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LCD L24317: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton’s Neuroma
Jul 28th, 2009 by Anna

LCD L24317: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton’s Neuroma

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Jurisdiction: Arizona

Effective: 01/01/2009

Revised: 05/18/2009

Indications and Limitations of Coverage and/or Medical Necessity. This policy addresses the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents and/or neurolytic agents into ganglion cysts, tendon sheaths, tendon origins/insertions, ligaments, costochondral areas, or near nerves of the feet (e.g., Morton’s neuroma) to affect therapy for a pathological condition.

Note: the term “Morton’s neuroma” is used in this policy generically to refer to a swollen inflamed nerve in the ball of the foot, including the more specific conditions of Morton’s neuroma (lesion within the third intermetatarsal space), Heuter’s neuroma (first intermetatarsal space), Hauser’s neuroma (second intermetatarsal space) and Iselin’s neuroma (fourth intermetatarsal space). This policy applies to each.

Injection of a carpal tunnel is indicated for the patient with a mild case of the carpal tunnel syndrome if oral non-steroidal anti-inflammatory drugs (NSAIDs) and orthoses have failed or are contraindicated. Though there are many similarities between Morton’s neuroma and carpal tunnel syndrome, CPT 2009 contains 64455 (anesthetic and/or steroid) and 64632 (neurolytic agent), the specific codes for the Morton‘s neuroma injections. Providers are reminded to use the appropriate one of these codes instead of the previously instructed use of 28899.

Injection into tendon sheaths, ligaments, tendon origins or insertions, ganglion cysts, or neuromas may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes. Proper use of this modality with local anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause. In some circumstances after diagnosis has been confirmed, injection of a sclerosing or neurolytic agent may be appropriate for longer-term management.

The signs or symptoms that justify these treatments should be resolved after one to three injections (see reference 2 below, under “Sources of Information and Basis for Decision”). Injections beyond three must be justified by the clinical record indicating a logical reason for failure of the prior therapy and why further treatment can reasonably be expected to succeed. A recurrence may justify a second course of therapy.

Injection therapies for Morton’s neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 64455 or 64632 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma). The provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas such as a carpal tunnel or Morton’s neuroma.

Injections for plantar fasciitis are addressed by 20550 and ICD-9-CM 728.71. Injections for calcaneal spurs are addressed as are other tendon origin/insertions by 20551. Injections to include both the plantar fascia and the area around a calcaneal spur are to be reported using a single 20551.

Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is questionable. Such injections are likely to result in a request for medical records which must evidence careful justification of necessity.

“Dry needling” of ganglion cysts, ligaments, neuromas, tendon sheaths and their origins/insertions are non-covered procedures.

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

CPT/HCPCS Codes

20526

INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL

20550

INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ’’FASCIA’’)

20551

INJECTION(S); SINGLE TENDON ORIGIN/INSERTION

20612

ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION

64455

INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON’S NEUROMA)

64632

DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE

ICD-9 Codes that Support Medical Necessity

These are the only covered ICD-9-CM codes that support medical necessity:

354.0* CARPAL TUNNEL SYNDROME

355.6* LESION OF PLANTAR NERVE

720.0 ANKYLOSING SPONDYLITIS

720.1 SPINAL ENTHESOPATHY

720.2 SACROILIITIS NOT ELSEWHERE CLASSIFIED

720.81 INFLAMMATORY SPONDYLOPATHIES IN DISEASES CLASSIFIED ELSEWHERE

720.89 OTHER INFLAMMATORY SPONDYLOPATHIES

720.9 UNSPECIFIED INFLAMMATORY SPONDYLOPATHY

723.7 OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT IN CERVICAL REGION

724.71 HYPERMOBILITY OF COCCYX

724.79 OTHER DISORDERS OF COCCYX

726.0 ADHESIVE CAPSULITIS OF SHOULDER

726.10 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED

726.11 CALCIFYING TENDINITIS OF SHOULDER

726.12 BICIPITAL TENOSYNOVITIS

726.19 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION

726.2 OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE CLASSIFIED

726.30 ENTHESOPATHY OF ELBOW UNSPECIFIED

726.31 MEDIAL EPICONDYLITIS

726.32 LATERAL EPICONDYLITIS

726.33 OLECRANON BURSITIS

726.39 OTHER ENTHESOPATHY OF ELBOW REGION

726.4 ENTHESOPATHY OF WRIST AND CARPUS

726.5 ENTHESOPATHY OF HIP REGION

726.60 ENTHESOPATHY OF KNEE UNSPECIFIED

726.61 PES ANSERINUS TENDINITIS OR BURSITIS

726.62 TIBIAL COLLATERAL LIGAMENT BURSITIS

726.63 FIBULAR COLLATERAL LIGAMENT BURSITIS

726.64 PATELLAR TENDINITIS

726.65 PREPATELLAR BURSITIS

726.69 OTHER ENTHESOPATHY OF KNEE

726.70 ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED

726.71 ACHILLES BURSITIS OR TENDINITIS

726.72 TIBIALIS TENDINITIS

726.73 CALCANEAL SPUR

726.79 OTHER ENTHESOPATHY OF ANKLE AND TARSUS

726.8 OTHER PERIPHERAL ENTHESOPATHIES

726.90 ENTHESOPATHY OF UNSPECIFIED SITE

726.91 EXOSTOSIS OF UNSPECIFIED SITE

727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED

727.01 SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE

727.02 GIANT CELL TUMOR OF TENDON SHEATH

727.03 TRIGGER FINGER (ACQUIRED)

727.04 RADIAL STYLOID TENOSYNOVITIS

727.05 OTHER TENOSYNOVITIS OF HAND AND WRIST

727.06 TENOSYNOVITIS OF FOOT AND ANKLE

727.09 OTHER SYNOVITIS AND TENOSYNOVITIS

727.1 BUNION

727.2 SPECIFIC BURSITIDES OFTEN OF OCCUPATIONAL ORIGIN

727.3 OTHER BURSITIS DISORDERS

727.40 SYNOVIAL CYST UNSPECIFIED

727.41 GANGLION OF JOINT

727.42 GANGLION OF TENDON SHEATH

727.43 GANGLION UNSPECIFIED

727.49 OTHER GANGLION AND CYST OF SYNOVIUM TENDON AND BURSA

727.50 RUPTURE OF SYNOVIUM UNSPECIFIED

727.51 SYNOVIAL CYST OF POPLITEAL SPACE

727.59 OTHER RUPTURE OF SYNOVIUM

727.60 NONTRAUMATIC RUPTURE OF UNSPECIFIED TENDON

727.61 COMPLETE RUPTURE OF ROTATOR CUFF

727.62 NONTRAUMATIC RUPTURE OF TENDONS OF BICEPS (LONG HEAD)

727.63 NONTRAUMATIC RUPTURE OF EXTENSOR TENDONS OF HAND AND WRIST

727.64 NONTRAUMATIC RUPTURE OF FLEXOR TENDONS OF HAND AND WRIST

727.65 NONTRAUMATIC RUPTURE OF QUADRICEPS TENDON

727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON

727.67 NONTRAUMATIC RUPTURE OF ACHILLES TENDON

727.68 NONTRAUMATIC RUPTURE OF OTHER TENDONS OF FOOT AND ANKLE

727.69 NONTRAUMATIC RUPTURE OF OTHER TENDON

727.81 CONTRACTURE OF TENDON (SHEATH)

727.82 CALCIUM DEPOSITS IN TENDON AND BURSA

727.83 PLICA SYNDROME

727.89 OTHER DISORDERS OF SYNOVIUM TENDON AND BURSA

727.9 UNSPECIFIED DISORDER OF SYNOVIUM TENDON AND BURSA

728.4 LAXITY OF LIGAMENT

728.5 HYPERMOBILITY SYNDROME

728.6 CONTRACTURE OF PALMAR FASCIA

728.71 PLANTAR FASCIAL FIBROMATOSIS

728.79 OTHER FIBROMATOSES OF MUSCLE LIGAMENT AND FASCIA

729.0 RHEUMATISM UNSPECIFIED AND FIBROSITIS

729.1 MYALGIA AND MYOSITIS UNSPECIFIED

729.4 FASCIITIS UNSPECIFIED

733.6 TIETZE’S DISEASE

840.0 ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN

840.1 CORACOCLAVICULAR (LIGAMENT) SPRAIN

840.2 CORACOHUMERAL (LIGAMENT) SPRAIN

840.3 INFRASPINATUS (MUSCLE) (TENDON) SPRAIN

840.4 ROTATOR CUFF (CAPSULE) SPRAIN

840.5 SUBSCAPULARIS (MUSCLE) SPRAIN

840.6 SUPRASPINATUS (MUSCLE) (TENDON) SPRAIN

840.7 SUPERIOR GLENOID LABRUM LESION

840.8 SPRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM

840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM

841.0 RADIAL COLLATERAL LIGAMENT SPRAIN

841.1 ULNAR COLLATERAL LIGAMENT SPRAIN

841.2 RADIOHUMERAL (JOINT) SPRAIN

841.3 ULNOHUMERAL (JOINT) SPRAIN

841.8 SPRAIN OF OTHER SPECIFIED SITES OF ELBOW AND FOREARM

841.9 SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM

842.00 SPRAIN OF UNSPECIFIED SITE OF WRIST

842.01 SPRAIN OF CARPAL (JOINT) OF WRIST

842.02 SPRAIN OF RADIOCARPAL (JOINT) (LIGAMENT) OF WRIST

842.09 OTHER WRIST SPRAIN

842.10 SPRAIN OF UNSPECIFIED SITE OF HAND

842.11 SPRAIN OF CARPOMETACARPAL (JOINT) OF HAND

842.12 SPRAIN OF METACARPOPHALANGEAL (JOINT) OF HAND

842.13 SPRAIN OF INTERPHALANGEAL (JOINT) OF HAND

842.19 OTHER HAND SPRAIN

843.0 ILIOFEMORAL (LIGAMENT) SPRAIN

843.1 ISCHIOCAPSULAR (LIGAMENT) SPRAIN

843.8 SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH

843.9 SPRAIN OF UNSPECIFIED SITE OF HIP AND THIGH

844.0 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE

844.1 SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE

844.2 SPRAIN OF CRUCIATE LIGAMENT OF KNEE

844.3 SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE

844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG

844.9 SPRAIN OF UNSPECIFIED SITE OF KNEE AND LEG

845.00 UNSPECIFIED SITE OF ANKLE SPRAIN

845.01 DELTOID (LIGAMENT) ANKLE SPRAIN

845.02 CALCANEOFIBULAR (LIGAMENT) ANKLE SPRAIN

845.03 TIBIOFIBULAR (LIGAMENT) SPRAIN DISTAL

845.09 OTHER ANKLE SPRAIN

845.10 UNSPECIFIED SITE OF FOOT SPRAIN

845.11 TARSOMETATARSAL (JOINT) (LIGAMENT) SPRAIN

845.12 METATARSAOPHALANGEAL (JOINT) SPRAIN

845.13 INTERPHALANGEAL (JOINT) TOE SPRAIN

845.19 OTHER FOOT SPRAIN

846.0 LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN

846.1 SACROILIAC (LIGAMENT) SPRAIN

846.2 SACROSPINATUS (LIGAMENT) SPRAIN

846.3 SACROTUBEROUS (LIGAMENT) SPRAIN

846.8 OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN

846.9 UNSPECIFIED SITE OF SACROILIAC REGION SPRAIN

847.0 NECK SPRAIN

847.1 THORACIC SPRAIN

847.2 LUMBAR SPRAIN

847.3 SPRAIN OF SACRUM

847.4 SPRAIN OF COCCYX

847.9 SPRAIN OF UNSPECIFIED SITE OF BACK

848.0 SPRAIN OF SEPTAL CARTILAGE OF NOSE

848.1 JAW SPRAIN

848.2 THYROID REGION SPRAIN

848.3 SPRAIN OF RIBS

848.40 STERNUM SPRAIN UNSPECIFIED PART

848.41 STERNOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN

848.42 CHONDROSTERNAL (JOINT) SPRAIN

848.49 OTHER SPRAIN OF STERNUM

848.5 PELVIC SPRAIN 848.8 OTHER SPECIFIED SITES OF SPRAINS AND STRAINS

848.9 UNSPECIFIED SITE OF SPRAIN AND STRAIN

*Use 354.0 for Carpal Tunnel Syndrome. ONLY CPT 20526 may be used with this diagnosis code.

*Use 355.6 for Morton’s metatarsalgia, neuralgia, or neuroma. NOTE: ONLY CPT 64455 or 64632 may be used with this diagnosis code.

Documentation Requirements

The clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use injection. If the number of injections exceeds three, the record must justify these added injections since the presumed need for further injections should raise the issues of correct diagnosis or correct choice of therapy as well as concerns for adverse side effects. Records must be made available upon request.

Submission of injection codes 64470-64476 (injection, paravertebral facet joint or facet joint nerve) or joint space injection codes (20600, 20605, and 20610) in addition to 20550 and/or 20551 must be supported by documentation in the medical record of the medical necessity of the separate procedure(s).

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

Source: LCD L24317

http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24317&lcd_version=8&basket=lcd%3A24317%3A8%3AInjections+-+Tendon||+Ligament||+Ganglion+Cyst||+Tunnel+Syndromes+and+Morton%27s+Neuroma%3AMAC+-+Part+B%3ANoridian+Administrative+Services+(03102)%3A

CPT codes, descriptors and other data are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

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UPDATE ALERT: Therapeutic Shoes Revision has been Withdrawn
Jun 25th, 2009 by Anna

LCD Update: Therapeutic Shoes for Persons with Diabetes

******************************************************************************************************************************************************************************

UPDATE ALERT:

effective 07/07/2009

Therapeutic Shoes - Withdrawal of Policy Article

A revision of the Therapeutic Shoes for Persons with Diabetes Policy Article was recently released. The effective date was listed as August 1, 2009. That version of the Policy Article is being withdrawn.

The current version of the Policy Article which has an effective date of October 1, 2008, remains in effect until a new revised Policy Article is published.

****************************************************************************************************************************************************************************************************************

Jurisdiction: Alaska, American Samoa, Arizona, California - Entire State, Guam, Hawaii, Iowa, Idaho, Kansas, Missouri - Entire State, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Northern Mariana Islands

Effective 08/01/2009, LCD L157 Therapeutic Shoes for Persons with Diabetes will have the following policy updates:

The GY modifier will be added in the LCD

Documentation Requirements will be updated to reflect the following:

Revised: Instructions for certification statement to indicate that it must be completed by the certifying physician

Revised: Instructions concerning KX modifier to refer to Policy Article

Clarified: Information documenting that KX modifier requirements have been met must be in the records of the clarifying physician.

Added: instructions for use of GY modifier

The full LCD can be found at the following link: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=157&lcd_version=30&show=all

The revised version effective 08/01/2009 can be found at the following link: http://www.cms.hhs.gov/mcd/viewarticle.asp?article_id=37076&article_version=15&show=all

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LCD Update Effective 08/01/2009: Skin Lesion Removal (Excludes AK and Includes MOHS)
Jun 10th, 2009 by Anna

LCD Update Effective 08/01/2009: Skin Lesion Removal (Excludes AK and Includes MOHS)

Jurisdiction: Arizona

Dated 06/10/2009

LCD L24361

LCD L24361, Skin Lesion Removal (excludes AK and Includes MOHS) has been revised and the new coverage determinations will be effective 08/01/2009. The changes include the following:

  • ICD-9-CM Codes 238.2 & 692.75 were added to List I
  • ICD-9-CM Code 078.12 was added to List II
  • CPT Code 96567 was added to the LCD

The FUTURE draft of LCD L24361 is available at the following link:

http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=27521&lcd_version=15&basket=lcd%3A27521%3A15%3ASkin+Lesion+Removal+(Includes+AK+and++Excludes+MOHS)%3AMAC+-+Part+B%3ANoridian+Administrative+Services+(03102)%3A24361

The CURRENT draft of LCD L24361 is available at the following link:

http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24361&lcd_version=7&basket=lcd%3A24361%3A7%3ASkin+Lesion+Removal+(Excludes+AK+and+MOHS)%3AMAC+-+Part+B%3ANoridian+Administrative+Services+(03102)%3A

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64455 & 64632: New 2009 CPT Codes
May 11th, 2009 by Anna

64455 & 64632: New 2009 CPT Codes

May 11, 2009

CPT Code 64455

64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg. Morton’s neuroma)

Explanation: injection of a local anesthetic agent and/or steroid into a plantar common digital nerve from the dorsal direction. Often performed to treat Morton’s neuroma. Do not report with 64632.

ICD-9-CM Procedural

04.81 Injection of anesthetic into peripheral nerve for analgesia

ICD-9-CM Diagnostic

355.6 Lesion of plantar nerve

355.71 Causalgia of lower limb

355.79 Other mononeuritis of lower limb

355.8 Unspecified mononeuritis of lower limb

719.47 Pain in joint, ankle and foot

727.06 Tenosynovitis of foot and ankle

729.1 Unspecified myalgia and myositis

729.9 Unspecified neuralgia, neuritis, and radiculitis

729.5 Pain in soft tissues of limb

CPT code 64455 cannot be reported with 64632 and has zero global days.

CPT Code 64632

64632 Destruction by neurolytic agent; plantar common digital nerve

Explanation: Procedure is performed to treat chronic pain. The procedure is designed to destroy the specific site(s) in the nerve root that produce(s) pain while leaving sensation in tact. Generally, intravenous conscious sedation is used during initial phase of procedure so the patient can assist the physician in identifying the site of pain and the correct placement of neurolytic agent, and local anesthesia is administered during the destruction phase of the procedure. Report 64632 for the plantar common digital nerve. Do not report with 64455.

ICD-9-CM Procedural

04.2 Destruction of cranial and peripheral nerves

ICD-9-CM Diagnostic

355.6 Lesion of plantar nerve

355.71 Causalgia of lower limb

355.79 Other mononeuritis of lower limb

355.8 Unspecified mononeuritis of lower limb

719.47 Pain in joint, ankle and foot

727.06 Tenosynovitis of foot and ankle

729.1 Unspecified myalgia and myositis

729.9 Unspecified neuralgia, neuritis, and radiculitis

729.5 Pain in soft tissues of limb

CPT code 64632 cannot be reported with 64455 and has zero global days.

CPT only © 2008 American Medical Association. All Rights Reserved.

Source: Coding Companion for Podiatry by Ingenix, 2008

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Required Provider Information on Medicare Claims for Routine Foot Care
Apr 16th, 2009 by Anna

Required Provider Information on Medicare Claims for Routine Foot Care

April 16, 2009

Medicare will only reimburse routine foot care if the patient is under active care of a doctor of medicine or osteopathy who properly documents a condition that Medicare’s policy will allow coverage. When submitting routine foot care claims to Medicare, you must report the name of the doctor providing active care, the NPI of that doctor, and the date the patient was last seen by the indicated physician.

The NPI of the providing physician and the date the patient was last seen must be present in block 19 of the CMS-1500. Missing information will result in returned and unpaid claims, using Claim Adjustment Code 16 “claim/service lacks information which is needed for adjudication.” When returning claims as unprocessable, Medicare will use Remittance Advice Remark codes N253 – Missing/incomplete/invalid attending provider primary identifier and N324 – Missing/incomplete/invalid last seen/visit date.

Source: https://www.noridianmedicare.com/provider/updates/docs/se0907_foot_care.pdf

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Place of Service Codes
Apr 9th, 2009 by Anna

Place of Service Codes

April 9, 2009

When billing E/M CPT codes and other CPT codes, the place of service (POS) code must be accurate in order to ensure quick and accurate reimbursement. A claim may be denied if the POS code is incorrect.

Place of Service Codes

04 – Homeless Shelter 26 – Military Treatment Facility
05 – Indian Service Free Standing Facility 31 – Skilled Nursing Facility (SNF)
11 – Office 32 – Nursing Facility
12 – Home 33 – Custodial Care
13 – Assisted Living 34 – Hospice
14 – Group Home 54 – Intermediate Care Facility (ICF)
20 – Urgent Care Facility 55 – Residential Substance Abuse Treatment Facility
21 – Inpatient Hospital 56 – Psychiatric Residential Treatment Center
22 – Outpatient Hospital 61 – Comprehensive Outpatient Rehab Facility
23 – Emergency Room – Hospital 62 – Comprehensive Outpatient Rehab Facility
24 – Ambulatory Surgical Center 72 – Rural Health Clinic
25 – Birthing Center 99 – Other Place of Service Not Listed

Certain E/M CPT codes can only be used in certain locations and it is important that the POS codes match the billed CPT codes. Below are descriptions of the most common POS codes Thousand Cranes clients use.

POS 11 - Office

Office: Any location, other than a hospital, SNF, military treatment facility, community health center, state or local public clinic or ICF, where the health professional routinely provides health examinations, diagnoses, or treatment of illness or injury on an ambulatory basis.

CPT Codes: Office or Outpatient codes 99201 – 99215, 99354 – 99355, and Office or Other Outpatient Consultations 99241 – 99245.

POS 12 – Home

Home: A location other than a hospital or other facility, where the patient receives care in a private residence.

Use POS 12 to report E/M services provided in a private residence of the patient. Surgical procedures can be billed as well. May be used for all DMEPOS services. Do not use POS 12 for assisted living (POS 13) or POS 14 (group home) codes.

CPT Codes: New patient home service codes 99341 – 99345, Established patient codes 99347 – 99350.

POS 20 – Urgent Care Facility

Urgent Care Facility: A location, distinct from a hospital emergency room,an office or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

CPT Codes: E/M codes 99201 – 99215, Consult 99241 – 99245, surgical codes

POS 21 – Inpatient Hospital

Inpatient Hospital: A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services, by or under, the supervision of physicians to patients admitted for a variety of medical conditions.

CPT Codes: Observation 99217 – 99220, Inpatient 99221 – 99233, Same day observation 99234 – 99239, Consult 99251 – 99255, Prolonged service 99356 – 99358.

POS 22 – Outpatient Hospital

Outpatient Hospital: A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

CPT Codes: Office or Outpatient Service Codes 99201 – 99215, 99354 – 99355, Office or Other Outpatient Consultations 99241 – 99245

CPT codes, descriptors and other data are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

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Incision & Drainage
Feb 3rd, 2009 by Anna

Incision & Drainage
CPT codes 10060/10061, 10080/10081, 10120/10121, 10140, 10160 and 10180

Code Descriptions
10060 I & D of abscess (cutaneous or subcutaneous abscess, cyst, or paronychia); simple or single
10061 I & D of abscess (cutaneous or subcutaneous abscess, cyst, or paronychia); complicated or multiple
10080 Incision and drainage of pilonidal cyst; simple
10081 Incision and drainage of pilonidal cyst; complicated
10120 Incision and removal or foreign body, subcutaneous tissues; simple
10121 Incision and removal or foreign body, subcutaneous tissues; complicated
10140 Incision and drainage of hematoma, seroma or fluid collection
10160 Puncture aspiration of abscess, hematoma, bulla, or cyst
10180 Incision and drainage, complex, post-op wound infection

The above referenced CPT codes used for incision & drainage have a 10 day global period and are not approved for an assistant surgeon.  To be paid, adequate medical necessity must be justified.

Incision & Drainage CPT Codes Documentation
The following documentation must be present in the medical record:

1)    A detailed description of the abscess (location, signs/symptoms, appearance, size, etc)
2)    A culture and sensitivity test must be performed of the puss (puss is assumed in an I&D procedure)
3)    The treating physician must require and document that the patient is applying astringent soaps to the I&D site
4)    Patient must be prescribed a topical antibiotic or an oral antibiotic

For complicated cases (CPT 10061, 10081, 10121)
1)    Op report including the use of local anesthesia
2)    Patient must be prescribed an ORAL antibiotic

Diagnosis Codes associated with CPT Procedure Codes
*Please check with your local carrier for an exhaustive list

10060    I & D of abscess (cutaneous or subcutaneous abscess, cyst, or paronychia); simple or single
10061    I & D of abscess (cutaneous or subcutaneous abscess, cyst, or paronychia); complicated or multiple

110.1    Dermatophytosis on nail
680.6    Carbuncle and furuncle of leg (not foot)
680.7    Carbuncle and furuncle of foot
681.01    Felon
681.10    Cellulitis and abscess of toe(s)
681.11    Onychia and paronychia of toe
682.6    Cellulitis and abscess of leg, ankle (not foot)
682.7    Cellulitis and abscess of foot (not toes)
686.00    Pyoderma unspecified
686.01    Pyoderma gagnrenosum
686.09    Other Pyoderma
686.1    Pyogenic granuloma of skin and subcutaneous tissue
686.8    Infection of skin, subcutaneous tissue
705.83    Hidradenitis
705.89    Abscess of sweat gland
706.2    Sebaceous cyst
709.8    Bulla, other specified disorder of skin
782.2    Subcutaneous nodule, localized superficial swelling, mass, lump
958.3    Port traumatic infection, closed
998.51    Infected postoperative seroma
998.59    Post operative infection, abscess


10080    Incision and drainage of pilonidal cyst; simple
10081    Incision and drainage of pilonidal cyst; complicated

685.0    Pilonidal cyst with abscess
685.1    Pilonidal cyst with no mention of abscess

10120    Incision and removal or foreign body, subcutaneous tissues; simple
10121    Incision and removal or foreign body, subcutaneous tissues; complicated

916.6    Superficial foreign body (splinter) without infection of leg, ankle
916.7    Superficial foreign body (splinter) with infection of leg, ankle
916.8    Unspecified superficial injury of leg, ankle, no infection
916.9    Unspecified superficial injury of leg, ankle, with infection
917.6    Superficial foreign body (splinter) without infection of foot and toes
917.7    Superficial foreign body (splinter) with infection of foot and toes
917.8    Unspecified superficial injury of foot, toes, no infection
917.9    Unspecified superficial injury of leg, ankle, with infection
998.4    Foreign body accidentally left during procedure

10140    Incision and drainage of hematoma, seroma or fluid collection

906.3    Late effect of contusion
924.10    Contusion of lower leg
924.20    Contusion of foot
924.21    Contusion of ankle
924.3    Contusion of toe, toenail
959.7    Injury unspecified leg, foot, ankle
998.12    Hematoma complicating a procedure
998.13    Seroma complication a procedure
998.51    Infected postoperative seroma

10160    Puncture aspiration of abscess, hematoma, bulla, or cyst

681.11    Onychia and paronychia of toe
682.6    Cellulitis and abscess of leg, ankle (not foot)
682.7    Cellulitis and abscess of foot (not toes)
705.89    Abscess of sweat gland
706.2    Sebaceous cyst
709.8    Bulla, other specified disorder of skin
906.3    Late effect of contusion
924.10    Contusion of lower leg
924.20    Contusion of foot
924.21    Contusion of ankle
924.3    Contusion of toe, toenail
959.7    Injury unspecified leg, foot, ankle
998.12    Hematoma complicating a procedure

10180    Incision and drainage, complex, post-op wound infection

998.51*    Infected postoperative seroma
998.59*    Other postoperative infection

CCI Edits
The following tables show codes that will not be paid if billed as component codes to the primary code.  The component codes may be paid if the procedure is performed on a separate anatomical site or as a distinct separate procedure.  The appropriate modifier must be appended to the primary code.  Modifiers that allow for payment are:
-TA, -T1, T2, -T3, -T4, -T5, -T6, -T7, -T8, -T9, -LT, -RT, -58, -59, -78, -79
*Component code 69990 is never payable even with an appropriate modifier

These following codes will not be paid if billed with CPT code 10060:

11055    11056    11057    11422    11423    11424    11426    11600
11601    11602    11603    11604    11606    11620    11621    11622
11623    11624    11626    11719    11720    11721    11730    11740
11765    20000    20005    20500    29580    64450    69990*    97597
97598    97602    97605    97606    G0127

These following codes will not be paid if billed with CPT code 10061:
10060    11055    11056    11057    11406    11424    11426    11604
11606    11623    11624    11626    11719    11720    11721    11730
11740    11750    11765    20005    20500    29580    64450    69990*
90780    97597    97598    97602    97605    97606    G0127

These following codes will not be paid if billed with CPT code 10080:

20500    64450    69990*

These following codes will not be paid if billed with CPT code 10081:
10080    20500    64450    69990*

These following codes will not be paid if billed with CPT code 10120:

11055/11056    11057    11719    11720    11721    64450    69990*    G0127

These following codes will not be paid if billed with CPT code 10121:
10120    11720    11721    64450    69990*

These following codes will not be paid if billed with CPT code 10140:

11055    11056    11057    11719    11720    11721    29580    64450
69990*    G0127

These following codes will not be paid if billed with CPT code 10160:

10061    10140    11055    11056    11057    11719    11720    11721
29580    64450    69990*    G0127

Source:

Bluth, Dan DPM. (2009). The 2009 Podiatry Manual. Concord, CA: DRB

CPT codes, descriptions and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

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Updated 01/01/2009: LCD for Application of Bioengineered Skin Substitutes: Ulcers (of Lower Extremities)
Jan 8th, 2009 by Anna

Updated 01/01/2009: LCD for Application of Bioengineered Skin Substitutes: Ulcers (of Lower Extremities)

Geographic Jurisdiction: Arizona
Effective: 01/01/2009

The Centers for Medicare & Medicaid Services (CMS) has revised the Local Coverage Determination for application of bioengineered skin substitutes pertaining to ulcers of the lower extremities.  For the full LCD, please refer to the LCD L24273 prepared by CMS. LCD L24273 Application of Bioengineered Skin Substitutes: Ulcers (of Lower Extremities)

The edits are as follows:

CODE DESCRIPTION CHANGES:

The description for the codes 15002, 15003, 15004, 15005 and 15341 was changed per the 2009 CPT/HCPCS update effective 01/01/09.  The new descriptions are as follows:

15002: SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN

15003: SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

15004: SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN

15005: SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

15431: ACELLULAR XENOGRAFT IMPLANT; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

DELETED J CODES

The following was deleted and replaced with Q codes per the 2009 CPT/HCPCS update effective 01/01/09:

J7340 was deleted and replaced with Q4101
J7341 was deleted and replaced with Q4102
J7342 was deleted and replaced with Q4106

The following was also deleted per the 2009 CPT/HCPCS update effective 01/01/09:

J7343
J7344
J7346
J7347
J7348
J7349


Source:

http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24273&lcd_version=29&show=all

CPT codes, descriptions and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

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Ankle-Foot Orthoses: Correct Coding
Dec 5th, 2008 by Anna

Arizona AFO is a company that manufactures a line of custom fabricated ankle-foot orthoses. Other companies manufacture similar products. The Pricing, Data Analysis, and Coding (PDAC) contractor has recently reviewed the Arizona AFO line of products and determined the appropriate HCPCS codes to be used when billing for these and similar items.

For the Arizona Short, Arizona Tall, Arizona Extended, Arizona Unweighting, and similar custom fabricated braces, only the following codes should be used:

  • L1940 Ankle foot orthosis, plastic or other material, custom fabricated
  • L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section

L2330 is used whether the closure is a lacer closure or a velcro closure. L2820 is used only if a soft interface, either leather or other material, is provided.

The following codes must not be used for these braces:

  • L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
  • L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
  • L2280 Addition to lower extremity, molded inner boot

For the Arizona Partial Foot model or similar orthosis, use codes L1940, L2330, L2820, and L5000 (Partial foot, shoe insert with longitudinal arch, toe filler).

Questions concerning the coding of other orthoses should be referred to the Pricing, Data Analysis, and Coding (PDAC) contractor.

Suppliers who have incorrectly coded these orthoses should submit a voluntary refund to the DME MAC.

Source:

https://www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkklupZEVpVBtLUquY&tmpl=dme_viewnews&style=part_ab_viewnews

CPT codes, descriptors and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

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Paring or Cutting Benign Hyperkeratotic Lesion: CPT Codes 11055-11057
Nov 24th, 2008 by Anna

Paring or Cutting Benign Hyperkeratotic Lesion: CPT Codes 11055-11057

Contractor: Noridian Administrative Services (NAS)
Contractor Type: Medicare Part B, Arizona Jurisdiction

Effective for services performed on or after 10/01/2008

11055    Paring or cutting of benign hyperkeratotic lesion (e.g. corn or callus); single lesion
11056    Paring or cutting of benign hyperkeratotic lesion (e.g. corn or callus); 2 to 4 lesions
11057    Paring or cutting of benign hyperkeratotic lesion (e.g. corn or callus); more than 4 lesions

CPT Codes 11055, 11056 and 11057 are used when performing a paring or cutting approach to hyperkeratosis.  Any other approach to treating and managing hyperkeratosis is not addressed in this memo.  Medicare does not reimburse for routine foot care, therefore, CPT Codes 11055-11057 will only be reimbursed by Medicare if the treatment is medically necessary.

When reporting a claim using CPT Codes 11055-11057, two ICD-9-CM Codes must be used to qualify claim as payable through Medicare.

The first of the two ICD-9-CM Codes must be:

700         Corns and callosities
701.1      Keratoderma acquired
757.39    Other specified congenital anomalies of skin

The second ICD-9-CM Code must be one of the following:

686.9    Unspecified local infection of skin and subcutaneous tissue
729.5     Pain in limb

CPT codes, descriptions and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

References:
Medicare Part B LCD L24374
http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24374&lcd_version=6&show=all

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