CPT 75571 - 75574

CPT/HCPCS Codes  Group 1 Codes:

75572 Ct hrt w/3d image
75573 Ct hrt w/3d image congen
75574 Ct angio hrt w/3d image


Group 2 Codes:

75571 Ct hrt w/o dye w/ca test


Coverage Indications, Limitations, and/or Medical Necessity

Indications

As an alternative to invasive coronary angiography following a stress test that is equivocal or suspected to be inaccurate.

Instead of myocardial perfusion imaging in the evaluation of coronary artery disease in those patients who have moderate pre-test probability of disease based on clinical risk factors and abnormal diagnostic studies, not symptoms alone.

To evaluate the cause of symptoms in patients with known coronary artery disease.

Assessment of suspected congenital anomalies of coronary circulation or great vessels.

Assessment of coronary or pulmonary venous anatomy for the procedures described below:

CTA of the coronary veins is indicated when imaging of the coronary venous anatomy is necessary for biventricular pacemaker lead insertion.

CTA of the pulmonary veins is indicated when imaging of the pulmonary vasculature is necessary for pulmonary vein catheter ablation procedures for atrial fibrillation.
Limitations

Since the majority of the clinical research utilized a 64-slice CT scanner it is the recommended equipment. However, the intent of this LCD is not to monitor equipment utilization.

The procedure must be performed under the direct supervision of and interpreted by a cardiologist or radiologist who meets the competency guidelines outlined by the published guidelines, ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance, or American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging.

NOT COVERED:

CPT 75571
Using 71275 or 76497
Screening tests are defined as those tests done in the absence of signs, symptoms, or presence of disease. The use of these procedures (75572, 75573, 75574 for coronary CT angiography) in patients without signs, symptoms or presence of disease is considered to be screening by this Contractor.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

I20.1 - I20.9 - Opens in a new window Angina pectoris with documented spasm - Angina pectoris, unspecified
I25.10 - I25.119 - Opens in a new window Atherosclerotic heart disease of native coronary artery without angina pectoris - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.41 - I25.739 - Opens in a new window Coronary artery aneurysm - Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 - I25.759 - Opens in a new window Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 - I25.810 - Opens in a new window Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.82 - I25.9 - Opens in a new window Chronic total occlusion of coronary artery - Chronic ischemic heart disease, unspecified
I48.0 - I48.92 - Opens in a new window Paroxysmal atrial fibrillation - Unspecified atrial flutter
Q20.0 - Q25.0 - Opens in a new window Common arterial trunk - Patent ductus arteriosus
Q25.3 - Q26.4 - Opens in a new window Supravalvular aortic stenosis - Anomalous pulmonary venous connection, unspecified
Q26.8 Other congenital malformations of great veins
R06.02 Shortness of breath
R07.2 Precordial pain
R94.30 - R94.39 - Opens in a new window Abnormal result of cardiovascular function study, unspecified - Abnormal result of other cardiovascular function study
Z01.810 Encounter for preprocedural cardiovascular examination


Indications

MDCT angiography of the chest for non-cardiac assessment (71275) will be considered medically reasonable and necessary for the following signs or symptoms of disease:
• Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli;

• Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio- venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart;

• Assessment of suspected congenital anomalies of the heart or great vessels; and

• Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis.

MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary for the following signs or symptoms of disease:

• Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid performing diagnostic cardiac catheterization. MDCT and coronary angiography are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. (If a high pretest probability of disease exists, as if the patient has known CAD, it is assumed the patient would go to coronary angiography as the definitive test, where possible angioplasty and/or stenting could be performed at the same time).

• Assessment of suspected congenital anomalies of coronary circulation.

• Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging,if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary
angiography would be done in addition to a subsequent coronary catheterization and angiogram).

• Evaluation of pulmonary veins prior to arrhythmia ablation procedures

• Evaluation of cardiac veins prior to insertion of biventricular pacemaker Additionally, at times, it may be necessary to evaluate the patient for both cardiac and noncardiac disease.

Pending the assignment of a code that more precisely describes this service, protocols using cardiovascular CT angiography for the evaluation of acute chest pain in the emergency setting, where pulmonary and/or aortic vascular etiology are also a concern, must be coded with CPT code 71275 only. Billing CPT code 71275 plus one of the following CPT codes (75571, 75572, 75573, or 75574) would attest to the fact that two completely separate procedures were performed in their entirety.

Limitations

• The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.

• The test is never covered for patients with stable coronary artery disease without any significant change in signs or symptoms.

• The selection of the test should be made within the context of other testing modalities so that the resulting information facilitates the management decision, and does not merely add an additional layer of testing. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive calcification that would diminish the interpretive value.

• Coverage of this modality for coronary artery assessment is limited to devices that process thin, highresolution slices (0.75 mm or less) A multidetector scanner must have a row of at least 32 detectors. For non-cardiac thoracic assessment, the multidetector scanner may have a capability of less than 16 slices or less. The rotational gantry speeds for cardiac evaluation must be 420 milliseconds or less.

• The administration of beta-blockers and/or other medications and the monitoring of the patient by a physician during the MDCT are not separately payable services.

• All studies must be ordered by a physician or a qualified non-physician practitioner. A physician or qualified non-physician provider must be present during testing whenever cardioactive agents or contrast agents are administered (direct physician supervision). Ideally, this supervising physician will be experienced in this procedure and ACLS-certified.

• Electron Beam Technology provides high temporal resolution and enables quantitative assessment of the coronary artery calcium, but because of limited spatial resolution as a result of the limited z axis resolution (slice thickness=3.0 mm), it does not permit direct visualization in multi-reformation of the whole coronary system. Therefore, CT angiography of the heart is not considered medically necessary when performed with an EBT scanner.

The following codes will be considered reasonable and necessary for CT Angiography of the Chest for Cardiac indications for CPT codes 75571, 75572, 75573, 75574.

CPT 76856, 76857 - Radiology pevic ultrasound procedure

Indications

Pelvic pain undiagnosed by standard exam;
Dysmenorrhea;
Menorrhagia;
Metrorrhagia;
Menometrorrhagia;
Postmenopausal bleeding;
Abnormal pelvic examination;
Further evaluation of abnormality found on other imaging studies; and
Cancer

76856 is a complete evaluation and must minimally include:

Female: description and measurements of the uterus and adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology.

Male: evaluation and measurement of the bladder, evaluation of the prostate and seminal vesicles and any pelvic pathology.

76857 is a limited study and typically focuses on one or more elements listed under 76856 and/or the reevaluation of one or more pelvic abnormalities.

Limitations

Post voiding residual bladder volume is not reimbursable by CPT codes 76856 and 76857. Measurement of post voiding residual should be billed using CPT code 51798.

The accuracy of ultrasonographic studies depends on the knowledge, skills and experience of the technologist and interpreter. Consequently, the providers of interpretations must be capable of demonstrating documented training and experience and maintain documentation of such for possible audit. Further, ultrasonographic studies must be either (1) performed by persons with appropriate training that have demonstrated minimum entry level competency by being credentialed by a nationally recognized credentialing organization in ultrasound technology (e.g., American Registry of Radiologic Technologists (ARRT) in sonography), (2) performed by or under the direct supervision of a physician, or (3) performed in facilities with laboratories accredited in ultrasonography.


CPT/HCPCS Codes


76856 Us exam pelvic complete
76857 Us exam pelvic limited



ICD-10 CODE DESCRIPTION

A18.14 Tuberculosis of prostate
A56.11 Chlamydial female pelvic inflammatory disease
C45.1 Mesothelioma of peritoneum
C48.0 - C48.8 - Opens in a new window Malignant neoplasm of retroperitoneum - Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C52 - C57.4 - Opens in a new window Malignant neoplasm of vagina - Malignant neoplasm of uterine adnexa, unspecified
C57.9 - C58 - Opens in a new window Malignant neoplasm of female genital organ, unspecified - Malignant neoplasm of placenta
C61 - C62.92 - Opens in a new window Malignant neoplasm of prostate - Malignant neoplasm of left testis, unspecified whether descended or undescended
C63.9 Malignant neoplasm of male genital organ, unspecified
C67.0 - C67.9 - Opens in a new window Malignant neoplasm of trigone of bladder - Malignant neoplasm of bladder, unspecified
C76.3 Malignant neoplasm of pelvis
D06.0 - D07.39 - Opens in a new window Carcinoma in situ of endocervix - Carcinoma in situ of other female genital organs
D25.0 - D27.9 - Opens in a new window Submucous leiomyoma of uterus - Benign neoplasm of unspecified ovary
D28.1 - D28.2 - Opens in a new window Benign neoplasm of vagina - Benign neoplasm of uterine tubes and ligaments
D28.9 - D29.9 - Opens in a new window Benign neoplasm of female genital organ, unspecified - Benign neoplasm of male genital organ, unspecified
D39.0 - D39.12 - Opens in a new window Neoplasm of uncertain behavior of uterus - Neoplasm of uncertain behavior of left ovary
D39.8 - D40.0 - Opens in a new window Neoplasm of uncertain behavior of other specified female genital organs - Neoplasm of uncertain behavior of prostate
D41.3 - D41.8 - Opens in a new window Neoplasm of uncertain behavior of urethra - Neoplasm of uncertain behavior of other specified urinary organs
D78.01 - D78.02 - Opens in a new window Intraoperative hemorrhage and hematoma of the spleen complicating a procedure on the spleen - Intraoperative hemorrhage and hematoma of the spleen complicating other procedure
D78.21 - D78.22 - Opens in a new window Postprocedural hemorrhage of the spleen following a procedure on the spleen - Postprocedural hemorrhage of the spleen following other procedure
E28.0 - E28.9 - Opens in a new window Estrogen excess - Ovarian dysfunction, unspecified
E36.01 - E36.02 - Opens in a new window Intraoperative hemorrhage and hematoma of an endocrine system organ or structure complicating an endocrine system procedure - Intraoperative hemorrhage and hematoma of an endocrine system organ or structure complicating other procedure
E89.40 - E89.41 - Opens in a new window Asymptomatic postprocedural ovarian failure - Symptomatic postprocedural ovarian failure
G97.31 - G97.32 - Opens in a new window Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure - Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating other procedure
G97.51 - G97.52 - Opens in a new window Postprocedural hemorrhage of a nervous system organ or structure following a nervous system procedure - Postprocedural hemorrhage of a nervous system organ or structure following other procedure
I72.3 Aneurysm of iliac artery
I72.9 Aneurysm of unspecified site
I80.211 - I80.219 - Opens in a new window Phlebitis and thrombophlebitis of right iliac vein - Phlebitis and thrombophlebitis of unspecified iliac vein
K35.2 - K37 - Opens in a new window Acute appendicitis with generalized peritonitis - Unspecified appendicitis
K50.00 - K50.919 - Opens in a new window Crohn's disease of small intestine without complications - Crohn's disease, unspecified, with unspecified complications
K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding
K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding
K57.40 Diverticulitis of both small and large intestine with perforation and abscess without bleeding
K57.52 Diverticulitis of both small and large intestine without perforation or abscess without bleeding
K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding
K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
K66.1 - K66.8 - Opens in a new window Hemoperitoneum - Other specified disorders of peritoneum
K68.11 Postprocedural retroperitoneal abscess
K68.9 Other disorders of retroperitoneum
K91.61 - K91.62 - Opens in a new window Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure - Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating other procedure
K91.840 - K91.841 - Opens in a new window Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure - Postprocedural hemorrhage of a digestive system organ or structure following other procedure
N13.9 Obstructive and reflux uropathy, unspecified
N21.0 Calculus in bladder
N31.0 - N33 - Opens in a new window Uninhibited neuropathic bladder, not elsewhere classified - Bladder disorders in diseases classified elsewhere
N36.44 Muscular disorders of urethra
N41.0 - N41.9 - Opens in a new window Acute prostatitis - Inflammatory disease of prostate, unspecified
N70.01 - N71.9 - Opens in a new window Acute salpingitis - Inflammatory disease of uterus, unspecified
N73.0 - N74 - Opens in a new window Acute parametritis and pelvic cellulitis - Female pelvic inflammatory disorders in diseases classified elsewhere
N80.0 - N80.9 - Opens in a new window Endometriosis of uterus - Endometriosis, unspecified
N82.8 Other female genital tract fistulae
N83.53 - N84.0 - Opens in a new window Torsion of ovary, ovarian pedicle and fallopian tube - Polyp of corpus uteri
N84.8 - N85.9 - Opens in a new window Polyp of other parts of female genital tract - Noninflammatory disorder of uterus, unspecified
N89.7 Hematocolpos
N91.0 - N94.0 - Opens in a new window Primary amenorrhea - Mittelschmerz
N94.4 - N94.89 - Opens in a new window Primary dysmenorrhea - Other specified conditions associated with female genital organs and menstrual cycle
N95.0 Postmenopausal bleeding
N98.1 Hyperstimulation of ovaries
N99.510 - N99.518 - Opens in a new window Cystostomy hemorrhage - Other cystostomy complication
N99.61 - N99.62 - Opens in a new window Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure - Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating other procedure
N99.820 - N99.83 - Opens in a new window Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure - Residual ovary syndrome
Q50.01 - Q56.4 - Opens in a new window Congenital absence of ovary, unilateral - Indeterminate sex, unspecified
Q64.0 Epispadias
Q64.11 Supravesical fissure of urinary bladder
Q64.5 - Q64.79 - Opens in a new window Congenital absence of bladder and urethra - Other congenital malformations of bladder and urethra
R10.0 - R10.9 - Opens in a new window Acute abdomen - Unspecified abdominal pain
R16.0 - R16.2 - Opens in a new window Hepatomegaly, not elsewhere classified - Hepatomegaly with splenomegaly, not elsewhere classified
R18.0 - R19.09 - Opens in a new window Malignant ascites - Other intra-abdominal and pelvic swelling, mass and lump
R19.30 - R19.37 - Opens in a new window Abdominal rigidity, unspecified site - Generalized abdominal rigidity
R19.8 Other specified symptoms and signs involving the digestive system and abdomen
R31.0 - R31.9 - Opens in a new window Gross hematuria - Hematuria, unspecified
T81.4XXA Infection following a procedure, initial encounter
T88.8XXA Other specified complications of surgical and medical care, not elsewhere classified, initial encounter
Z48.22 Encounter for aftercare following kidney transplant
Z85.40 - Z85.41 - Opens in a new window Personal history of malignant neoplasm of unspecified female genital organ - Personal history of malignant neoplasm of cervix uteri
Z85.44 Personal history of malignant neoplasm of other female genital organs
Z87.42 Personal history of other diseases of the female genital tract
Z87.59 Personal history of other complications of pregnancy, childbirth and the puerperium
Z94.0 Kidney transplant status

Hearth MRI and IMAGING Procedure code

HEART

Cardiac magnetic imaging differs from traditional magnetic resonance imaging (MRI) in its ability to provide a physiologic evaluation of cardiac function. Traditional MRI relies on static images to obtain clinical diagnoses based upon anatomic information. Improvement in spatial and temporal resolution has expanded the application from an anatomic test and includes physiologic evaluation of cardiac function.

 Flow and velocity assessment for valves and intracardiac shunts is performed in addition to a function and morphologic evaluation. Use 75559 with 75565 to report flow with pharmacologic wall motion stress evaluation without contrast. Use 75563 with 75565 to report flow with pharmacologic perfusion stress with contrast.

Listed procedures may be performed independently or in the course of overall medical care. If the physician providing these services is also responsible for diagnostic workup and/ or follow-up care of the patient, see appropriate sections also. Only one procedure in the series 75557-75563 is appropriately reported per session. Cardiac MRI studies may be performed at rest and/or during pharmacologic stress.

Therefore, the appropriate stress testing code from the 93015-93018 series should be reported in addition to 75559 or 75563.

75557 Cardiac magnetic resonance imaging for morphology and function without contrast material;

75559 with stress imaging

75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

75563 with stress imaging

75565 Cardiac magnetic resonance imaging for velocity flow mapping
(List separately in addition to code)

(Use 75565 in conjunction with 75557, 75559, 75561, 75563)

(Do not report 75557, 75559, 75561, 75563, 75565 in conjunction with 76376, 76377)

CPT 73510 - Upper and Lower Extremities Procedure codes - Radiology

UPPER EXTREMITIES

73000 Radiologic examination; clavicle, complete

73010 scapula, complete

73020 Radiologic examination, shoulder; one view

73030 complete, minimum of two views

73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation
(Do not report 77002 in conjunction with 73040)

73050 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction

73060 humerus, minimum of two views

73070 Radiologic examination, elbow; two views

73080 complete, minimum of three views

73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation

(Do not report 77002 in conjunction with 73085)

73090 Radiologic examination; forearm, two views

73092 upper extremity, infant, minimum of two views

73100 Radiologic examination, wrist; two views

73110 complete, minimum of three views

73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation
(Do not report 77002 in conjunction with 73115)

73120 Radiologic examination, hand; two views

73130 minimum of three views

73140 Radiologic examination, finger(s), minimum of two views

73200 Computed tomography, upper extremity; without contrast material

73201 with contrast material(s)

73202 without contrast material, followed by contrast material(s) and further sections

73206 Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73218 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)

73219 with contrast material(s)

73220 without contrast material(s), followed by contrast material(s) and further sequences

73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)

73222 with contrast material(s)

73223 without contrast material(s), followed by contrast material(s) and further sequences

73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s)


LOWER EXTREMITIES

73500 Radiologic examination, hip; unilateral, one view

73510 complete, minimum of two views

73520 Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis

73525 Radiologic examination, hip, arthrography, radiological supervision and interpretation
(Do not report 77002 in conjunction with 73525)

73530 Radiologic examination, hip, during operative procedure

73540 Radiologic examination, pelvis and hips, infant or child, minimum of two views

73550 Radiologic examination, femur, two views

73560 Radiologic examination, knee; one or two views

73562 three views

73564 complete, four or more views

73565 both knees, standing, anteroposterior

73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation
(Do not report 77002 in conjunction with 73580)

73590 Radiologic examination; tibia and fibula, two views

73592 lower extremity, infant, minimum of two views

73600 Radiologic examination, ankle; two views

73610 complete, minimum of three views

73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation
(Do not report 77002 in conjunction with 73615)

73620 Radiologic examination, foot; two views

73630 complete, minimum of three views

73650 Radiologic examination; calcaneus, minimum of two views

73660 toe(s), minimum of two views

73700 Computed tomography, lower extremity; without contrast material

73701 with contrast material(s)

73702 without contrast material, followed by contrast material(s) and further sections

73706 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73718 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)

73719 with contrast material(s)

73720 without contrast material(s), followed by contrast material(s) and further sequence

73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material

73722 with contrast material(s)

73723 without contrast material(s), followed by contrast material(s) and further sequences

73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s)

GASTROINTESTINAL , URINARY TRACT Procedure codes

GASTROINTESTINAL TRACT

74210 Radiologic examination; pharynx and/or cervical esophagus

74220 esophagus

74230 Swallowing function, with cineradiography/videoradiography

74235 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation

74240 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB

74241 with or without delayed films, with KUB,

74245 with small intestine, includes multiple serial films

74246 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB

74247 with or without delayed films, with KUB

74249 with small intestine follow-through

74250 Radiologic examination, small intestine, includes multiple serial films;

74251 via enteroclysis tube

74260 Duodenography, hypotonic

74270 Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB

74280 air contrast with specific high density barium, with or without glucagon

74283 Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus)

74290 Cholecystography, oral contrast;

74300 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation

74301 additional set intraoperative, radiological supervision and interpretation
(List separately in addition to primary procedure)

(Use 74301 in conjunction with 74300)

74305 through existing catheter, radiological supervision and interpretation

74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation

74327 Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket or snare (eg, Burhenne technique), radiological supervision and interpretation

74328 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation

74329 Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation

74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation

74340 Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation

74355 Percutaneous placement of enteroclysis tube, radiological supervision and interpretation

74360 Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision and interpretation

74363 Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, radiological supervision and interpretation



URINARY TRACT

74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography;

74410 Urography, infusion, drip technique and/or bolus technique;

74415 with nephrotomography

74420 Urography, retrograde, with or without KUB

74425 Urography, antegrade, (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation

74430 Cystography, minimum of three views, radiological supervision and interpretation

74440 Vasography, vesiculography, or epididymography, radiological supervision and interpretation

74445 Corpora cavernosography, radiological supervision and interpretation

74450 Urethrocystography, retrograde, radiological supervision and interpretation

74455 Urethrocystography, voiding, radiological supervision and interpretation

74470 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation

74475 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

74480 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological
supervision and interpretation

74485 Dilation of nephrostomy, ureters or urethra, radiological supervision and interpretation



GYNECOLOGICAL AND OBSTETRICAL

74710 Pelvimetry, with or without placental localization

74740 Hysterosalpingography, radiological supervision and interpretation

74742 Transcervical catheterization of fallopian tube, radiological supervision and interpretation

74775 Perineogram (eg, vaginogram, for sex determination or extent of anomalies)

MMIS RADIOLOGY MODIFIERS LIST

Note: NCCI associated modifiers are recognized for NCCI code pairs/related edits. For additional information please refer to the CMS website: http://www.cms.hhs.gov/NationalCorrectCodInitEd/

-26 Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier -26 to the usual procedure number.

-50 Bilateral Procedures (X-ray): Unless otherwise identified in the listing, when bilateral X-ray examinations are performed at the same time, the service will be identified by adding the modifier -50 to the usual procedure code number. (Reimbursement will not exceed 160% of the maximum State Medical Fee Schedule amount. One claim line is to be billed representing the bilateral procedure. Amount billed should reflect total amount due.)

-76 Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. (When a repeat X-ray examination of the same part and for the same illness is required for reasons other than technical or professional error in the original X-ray, it will be identified by adding modifier -76.) (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.)

-AQ Physician Providing a Service in an Unlisted Health Professional Shortage Area (HPSA)

-FP Service Provided as Part of Family Planning Program: All Family Planning Services will be identified by adding the modifier -FP to the usual procedure code number. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.)

-LT Left Side (used to identify procedures performed on the left side of the body): Add modifier –LT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same operative session.)

-RT Right Side (used to identify procedures performed on the right side of the body): Add modifier –RT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same operative session.)

-TC Technical Component: Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier -TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians.

Radiology billing - GENERAL RULES AND INFORMATION

General rules which apply to all procedure codes in the Radiology Services Fee Schedule sections of Diagnostic Radiology, Diagnostic Ultrasound, Radiation Oncology and Nuclear Medicine are as follows:

1. Dollar values include usual contrast media, equipment and materials. An additional charge may be warranted when special surgical trays and materials are provided by the physician.

2. Dollar values include consultation and a written report to the referring physician.

3. When multiple X-ray examinations are performed during the same visit, reimbursement shall be limited to the greater fee plus 60% of the lesser fee(s). When more than one part of the body is included in a single X-ray for which reimbursement is claimed, the charge shall be only for a single X-ray. When bilateral X-ray examinations are performed during the same visit, reimbursement shall be limited to 160% of the procedure value (see modifier -50). The above provisions regarding fee reductions for multiple X-rays are applicable to X-rays taken of all parts of the body.

4. When repeat X-ray examinations of the same part and for the same illness are required because of technical or professional error in the original X-rays, such repeat X-rays are not eligible for payment. (See Rule 5 below.)

5. When repeat X-ray examination of the same part and for the same illness is required for reasons other than technical or professional error in the original X-ray. It should be identified by use of modifier -76.

6. RADIOLOGICAL SUPERVISION AND INTERPRETATION CODES: The Maximum fee is applicable when the physician incurs the costs of both the technical /administrative and professional components of the imaging procedure. (For the professional component of radiologic procedures, see modifier -26). When a procedure is performed by two physicians, the radiologic portion of the procedure is designated as "radiological supervision and interpretation." When a physician performs both the procedure and provides imaging supervision and interpretation, a combination of procedure codes outside the 70000 series and imaging supervision and interpretation codes are to be used.

7. BY REPORT: A service that is rarely provided, unusual, variable, or new may require a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary to provide the service. Additional items which may be included are:

complexity of symptoms, final diagnosis, pertinent physical findings (such as size, locations, and number of lesion(s), if appropriate), diagnostic and therapeutic procedures including major and supplementary surgical procedures, if appropriate), concurrent problems, and follow-up care.

When the value of a procedure is to be determined "By Report" (BR), information concerning the nature, extent and need for the procedure or service must be furnished in addition to the time, skill and equipment necessitated. Appropriate documentation (eg, procedure description, itemized invoices, etc) should accompany all claims submitted.

Itemized invoices must document acquisition cost, the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations.


8. SEPARATE PROCEDURES: Some of the listed procedures are commonly carried out as an integral part of a total service, and as such, do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it may be listed as a "separate procedure." Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be reported as a separate procedure.

9. FEES: The fees are listed in the Physician Radiology Fee Schedule, available at
http://www.emedny.org/ProviderManuals/Physician/index.html
Listed fees are the maximum reimbursable Medicaid fees. Fees for the MOMS Program can be found in the Enhanced Program fee schedule.

RADIOPHARMACEUTICAL IMAGING AGENTS

RADIOPHARMACEUTICAL IMAGING AGENTS (Report and Invoice Required)

A4641 Radiopharmaceutical, diagnostic, not otherwise classified

A4642 Indium In-111 satumomab pendetide, diagnostic, per study dose up to 6 millicuries

A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose

A9501 Technetium Tc-99m teboroxime, diagnostic, per study dose

A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose

A9503 Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 millicuries

A9504 Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries

A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie

A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries

A9508 Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie

A9509 Iodine I-123 sodium iodide, diagnostic, per millicurie

A9510 Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries

A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie

A9516 Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries

A9517 Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie

A9520 Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 milicuries

A9521 Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 millicuries

A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries

A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries

A9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie

A9528 Iodine I-131 sodium iodide capsule(s), diagnostic, per millicurie

A9529 Iodine I-131 sodium iodide solution, diagnostic, per millicurie

A9530 Iodine I-131 sodium iodide solution, therapeutic, per millicurie

A9531 Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries)

A9532 Iodine I-125 serum albumin, diagnostic, per 5 microcuries

A9536 Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries

A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries

A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries

A9539 Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries

A9540 Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose,  up to 10 millicuries

A9541 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries

A9542 Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries

A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries

A9544 Iodine I-131 tositumomab, diagnostic, per study dose

A9545 Iodine I-131 tositumomab, therapeutic, per treatment dose

A9546 Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie

A9547 Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie

A9548 Indium In-111 pentetate, diagnostic, per 0.5 millicurie

A9550 Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicurie

A9551 Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 millicuries

A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries

A9553 Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries

A9554 Iodine I-125 sodium Iothalamate, diagnostic, per study dose, up to 10 microcuries

A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries

A9557 Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 millicuries

A9558 Xenon Xe-133 gas, diagnostic, per 10 millicuries

A9559 Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie

A9560 Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries

A9561 Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries

A9562 Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries

A9563 Sodium phosphate P-32, therapeutic, per millicuries

A9564 Chromic phosphate P-32 suspension, therapeutic, per millicurie

A9566 Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries

A9567 Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries

A9568 Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries

A9569 Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose

A9570 Indium In-111 labeled autologous white blood cells, diagnostic, per study dose

A9571 Indium In-111 labeled autologous platelets, diagnostic, per study dose

A9572 Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries

A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries

A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries

A9584 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries

A9600 Strontium Sr-89 chloride, therapeutic, per millicurie

A9604 Samarium SM-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries

A9606 Radium Ra-223 dichloride,therapeutic, per microcurie

A9699 Radiopharmaceutical, therapeutic, not otherwise classified

J3472 Hyaluronidase, ovine, preservative free, per 1000 USP units

GENITOURINARY THERAPEUTIC Procedure codes

GENITOURINARY SYSTEM

78700 Kidney imaging morphology;

78701 with vascular flow

78707 with vascular flow and function, single study, without pharmacological intervention

78708 with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78709 with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78710 tomographic (SPECT)

78725 Kidney function study, non-imaging radioisotopic study

78730 Urinary bladder residual study  (List separately in addition to primary procedure) (Use 78730 in conjunction with 78740)

78740 Ureteral reflux study (radiopharmaceutical voiding cystogram)  (Use 78740 in conjunction with 78730 for urinary bladder residual study)

78761 Testicular imaging with vascular flow

78799 Unlisted genitourinary procedure, diagnostic nuclear medicine

THERAPEUTIC

79005 Radiopharmaceutical therapy, by oral administration

79101 Radiopharmaceutical therapy, by intravenous administration (Do not report 79101 in conjunction with 36400, 36410, 79403, 90760, 90774 or 90775, 96409)

79200 Radiopharmaceutical therapy, by intracavitary administration

79300 Radiopharmaceutical therapy, by interstitial radioactive colloid administration

79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion (Do not report 79403 in conjunction with 79101)

79440 Radiopharmaceutical therapy, by intra-articular administration

79445 Radiopharmaceutical therapy, by intra-arterial particulate administration (Report required)  (Do not report 79445 in conjunction with 90773, 96420)

(Use appropriate procedural and radiological supervision and interpretation codes for the angiographic and interventional procedures provided prerequisite to intra-arterial radiopharmaceutical therapy)

79999 Radiopharmaceutical therapy, unlisted procedure

RESPIRATORY NERVOUS Procedure codes

RESPIRATORY SYSTEM

78579 Pulmonary ventilation imaging (eg, aerosol or gas)

78580 Pulmonary perfusion imaging (eg, particulate)

78582 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging

78597 Quantitative differential pulmonary perfusion, including imaging when performed


78598 Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

78599 Unlisted respiratory procedure; diagnostic nuclear medicine


NERVOUS SYSTEM

78600 Brain imaging, less than 4 static views;

78601 with vascular flow

78605 Brain imaging, minimum 4 static views;

78606 with vascular flow

78607 Brain imaging, tomographic (SPECT)

78610 Brain imaging, vascular flow only

78630 Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography

78635 ventriculography

78645 shunt evaluation

78647 tomographic (SPECT)

78650 Cerebrospinal fluid leakage detection and localization

78660 Radiopharmaceutical dacryocystography

78699 Unlisted nervous system procedure, diagnostic nuclear medicine



OTHER PROCEDURES

78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area


78801 multiple areas

78802 whole body, single day imaging

78803 tomographic (SPECT)

78804 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring two or more days
imaging

78805 Radiopharmaceutical localization of inflammatory process; limited area

78806 whole body

78807 tomograhic (SPECT)

78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine

CARDIOVASCULAR SYSTEM Procedure code list

CARDIOVASCULAR SYSTEM

Myocardial perfusion and cardiac blood pool imaging studies may be performed at rest and/or during stress. When performed during exercise and/or pharmacologic stress, the appropriate stress testing code from the 93015-93018 series should be reported in addition to code(s) 78451-78454, 78472, 78473, 78481 and 78483.

78414 Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations

78445 Non-cardiac vascular flow imaging (ie, angiography, venography)


78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

78452 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

78454 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

78456 Acute venous thrombosis imaging, peptide

78457 Venous thrombosis imaging, venogram; unilateral

78458 bilateral

78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative

78468 with ejection fraction by first pass technique

78469 tomographic SPECT with or without quantification

78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study
plus ejection fraction, with or without additional quantitative processing

78473 multiple studies, wall motion study plus ejection pharmacologic), with or without additional quantification

78481 Cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

78483 multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing

78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique
(List separately in addition to primary procedure) (Use 78496 in conjunction with code 78472)

78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine

GASTROINTESTINAL AND MUSCULOSKELETAL Procedure codes

GASTROINTESTINAL SYSTEM

78201 Liver imaging; static only

78202 with vascular flow

78205 Liver imaging (SPECT);

78206 with vascular flow

78215 Liver and spleen imaging; static only

78216 with vascular flow

78226 Hepatobiliary system imaging, including gallbladder when present;

78227 with pharmacologic intervention, including quantitative measurement(s), when preformed

78230 Salivary gland imaging;

78231 with serial images

78232 Salivary gland function study

78258 Esophageal motility

78261 Gastric mucosa imaging

78262 Gastroesophageal reflux study

78264 Gastric emptying study

78270 Vitamin B-12 absorption study (eg, Schilling test); without intrinsic factor

78271 with intrinsic factor

78272 Vitamin B-12 absorption studies combined, with and without intrinsic factor

78278 Acute gastrointestinal blood loss imaging

78290 Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus)

78291 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt)


78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine


MUSCULOSKELETAL SYSTEM

78300 Bone and/or joint imaging; limited area

78305 multiple areas

78306 whole body

78315 three phase study

78320 tomographic (SPECT)

78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry

78351 dual photon absorptiometry

78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine

ENDOCRINE , HEMATOPOIETIC Procedure code list

DIAGNOSTIC ENDOCRINE SYSTEM

78012 Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

78013 Thyroid imaging (including vascular flow, when performed);

78014 Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

78015 Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only)

78016 with additional studies (eg, urinary recovery)

78018 whole body

78020 Thyroid carcinoma metastases uptake (List separately in addition to primary procedure) (Use 78020 in conjunction with 78018 only)

78070 Parathyroid planar imaging (including subtraction, when performed);

78071 with tomographic (SPECT)

78072 with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization

78075 Adrenal imaging, cortex and/or medulla

78099 Unlisted endocrine procedure, diagnostic nuclear medicine

HEMATOPOIETIC, RETICULENDOTHELIAL AND LYMPHARIC SYSTEM

78102 Bone marrow imaging; limited area

78103 multiple areas

78104 whole body

78110 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling

78111 multiple samplings

78120 Red cell volume determination (separate procedure); single sampling

78121 multiple samplings

78122 Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique)

78130 Red cell survival study;

78135 differential organ/tissue kinetics, eg, splenic and/or hepatic sequestration

78185 Spleen imaging only, with or without vascular flow

78190 Kinetics, study of platelet survival, with or without differential organ/tissue localization (Report required)

78191 Platelet survival study

78195 Lymphatics and lymph nodes imaging

78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine

CPT 59400, 58571, 58570, 58572, 58573 58150, 58152- Laparoscopy Hysterectomy surgical - full list

Total Laparoscopic Hysterectomy Procedure code

58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less $946

58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less, with removal of tube(s) and/or ovary(ies) $1,056

58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250g 1,177

58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250g, with removal of tube(s) and/or ovary(ies) 1,351

59400- Obstetrical care -  average fee payment - $2370 - $2380

58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)

58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)

58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

Abdominal

58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)

58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)

58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)


Laparoscopic

58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g

58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)



Vaginal

58260 Vaginal hysterectomy, for uterus 250 g or less

58262 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)

58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

58267 Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

58275 Vaginal hysterectomy, with total or partial vaginectomy

58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele

58290 Vaginal hysterectomy, for uterus greater than 250 g

58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

58293 Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele


Laparoscopic-Assisted Vaginal

58550 Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less

58552 Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g

58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)



Obstetrical Billing Guidelines

Services included in the Global OB CPT®’ Code 59400 (Vaginal delivery) or 59510 (Cesarean delivery) Note:

• The following information is applicable to Plans with maternity benefits.

• Maternity care is subject to a one-time office visit copayment. For BCBS plans with a copayment, this copayment should be
collected at the time of the initial OB office visit.

• Physicians will be reimbursed for the initial OB visit separately from the “global maternity care” and should submit a claim for this service at the time of the initial OB visit. Claims should include expected delivery date.

All subsequent office visits for maternity care and delivery are considered as part of the “global maternity care” reimbursement.

Submit claim upon delivery 


Amniocentesis Code amniocentesis separately from the global delivery code. Amniocentesis is not included in the Global CPT codes of 59400 (Vaginal delivery) or 59510 (Cesarean delivery).

Ultrasounds Code ultrasounds separately from the global delivery code. Ultrasounds are not included in the Global CPT codes of 59400 (Vaginal delivery) or 59510 (Cesarean delivery).

Where to Find More Information On Obstetrical Billing The answers to most obstetrical billing questions can be found in the “Physician’s Current Procedural Terminology (CPT)” manual. Maternity Care and Delivery is a subsection of the Surgery section. Surgical procedures are either package (global) services or starred procedures (non-global). An understanding of the global package services is needed to code Maternity Care and Delivery Services correctly. For additional resources on CPT coding, contact the American Medical Association (AMA) order desk at (800) 621-8335.


Global maternity care includes pregnancy-related antepartum care, admission to labor and delivery, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum.

A global charge should be billed for maternity claims when all maternity-related services, as outlined in Blue Cross and Blue Shield of North Carolina’s (BCBSNC’s) corporate medical policy “Guidelines for Global Maternity Reimbursement,” are provided by the same physician or physicians practicing at the same location. The number of antepartum visits may vary from patient to patient; however, if global maternity care (more than three antepartum visits, delivery and postpartum care) is provided, all maternity-related visits should be billed under the global maternity code. Individual E&M codes should not be billed to report maternity-related E&M visits. Prenatal care is considered an integral part of the global reimbursement and will not be paid separately

The Current Procedural Terminology® (CPT) manual identifies the following CPT codes as global maternity services:
+ 59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

+ 59510 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care

+ 59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after  previous cesarean delivery

+ 59618 - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous  cesarean delivery

Billing tips:

+ An initial visit, confirming the pregnancy, is not a part of global maternity care services (verification of benefits will determine appropriate member liability).

+ A global charge should be billed when one or more physicians, practicing at the same location (filing under the same federal tax identification number), provide all components of the patient’s maternity care including; four or more antepartum visits, delivery and postpartum care. Note: Claims filed for partial maternity care with
E&M codes for one to three visits will deny when billed prior to the actual delivery, as all claims related to the maternity care must be received in order to account for the appropriate number of visits.

+ Antepartum services such as laboratory tests (excluding dipstick urinalysis), diagnostic ultrasound, amniocentesis,  ordocentesis, chorionic villus sampling, fetal stress test, and fetal non-stress test are not considered part of global  aternity services and should be billed separately.


Maternity billing codes

OB Global Billing:

59400 - Billed for vaginal delivery including ante-partum and postpartum. Do not use this code if less than 4 ante-partum visits performed. May have 22 or 52 modifier(s) appended.

59510 -Billed for c-section delivery including ante-partum and postpartum. Do not use this code if less than 4 ante-partum visits performed. May have 22, 52, AS, 80 modifier(s) appended.

59610 -Billed for VBAC delivery including ante-partum and postpartum. Do not use this code if less than 4 ante-partum visits performed. May have 22 or 52 modifier(s) appended.

59618 -Billed for c-section after attempted VBAC including ante-partum and postpartum. Do not use this code if less than 4 ante-partum visits performed. May have 22, 52, AS,80 modifier(s) appended.


DESCRIPTION OF SERVICES

A hysterectomy is a surgical procedure to remove the uterus, and in some cases, the ovaries and fallopian tubes as well. In a total hysterectomy, the entire uterus, including the cervix, is removed. In a supracervical or partial hysterectomy, the upper part of the uterus is removed, but the cervix is left in place. Benign conditions that might be treated with a hysterectomy include uterine fibroids, endometriosis, pelvic organ prolapse and abnormal uterine bleeding.

Hysterectomies can be performed vaginally, abdominally or with laparoscopic or robotic assistance. In a vaginal hysterectomy, the uterus is removed through the vagina. In an abdominal hysterectomy, the uterus is removed through an incision in the lower abdomen. A laparoscopic approach uses a laparoscope to guide the surgery. A laparoscope is a thin, lighted tube that is inserted into the abdomen through a small incision in or around the navel.

The scope has a small camera that projects images onto a monitor. Additional small incisions are made in the  abdomen for other surgical instruments used during the surgery. In a total laparoscopic hysterectomy, the uterus is removed in small pieces through the incisions or through the vagina. In a laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina, and the laparoscope is used to guide the surgery. In a robotic-assisted laparoscopic hysterectomy, the surgeon uses a robot attached to the instruments to assist in the surgery (ACOG, 2011).


Hysterectomies - Complications and Trauma 

CPT codes:

58150, 58152, 58180, 58200, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58545, 58546, 58550, 58552, 58553, 58554, 58570,  58571, 58572,58573,

Hysterectomy Services

Texas Medicaid reimburses hysterectomies when they are medically necessary. Texas Medicaid does not reimburse hysterectomies performed for the sole purpose of sterilization.

Providers can use any of the following procedure codes to submit claims for hysterectomy procedures:

Hysterectomy Acknowledgment

Hysterectomy services are considered for reimbursement when a signed Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information form is faxed to TMHP, the claim is filed with a signed Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information form, or documentation supporting that the Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information form could not be obtained or was not necessary.

All Texas Medicaid clients (including those in a STAR or STAR+PLUS Program health plan) receiving hysterectomy services must sign a Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information form. The acknowledgment must be submitted to TMHP with the claim or to the client’s health plan.

Procedure Codes

51925 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58541 58542 58543 58544 58548 58550 58552 58553 58554 58570 58571 58572 58573 59135 59525




CLINICAL EVIDENCE

Studies have shown that a vaginal approach to hysterectomy has fewer complications, requires a shorter hospital stay and is associated with better outcomes than a laparoscopic or abdominal approach.

A Cochrane review of 47 randomized controlled trials (n=5102) evaluating the abdominal, laparoscopic, and vaginal approach concluded that vaginal hysterectomy (VH) appears to be superior to laparoscopic and abdominal hysterectomy. VH is preferred to abdominal hysterectomy (AH) when possible, citing the advantages of a more rapid recovery and fewer postoperative complications of fever and/or infection. Where VH is not possible, a laparoscopic approach is preferred over AH with the same advantages as the vaginal approach, but requires a longer operating time and had more urinary tract injuries (Aarts et al., 2015).


A meta-analysis of five randomized studies comparing total laparoscopic hysterectomy (TLH) and VH for benign disease reported no differences in perioperative complications between the two procedures. TLH was associated with reduced postoperative pain scores and reduced hospital stay but took longer to perform. No differences in blood loss, rate of conversion to laparotomy or urinary tract injury were identified (Gendy et al., 2011).


Walsh et al. (2009) performed a meta-analysis of randomized controlled trials to compare outcomes in total abdominal hysterectomy (TAH) and TLH for benign disease in women who were not candidates for a vaginal approach. Results indicated that TLH is associated with reduced overall peri-operative complications and reduced estimated blood loss. Additionally, there are trends towards shorter hospital stay and postoperative hematoma formation compared to TAH. However, there were longer operating times in the TLH group. Although the rates of major complication were not statistically different, the authors note that this analysis is likely underpowered to detect many major complications. Larger studies are needed to assess the impact on major complications and long-term clinical outcomes.

Prophylactic Hysterectomy is a covered benefit when at least one of the following criteria is met:

1. Patients with known hereditary nonpolyposis colon cancer (HNPCC) who have completed childbearing.

2. Patients with an HNPCC associated mutation that have completed childbearing.

DESCRIPTION

Prophylactic Cancer Risk Reduction Surgery

Includes: Prophylactic Mastectomy

Prophylactic Oophorectomy

Prophylactic Total Gastrectomy

Prophylactic Hysterectomy

Prophylactic Thyroidectomy



A hysterectomy is a surgical procedure to remove the uterus, and in some cases, the ovaries and fallopian tubes as well. In a total hysterectomy, the entire uterus, including the cervix, is removed. In a supracervical or partial hysterectomy, the upper part of the uterus is removed, but the cervix is left in place. Benign conditions that might be treated with a hysterectomy include uterine fibroids, endometriosis, pelvic organ prolapse and abnormal uterine bleeding.

Hysterectomies can be performed vaginally, abdominally or with laparoscopic or robotic assistance. In a vaginal hysterectomy, the uterus is removed through the vagina. In an abdominal hysterectomy, the uterus is removed through an incision in the lower abdomen. A laparoscopic approach uses a laparoscope to guide the surgery. A laparoscope is a thin, lighted tube that is inserted into the abdomen through a small incision in or around the navel.

The scope has a small camera that projects images onto a monitor. Additional small incisions are made in the abdomen for other surgical instruments used during the surgery. In a total laparoscopic hysterectomy, the uterus is removed in small pieces through the incisions or through the vagina. In a laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina, and the laparoscope is used to guide the surgery. In a robotic-assisted laparoscopic hysterectomy, the surgeon uses a robot attached to the instruments to assist in the surgery (ACOG, 2011).CLINICAL EVIDENCE Studies have shown that a vaginal approach to hysterectomy has fewer complications, requires a shorter hospital stay and is associated with better outcomes than a laparoscopic or abdominal approach.

A Cochrane review of 47 randomized controlled trials (n=5102) evaluating the abdominal, laparoscopic, and vaginal approach concluded that vaginal hysterectomy (VH) appears to be superior to laparoscopic and abdominal hysterectomy. VH is preferred to abdominal hysterectomy (AH) when possible, citing the advantages of a more rapid recovery and fewer postoperative complications of fever and/or infection. Where VH is not possible, a laparoscopic approach is preferred over AH with the same advantages as the vaginal approach, but requires a longer operating time and had more urinary tract injuries (Aarts et al., 2015).

A meta-analysis of five randomized studies comparing total laparoscopic hysterectomy (TLH) and VH for benign disease reported no differences in perioperative complications between the two procedures. TLH was associated with reduced postoperative pain scores and reduced hospital stay but took longer to perform. No differences in blood loss, rate of conversion to laparotomy or urinary tract injury were identified (Gendy et al., 2011).

A Cochrane review of 34 randomized controlled trials (n=4495) AH, TLH, and VH concluded that VH should be performed in preference to AH where possible. The authors found that VH meant a quicker return to normal activities, fewer infections and episodes of raised temperature after surgery and a shorter hospital stay compared to AH. When a vaginal approach is not possible, a laparoscopic approach may avoid the need for an AH. TLH meant a quicker return to normal activities, less blood loss and a smaller drop in blood count, a shorter hospital stay and fewer wound infections and episodes of raised temperature after surgery compared to AH; however, laparoscopic surgery is associated with longer operating times and higher rates of urinary tract injury. More research is needed, particularly to examine the long-term effects of the different types of surgery (Nieboer et al., 2009).

Hysterectomy

ICD-10 Codes that apply:

Z15.04 Genetic susceptibility to malignant neoplasm of endometrium

Z15.09 Genetic susceptibility to other malignant neoplasm

Z40.09 Encounter for prophylactic removal of other organ

Z41.8 Encounter for other procedures for purposes other than remedying health state

Z80.0 Family history of malignant neoplasm of digestive organs

Z80.8 Family history of malignant neoplasm of other organs or systems

Z83.71 Family history of colonic polyps

Z86.010 Personal history of colonic polyps



Guideline form OXFORD insurance

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.

CPT Code Description

Abdominal
58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)
58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

Laparoscopic
58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; wit removal of tube(s) and/or ovary(s)

Vaginal
58260 Vaginal hysterectomy, for uterus 250 g or less
58262 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58267 Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
58275 Vaginal hysterectomy, with total or partial vaginectomy
58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele
58290 Vaginal hysterectomy, for uterus greater than 250 g
58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
58293 Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Laparoscopic-Assisted Vaginal
58550 Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less
58552 Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

A hysterectomy is a surgical procedure to remove the uterus, and in some cases, the ovaries and fallopian tubes as well. In a total hysterectomy, the entire uterus, including the cervix, is removed. In a supracervical or partial hysterectomy, the upper part of the uterus is removed, but the cervix is left in place. Benign conditions that might be treated with a hysterectomy include uterine fibroids, endometriosis, pelvic organ prolapse and abnormal uterine bleeding.

Hysterectomies can be performed vaginally, abdominally or with laparoscopic or robotic assistance. In a vaginal hysterectomy, the uterus is removed through the vagina. In an abdominal hysterectomy, the uterus is removed through an incision in the lower abdomen. A laparoscopic approach uses a laparoscope to guide the surgery. A laparoscope is a thin, lighted tube that is inserted into the abdomen through a small incision in or around the navel.

The scope has a small camera that projects images onto a monitor. Additional small incisions are made in the abdomen for other surgical instruments used during the surgery. In a total laparoscopic hysterectomy, the uterus is removed in small pieces through the incisions or through the vagina. In a laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina, and the laparoscope is used to guide the surgery. In a robotic-assisted laparoscopic hysterectomy, the surgeon uses a robot attached to the instruments to assist in the surgery (ACOG, 2011).CLINICAL EVIDENCE Studies have shown that a vaginal approach to hysterectomy has fewer complications, requires a shorter hospital stay and is associated with better outcomes than a laparoscopic or abdominal approach.

A Cochrane review of 47 randomized controlled trials (n=5102) evaluating the abdominal, laparoscopic, and vaginal approach concluded that vaginal hysterectomy (VH) appears to be superior to laparoscopic and abdominal hysterectomy. VH is preferred to abdominal hysterectomy (AH) when possible, citing the advantages of a more rapid recovery and fewer postoperative complications of fever and/or infection. Where VH is not possible, a laparoscopic approach is preferred over AH with the same advantages as the vaginal approach, but requires a longer operating time and had more urinary tract injuries (Aarts et al., 2015).

A meta-analysis of five randomized studies comparing total laparoscopic hysterectomy (TLH) and VH for benign disease reported no differences in perioperative complications between the two procedures. TLH was associated with reduced postoperative pain scores and reduced hospital stay but took longer to perform. No differences in blood loss, rate of conversion to laparotomy or urinary tract injury were identified (Gendy et al., 2011).

A Cochrane review of 34 randomized controlled trials (n=4495) AH, TLH, and VH concluded that VH should be performed in preference to AH where possible. The authors found that VH meant a quicker return to normal activities, fewer infections and episodes of raised temperature after surgery and a shorter hospital stay compared to AH. When a vaginal approach is not possible, a laparoscopic approach may avoid the need for an AH. TLH meant a quicker return to normal activities, less blood loss and a smaller drop in blood count, a shorter hospital stay and fewer wound infections and episodes of raised temperature after surgery compared to AH; however, laparoscopic surgery is associated with longer operating times and higher rates of urinary tract injury. More research is needed, particularly to examine the long-term effects of the different types of surgery (Nieboer et al., 2009).

Walsh et al. (2009) performed a meta-analysis of randomized controlled trials to compare outcomes in total abdominal hysterectomy (TAH) and TLH for benign disease in women who were not candidates for a vaginal approach. Results indicated that TLH is associated with reduced overall peri-operative complications and reduced estimated blood loss. Additionally, there are trends towards shorter hospital stay and postoperative hematoma formation compared to TAH. However, there were longer operating times in the TLH group. Although the rates of major complication were not statistically different, the authors note that this analysis is likely underpowered to detect many major complications. Larger studies are needed to assess the impact on major complications and long-term clinical outcomes.

CPT code 64635, 64640, 64615, 64612 - Destruction neurolytic procedure

procedure code and description

64635: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); lumbar or sacral, single facet joint

64640: Destruction by neurolytic agent; other peripheral nerve or branch RF denervation in the sacroiliac region is commonly done at L5, S1, S2, and S3 levels. -average fee payment $140  - $150

64615 - Chemodenerv musc migraine  - average fee payment - $160 - $170

Introduction:

This policy does not address sacral conditions or injections or neurotomies. Sacral injections, identified on the claim by the ICD-10 codes M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, are not subject to the requirements of this LCD.

Facet joints are paired diarthrodial articulations of the superior and inferior articular processes of adjacent vertebrae. The medial branches (MB) of the dorsal rami of the segmental nerves innervate facet joints and the MB nerves from the two adjacent dorsal rami innervate each joint. (Exceptions to this rule are the C2-3 facet joint, which is innervated by the third occipital nerve; and the L5-S1 facet joint, which is innervated by the L4 MB and the L5 dorsal ramus.)

Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.

Definitions

A zygapophyseal (aka facet) joint “level” refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint.

A “session” is defined as all injections/blocks/RF procedures performed on one day and includes medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and radiofrequency (RF) ablations.

A “region” is all injections performed in cervical/thoracic or all injections performed in lumbar (not sacral) spinal areas.

"Diagnosis” of facet-mediated pain requires the establishment of pain relief following medial branch blocks (MBB) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source.

Medical Review Required for Procedure  Code 64615

Effective with dates of service beginning April 15, 2013, Medical Review is required for Current Procedural Terminology (Procedure ) code 64615 (Chemodenervation of muscle(s): innervated by facial…for chronic migraine) to determine if the following criteria have been met prior to allowing payment. For the treatment to be reimbursed using this code, documentation must be submitted with the claim that demonstrates that the patient meets these criteria related to chronic migraine:

• Fifteen or more days of headache or a headache that lasts 4 hours or more per day over 30 days

Please visit www.lamedicaid.com for the notice. If you have any questions please contact Molina Provider Relations at (800)473-2783 or (225)924-5040.

Effective January 1, 2013, physicians will be able to report the new Procedure  code 64615 when performing chemodenervation to treat chronic migraine.  Headache Medicine specialists have used OnabotulinumtoxinA “off-label” as an efficacious treatment for headache prophylaxis for a number of years.  The October 15, 2010 FDA approval of Botox “…to prevent headaches in adult patients with chronic migraine” followed the pooled results from the double-blind, randomized, placebo-controlled Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMT) 1 and 2 trials (Headache 2010; 50:921-936).    PREEMT demonstrated that OnabotulinumtoxinA was an effective prophyla tic treatment for chronic migraine.    The PREEMT studies also defined the appropriate patient selection, injection sites, dosages and technique.    It is likely that for reimbursement, insurers will monitor to document that the PREEMT protocol and injection paradigm targets were followed according to the published reports.

 Basically every insurance plan does require pre-authorization.  This usually includes the documentation of medical necessity.  The diagnosis of “chronic migraine” must also be clearly defined in the physician’s medical records.   The medication “J code” for Botox is J0585.   The new Procedure  administration code 64615 will need to be included.    Usually carriers request the physician’s medical records to verify the documentation of diagnosis.  Some insurance carriers also require a Botox Prior Authorization Form be completed and attached to the medical records.  Authorization may take up to a few days to 10 days or longer.

Billing Guide for Procedure 64635, 64640


Physicians who currently perform RF denervation procedure in the sacroiliac region commonly use the following approach in coding:

RF lesion at L5/S1 facet joint: 64635

RF lesions at S1: 64640-59

RF lesions at S2: 64640-59

RF lesions at S3: 64640-59

Note: For bilateral procedures, use Modifier-50

According to the AMA, as published in the Procedure  Assistant, December 2009:

“To differentiate between the work when performing sacral nerve destruction of S1, S2, S3, and S4, each individually separate peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, code 64640 is reported four times. It is suggested that Modifier 59, Distinct Procedural Service, be appended as well

When injection therapies for tarsal tunnel syndromes include "Baxter's injections" and/or injections for Morton’s neuroma use Procedure  codes 64455 or 64632.


Note:

This information should be used in combination with LCD INJ-018 Treatment with Botulinum Toxin type A & type B.

For a Radiofrequency Treatment of the SI Joint, use code 64640. 

The most common diagnosis codes for SI Joint Injection procedures are 724.6 for Disorders of the Sacrum and 720.2 for Sacroiliitis.

If an injection is administered in the Sacroiliac Joint without the use of Fluoroscopic guidance, report only the procedure code for the SI Joint Injection.

The following CPT codes are to be reported for the procedures performed, noting that CPT 64640 is to be used for treatment of laryngeal and/or oromandibular dystonia.

Drug Administration Codes

Group 2 Codes:
31513 LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD INJECTION
31570 LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC;
31599 UNLISTED PROCEDURE, LARYNX
43499 UNLISTED PROCEDURE, ESOPHAGUS
46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER
52287 CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER
64611 CHEMODENERVATION OF PAROTID AND SUBMANDIBULAR SALIVARY GLANDS, BILATERAL
64612 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL NERVE, UNILATERAL (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM)
64615 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL, TRIGEMINAL, CERVICAL SPINAL AND ACCESSORY NERVES, BILATERAL (EG, FOR CHRONIC MIGRAINE)
64616 CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S), EXCLUDING MUSCLES OF THE LARYNX, UNILATERAL (EG, FOR CERVICAL DYSTONIA, SPASMODIC TORTICOLLIS)
64617 CHEMODENERVATION OF MUSCLE(S); LARYNX, UNILATERAL, PERCUTANEOUS (EG, FOR SPASMODIC DYSPHONIA), INCLUDES GUIDANCE BY NEEDLE ELECTROMYOGRAPHY, WHEN PERFORMED
64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
64642 CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S)
64643 CHEMODENERVATION OF ONE EXTREMITY; EACH ADDITIONAL EXTREMITY, 1-4 MUSCLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64644 CHEMODENERVATION OF ONE EXTREMITY; 5 OR MORE MUSCLES
64645 CHEMODENERVATION OF ONE EXTREMITY; EACH ADDITIONAL EXTREMITY, 5 OR MORE MUSCLES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64646 CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S)
64647 CHEMODENERVATION OF TRUNK MUSCLE(S); 6 OR MORE MUSCLES
64650 CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE
64653 CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, FACE, NECK), PER DAY
64999 UNLISTED PROCEDURE, NERVOUS SYSTEM
67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE
95873 ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
95874 NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, selected muscles can be treated. The clinical indications for botulinum toxins have increased exponentially since first used two decades ago. They are used in the treatment of overactive skeletal muscles (e.g. Hemifacial spasm, dystonia and spasticity), smooth muscles (e.g. Detrusor over activity and achalasia), glands (e.g. Sialorrhoea and hyperhidrosis) and additional conditions that are being investigated.


Coding Information General

Paravertebral Facet Joint Injection

1. Each CPT code listed (single level, second level, third and any additional levels) may be billed with a Modifier 50 when injecting a level bilaterally. For one level unilateral or bilateral CPT codes 64490 or 64493 should be used. If the facet joint injection is performed at more than one level unilateral or bilateral CPT codes 64491, 64492, 64494 or 64495 should be used for the additional levels. For bilateral procedures Modifier 50 should be appended to the procedure codes with number of services of one.

2. Use the appropriate CPT code in Item 24D on the CMS-1500 claim form (or electronic equivalent) and link it to the applicable ICD-9-CM code listed above under the ICD-9-CM Codes that Support Medical Necessity section.

3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64490- 64495.

4. If the injection is made around or into the spinal nerve, the service should be billed as a paravertebral nerve injection.

5 When destruction of the facet joint nerve is performed following the blockage, only the codes for the nerve destruction should be billed since their allowance includes that of the facet nerve blockage procedure.

Paravertebral Facet Joint Denervation

1. If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.
2. Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).
3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.


There are currently four botulinum toxin products commercially available in the United States: onabotulinumtoxinA, rimabotulinumtoxinB, abobotulinumtoxinA, and incobotulinumtoxinA. Each preparation has distinct pharmacological and clinical profiles specified on the product insert. Dosing patterns are also specific to the preparation of neurotoxin and are very different between different serotypes. Failure to recognize the unique characteristics of each formulation of botulinum toxin can lead to undesired patient outcomes. It is expected that physicians will be familiar with and experienced in the use of these agents, and utilize evidence-based medicine to select the appropriate drug and dose regimen for each patient condition. Although botulinum toxins have only been FDA-approved for limited uses, they are frequently used off-label as well. A patient who is not responsive or who ceases to respond to one serotype may respond to the other.

Coverage Limitations

Voluntary muscular contraction depends upon the release of acetylcholine from vesicles within a nerve ending following stimulation of the nerve. The acetylcholine is released into the neuromuscular junction, binding to specific proteins called receptors in the membrane of the muscle fiber. The effect of the acetylcholine at these receptors is to cause the muscle to contract. When a sufficient amount of acetylcholine has been released with subsequent binding to the muscle fiber proteins, muscle contraction occurs. Botulinum toxin type A and botulinum toxin type B create a chemical blockade by inhibiting the release of acetylcholine from the nerve ending vesicles thereby preventing the acetylcholine from binding to the proteins in the receptor site on the muscle. Localized weakness or paralysis occurs in the muscle injected with botulinum toxin.

Approved indications for botulinum toxin type A and toxin type B differ. WPS GHA has determined that the separate accepted indications for the botulinum toxin products will be combined into a single list of covered indications in this Local Coverage Determination (LCD). It is the responsibility of providers, however, to use each drug in accordance with approved indications unless there are valid and documented reasons stating why the unapproved or unaccepted form is used. While this policy contains a single list of covered indications, this is not meant to imply that botulinum toxin products are interchangeable.

Before consideration of coverage may be made:
In most cases it should be established that the patient has been unresponsive to conventional methods of treatments such as medication, physical therapy and other methods used to control and/or treat spastic condition.

Coverage of botulinum toxin for certain spastic conditions (e.g., cerebral palsy, stroke, head trauma, spinal cord injuries, and multiple sclerosis) will be limited to those conditions listed in the Codes that Support Medical Necessity section of this policy. All other uses in the treatment of other types of spasm will be considered as investigational and therefore, noncovered by Medicare.

Since organic writer's cramp is uncommon, Medicare would not expect to see the treatment of this condition to be billed frequently.

The patient who has a spastic or excessive muscular contraction condition is usually started with a low dose of botulinum toxin. Other spastic or muscular contraction conditions, such as eye muscle disorders, (e.g., blepharospasm) may require lesser amounts of botulinum toxin. For larger muscle groups, it is generally agreed that once a maximum dose per site has been reached and there is no response, the treatment is discontinued. The treatments may be resumed at a later date. With response, the effect of the injections generally lasts for three months at which time the patient may require repeat injections to control the spastic or excessive muscular condition.

It is usually considered not medically necessary to give botulinum toxin injections for spastic conditions more frequently than every 90 days. There may be slight variation based on FDA indications for a particular product.

Coverage of treatments provided may be continued unless any two treatments in a row, utilizing an appropriate or maximum dose of botulinum toxin failed to produce satisfactory clinical response.

Medicare will allow payment for one injection per site regardless of the number of injections made into the site. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative.

Botulinum toxin may be covered in the treatment of achalasia. This use appears to be safe and effective. Two-thirds of patients respond within six months of treatment and effectiveness lasts an average of more than one year for the initial treatment, although shorter and longer durations have been reported.

The use of botulinum toxin should not be endorsed for all patients but it can be considered individually if:
The patient has failed conventional therapy;

The patient is at high risk of complications of pneumatic dilation or surgical myotomy;

The patient has failed a prior myotomy or dilation;

The patient has had a previous dilation-induced perforation;

The patient has an epiphrenic diverticulum or hiatal hernia, both of which increase the risk of dilation-induced perforation.

Some patients may fail a first injection and respond to a second. Further therapy should be questioned if two treatments in a row fail. Therapy can be repeated later in those who fail after an initial response.

Migraine headaches are described as an intense pulsing or throbbing pain in one area of the head. The headaches are often accompanied by nausea, vomiting, and sensitivity to light and sound. Migraine usually begins with intermittent headache attacks 14 days or fewer each month (episodic migraine), but some patients go on to develop the more disabling chronic migraine. To treat chronic migraines, botulinum toxin is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. Botulinum toxin has not been shown to work for the treatment of migraine headaches that occur 14 days or less per month, or for other forms of headache.

Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded satisfactorily to conventional therapy.

ICD-10 CODE DESCRIPTION

M62.411* Contracture of muscle, right shoulder

M62.412* Contracture of muscle, left shoulder

M62.421* Contracture of muscle, right upper arm

M62.422* Contracture of muscle, left upper arm

M62.431* Contracture of muscle, right forearm

M62.432* Contracture of muscle, left forearm

M62.441* Contracture of muscle, right hand

M62.442* Contracture of muscle, left hand

M62.451* Contracture of muscle, right thigh

M62.452* Contracture of muscle, left thigh

M62.461* Contracture of muscle, right lower leg

M62.462* Contracture of muscle, left lower leg

M62.471* Contracture of muscle, right ankle and foot

M62.472* Contracture of muscle, left ankle and foot

M62.48* Contracture of muscle, other site

M62.49* Contracture of muscle, multiple sites

M62.831* Muscle spasm of calf

M62.838* Other muscle spasm

Destruction neurolytic procedure code list

CPT Code Description

64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch
64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale
64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring
64620 Destruction by neurolytic agent, intercostal nerve
64630 Destruction by neurolytic agent; pudendal nerve
64632 Destruction by neurolytic agent; plantar common digital nerve
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (See the Policy guidelines titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64640 Destruction by neurolytic agent; other peripheral nerve or branch
64680 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus
64999 Unlisted procedure, nervous system

UHC insurance guidelines

Coding Clarification: There are numerous reasonable and necessary conditions that might warrant the use of these procedures but which are too many to list. However, an appropriate ICD-10 diagnosis must be submitted with each claim and failure to do so may result in denial or delay in claim processing. The highest level of specificity should be used to report the patient's condition. The most current ICD-10 codebook should be used to ensure proper payment.

CPT Code Description

64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch
64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale
64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring
64620 Destruction by neurolytic agent, intercostal nerve
64630 Destruction by neurolytic agent; pudendal nerve
64632 Destruction by neurolytic agent; plantar common  digital nerve
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more
information)
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (See the Policy guidelines titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more
information)
64640 Destruction by neurolytic agent; other peripheral nerve or branch
64680 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus
64999 Unlisted procedure, nervous system