CR8954 provides additional direction specifically for PILD, procedure code G0276, when performed in a randomized, blinded clinical trial ONLY, for claims with dates of service on or after January 1, 2015. Healthcare Common Procedure Coding System (HCPCS) G0276 - Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD), or placebo control, performed in an approved coverage with evidence development (CED) clinical trial, is to be used only when the CED PILD trial is blinded, randomized, and controlled and contains a placebo procedure control arm. It appears in the January 2015 updates of the Medicare Physician Fee Schedule Database and the Integrated Outpatient Code Editor (IOCE).
ALL PILD for LSS claims with dates of service December 31, 2014, and earlier, should be processed
with procedure code 0275T ONLY and are not subject to reprocessing regardless of the type of trial in which the services were rendered.
Billing Requirements
Medicare will accept HCPCS code G0276 for PILD for LSS claims received with dates of service on and after January 1, 2015, when those services are provided in a blinded, randomized, controlled trial with a placebo procedure control arm under CED only.
Claims for PILD for LSS with dates of service on and after January 1, 2015, will be accepted when billed in a place of service (POS) 22 (outpatient) or 24 (ambulatory surgical center), using HCPCS G0276, along with:
• ICD-9 diagnosis range 724.01-724.03, or,
• ICD-10 diagnosis range M48.05-M48.07 (when ICD-10 is implemented)Only when billed with:
• Diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) (once ICD-10 is implemented) either in the primary/secondary positions;
• Modifier -Q0; and
• An 8-digit clinical trial identifier number listed on the CMS CED website.
Medicare will return claims for PILD for LSS claims, HCPCS G0276, as unprocessable when billed with a diagnosis code other than 724.01-724.03 (ICD-9), or,M48.05-M48.07 (ICD-10) (when ICD-
10 is implemented)using:
• Claim Adjustment Reason Code (CARC) B22: “This payment is adjusted based on the diagnosis.”
• Remittance Advice Remark Code (RARC) N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."
• Group Code-Contractual Obligation(CO).
Medicare will return PILD for LSS claims, HCPCS G0276, as unprocessable when billed in a
POS other than 22 or 24 using:
• CARC 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.”
• RARC N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."
• Group Code- CO.
Medicare will return PILD for LSS claims, HCPCS G0276, as unprocessable if they do not contain the required clinical trial diagnosis code V70.7 (ICD-9) or Z00.6 (ICD-10) (once ICD-10 is implemented) in either the primary/secondary positions with the following:
• CARC B22: “This payment is adjusted based on the diagnosis.”
• RARC M76: “Missing/incomplete/invalid diagnosis or condition”
• RARC N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."
• Group Code- CO.
Medicare will return PILD for LSS claims, HCPCS G0276, as unprocessable when billed without a -
Q0 modifier with the following:
• CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing.”
• RARC N657: “This should be billed with the appropriate code for these services."
• RARC N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."
• Group Code – CO.
Also, remember that you must submit the numeric, 8-digit clinical trial identifier number in the electronic 837P in Loop 2300 REF02 (REF01=P4) or preceded by "CT" when placed in Field 19 of paper claim form CMS-1500.
For hospital outpatient procedures on type of bill (TOB) 13X or 85X, on or after January 1, 2015, Medicare will allow payment for PILD for LSS, HCPCS G0276, along with:
• ICD-9 diagnosis range 724.01-724.03; or,
• ICD-10 diagnosis range M48.05-M48.07 (once ICD-10 is implemented)Only when billed with:
• Diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) (once ICD-10 is implemented) and condition code 30 either in the primary/secondary positions;
• Modifier -Q0; and
• An 8-digit clinical trial identifier number listed on the CMS CED website.
For hospital outpatient procedures on TOB 13X or 85X, on or after January 1, 2015, MACs will line
-level deny claims for PILD for LSS, HCPCS G0276, along with:
• ICD-9 diagnosis range 724.01-724.03; or,
• ICD-10 diagnosis range M48.05-M48.07 (once ICD-10 is implemented);
When billed without diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) (once ICD-10 is implemented) and condition code 30 either in the primary/secondary positions, Modifier -Q0, or an 8-digit clinical trial identifier number listed on the CMS CED website, with the following:
• CARC: 50 -These are non-covered services because this is not deemed a “medical necessity” by the payer.
• RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.
NOTE: Beginning with PILD for LSS claims with dates of service on and after January 1, 2015, there are 2 distinct procedure codes that are to be used: G0276 for clinical trials that are blinded, randomized, and controlled, and contain a placebo procedure control arm (use this CR 8954 for claims processing instructions), and 0275T for all other clinical trials (use CR 8757 for claims processing instructions).
No comments:
Post a Comment