribs

Codes 0245T thru 0248T were end dated 12/31/2014 and replaced with CPT codes 21811 thru 21813.

Payment for CPT codes 0245T thru 0248T is allowed for the open treatment and internal fixation of fractured ribs and or flail chest when medically necessary effective 08/01/2012. The ICD-10-CM diagnosis codes supporting medical necessity for 0245T, 0246T, 0247T, and 0248T are:

S22.31XA Fracture of one rib,right side, initial encounter for closed one rib S22.32XA Fracture of one rib,left side, initial encounter for closed one rib S22.41XA Multiple fractures of ribs,right side, initial encounter for closed fracture S22.42XA Multiple fractures of ribs,left side, initial encounter for closed fracture S22.43XA Multiple fractures of ribs,bilateral, initial encounter for closed fracture S22.31XB Fracture of one rib, right side, initial encounter for open fracture S22.32XB Fracture of one riv, left side, initial encounter for open fracture S22.41XB Multiple fractures of ribs, right side, initial encounter for open fracture S22.42XB Multiple fractures of ribs, left side, initial encounter for open fracture S22.43XB Multiple fractures of ribs, bilateral, intial enocounter for open fracture S22.5XXA Flail chest, initial enocunter for closed fracture S22.5XXB Flail chest, initial encounter for open fracture

0249T Ligation, hemorrhoidal vascular bundles(s), including ultrasound guidance

Effective January 1, 2014 CGS will cover CPT 0249T for Doppler-guided hemorrhoid artery litagation with or without retro-anal repair for Grade II or III hemorrhoids that have failed rubber band litagation or conservative treatment.

Conservative treatments include behavior modification, high fiber diets to control constipation, and hydrocrtisone cream or suppositories.

Based on AMA CPT book it is not appropriate to submit the following CPT codes with 0249T: 46020, 46221, 46250-46262, 46600, 46945, 46945, 76872, 76942, and 76998.

0262T Implantation catheter-delivered prosthetic pulmonary valve

Effective 01/01/2015 CGS will cover 0262T if the following indications are met:

• Existence of a full (circumferential) right ventricular outflow tract (RVOT) consuit that was egqual to or greater than 16 mm in diameter when originally implanted, and • Dysfunctional RVOT conduits with a clinical indication for intervention, And/OR; regurgitation:> moderate regurgitation, and/orstenosis: mean RVOT gradient >35 mm Hg

Printed on 2/18/2018. Page 7 of 16 0262T was end dated effective 12/31/2015 and replaced with CPT code 33477 01/01/2016.

0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetecomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT) , with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar.

Effective July 1, 2012 0275T is allowed when performed in place of service 11 (office), 22 (outpatient hospital), or 24 (ambulatory surgical center).

Based on CR 5787 0275T is now considered covered based on NCD 150.13. This coverage is retro back to 01/01/14 with implementation of 10/01/14. Please follow NCD guidelines listed in IOM.

0281T Percutaneous transcatheter closure of the left atrial appendage (LAA) Effective 01/01/2015-02/07/2016 CGS will cover the Watchman device for LAA when done as part of a clinical trial. Claims should be filed with 0281T and Q0 modifier. All other devices used for LAA are still considered investigational and experimental at this time.

Code 0281T deleted effective 12/31/2016 and replaced with CPT code 33340 effective 01/01/2017.

Effective February 8, 2016 0281T will be covered based on NCD for Left Atrial Appendage Closure (LACC) per the new NCD 20.34

0295T, 0296T, 0297T, 0298T External Electrocardiographic Recording More than 48 hours (Zio Patch)

HCPCS codes 0295T, 0296T, 0297T, and 0298T will be allowed effective 08/01/14 if one of the following ICD-10 is on the claim for Zio Patch. The use of Zio Patch for screening is still non-covered.:

I44.1-Atrioventricular block, second degree I44.2-AtrioveUnspecified atrioventricular blockntricular block, complete I44.30-Unspecified atrioventricular block I45.9-Conduction disorder, unspecified I47.0-Re-entry ventricular arrhythmia I47.1-Supraventricular tachycardia I47.2-Ventricular tachycardia I47.9-Paroxysmal tachycardia, unspecified I49.2-Junctional premature depolarization I48.0-Paroxysmal atrial fibrillation I48.1-Persistent atrial fibrillation I48.2-Chronic atrial fibrillation I48.3-Typical atrial flutter I48.4-Atypical atrial flutter I49.01-Ventricular fibrillation I49.02- Ventricular flutter I49.1-Atrial premature depolarization I49.3-Ventricular premature depolarization I49.40-Unspecified premature depolarization I49.49-Other premature depolarization I49.5-Sick sinus syndrome I49.8-Other specified cardiac arrhythmias I49.9-Cardiac arrhythmia, unspecified R00.0-Tachycardia, unspecified - R00.1-Bradycardia, unspecified R00.2-Palpitations R42-Dizziness and giddiness R55-Syncope and collapse

0308T The insertion of ocular telescope prosthesis including the removal of crystalline lens

Payment for CPT code 0308T is allowed for the insertion of ocular telescope prosthesis including the removal of crystalline lens after cataract extraction when medically necessary effective 07/01/12. The ICD-10-CM diagnosis codes supporting medical necessity for 0308T are H35.3111, H35.3112, H35.3113, H35.3114, H35.3121, H35.3122, H35.3123, H35.3124, H35.3131, H35.3132, H35.3133, H35.3134 with one of

Printed on 2/18/2018. Page 8 of 16 the following for patients 65 and older: H25.11, H25.12, or H25.13.

0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0325T, 0326T, 0327T, and 0328T subcutaneous defibrillator electrode

These codes are covered based on NCD 20.3

Effective 01/01/2013 0319T-0328T is payable without a Q0 modifier if billed with one of the following ICD-10 codes : I46.2 I46.8 I46.9 I47.0 I47.2 I49.01 I49.02 I49.9 T82.110A T82.111A T82.118A T82.120A T82.121A T82.128A T82.190A T82.191A T82.198A Z45.02 Z86.74

Or if in an approved clinical trial with a Q0 modifier appended with one of the following ICD-10 for primary prevention: I09.81 I11.0 I13.0 I13.2 I21.01 I21.02 I21.09 I21.11 I21.19 I21.21 I21.29 I21.3 I21.4 I22.0 I22.1 I22.2 I22.8 I22.9 I25.2 I25.5 I25.6 I25.89 I42.0 I42.1 I42.2 I42.5 I42.8 I45.81 I50.1 I50.21 I50.22 I50.23 I50.30 I50.31 I50.32 Printed on 2/18/2018. Page 9 of 16 I50.33 I50.40 I50.41 I50.42 I50.43 I50.9 Z45.02

Codes 0319t trhu 0328T were end dated 12/31/2014 and replaced with CPT codes 33240, 33241, 33262, 33270-33273, 93260, 93261, and 93644 01/01/2015.

0343T, 0344T, 0345T Transcatheter Mitral Valve Repair (TMVR)

Effective for dates of service August 7, 2014 and forward, CGS will pay claims for TMVR based on NCD 20.33. TMVR will be covered when billed with CPT codes 0343T, 0344T, and 0345T in a clinical trial with ICD-10 diagnosis code I34.0 or I34.8 and secondary ICD-10 diagnosis code Z00.6 performed in POS 21. TMVR claims in a clinical trial billed without ICD-10 diagnosis code I34.0 or I34.8 and secondary ICD-10 diagnosis code Z00.6 will be denied.

Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.

0377T-Anoscopy with directed submucosal injection of bulking agent for fecal incontinence using products such as NASHA/Dx (Solesta ®)

Solesta ® Treatment for fecal incontinence is covered by CGS effective 01/01/2015 when the following criteria is met:

• Patient is 18 years or older • Has a documented history of fecal incontinence for at least 12 months • Documentation supports the patient has tried and failed conservative therapy (e.g., diet, fiber, anti- motility medications) • Documentation supports = 4 fecal incontinence episodes over a 14-day period; and • The beneficiary does NOT have any of the following conditions:

1. Active inflammatory bowel disease; 2. Immunodeficiency disorders or ongoing immunosuppressive therapy 3. Previous radiation treatment to the pelvic area; 4. Significant mucosal or full thickness rectal prolapse; 5. Active anorectal conditions including: abscess, fissures, sepsis, bleeding, proctitis, or other infections; 6. Anorectal atresia, tumors, stenosis or malformation; 7. Rectocele; 8. Rectal varices; 9. Presence of existing implant (other than Solesta) in anorectal region; 10. Allergy to hyaluronic acid based products (e.g., Synvisc, Synvisc-One, Hyalgan, Supartz, Euflexxa, Orthovisc); 11. Grade IV hemorrhoids; 12. History of anorectal surgery within the previous 12 months.

CGS will allow the services based on the FDA-recommended dose of 4 sub-mucosal injections for an initial treatment and 4 sub mucosal injections for repeat therapy no less than 4 weeks after the initial treatment. Treatment exceeding the FDA recommendations will be denied.

0394T: High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed

Effective 01/01/2018 CGS will allow services for 0394T when reasonable and necessary.

0474T: Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space describes the CyPass Micro-Stent System.

Printed on 2/18/2018. Page 10 of 16 Effective 07/01/2017 CyPass Micor-Stent System will be allowed when medically necessary. The following Icd-10 diagnosis codes support medical necessity for 0474T:

H40.10X1

H40.10X2

H40.10X3

H40.10X4

H40.1111

H40.1112

H40.1113

H40.1114

H40.1121

H40.1122

H40.1123

H40.1124

H40.1131

H40.1132

H40.1133

H40.1134

H40.1211

H40.1212

H40.1213

H40.1214

H40.1221

H40.1222

H40.1223

H40.1224 Printed on 2/18/2018. Page 11 of 16 H40.1231

H40.1232

H40.1233

H40.1234

H40.1311

H40.1312

H40.1313

H40.1314

H40.1321

H40.1322

H40.1323

H40.1324

H40.1331

H40.1332

H40.1333

H40.1334

H40.1411

H40.1412

H40.1413

H40.1414

H40.1421

H40.1422

H40.1423

H40.1424

H40.1431

H40.1432 Printed on 2/18/2018. Page 12 of 16 H40.1433

H40.1434

0387T, 0389T, 0390T, and 0391T Leadless Pacemakers

CGS will cover 0389T-0391T based on NCD 20.8.4 indications that were outlined in CR 10117. This will be implemented August 29, 2017 with effective date of January 18, 2017. Please review the NCD for indications of coverage. As there is a CED requirement for these codes.

Coding Guidelines:

Please refer to "Category III CPT® Codes – Supplemental Instructions Article (A52376)."

Back to Top 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.

Revenue codes only apply to providers who bill these services to the fiscal intermediary 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.

Revenue Code Revenue Code Description 020X Intensive Care Unit - General Classification 021X Coronary Care Unit - General Classification 024X All Inclusive Ancillary - General Classification 025X Pharmacy - General Classification 026X IV Therapy - General Classification 027X Medical/Surgical Supplies and Devices - General Classification 030X Laboratory - General Classification 031X Laboratory Pathology - General Classification

Printed on 2/18/2018. Page 13 of 16 Revenue Code Revenue Code Description 032X Radiology - Diagnostic - General Classification 033X Radiology - Therapeutic and/or Chemotherapy Administration - General Classification 034X Nuclear Medicine - General Classification 036X Operating Room Services - General Classification 040X Other Imaging Services - General Classification 048X Cardiology - General Classification

CPT/HCPCS Codes N/A ICD-10 Codes that are Covered Group 1 Paragraph:

Please see "Abstract"

Group 1 Codes: N/A ICD-10 Codes that are covered Information Table Code Description

ICD-10 Codes that are Not Covered N/A Back to Top Revision History Information

Revision Revision History History Revision History Explanation Date Number Revision Effective: 01/01/2018 Revision Explanation: added 0394T will be covered when reasonable and necessary. 01/01/2018 R28

Revision Effective: N/A 08/29/2017 R27 Revision Explanation: Annual review no changes made. Revision Effective: 08/29/2017 Revision Explanation: added coverage for codes 0389t-0391T based on NCD 20.8.4. 08/29/2017 R26

Revision Effective: 07/01/2017 07/01/2017 R25 Revision Explanation: added coverage for new code 0474T effective 07/01/2017. Revision Effective: 01/01/2017 01/01/2017 R24 Revision Explanation: Codes 0171T, 0172T and 0281T were deleted effective 12/31/2016. Revision Effective: N/A 10/01/2016 R23 Revision Explanation: Annual review no changes made. Revision Effective: 10/01/2016 Revision Explanation: The following ICd-10 codes were deleted H35.31 for 0308T and H40.11X1, H40.11X2, H40.11X3, and H40.11X4 for 0176T, 0177T, 0191T, and 0376T. The new codes were added for the respective codes H35.3111, H35.3112, H35.3113, 10/01/2016 R22 H35.3114, H35.3121, H35.3122, H35.3123, H35.3124, H35.3131, H35.3132, H35.3133, H35.3134, H40.1111, H40.1112, H40.1113, H40.1114, H40.1121, H40.1122, H40.1123, H40.1124, H40.1131, H40.1132, H40.1133, and H40.1134. There were no replacement codes for H40.11X4. Revision Effective: 10/01/2015 02/08/2016 R21 Revision Explanation: After review found typo in ICD-10 codes for 0295T, 0296T, 0297T, and 0298T the first I49.9 should have been I49.49. Revision Effective: 02/08/2016 02/08/2016 R20 Revision Explanation: added NCD 20.34 for 0281T. 02/08/2016 R19 Revision Effective: N/A Printed on 2/18/2018. Page 14 of 16 Revision Revision History History Revision History Explanation Date Number Revision Explanation: Updated codes that have been end dated and replaced with newer codes for 0319T-0328t, 0245T-0248T, 0262T, and 0176T-0177T. Revision Effective Date: 02/08/2016 02/08/2016 R18 Revision Explanation: 0281T will be covered based on LAA NCD effective 02/08/2016. Revision Effective Date: N/A 10/01/2015 R17 Revision Explanation: Annual review no changes made. R1 01/01/2016 R16 Revision Effective: N/A Revision Explanation: Annual review no changes made. Revsion Effective: 10/01/2015 05/17/2015 R15 Revision Explanation: Accepted revenue code description changes. Revision#: R13 01/01/2015 R14 Revision Effective: 01/01/2015 Revision Explanation: Added coverage for 0262T Revision#: R12 Revision Effective: 10/01/2015 10/01/2015 R13 Revision Explanation:0226t and 0227T were replaced with G6027 and G6028 effective 01/01/2015 instead of 46601 and 46607. Revision#: R12 01/01/2015 R12 Revision Effective: 10/01/2015 Revision Explanation: Added instructions for 0377T for treatment of fecal incontinence. Revision#: R11 Revision Effective: 10/01/2015 01/01/2015 R11 Revision Explanation: Added code 0376T to coverage instructions for 0191T since this new code is done in conjunction with the other. Revision#: R10 Revision Effective: 08/07/2014 10/01/2015 R10 Revision Explanation: Added POS 21 for codes 0343T-0345T instructions. Left off in error as well as changed ICD-9 to ICD-10 Revision#: R9 Revision Effective: 10/01/2015 10/01/2015 R9 Revision Explanation: Based on NCD 20.33 codes 0343T-0345T will be covered as outlined in CR 9002. Revision#: R8 10/01/2015 R8 Revision Effective 10/01/2015 Revision Explanation: Added coverage instructions for 0281T left atrial appendage Revision#: R7 10/01/2015 R7 Revision Explanation: added 0226t and 0227T as covered effective 11/01/2014. Revision#: R6 10/01/2015 R6 Revision Explanation: Corrected effective date for 0319T-0328t to 01/01/2013 instead of 01/01/2014. Revision#: R5 Revision Explanation:0051T-0053T are payable now based on NCD, 0319T-0328T are 10/01/2015 R5 now covered with indications for with and without Q0 modifier based on NCD, and added age requirement for 0308T based on FDA. Revision#: R4 10/01/2015 R4 Revision Explanation: Based on CR8757 0275T covered under NCD 150.13. Revision Effective: 10/01/2015 10/01/2015 R3 Revision Explanation: Added 0295T-0298T coverage as outlined in the Abstract section. Revision Effective: 10/01/2015 10/01/2015 R2 Revision Explanation: Added 0320T coverage added. Revision Effective: 10/01/2014 10/01/2015 R1 Revision Explanation: 0249T coverage was added. Back to Top Related Local Coverage Document(s) N/A

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Public Version(s) Updated on 01/18/2018 with effective dates 01/01/2018 - N/A Updated on 12/21/2017 with effective dates 08/29/2017 - N/A Updated on 08/17/2017 with effective dates 08/29/2017 - N/A Updated on 08/04/2017 with effective dates 07/01/2017 - N/A Updated on 12/28/2016 with effective dates 01/01/2017 - N/A Some older versions have been archived. Please visit MCD Archive Site to retrieve them. Back to Top Keywords

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