CPT CODE 97530, 97532, 97533, 97535, 97537, 97542

 Procedure codes and Description

97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

97532 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

97537 Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes

97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes

Policy Overview

This policy describes Optum’s documentation requirements for reimbursement of the Physical Medicine and Rehabilitation (PM&R) CPT codes which make up the timed, skilled, direct one-on-one component of treatment. Specifically CPT codes, 97110- 97140, 97530-97542, 97750-97762.

In cases that a state determines a procedure code that is not identified by CPT as a timed therapeutic procedure will be reimbursed as a timed therapeutic procedure, the documentation requirements described in this policy will apply

Reimbursement Guidelines

Documentation Requirements – Timed Therapeutic Intervention

Optum will align timed therapeutic treatment documentation requirements with the American Physical Therapy Association’s Defensible Documentation for Patient/Client Management document and Centers for Medicare and Medicaid Services (CMS) National Policy.

Background Information

The CPT section devoted to “therapeutic procedures” contains many of the CPT codes utilized by rehabilitation providers to describe the skilled, direct one-on-one component of treatment. These codes describe the bulk of hands-on, skilled care typically provided by rehabilitation providers.

CPT defines Therapeutic Procedures 97110-97140, 97530-97542, 97750-97762 as follows:

• A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.

• Physician or therapist required to have direct (one-on-one) patient contact.

• Therapeutic procedure, one or more areas, each 15 minutes;

Additionally, the definition of CPT codes 97750-97755, Therapeutic Procedures, Tests and Measurement includes, “with written report, each 15 minutes.”

In the case of the timed therapeutic CPT codes, documentation should reflect the thought process and skilled decision making of the licensed therapy provider. As such, documentation of patient/client care needs to be more than a litany of procedures related to a date of service. Documentation must include evidence of knowledge and skill related to the procedures performed. It also should provide verification of professional judgment. This concept of clinical decision making can be incorporated into clinical documentation.

General Guidelines

In addition to the documentation requirements referenced in Optum’s Guideline for Record Keeping policy, there are specific requirements that must be evident in the patient medical record for reimbursement of certain time-based therapeutic procedure interventions. Documentation of certain timed-based procedures should be recorded on the day of the patient visit and include both of the following:

A. Substantiation that the skilled services of a licensed therapy provider or physician were required.

B. Substantiation that services met the one-on-one timed-based requirement.

40. Skilled Intervention

1. Documentation to support skilled intervention is required. Demonstration of skilled care requires documentation of the type and level of skilled assistance given to the patient, clinical decision making or problem solving, and continued analysis of patient progress. This may be documented by recording both the type and amount of manual, visual, and/or verbal cues used by the licensed therapy provider to assist the patient in completing the exercise/activity completely and

correctly. Skilled care may also be documented through explanation regarding rationale for choosing the interventions and/or the rationale for the continued use of the intervention. Another way of documenting skilled care may be to provide documented observation regarding responses before, during, and after an intervention as well as the patient’s specific response to the intervention.

2. Services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute skilled physical medicine and rehabilitation services. Services provided by practitioners/staff who are not qualified licensed therapy providers are not skilled intervention services. Unskilled services are palliative procedures that are repetitive or reinforce previously

learned skills, or maintain function after a maintenance program has been developed.

3. The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a licensed therapy provider. Services that do not require the skill of a licensed therapy provider are not considered skilled services, even if they are performed or supervised by a qualified professional.

4. While a patient’s particular medical condition is a valid factor in deciding if skilled physical medicine and rehabilitation services are needed, a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a licensed therapy provider are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel. 

Timed and Untimed Codes

When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units. For timed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition.

EXAMPLE: A beneficiary received a speech-language pathology evaluation represented by HCPCS “untimed” code 92521. Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day.

Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report these “timed” procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.

EXAMPLE: A beneficiary received a total of 60 minutes of occupational therapy, e.g., HCPCS “timed” code 97530 which is defined in 15 minute units, on a given date of service. The provider would then report 4 units of 97530.

Utilization Guidelines and Maximum Billable Units per Date of Service

Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as

medically necessary the duration of the session and the amount of activities/procedures performed.

The following timed modalities and procedures should be reported no more than 4 (four) units per code per day per discipline; additional units require supportive

documentation.

97032, 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97760, 97761, 97762. 

General Guidelines for Therapeutic Procedures

(CPT codes 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761 and 97762)

Therapeutic procedures are procedures that attempt to reduce impairments and restore function through the applications of clinical skills and/or services.

CPT codes 97110, 97112, 97113, 97116, 97124, 97139 and 97140 are designed for one or more areas.

Use of these procedures requires the physical therapist to have direct (one-on-one) patient contact. Only the actual time of the provider’s direct contact with the patient proving a service which requires the skills and expertise of that provider is considered for coverage. Supervision of a previously taught exercise or exercise

program, patients performing an exercise independently without direct contact by the provider, or use of different exercise equipment without requiring the

intervention/skills of the therapist are not covered. The patient may be in the facility longer than that period of time, but only the time the provider is actually providing direct, one-on-one, patient contact which requires the skills of a therapist is considered covered time for these procedures, and only those minutes of treatment should be recorded.

Use of these procedures is expected to result in improvement of the limitations/deficits in a reasonable and generally predictable amount of time.

Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code.

CPT codes 97110, 97112, 97113, 97116, and 97530 describe several different types of therapeutic interventions. The expected goals documented in the treatment plan,

effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, because any one or a

combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

On each treatment visit the treatment record must support the codes billed and must specify which exercise/activity is being performed for each code billed.

Documentation must also justify the coverage of multiple services/units of each code. In general, no more than 1-2 services/units of time for each code are needed

on a date of service. Similarly, no more than 2-3 of these different codes are generally covered on a visit date. Documentation must support each code and the

number of services/units of time. For example, 10 units of time for 5 different codes would be unlikely.

Anesthesia Billing overview- Reimbursement formulas with modifier

Anesthesia Services

Anesthesia services must be submitted with a CPT anesthesia code in the range 00100-01999, excluding 01953 and 01996, and are reimbursed as time-based using the Standard Anesthesia Formula. Refer to the attached Anesthesia Codes list for all applicable codes. For purposes of this policy the code range 00100-01999 specifically excludes 01953 and 01996 when referring to anesthesia services. CPT codes 01953 and 01996 are not considered anesthesia services because, according to the ASA RVG®, they should not be reported as time-based services.

Modifiers Required

Anesthesia Modifiers

All anesthesia services including Monitored Anesthesia Care must be submitted with a required anesthesia modifier in the first modifier position. These modifiers identify whether a procedure was personally performed, medically directed, or medically supervised. Consistent with CMS, UnitedHealthcare will adjust the Allowed Amount by the Modifier Percentage indicated in the table below.

Reimbursement Percentage

AA Anesthesia services performed personally by an anesthesiologist. 100%

AD Medical supervision by a physician: more than four concurrent anesthesia procedures. *For additional information, refer to Standard Anesthesia Formula with Modifier AD under Reimbursement Formula 100%

QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. 50%

QX Qualified nonphysician anesthetist with medical direction by a physician 50%

QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist 50%

QZ CRNA service; without medical direction by a physician. 100%

Additional anesthesia billing guidelines to consider::

• Gateway processes anesthesia services based on anesthesia procedure codes only.

• All services must be billed in minutes. Fractions of a minute should be rounded to whole minutes (30 seconds or greater: round up; less than 30 seconds: round down).

• Physical status modifiers, P1-P6, will not allow any additional payment. These are informational modifiers only and should be submitted after the pricing modifier.

• The claim should include ONLY the primary anesthesia code except when there is an addon code that should be reported along with the primary anesthesia service.


• If you provide pain management services, continue to bill with surgical codes.

• If you provide medical procedures such as Swan Ganz, Laryngoscopy Indirect with Biopsy, Venipuncture Cutdown, Placement of Catheter or Central Vein, then continue to bill with the medical procedure code.

• When billing OB anesthesia codes 01960, 01961, 01962, 01963, and 01967 you do not need to add an additional hour for patient consultation. The Department of Human Services has already added 4 to the relative value unit for these codes.

• When billing anesthesia for all obstetrical procedures, use the anesthesia procedure codes as defined in the Anesthesia section of the CPT4 manual. Should you have any questions about this communication please contact your Provider Relations Representative or Gateway’s Customer Service Department. Customer Service is available 8:30 am to 4:30 pm Monday through Friday by calling 1-800-392-1147 for Medicaid or 1-800-685-5209 for Medicare Assured.


Preventative Medicine and Sick Visits

As per AMA CPT Guidelines, Gateway shall allow reimbursement for a medically necessary sick visit Evaluation and Management (E/M) Service at the same visit as a Preventative Medicine Service (CPT 99381

– 99429) when it is clinically appropriate. Providers shall use CPT codes 99201 – 99215 to report a sick visit E/M with CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the Preventative Medicine code reported. If modifier 25 is not appended, the sick visit will deny. Please verify with the Medicaid Fee Schedule for reimbursable Preventative Medicine Service codes.

Modifier 25 vs Modifier 57

As per AMA CPT Guidelines, Gateway will reimburse E/M Services on the same day as a global surgical procedure for the following circumstances: Modifier 25 – Significant evaluation and management service by same physician on date of global procedure

• E/M Service that is significant and separate on the day of a procedure with a 0 or 10-day global surgical periodModifier 57 – Decision for surgery made within global surgical period

• E/M Service that is the decision for surgery on the day of or on the day before a procedure with a 90-day global surgical procedure

The modifiers should be appended to the E/M Service. Absence of the modifiers will cause the E/M Service will deny as global to the procedure.


Reimbursement Formula

Base Values:

Each CPT anesthesia code is assigned a Base Value by the ASA, and UnitedHealthcare uses these values for determining reimbursement. The Base Value of each code is comprised of units referred to as the Base Unit Value.

Time Reporting: Consistent with CMS guidelines, UnitedHealthcare requires time-based anesthesia services be reported with actual Anesthesia Time in one-minute increments. For example, if the Anesthesia Time is one hour, then 60 minutes should be submitted.

Reimbursement Formulas:

Time-based anesthesia services are reimbursed according to the following formulas: Standard Anesthesia Formula without Modifier AD* = ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage. Standard Anesthesia Formula with Modifier AD* = ([Base Unit Value of 3 + 1 Additional Unit if anesthesia notes indicate the physician was present during induction] x Conversion Factor) x Modifier Percentage.

*For additional information, Refer to Modifiers.

Qualifying Circumstances

Qualifying circumstances codes identify conditions that significantly affect the nature of the anesthetic service provided. Qualifying circumstances codes should only be billed in addition to the anesthesia service with the highest Base Unit Value. The Modifying Units identified by each code are added to the Base Unit Value for the anesthesia service according to the above Standard Anesthesia Formula.


ANESTHESIA MODIFIERS


Miscellaneous

Anesthesia Services Provided by the Operating Surgeon

Local infiltration, digital block, or topical anesthesia administered by the operating surgeon is included in the unit value for the surgical procedure.

If the attending surgeon administers anesthesia, the value shall be the lesser of the basic unit value without benefit for time or 25 percent of the total dollar value of the surgery. (See modifier 47\ for guidelines on reporting administration of anesthesia by the attending surgeon.)

Major regional anesthesia administered by the surgeon, such as a spinal epidural or major peripheral nerve block, shall be reimbursed the basic anesthesia value only without benefit for time. (See modifier 47 for guidelines on reporting administration of anesthesia by the attending surgeon.)

If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should so indicate with the use of a modifier NT for “no time.”

Nerve Block

For diagnostic or therapeutic nerve block, see 62310–62319 and 64400–64530.

For diagnostic or therapeutic nerve blocks performed by the surgeon, anesthesiologist, or CRNA, only one reimbursement per procedure shall be allowed, regardless of the time required (e.g., see codes 62310–62319, 64400–64530).

Field Avoidance

Any procedure around the head, neck, or shoulder girdle that requires field avoidance or any procedure compromising the anesthesia administration (e.g., requiring a position other than supine or lithotomy) has a minimum basic value of 5.0 units regardless of any lesser basic value assigned to such procedures. In this case, modifier 22 is required.

Multiple Procedures

Anesthesia reimbursement for multiple procedures is based on the procedure with the highest base value, plus modifying units (if appropriate), plus total time units for all combined surgical procedures.

No additional base value shall be reimbursed for anesthesia rendered during additional surgical procedures (other than the primary procedure) performed on the same day during the same operative setting.

CPT H1001, H1001, H1003 - Prenatal care

CPT CODE and Description

H1000  PRENATAL CARE, AT-RISK ASSESSMENT
H1001 Prenatal care, at-risk enhanced service; antepartum management
H1003 Prenatal care, at-risk enhanced service; education



HCPCS Code  H1000 - Prenatal care atriskassessm


Risk Assessment 

Risk assessment is the systematic review of relevant member data to identify potential problems and determine a plan for care.  Early identification of high risk pregnancies with appropriate consultation and intervention contributes significantly to an improved perinatal outcome and lowering of maternal and infant morbidity and mortality.   A care plan for high risk members, in addition to standard care, includes referral to or consultation with an appropriate specialist, individualized counseling and services designed to address the risk factor(s) involved.  A care plan for low risk members includes primary care services and additional services specific to the needs of the individual.  

Risk Assessments may be provided by one of the following licensed Medicaid providers:

**   Physician
**   Certified Nurse Practitioner
**   Certified Nurse-Midwife

The service is reported using HCPCS H1000 Prenatal Care, At Risk Assessment for a low risk assessment or HCPCS H1001 Prenatal Care, At Risk Enhances Service; Antepartum Management for high risk assessment.  Limited to two (2) assessments during any 10-month period.

Single Prenatal Visit(s) Other than Initial Visit

A single prenatal visit other than the initial visit is a single prenatal visit for an established member who does not return to complete care for unknown reasons.  The initial assessment visit was completed, a plan of care established, one or two follow-up visits completed, without further care provided.

Single Prenatal Visit may be provided by one of the following licensed Medicaid providers:

**   Physician
**   Certified Nurse Practitioner
**   Certified Nurse-Midwife 

The service is reported using an appropriate CPT E/M code.  Limited to three (3) visits in any 10-month period.  The service may be billed only when the member is lost to follow up for any reason.  


Prenatal Assessment Visit (Initial Visit Only)

The initial prenatal assessment visit is a single prenatal visit for a new patient with a confirmed pregnancy, providing an evaluation of the mental and physical status of the patient, an in depth family and medical history, physical examination, development of the medical data and initiation of a plan of care.  
Prenatal Assessment Visit may be provided by one of the following licensed Medicaid providers:

**   Physician
**   Certified Nurse Practitioner
**   Certified Nurse-Midwife 

The service is reported using an appropriate CPT E/M code.  Limited to one (1) visit in any 10-month period, to be used only when the patient is referred immediately to a community practitioner because of identified risks or otherwise lost to follow-up because the patient does not return. 

Billing Guidelines from Uhc

Florida
** Prenatal care must be billed separately from the delivery and postpartum care.
** FL providers are to submit prenatal codes H1001 and/or H1000.
** Up to 10 visits are allowed for prenatal care.** Up to two postpartum visits are allowed within 90 days following delivery, per recipient.
** Delivery of two or more infants from a single pregnancy, by different delivery method, separately.  Same delivery method is non-covered


BCBS insurance Guidelines

Pre-term Birth Prevention Services

Blue Cross will reimburse for certain pre-term birth prevention serviceswhen the patient’s contract covers these services.

CODE                     NARRATIVE               BILLING
H1001       Prenatal care, at-risk enhancedservice; antepartum management        If the patient isidentified via the assessment as high risk. This code may be billed once.

H1003       Prenatal care, at-risk enhanced                            If the patient isidentified via the assessment as high risk. This code may be billed once.




The services represented by the prenatal care at-risk codes H1002, H1004 and H1005 are already included in the provider’s normal prenatal care and not separately reimbursed.



All Prenatal visits must be billed using the appropriate E&M code for each prenatal visit.  Specific CPT and  HCPCS  Codes  are  listed.   MFC  has  included  a  list  of  CPT  Codes  provided  by  MDH.   This  list  is subject to change at any time without notice when MDH updates their On-Line information.

** Delivery services can be billed 1 of 2 ways: o Delivery Service + Post Partum Care o Delivery Services Only

** Providers may bill: o H1000 (Risk Assessment) once per pregnancy o H1003  (Enhanced  Services)  once  per  visit  for  Maryland  Medicaid  members.   Providers  must document in the medical record that health education and counseling appropriate to the needs of the pregnant woman was provided.

** OBs must bill for circumcisions under the infant’s own name and Medicaid Number /MFC Number.** For procedure codes with a global value MMM, the global period equals 56 days.

** When a provider bills a delivery + post partum care at the time of delivery, the provider must rebill using the exact same codes when the post partum visit actually takes place and adding the modifier TH to the claim.  Use of this modifier however will indicate he date that the postpartum visit actually occurred.  The postpartum visit has to occur on or between 21 and 56 days after delivery. ** If the provider bills the delivery only code, and then later bills the delivery + postpartum code to indicate that  the  postpartum  visit  occurred,  the  original  delivery  only  payment  is  retracted  and  the  delivery  + postpartum code billed is paid

Timeliness of Prenatal Care

Measurement: Deliveries  that  received  prenatal  care  visit  in  the  first  trimester  or  within  42  days of enrollment in a health plan.

Required documentation in the medical record for PRENATAL care visit:

1)A basic physical obstetrical examination that includes

** Auscultation for fetal heart tone, or ** Pelvic exam with obstetric observations, or
** Measurement of fundus height (a standardized prenatal flow sheet may be used)

2)Prenatal Care Procedure: Could be:
** Screening test/obstetric panel or ** TORCH antibody panel alone, or
** A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, or
** Ultrasound/Echography of a pregnant uterus

3)Documentation  of  LMP  or  EDD  with either prenatal  risk  assessment  &  counseling/education, or complete obstetrical history

Required coding for PRENATAL care visit:

Stand Alone Prenatal Visits
CPT: 59425, 59426,99201-99205, 99211-99215, 99241-99245, 99500
CPT II: 0500F, 0501F, 0502F
HCPCS: H1000, H1001, H1002, H1003, H1004

CPT H0001, H0004, H0002, H0005, H0046, H0046

CPT code and Description

H0001 Alcohol and/or drug assessment
H0004 Behavioral health counseling and therapy (15 min)
H0002 Behavioral health screening to determine eligibility for admission to treatment program 
H0005 Alcohol and/or drug services; group counseling by a clinician
H0046 Mental Health Services, Not Otherwise Specified (60 Min)
H0047 Alcohol and/or other drug abuse services, not otherwise specified


Billing Guidelines

CPT H0046- Direct communications with the client and/or collaterals designed to help an enrolled individual attain goals as prescribed in his/her individual service plan. Usage is limited to medically necessary contacts less than 10 minutes that cannot otherwise be reported elsewhere. (Excludes: reminder (non-therapeutic) phone calls, listening to voice mails, e-mails)

For example, a clinician providing a half-hour of individual psychotherapy may code the service as 90832 (Psychotherapy, 30 min with patient and/or family member). If, however, the client leaves after 10 minutes, coding 90832 for that service would not meet fidelity for that code. It would not only be difficult to contend that insight-oriented, behavior modifying or supportive psychotherapy had been provided during such a short time, and CPT guidelines specifically require a minimum of 16 minutes for the use of this code. The service could be coded and reported using H0046, “Mental Health Services Not Otherwise Specified,” which can be reported in minutes. See Individual Treatment services modality for H0046 usage limitations.

CPT H0047 - Direct communications with the client and/or collaterals designed to help an enrolled individual attain goals as prescribed in his/her individual service plan. (Excludes: reminder (non-therapeutic) phone calls, listening to voice mails, e-mails) For Medicaid funded services, this service may only be provided by a CDP or CDPT.

If H0046 (Mental health services, not otherwise specified) is provided for 9 minutes, report 9 minutes.

If H0047 (Alcohol and/or other drug abuse services, not otherwise specified) is provided for 7 minutes, report 7 minutes.

CPT H0001 - Must be doneface-to-face. Provider type - 20-Chemical Dependency Professional  21-Chemical Dependency Professional Trainee

CPT H004 - 10 Minutes minimumfor first unit - Provider type - 20-Chemical Dependency Professional  21-Chemical Dependency Professional Trainee. 01-RN/LPN  02-ARNP/PA   03-Psychiatrist/MD   04-MA/Ph.D.   05-Below Masters Degree  09-Bachelors Level w/Exception Waiver   10-Master Level w/Exception Waiver.



Reimbursement Guidelines from UHC insurance


Documentation maybe reviewed for appropriate coding, existence of a more appropriate code, coverage, reimbursement allowance and prior notification if needed. Unlisted codes that do not have documentation will be denied.

Texas 

Documentation and review not needed for:
** 99429,State requires providers to bill unlisted code 99429 whenproviding dental varnish
** A4335 when billed with an U9 modifier
** H0046when billed by an FQHC for Texas MMP
** H0046 when billed for Texas Chip, Star Kidsand Star Plus** B9998 when billed with modifiers U1-U5



SUBSTANCE ABUSE PROCEDURE CODES

H0001  Alcohol  and/or  drug  assessment  – means  the  evaluation  of  an  individual  by  a clinician to determine the presence, nature, and extent of substance use disorder with the goal of formulating a plan for services (if such services are offered) and treating the client in the most appropriate treatment environment.

H0003 Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs – means the laboratory testing of client specimens to detect the presence of alcohol and other drugs.

H0005  Alcohol  and/or  drug  services;  group  counseling  by  a  clinician –  means services   provided   by   a   clinician   to   assist two or more individuals and/or their families/significant  others  to  achieve  treatment  objectives  through  the  exploration  of substance use disorders and their ramifications, including an examination of attitudes and feelings, and considering alternative solutions and decision making with regard to alcohol and other drug related problems.

H0006 Alcohol and/or drug services; case management – means services provided to link individuals to, or to assist and support clients in gaining access to or to develop their skills  for  gaining  access  to  needed  medical,  social,  educational  and  other  services essential to meeting basic human needs, as appropriate; to train the individual in the use of  basic  community  services;  and  to  monitor  treatment  progress  and  overall  service delivery. 

H0007 Alcohol and/or drug services; crisis intervention (outpatient) – means a face-to-face response to a crisis or emergency situation experienced by an individual, family member and/or significant others related to substance use disorders.

H0008 Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) –  means face-to-face interactions with an individual for the purpose of medically managing and  monitoring  withdrawal  symptoms  from  alcohol  and/or  drug  addiction  in  a  hospital with appropriate accreditation, certification, and licensure, staffed with a registered nurse on  the  premises  twenty-four  hours  per  day  and  a  licensed  physician  on  call  twenty-four hours per day. Detoxification services must be supervised by a licensed physician. 



Q:Will UnitedHealthcare reimburse more than one presumptive and/or one definitive drug test on the same date of service if a modifier is appended?
A:No, each of the presumptive and definitive drug codes define a single manual or automated laboratory service that is reported once per day, per patient,irrespective of the number of Drug Classes, sample validations, or Specimen Validity Testsperformed related to that service on any date of service. In accordance with the CPT and CMS guidelines UnitedHealthcare will not reimburse more than one presumptive and/or one definitive drug test per dayregardless of the number of billing providers.


Presumptive Codes

H0003  Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs(The H  codes are used by those state Medicaid agencies that are mandated by state law to establish separate codes for identifying mental health services that include alcohol and drug treatment services.)



Prenatal and Postnatal Psychosocial Counseling  

Psychosocial evaluation is provided as a prenatal and postnatal service to identify members and families with high psychological and social risks, to develop a psychosocial care plan and provide or coordinate appropriate intervention, counseling or referral necessary to meet the identified needs of each family.  
Counseling may be provided by one of the following licensed Medicaid providers:

**   Licensed Clinical Social Worker
**   Clinical Psychologist
**   Marriage and Family Therapist

The service is reported using HCPCS H0046 Mental Health Services, Not Otherwise Specified.  Limited to twelve (12) visits during any 12-month period. 

CPT 76705 AND 76706

Procedure Code(s) and Description

76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant,  follow-up)

76706  Ultrasound Screening Study for Abdominal Aortic Aneurysm


Preventive Benefit Instructions

Age 65 through 75 (ends on 76thbirthday). Requires at least one of the diagnosis codes listed in this row

Diagnosis Code(s)- covered ICD 10 codes

F17.210, F17.211, F17.213, F17.218, F17.219, Z87.891


Medicare guidelines for using AAA screen


Effective for services furnished on or after January 1, 2017, the following code and modifiers, are used for AAA screening services:76706: Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA). (For screening ultrasound or duplex ultrasound of the abdominal aorta other than screening, see 76770, 76775, 93978, 93979.)

Short Descriptor:  Us abdl aorta screen AAA

Modifiers:  TC, 26


Fee amount for technical and professional component

CPT 76705
Professional $30.24
Technical $63.72
Global$93.96


CPT 76706
Professional $28.44
Technical$68.40
Global$96.84


Documentation Requirements

Ultrasound performed using either a compact portable  ultrasound or a console ultrasound system are reported  using the same CPT codes as long as the studies that were  performed meet all the following requirements:

• Medical necessity as determined by the payer
• Completeness
• Documented in the patient’s medical record

A separate written record of the diagnostic ultrasound  or ultrasound-guided procedure must be completed and  maintained in the patient record.7 This should include a  description of the structures or organs examined and the  findings and reason for the ultrasound procedure(s).  Diagnostic ultrasound procedures require the production and retention of image documentation. It is recommended that permanent ultrasound images, either electronic or hardcopy, from all ultrasound services be retained in the patient record  or other appropriate archive.


Coverage

Use of ultrasound-guided procedures may be a covered benefit if such usage meets all requirements established by the particular payer. In many cases, because the use of ultrasound guidance is an emerging technology, it may be considered investigational and may not be a covered procedure.It is advisable that you check with your local Medicare Contractor. Also, it is essential that each claim be coded appropriately and supported with adequate documentation in the medical record.

Coverage by private payers varies by payer and by plan with respect to which medical specialties may perform ultrasound services. Some payers will reimburse ultrasound procedures to all specialties while other plans will limit reimbursement for ultrasound procedures to specific types of medical specialties.


In addition, there are plans that require providers to submit applications requesting these services be added to the list of services performed in their practice. It is important that you contact the payer prior to submitting claims to determine their requirements

cpt 81223, 81257, 81258, 81269, 81412 - Preconception Screening

Code Description CPT 

81223 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene sequence

81257 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) (effective 1/1/18)

81258 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant (effective 1/1/18)

81259 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence (effective 1/1/18)

81269 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants (effective 1/1/18)

81412 Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1

81479 Unlisted molecular pathology procedure


What are MoPath Codes?

MoPath codes are labels for molecular diagnostics tests that enable payers (i.e., Medicare, Medicaid, private insurance companies) to properly identify and bill for services. In 2012, the AMA CPT estab-lished a new set of analyte-specific MoPath codes to replace the methodology-based codes (CPT 83890-83914; 88384-88386) that previously allowed labs to bill different coding combinations (also known as “code stacks”) for tests evaluating the same analyte. These “stacking” codes were retired as of January 1, 2013. Labs are now required to report tests using the analyte-specific  MoPath codes.

The MoPath codes are categorized into Tier 1 and Tier 2 codes:

•  Tier 1 codes represent the majority of commonly performed single-analyte molecular tests.

•  Tier 2  codes represent procedures that are generally performed in  lower volumes than Tier 1 procedures (e.g., when the incidence of  the disease being tested is rare), and correspond to nine ascending levels of technical resources and interpretive work performed by the  physician or other qualified healthcare professional


Coverage

In general, CF genetic testing is widely covered for both carrier  screening and confirmatory diagnostic testing (Figures 1 and 2). Private payers generally separate coverage guidelines for CF carrier screening versus confirmatory diagnostic testing. For both indica-tions, the majority of payers have either issued positive coverage policies or no policies at all. The absence of a coverage policy does not necessarily indicate non-coverage, but implies that the procedure may be covered if medical necessity can be justified.


Based on private payer coverage guidelines, CF carrier screening is generally covered for individuals who meet any of the following criteria:

• Couples seeking prenatal care

•  Couples who are planning a pregnancy

•  Persons with a family history of CF

•  Persons with a 1st degree relative identified as a CF carrier

•  Reproductive partners of persons with CF Additionally, CF diagnostic testing is typically covered for individuals

who meet any of the following criteria:

• Individual who exhibits symptoms of CF but has a negative sweat test

• Infant with meconium ileus or other symptoms indicative of CF who is too young to produce inadequate volumes of sweat for a sweat chloride test 

•  Male infertility from either of the following:

- Congenital bilateral absence of vas deferens (CBAVD)

- Azoospermia or severe oligospermia  (i.e., < 5 million sperm/milliliter) with palpable vas deferens The majority of state Medicaid agencies do not have policies specifi-cally addressing coverage for CF genetic testing (carrier screening  or diagnostic testing), but instead have general coverage policies for  laboratory services performed by CLIA-approved labs.


Payment
For 2013, the Centers for Medicare & Medicaid Services (CMS) assigned the local Medicare Administrative Contractors (MACs) the responsibility of setting regional fee schedule amounts for the new MoPath code set (including payment rates for CF testing) via gapfilling.Gapfilling is used when a comparable test does not exist. CMS instructs local MACs to establish payment rates in the first year based on charges and routine discounts to charges, resources required, and other payers’ payment rates. For reimbursement in the second year and beyond, CMS calculates a national payment rate by using the median of the local MAC fee schedules.On September 30, 2013, CMS released the 2014 national Medicare fee schedule amounts for the MoPath codes, which were based on the final gapfill rates determined by each MAC

.  However, the national fee schedule did not include any payment rates for the cystic fibrosis testing codes. Since payment rates will vary by payer (both private and public), laboratories are encouraged to contact individual payers directly to clarify the fee schedule amounts for these codes in 2014.


Preconception Screening for Carrier Status of Genetic Diseases

Introduction

Genetic tests are laboratory tests that measure changes in human DNA, chromosomes, genes or gene products (proteins). Blood, skin, cheek swabs, and amniotic fluid are some common samples that can be tested. Genetic testing for carrier status is done on people planning a pregnancy. The goal is to see if they have a potential disease that could be passed on to their offspring. For certain disorders, a carrier state can exist where a person has no symptoms of the disease, but has the potential to pass the disease on to their children because they carry a gene for the disease. Often it takes at least two copies of the gene for the disease to cause symptoms. Usually carrier testing is done before conception when individuals are planning a pregnancy, but it may also be done in the early stages of pregnancy.



Policy Coverage Criteria 

This policy applies only if there is not a separate policy that outlines specific criteria for carrier testing. If a separate policy exists, then criteria for medical necessity in that policy supersedes the guidelines in this policy (see Related Policies).
Note: Usually carrier testing is done before conception when individuals are planning a pregnancy, but it may also be done in the early stages of pregnancy.
Test Type Medical Necessity Expanded Carrier

Expanded Carrier Screening Panels

Expanded carrier screening panels which test for mutations on many different genes are considered not medically necessary. Based on the individual tested, a subset of tests within the panel may be covered when the policy criteria are met.

The names of expanded carrier panels, and their individual mutation components, are rapidly evolving. Examples of panels addressed in this policy include but are not limited to: * Counsyl™ (Counsyl) * GoodStart Select™ (GoodStart Genetics) * Inherigen™ (GenPath) * InheriGen Plus * Inheritest™ (LabCorp) * Natera One™ Disease Panel (Natera)  Genetic Disease Medical Necessity The General Population  Cystic fibrosis (CPT 81220) Covered for all individuals with a panel that tests the most common genes 

Note: Carrier testing for cystic fibrosis using CPT 81223 “CFTR (eg, cystic fibrosis) gene analysis; full gene sequence” is considered not medically necessary for carrier testing.


Genetic Disease Medical Necessity  Spinal muscular atrophy (CPT 81400, 81401)

Covered for all individuals

Genetic Disease Medical Necessity Specific Groups or Populations

The following genetic testing may also be considered medically necessary due to an increased frequency of certain disorders in groups or populations
Ashkenazi Jewish founder mutations:

* Bloom syndrome  * Canavan disease  * Cystic fibrosis  * Familial dysautonomia  * Fanconi anemia (group C)  * Gaucher disease * Mucolipidosis IV  * Niemann-Pick (type A)

* Tay-Sachs disease

FMR1 variants (including Fragile-X syndrome)

Ashkenazi Jewish founder mutations may be considered medically necessary when the individual meets one of the following criteria: * Ashkenazi Jewish ancestry consisting of a minimum of one
Jewish grandparent * If the Jewish partner has a positive carrier test result, the other
partner (regardless of ethnic background) should be screened only for that identified mutation

Genetic testing for Ashkenazi Jewish founder mutation is considered not medically necessary for all other uses.

Genetic testing for FMR1 variants may be considered medically necessary when any of the following criteria are met: * Parent of either sex with intellectual disability, developmental delay, or autism spectrum disorder * Parent with a family history of fragile X syndrome or a family  history of undiagnosed intellectual disability  * Prenatal testing of fetuses of mothers  who are known carriers   to determine whether the fetus inherited the normal or mutant FMR1 gene

* Affected individuals or first- and second- degree relatives   of affected individuals who have had a positive cytogenetic fragile X test (less accurate historic test) result who are seeking further counseling related to the risk of carrier status

Genetic testing for FMR1 variants (including Fragile-X syndrome) is considered not medically necessary for all other

Genetic Disease Medical Necessity  uses.  Alpha-thalassemia

preconception (carrier) testing

Preconception (carrier) testing for alpha-thalassemia in prospective parents may be considered medically necessary when all of the following criteria are met: * At least one parent is of a high-risk ethnic group, such as
Southeast Asian, African or Mediterranean ancestry * At least one parent has had abnormal biochemical testing
which may include ANY of the following: o Anemia o Microcytosis (a low MCV – small blood cells) o Hypochromia (a low MCH or MCHC – red blood cells with
less hemoglobin) o Abnormal hemoglobin electrophoresis

Genetic testing for hemoglobinopathies, except for alphathalassemia, is considered not medically necessary.
Genetic Disease Medical Necessity Other Inherited Disorders

Carrier testing of specific disorder

May be considered medically necessary when ONE of the following criteria are present: * One or both parents have a first-  or second-degree relative*
who has the disorder * One parent is or both parents are a known carrier of the
disorder. 

Note: 1st-degree relatives are parents, siblings, and children. 2nd-degree relatives are grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings. 

AND all of the following criteria must also be met: * The natural history of the disease is understood and the
disease is likely to result in severe health problems * Other biochemical or clinical tests to diagnose carrier status are


Genetic Disease Medical Necessity Coding not available, or are less accurate than genetic testing * The genetic test has adequate sensitivity and specificity to guide clinical decision making  o The American College of Medical Genetics and Genomics (ACMG) recommends testing for specific mutations, which will result in carrier detection rate of 95% or higher for most disorders.

* A clear association of the genetic change with the disorder has been established Genetic testing for other specific disorders is considered not medically necessary when the criteria above are not met.




Related Information 

If there is no family history of, risk based or ethnic predilection for a disease, carrier screening is not recommended when the carrier rate is less than 1% in the general population.

ACMG has defined expanded panels as those that use next-generation sequencing to screen for variants in many genes, as opposed to gene-by-gene screening (eg, ethnic-specific screening or pan-ethnic testing for cystic fibrosis).
Expanded panels may include the diseases that are present with increased frequency in specific populations, but typically include testing for a wide range of diseases for which the patient is not at risk of being a carrier.
Carrier screening should only be performed in adults. 

For individuals who are at risk due to an established family history of fragile X syndrome, DNA testing alone is sufficient. If the diagnosis of the affected relative was based on previous cytogenetic testing for fragile X syndrome, at least one affected relative should have DNA testing.
Prenatal testing of a fetus should be offered when the mother is a known carrier to determine whether the fetus inherited the normal or mutant FMR1 gene. Ideally DNA testing should be performed on cultured amniocytes obtained by amniocentesis after 15 weeks’ gestation. DNA testing can be performed on chorionic villi obtained by chorionic villus sampling at 10 to 12 weeks’ gestation, but results must be interpreted with caution because the methylation status of the FMR1 gene is often not yet established in chorionic villi at the time of sampling. follow-up amniocentesis may be necessary to resolve an ambiguous result.


Definition of Terms


1st-, 2nd-, or 3rd-degree relative: For the purpose of familial assessment, 1st-, 2nd-, or 3rddegree relatives are blood relatives on the same side of the family (maternal or paternal). The maternal and paternal sides of the family should be considered independently for familial patterns of inherited disorders. 

* 1st-degree relatives are parents, siblings, and children.
* 2nd-degree relatives are grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings.
* 3rd-degree relatives are great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins 
Carrier testing: Carrier genetic testing is performed on people who display no symptoms for a genetic disorder but may be at risk for passing it on to their children.
A carrier of a genetic disorder has one abnormal allele for a disorder.  Carriers of an autosomal recessive mutation are typically unaffected.  Offspring who inherit the mutation from both parents usually manifest the disorder. When associated with an autosomal dominant or an Xlinked dominant disorder, the individual may be affected with the disorder or be at high risk of developing the disorder later in life. Women with an X-linked recessive mutation are usually unaffected. Males receiving a chromosome with an X-linked recessive mutation usually manifest the disorder.
Compound heterozygous: The presence of two different mutant alleles at a particular gene locus, one on each chromosome of a pair.

Expressivity/expression: The degree to which a penetrant gene is expressed within an individual.
Genetic testing: A test that analyzes chromosomes, DNA, RNA, genes, or gene products to detect inherited (germline) or non-inherited (somatic) genetic variants related to disease or health

Homozygous: Having the same alleles at a particular gene locus on homologous chromosomes (chromosome pairs).
Penetrance: The proportion of individuals with a mutation that causes a particular disorder who exhibit clinical symptoms of that disorder.

Residual risk: The risk that an individual is a carrier of a particular disease, but genetic testing for carrier status of the disease is negative (eg, if the individual has a disease-causing mutation that wasn’t included in the test assay).

Testing sequence: Testing sequence of carrier testing for genetic diseases is generally done on the mother or affected partner first, and if positive, then the other parent is tested.

Genetics Nomenclature Update

Human Genome Variation Society (HGVS) nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics (see Table 1). HGVS nomenclature is recommended by HGVS, the Human Variome Project, and the HUman Genome Organization (HUGO).

The American College of Medical Genetics and Genomics (ACMG) and Association for Molecular Pathology (AMP) standards and guidelines for interpretation of sequence variants represent expert opinion from ACMG, AMP, and the College of American Pathologists. These recommendations primarily apply to genetic tests used in clinical laboratories, including genotyping, single genes, panels, exomes, and genomes. Table 2 shows the recommended standard terminology—“pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign”—to describe variants identified that cause Mendelian disorders.

Table 1. Nomenclature to Report on Variants Found in DNA
Previous  Updated  Definition
Mutation Disease-associated variant Disease-associated change in the DNA sequence
Variant Change in the DNA sequence 
Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives

Table 2. ACMG-AMP Standards and Guidelines for Variant Classification
Variant Classification Definition
Pathogenic Disease-causing change in the DNA sequence

Variant Classification Definition 

Likely pathogenic Likely disease-causing change in the DNA sequence 
Variant of uncertain significance Change in DNA sequence with uncertain effects on disease
Likely benign Likely benign change in the DNA sequence
Benign Benign change in the DNA sequence
ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology. providing a diagnosis eliminates the need for further diagnostic workup. A chain of evidence supports improved outcomes following FMR1 variant testing.. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have a personal or family history of FXS who are seeking reproductive counseling, the evidence includes studies  evaluating the clinical validity of FMR1 variant testing and the effect on reproductive decision making. Testing the repeat region of the FMR1 gene in the context of reproductive decision making may include individuals with either a family history of FXS or a family history of undiagnosed intellectual disability, fetuses of known carrier mothers, or affected individuals or their relatives who have had a positive cytogenetic fragile X test result who are seeking further counseling related to the risk of carrier status among themselves or their relatives. DNA testing would accurately identify premutation carriers and distinguish premutation from full mutation carrier women. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

(HCPCS Codes R0070 - , R0075, R0076) - Transportation Component

Procedure codes (CPT & HCPCS) :


CPT Code Code Description

R0070 Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen

R0075 Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen


Reimbursement Guidelines
Effective for claims processed on or after July 29, 2018,Moda Health follows CMS guidelines in  allowing a  single  transportation  payment  for  each  trip  the  portable  x - ray provider makes transporting  x-ray equipment to a particular location.(CMS  1 ) When more than one patient is x-rayed at the same location ( e.g.,  a  nursing  home ), the allowable  amount  for  the transportation  service  will  be  reduced  (prorated) based upon the total number of patients receiving the portable x - ray services during that trip, regardless of their insurance status.

* If only one patient is served,  report procedure code  R0070 with no modifier,since the descriptor for this code reflects only one patient seen. 

* If more than one patient receives portable x-ray services during that trip, report R0075, regardless of whether or not all the patients have insurance, or under which carrier.


Note: When the x-ray equipment used is actually transported to the location where the x-ray was taken, then a transportation service may be billed.  If the x-ray equipment used is stored in the location where the x-ray was done (e.g., a nursing home) for use as needed, then an equipmenttransportation service (R0070, R0075) may not be billed.

HCPCS code R0075 must be billed with one of the following modifiers, to indicate how many patients wereserved on that trip to the facility or location. The allowable fee forR0075 will be adjusted based upon the modifier used.

Modifier Modifier Definition  Payment Adjustment


Modifier  UN Two patients served D ivided by 2 (50%)

Modifier UP Three patients served Divided by 3 (33.3%)

Modifier UQ Four patients served Divided by 4 (25%)

Modifier UR Five patients served Divided by 5 (20%)

Modifier US Six patients or more served Divided by 6, regardless of the number of  patients served (16.7%)

This component represents the transportation of the equipment to the patient. Establish local RVUs for the transportation R codes based on carrier knowledge of the nature of the service furnished. Carriers shall allow only a single transportation payment for each trip the portable x-ray supplier makes to a particular location. When more than one Medicare patient is x-rayed at the same location, e.g., a nursing home, prorate the single fee schedule transportation payment among all patients receiving the services. For example, if two patients at the same location receive x-rays, make one-half of the transportation payment for each.

R0075 must be billed in conjunction with the Procedure code radiology codes (7000 series) and only when the x-ray equipment used was actually transported to the location where the x-ray was taken. R0075 would not apply to the x-ray equipment stored in the location where the x-ray was done (e.g., a nursing home) for use as needed.salary and fringe benefits of the staff who determine the vehicles route (this could be proportional of office staff), repairs and maintenance of the vehicle(s), insurance for the vehicle(s), operating expenses for the vehicles and any other reasonable costs associated with this service as determined by the carrier. The carrier will have discretion for allocating indirect costs (those costs that cannot be directly attributed to portable x-ray transportation) between the transportation service and the technical component of the x-ray tests.
Suppliers may send carriers unsolicited cost information. The carrier may use this cost data as a comparison to its carrier priced determination. The data supplied should reflect a year’s worth (either calendar or corporate fiscal) of information. Each provider who submits such data is to be informed that the data is subject to verification and will be used to supplement other information that is used to determine Medicare’s payment rate.

Carriers are required to update the rate on an annual basis using independently determined measures of the cost of providing the service. A number of readily available measures (e.g., ambulance inflation factor, the Medicare economic index) that are used by the Medicare program to adjust payment rates for other types of services may be appropriate to use to update the rate for years that the carrier does not recalibrate the payment. Each carrier has the flexibility to identify the index it will use to update the rate. In addition, the carrier can consider locally identified factors that are measured independently of CMS as an adjunct to the annual adjustment.

NOTE: No transportation charge is payable unless the portable x-ray equipment used was actually transported to the location where the x-ray was taken. For example, carriers do not allow a transportation charge when the x-ray equipment is stored in a nursing home for use as needed. However, a set-up payment (see §90.4, below) is payable in such situations. Further, for services furnished on or after January 1, 1997, carriers may not make separate payment under HCPCS code R0076 for the transportation of EKG equipment by portable x-ray suppliers or any other entity.

Below are the definitions for each modifier that must be reported with R0075. Only one of these five modifiers shall be reported with R0075. NOTE: If only one patient is served, R0070 should be reported with no modifier since the descriptor for this code reflects only one patient seen.

UN - Two patients served
UP - Three patients served
UQ - Four patients served
UR - Five Patients served
US - Six or more patients served

Payment for the above modifiers must be consistent with the definition of the modifiers. Therefore, for R0075 reported with modifiers, -UN, -UP, -UQ, and –UR, the total payment for the service shall be divided by 2, 3, 4, and 5 respectively. For modifier –US, the total payment for the service shall be divided by 6 regardless of the number of patients served. For example, if 8 patients were served, R0075 would be reported with modifier –US and the total payment for this service would be divided by 6.

The units field for R0075 shall always be reported as “1” except in extremely unusual cases. The number in the units field should be completed in accordance with the provisions of 100-04, chapter 23, section 10.2 item 24 G which defines the units field as the number of times the patient has received the itemized service during the dates listed in the from/to field. The units field must never be used to report the number of patients served during a single trip. Specifically, the units field must reflect the number of services that the specific beneficiary received, not the number of services received by other beneficiaries.

As a carrier priced service, carriers must initially determine a payment rate for portable x-ray transportation services that is associated with the cost of providing the service. In order to determine an appropriate cost, the carrier should, at a minimum, cost out the vehicle, vehicle modifications, gasoline and the staff time involved in only the transportation for a portable x-ray service. A review of the pricing of this service should be done every five years.

Direct costs related to the vehicle carrying the x-ray machine are fully allocable to determining the payment rate. This includes the cost of the vehicle using a recognized depreciation method, the salary and fringe benefits associated with the staff who drive the vehicle, the communication equipment used between the vehicle and the home office, the salary and fringe benefits of the staff who determine the vehicles route (this could be proportional of office staff), repairs and maintenance of the vehicle(s), insurance for the vehicle(s), operating expenses for the vehicles and any other reasonable costs associated with this service as determined by the carrier. The carrier will have discretion for allocating indirect costs (those costs that cannot be directly attributed to portable x-ray transportation) between the transportation service and the technical component of the x-ray tests.

Suppliers may send carriers unsolicited cost information. The carrier may use this cost data as a comparison to its carrier priced determination. The data supplied should reflect a year’s worth (either calendar or corporate fiscal) of information. Each provider who submits such data is to be informed that the data is subject to verification and will be used to supplement other information that is used to determine Medicare’s payment rate.

Carriers are required to update the rate on an annual basis using independently determined measures of the cost of providing the service. A number of readily available measures (e.g., ambulance inflation factor, the Medicare economic index) that are used by the Medicare program to adjust payment rates for other types of services may be appropriate to use to update the rate for years that the carrier does not recalibrate the payment. Each carrier has the flexibility to identify the index it will use to update the rate. In addition, the carrier can consider locally identified factors that are measured independently of CMS as an adjunct to the annual adjustment.

NOTE: No transportation charge is payable unless the portable x-ray equipment used was actually transported to the location where the x-ray was taken. For example, carriers do not allow a transportation charge when the x-ray equipment is stored in a nursing home for use as needed. However, a set-up payment (see §90.4, below) is payable in such situations. Further, for services furnished on or after January 1, 1997, carriers may not make separate payment under HCPCS code R0076 for the transportation of EKG equipment by portable x-ray suppliers or any other entity.